Every finding on record at Glenview Terrace

Based on interview and record review, the facility failed to follow its elopement policy by not responding to the wander guard alarm immediately and by not conducting a head count to confirm whether anyone had eloped. The facility also failed to implement the elopement risk care plan interventions, as they did not frequently monitor R1.The Immediate Jeopardy began on 4/23/26 at 9:42:57 pm when R1 exited through the front door.Immediate Jeopardy was identified on 4/28/26. V1 (Administrator) and V13 (Nurse Consultant) were notified of the IJ on 4/28/26 at 12:15 PM. Although the immediacy was removed on 5/1/26, the facility remains out of compliance at a Severity Level II due to the need to evaluate the implementation of policies, procedures, audits, and Quality Assurance monitoring.The Findings include:R1 is an [AGE] year-old male admitted on [DATE] with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. R1 was admitted to the third-floor locked unit, which required a security key code for elevator access.A review of the elopement risk assessment dated [DATE] documents that R1 was at risk for elopement.A review of the care plan document indicates that R1 was care planned for elopement risk, with interventions including frequent monitoring during his stay in the facility and the use of an electronic monitoring device with R1.A review of the video recording (Camera 05) dated 4/23/26 at 22:01:28 shows R1 began to manipulate with third floor passenger elevator keypad with no staff around him to monitor.A review of the video recording (Camera 05) dated 4/23/26 at 22:05:35 shows R1 continue to manipulate with third floor passenger elevator keypad with no staff around him to monitor.A review of the video recording (Camera 05) dated 4/23/26 at 22:06:12 recorded R1 watching the housekeeper punch key codes to the service elevator while R1 was about 15 feet away from the housekeeper.A review of the video recording (Camera 05) dated 4/23/26 at 22:07:12 shows R1 getting on to third floor service elevatorAn analysis of the video recordings on Camera 05 indicates that R1 was playing around with third floor elevator keypad with no nursing staff supervision for 5 minutes and 50 seconds.On 4/28/26 at 11:00 AM, V1 (Administrator) stated that Camera times on Camera 05 and Camera 15 are not syncing. The real time R1 got on to the third-floor service elevator is 21:41:35 (Camera 05 time 22:07:12)A review of the video recordings (Camera 32) dated 4/23/26 at 21:42:10 shows R1 exiting from the service elevator to the first floor.A review of the video recordings (Camera 15) dated 4/23/26 at 21:42:57 shows R1 exiting through the alarmed door to the outside of the building.A further review of the video recordings (Camera 15) dated 4/23/26 at 21:48:00 showed that the first responder to the alarm showed up at the exit door.An analysis of the video recordings on Camera 15 (first floor exit door) indicates that the first responder (from the first floor) to the wander guard alarm showed up at the exit door after 5 minutes and 3 seconds.On 4/28/26 at 2:00 PM, V3 (Assistant Director of Nursing/ADON) stated, R1 was on high risk for elopement requiring frequent monitoring. The staff should respond to the wander guard alarm immediately upon activation with no delay. The head count should be done as per policy to see if any residents eloped.On 4/28/26 at 12:45 PM, V7 (Night Certified Nursing Assistant/CNA) on 4/23/26) stated, Nobody was aware that R1 was missing. When I made rounds a little after 11:00 PM, I couldn't find R1. I talked to V8 (Agency Nurse) on the PM shift. I checked every common shower room bathroom, but we couldn't find him. I didn't see V9 (PM CNA) when I came at 11:00 PM. I don't know where he was.On 4/28/26 at 1:30 PM, V8 (Nurse for evening/PM shift on 4/23/26) stated, I don't recall any alarms going off on the 4/23/26 PM shift. The night-shift CNA (V7), who always comes a little early, notified me that R1 is missing. I checked on my residents, and he was not there. If we had heard the alarm when R1 exited the building, I could have done a head count immediately. I have never experienced this elopement behavior. I heard about his behavior, and that's why he had a wander guard. V9 (PM CNA) wasn't there. He didn't even tell me he was going home early. When the night nurse called him, the PM CNA was already at home.On 4/28/26 at 1:10 PM, V9 (CNA for second shift on 4/23/26) stated, I spoke to R1 around 9: 00 PM. I joked with him and laughed. After that, I didn't see him, and I can't recall whether the alarm was going off or not.On 4/28/26 at 3:00 PM, the facility conducted a drill for the wander guard exit alarm and was unable to hear on the third floor where R1 was residing. On 4/28/26 at 3:05 PM, V11 (Registered Nurse/RN) stated that she couldn't hear any wander guard alarm going off at 3:00 PM today.On 4/28/26 at 3:15 PM, V10 (Second Nurse on 4/23/26 PM Shift) stated, I couldn't hear any wander guard alarm at 3:00 PM today. On 4/23/26, I had admission, and I was sitting at the nurses' station at around 9:00 PM and was doing my admission. It was around 11:00 PM when the night CNA (V7) made her round and noticed R1 was missing. We didn't hear any alarm. If we could have heard an alarm, we could have done a quick head count, figured out who was missing, and searched for him immediately.On 4/28/26 at 12:20 PM, V4 (Nurse supervisor on 4/23/26 PM shift) stated, I was the nurse supervisor on the afternoon (PM) shift on Thursday (4/23/25). I was informed by the unit secretary on the first floor that the alarm was going off, and the CNA went outside and didn't see anybody. I didn't go because they said the alarm had already stopped. It was my mistake, and I didn't tell my staff to do a head count. We were supposed to search for the missing resident as soon as possible. The alarm will trigger only on the first floor. I was on the second floor and didn't hear the alarm. It should trigger all the floors. I don't know how R1 got access to the elevator. Sometimes the elevator opens from the outside. A staff member could have punched the elevator code by mistake. R1 was an elopement risk and should have been monitored.Review of the facility presented the elopement policy revised on 7/15/25 document: 5. When a door alarm sounds, staff members shall immediately respond to determine the cause of the alarm. C. A head count will be initiated on all the units, and a complete accounting of the residents will be given to the administrator/Director of Nursing The Immediate Jeopardy that began on 4/23/26 was removed on 05/1/26 when the facility took the following actions to remove the immediacy:1. Immediate research was conducted by the facility staff in the surrounding area of the facility on 4/23/2026. Surrounding hospitals were called to locate the resident including cab companies. Calls are made to the surrounding hospitals to locate the resident. Exhibit A 2. Immediately the Police Department was notified on 4/24/2026 at 12:39AM by the Facility Administrator to report on the missing resident. Exhibit B3. Immediately on 4/23/2026, around 11 pm, a facility headcount was conducted by nurses on duty on each floor to account for residents. Resident was not present at the facility. Exhibit C4. There are 3 agency staff identified responding to a wander guard exit door alarm on the 1st floor-Ambulance Door and the facility CNA, who cancelled the sounding alarm without paging Code Yellow. The agency staff and facility staff did not conduct a headcount were immediately educated by DON/ Designee and suspended pending the investigation on 4/24/2026. Exhibit D5. An in-service was conducted to the Assigned Nurse PM Supervisor on 4/24/2026 by the DON on the policy for elopement specifically of staff responding to a sounding exit door /wander guard alarm by following steps of staff checking the outside of the building or vicinity of the area to identify if a resident has exited the building then to notify the immediate supervisor/DON to ensure the head count is initiated immediately on all the units to identify if any residents has exited without staff knowledge. The Assigned Nurse PM Supervisor on 4/23/2026 who failed to initiate the headcount immediately when the alarm went off was suspended on 4/24/2026 pending the investigation. Exhibit EThe Housekeeper who came out from the elevator on 3rd floor and observed the resident by the elevator door and did not report his observation to the assigned nurse was educated on 4/24/2026 to ensure that resident is provided redirection and report the observation to the nurse or supervisor. Exhibit E 6. An education was immediately conducted by SSD /Designee and DON/Designee to facility staff on the policy for elopement specifically of calling Code Yellow and staff responding to a sounding exit door /wander guard alarm by the following steps of staff checking the outside the building or vicinity of the area to identify if a resident has exited the building ,then to notify the immediate supervisor to ensure the head count is initiated immediately on all the units to identify if any residents has exited without staff knowledge. This in-service was completed on 4/24/2026. Exhibit FThe agency nurses and agency CNAs will be educated by the Clinical Managers prior to start of shift on the policy for elopement specifically of calling Code Yellow and staff responding to a sounding exit door alarm by the following steps of staff checking the outside the building or vicinity of the area to identify if a resident has exited the building , then to notify the immediate supervisor to ensure the head count is initiated immediately on all the units to identify if any residents has exited without staff knowledge. This will be effective 4/24/2026 and will be ongoing. Exhibit F.7. An education was immediately conducted to facility staff by DON/Designee to report significant changes in residents' behavior who are at risk for elopement to ensure the primary physician and /or the psychiatrist are notified of the increasing changes in resident behavior. This education was completed on 4/24/2026 and will be ongoing. Exhibit G 8. The SS Team and Clinical Manager Team reassess all residents to identify risk for elopement. The elopement assessments were completed on 4/24/2026. There are 7 residents identified at risk for elopement. This updated list including photos is placed in the elopement binder at the front desk and each nursing unit, ambulance door, employee entrance door for staff to reference residents with wandering behavior and uses a wander guard device and are at risk for elopement. Exhibit H9. The SS Team has reviewed and updated the care plan for elopement risk to 7 residents identified at risk for elopement. These 7 residents are monitored by visual checking by Nurses and CNAs, hourly, to ensure the residents are physically present in the facility and are safe. This check is being documented on the Elopement Risk Hourly Visual check tool. This visual check tool was initiated on 4/24/26. New admissions will be assessed for risk of elopement upon admission and will be ongoing. Exhibit I10. An in-service was conducted to all nurses and shift supervisors by the DON to ensure a headcount is implemented at the start of each shift and endorsement of residents not present in the facility for OOP, the medical procedure is endorsed to the incoming shift. This in-service was initiated on 4/24/2026 and will be ongoing. Exhibit J11. The residents not identified at risk for elopement will be monitored every 2 hours. This log was created to monitor the residents' whereabouts every 2 hours by Nurses and CNAs. This was initiated on 4/24/2026 and will be ongoing. Exhibit K12. Residents identified using a wander guard device who are at risk for elopement are checked daily for proper functioning and every shift for placement. This checking is documented in the monitoring tab by Nurses. This process is ongoing. Exhibit L 13. The Maintenance Department and designee check all exit doors and wander guard system daily for proper function. This checking is an ongoing process and documented in the Maintenance log. Exhibit M 14. The Administrator and Designee will conduct an audit to monitor residents at risk for elopement, to identify changes in behaviors, notify the PCP or Psychiatrist for further management and review and update the care plan for elopement behaviors and notification of family of the behavioral changes. This will be conducted 3x/week x12 weeks. Exhibit N 15. The Director of Social Services or Designee will conduct Code Yellow Elopement Drills to monitor staff competency in responding to exit door/Wander Guard alarm activation. Drills will ensure staff appropriately respond by checking the immediate area outside the building, notifying the supervisor, initiating a headcount on all units, and verifying resident location. This QA audit will be conducted 3x/week for 4 weeks then monthly. Exhibit 0 16. There are 4 facility staff currently on vacation. These staff members will be educated prior to return to work on policy for elopement specifically Code Yellow and of staff responding to a sounding exit door /wander guard alarm by the following steps of staff checking the outside the building or vicinity of the area to identify if a resident has exited the building, then to notify the immediate supervisor to ensure the head count is initiated immediately on all the units to identify if any residents has exited without staff knowledge and participate in the elopement drill prior to return to work. Exhibit P 17. Results of the QA Audit will be discussed in the monthly QAPI meeting until resolution.18. A QAPI was held 4/24/2026 with the IDT and Facility Medical Director to discuss and review the abatement plan for the elopement incident. The Facility Medical Director approved the abatement action plan. Exhibit Q19. The Code to the Service Elevator on 3rd floor has been changed 4/29/26.20. The facility is currently having S&S electronics install the wander guard system to include the elevators on the third floor so that no residents can have access to the elevators without the alarm going off, to alert staff. This will be completed on 4/30/26.

Based on interview and record review the facility failed to ensure each resident's dignity was maintained related to having a choice of a different breakfast alternative menu for one of three residents (R2) reviewed for residents rights. Findings Include:On 2/13/2026 at 12:00pm R2 said the dietary department will not allow the residents to have an alternative to breakfast waffles. They can only have toast white or wheat not pancakes and if she wants an extra meat instead of waffles dietary will not allow an extra meat. On 2/13/2026 at 1:30pm V6(Dietary Supervisor) said the facility does provide a breakfast alternative. It does not have pancakes and that the facility does not alternate waffles for an meat alternative, the alternative for waffles is white or wheat toast. On 2/16/2026 at 10:10am V1(Executive Director) said she was not aware that the resident's wanted pancakes instead of waffles and that the residents can have pancakes as an alternative.On 2/1/2026 at 10:30am V2(Director of Nursing) said all residents have the choice of a liberal diet and can ask for an alternative of pancakes if they would like, even if it's not on the alternative diet. R2's order summary report has a diagnosis of general diet regular texture dated 5/6/2024, A care plan dated 10/26/2022 provide assistance with meals if indicatedFacility Policy: Resident's Rights for people in Long Term Care FacilitiesSafety and Good CareYour facility must provide services to keep your physical and mental health, and sense of satisfaction.Food Preference Policy: revised 6/30/2025Purpose;The facility will provide food that accommodates allergies and preferences.Policy:3. If the resident refuses the food being served, the facility should offer alternatives that is consistent with the usual food item provided by the facility.

Based on interview and record review the facility failed to ensure colostomy care was provided for a dependent resident for one (R2) of two reidents reviewed for Colostomy Care.Findings Include:On 2/13/2026 at 12:00pm, R2 said that on 2/1/2026 at about 8:00pm she put on her call light and about 10-15 minutes later V11(Agency Certified Nursing Assistant-CNA) arrived and I asked her to empty my colostomy bag, V11 said she didn't feel comfortable. R2 said she asked V11 to inform the nurse because her colostomy bag was filling up. R2 said after about 30 minutes she put on her call light, V11 returned and said she asked the CNA's but not the nurse, and said she would ask the nurse. R2 said at 9:00pm she called the receptionist and asked her to page the supervisor over head she needed assistance and the receptionist sent R2 to the unit manager voice mail whom only works in the morning and not on weekends. R2 said she called the receptionist again and again she was sent to another voice mail. After the third time calling the receptionist, R2 said she called 911 emergency. When they arrived the agency nurse entered the room with her medications unaware that she needed a colostomy change, and at this point her bag was leaking out feces. On 2/13/2026 at 1:30pm V9(AM Receptionist) said if a resident called down to the front desk asking for anything she will over head page the supervisor or nurse to that room.On 2/16/2026 at 9:30am V10 (PM Receptionist) said R2 did call the front desk several times asking to speak with a supervisor. I sent her call to the voicemail of the unit manager and the house supervisor that night. I did not over head page. On 2/16/2026 at 11:30am V3 (Unit Manager) said I received the call on Monday when I returned to work about the incident and did inform V2 (Director of Nursing-DON), I expect the receptionist to over head page for assistance to that room and the CNA staff to inform the nurse if their is an issue with any skill.On 2/16/2026 at 11:45am V2(Director of Nursing-DON) said I expect the receptionist to over head page and follow up on any resident calling for assistance, I only discovered on Monday that R2 had called 911 for assistance I also expect the nursing staff including agency to follow up with the nurse if that is a request from the resident.On 2/16/2026 at 10:40am V1(Executive Director) said that R2 should not have ever had to call 911 for assistance. I expect the staff to inform the nurse if that's whom the resident ask to see. I expect the receptionist to notify staff on that unit to provide assistance. An admission record indicates that R2 has a diagnosis of irritable bowel syndrome, encounter for a colostomy, a care plan dated 10/20/2023 intervention to colostomy care every shift and as needed.Facility Policy: Colostomy Care 6/30/2025.Policy Statement : It is the policy of the facility to perform proper ostomy care in order to prevent exposure of the resident skin/stoma sites from fecal matter.12.Empty ostomy care every shift and as needed.

Based on interview and record review, the facility failed to follow its abuse prevention policy by not providing an environment free from abuse to protect one resident (R2) from physical abuse by another resident (R1), resulting in R2 being hit several times by R1. Findings include:R1 was an [AGE] year-old former resident of the facility, deceased [DATE], with medical diagnosis including but not limited to encounter for palliative care; cognitive communication deficit; anxiety disorder; and depression.R2 is an [AGE] year-old resident of the facility with a Brief Interview for Mental Status (BIMS) score of 15/15, with medical diagnosis including but not limited to unspecified fracture of first lumbar vertebra; nondisplaced fracture of sternal end of right clavicle; displaced simple supracondylar fracture without intercondylar fracture of left humerus; and history of falling.On [DATE] at 10:18 AM, R2 said he was asleep in bed at night on [DATE], when his roommate, R1, fell from his wheelchair to the ground, crawled over to R2's bed, and began hitting R2's legs with his fists, about ten times, boom, boom, boom, boom (motioning with his fists). R2 said he felt a little pain but was more afraid than anything.On [DATE] at 11:05 PM, V2 (Executive Director) said on [DATE] at around 10:00 PM, V20 (CNA) was putting R1 in bed, then stepped outside the room to retrieve two pillowcases R1 had requested. V2 said before V20 re-entered the room, she heard R2 cry out. V2 said upon entering the room, V20 saw R1 on R2's side of the room, holding on to R2. V2 said V20 then separated R1 and R2, called V22 (Floor Nurse), and removed R2 from the room.The facility's final investigation notes noted, in part, V20 said when she entered the room, R1 requested two pillowcases; she stepped away briefly to obtain them, and, upon reentering, heard R2 say R1 was grabbing him. The investigation notes further stated V20 immediately separated the two residents and reported the incident to V22.The facility Abuse and Neglect Policy statement, revised [DATE], states in part, It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse.

Based on observation, interview, and record review the facility failed to use appropriate infection control practices when taking blood pressure during medication administration. This deficiency affects one (R526) of one resident observed taking blood pressure during medication administration observation in the sample of 35 reviewed for Infection Prevention and Control Program. Findings include: On 6/10/25 at 12:28PM, V7 Agency LPN (Licensed Practical Nurse) said that he has to take BP (blood pressure) of R526 before administering her medications. V7 placed the BP cuff on upper arm of R526 without disinfecting the BP monitor portable machine prior to use. V7 obtained 110/75mmHg. After taking the BP, he placed the BP portable machine on top of the medication cart without disinfecting it after using. V7 prepared medication for R526 and administered the medication orally. On 6/10/25 at 12:34PM, V7 Agency LPN said that he is done with his noon time scheduled medications administration. V7 pushed his medication cart in front of the nursing station. V7 still did not disinfect the BP portable machine that he placed on top of the medication cart. At 12:45pm, informed V7 of observation made that he did not disinfect the BP portable machine before and after he used it to take BP of R526. V7 said that he forgot to disinfect the BP portable machine including BP cuff before and after using it with R526. On 6/11/25 at 3:02PM, Informed V2 DON (Director of Nursing) of above observations and concerns. On 6/11/25 at 8:25AM, Informed V17 Infection Coordinator of above observation and concern. V17 said that BP portable machine- including BP cuff should be disinfected before and after using it with resident. Facility's policy on medical equipment, instruments and Health IT Devices Infection Control Plan revised 8/16/24 indicates: Policy Statement: it is the policy of this facility to prevent infection and create/maintain a safe environment for the residents, their visitors and staff thru proper handling, cleaning, and sanitizing of medical care equipment, instruments and or other related health IT devices. Procedures: 7. Nursing personnel shall wipe down/clean reusable equipment between residents using a facility approved cleaner/disinfect 12. Some medical care equipment items shall be cleaned and or sanitized with facility approved disinfectant agent between each resident use.

Based on observation, interview, and record review the facility failed to ensure an accurate count of controlled medication on the controlled drug administration record sheet. This deficiency affects 1 of 3 medication carts reviewed for Controlled Medication count Management. The facility also failed to follow its policy on medication administration on prohibiting pre-pouring of medications. This deficiency affects two (R110 and R525) of twelve residents in the sample of 35 reviewed for administration of medication. Findings include: On 6/10/25 at 9:10AM, checked medication cart with V4 LPN (Licensed Practical Nurse). Observed pre-poured medications in plastic medication cup inside the top drawer and controlled/narcotic drawer. V4 said that she prepared the medication for R525 and R110. V4 said that she is about to give the medication, but she answered another resident's call light. V4 said that she should not pre-pour the medications. Medications prepared should be given to the resident immediately. Reviewed and counted controlled/narcotic medications with V4. Observed discrepancies for R525's Controlled medication bingo card of Tramadol 50mg indicated 15 tablets medications left while the Controlled drug administration record documented 17 left medications and Alprazolam 0.25mg indicated 5 tablets medication left while the controlled drug administration record documented 6 left. V4 LPN said that she forgot to sign the date, time, and amount the controlled medication that she took at controlled administration record. On 6/10/25 at 9:19AM, informed V5 ADON (Assistant Director of Nursing) of above observations. V5 said that medications prepared by the nurse should be administrated immediately. The nurse (V4 LPN) should not be pre- pouring medication for the residents. V5 said that after removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken. On 6/11/25 at 3:02PM, informed V2 DON (Director of Nursing) of above observations and concerns. V2 said that it is not their facility's practice to pre-pour medications of residents for medication administration. Facility unable to provide medication policy specific for prohibiting pre-pouring of resident's medications. Facility's policy on Controlled Medication Count revised 7/26/24. Policy statement: It is the policy of the facility to maintain an accurate count of schedule II-controlled medications. Procedure: 1. After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken. Facility's policy on Medication Administration revised 8/16/24 indicated: Policy statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedure.

2. On 6/10/25 at 10:45AM, observed R186 lying in bed with LAL (Low air loss) mattress. V7 Agency LPN (Licensed Practical Nurse) said that R186 has multiple chronic wounds on BLE and has Kennedy terminal ulcer to sacral area. She is on hospice care. She is non-verbal, may open eyes when called. She needs total care with ADLs (Activity of Daily Living) and transfers. V7 said that they monitor her for pain every shift. R186 is initially admitted on [DATE] with admission diagnosis listed in part but not limited to Sequelae of Cerebral Infarction, Atherosclerosis of native arteries of right leg with ulceration of other part of foot, non-pressure chronic ulcer of other part of left foot, Altered mental status, Palliative care, Diaper dermatitis, Type 2 Diabetes Mellitus. Active Physician order sheet indicated she is on Acetaminophen rectal suppository 650mg insert 1 suppository rectally every 4 hours as needed (PRN) for pain/fever. Hydromorphone HCl solution 2mg/ml give 0.2ml by mouth every 2 hours PRN for dyspnea/pain. Comprehensive care plan indicated she is at risk for pain due to history of femur fracture from fall. Pain tool assessment used for R186 every shift indicated numerical pain scale assessment from 5/25/25 to 6/9/25 which is coded from 0-2. On 6/11/25 at 3:02PM, V2 DON (Director of Nursing) said that they utilized PAINAD (Pain Assessment in Advanced Dementia) for residents with advanced dementia who may be unable to verbally express their pain. Informed V2 that R186's every shift pain assessment record from 5/25/25 to 6/9/25 indicated that the nurses were using the numeric pain scale pain assessment tool. The numeric pain scale is a tool used to assess and quantify pain intensity. It is typically ranges from 0-10 with 0 representing no pain and 10 representing the worst pain. Residents are asked to select the number that best reflects their current level of pain. This pain assessment tool is typically used for resident who is alert and oriented not for cognitively impaired and nonverbal like R186. Informed V2 that the facility failed to ensure to utilize appropriate pain assessment tool for resident with cognitive impairment or non-verbal resident for pain management. Informed V2 that the nurses stated using the PAINAD tool assessment when surveyor asked for it on 6/10/25. Facility's PAINAD (Pain Assessment in Advanced Dementia) tool assessment form indicated: observation of 5 key behaviors: Breathing, Negative vocalization, Facial expression, Body language, and consolability. By observing these behaviors, the nurses can assess the severity of pain in individual with advance dementia. Facility's policy on Pain revised 1/30/25 indicated: Policy statement: It is the policy of the facility to ensure that all residents are assessed for pain in every situation where there is a potential for pain. Based on observation, interview, and record review, the facility failed to have an ordered narcotic pain medication available for five and a half hours for a resident (R330) with severe pain and the facility failed to utilize a pain assessment tool for a cognitively impaired/non-verbal resident (R186) for pain management for two out of four residents reviewed for pain in a total sample of 35. Findings Include: 1. R330 is a [AGE] year old with the following diagnosis: lupus erythematosus; fibromyalgia; fracture of the right humerus, right tibia, and right fibula; and wedge compression fracture of the T11-T12 vertebra. On 6/11/25 at 11:10 AM, R330 stated R330 was hit by a car which fractured R330's right arm and lower right leg. R330 reported they live with chronic pain due to R330's lupus diagnosis. R330 stated R330 normally lives at a pain level of seven out of ten with scheduled pain medication. R330 reported the best pain relief is the narcotic pain medication which is ordered as needed so R330 has been requesting it about every four hours. R330 stated R330 also receives scheduled Tylenol but that does nothing to bring down R330's pain. On 6/12/25 at 10:02 AM, V26 (LPN) stated R330 last received the narcotic pain medication around 4AM. V26 reported R330 requested the narcotic pain medication around 8:30AM but the medication was not available. V26 stated the medication should be reordered from pharmacy before the last dose is given. V26 reported the medication card will tell the nurse when to order it from pharmacy. V26 was not able to answer why the medication was not delivered but stated the previous shift nurse should have reordered the medication at the time it was administered so pharmacy would have time to deliver the pain medication. V26 reported the medication was reordered about an hour ago STAT so it is expected to be delivered in about an hour. V26 stated the narcotic medication is usually stocked in the pyxis system but is currently out of stock. V26 reported R330 stated R330's current pain level was ten out of ten. On 6/12/25 at 10:08 AM, R330 stated V26 told R330 that the facility did not have the narcotic pain medication in stock. R330 reported a fentanyl patch was put on this morning but has not been on long enough to give any pain relief. R330 stated pain was a ten out of ten in R330's right arm, right leg, and lower back. R330 described the pain as sharp in the upper and lower extremities and aching in the lower back. R330 reported refusing to work with therapy when asked earlier this morning due to R330's uncontrolled pain. On 6/12/25 at 12:21 PM, V5 (ADON) stated V5 called pharmacy to get an update and the medication will be delivered in about 30 minutes. V5 reported the narcotic pain medication still has not been given yet. V5 was unable to give a number on the pain scale for R330 at this time. On 6/12/25 at 12:27 PM, V27 (Physical Therapist) stated V27 worked with R330 today around 11AM. V27 reported R330 constantly complained of pain throughout the entire session. V27 stated the nurse told V27 that the medication was not in stock, and they needed to wait for it to be ordered. V27 reported R330 was able to participate in therapy but wasn't able to complete all the planned exercises because of R330's pain level. V27 stated R330 rated the pain a ten out of ten at the beginning of the session and a fourteen out of ten at the end of the session. On 6/12/15 at 12:32 PM, V2 (DON) stated the nurse is responsible for reordering the medication from pharmacy when the medication card is running low. V2 reported each medication card will indicate when pharmacy needs to be called for more medication to be sent. V2 stated the nurse should order the medication at this time so it is available for the next dose. When asked why the pyxis system wasn't accessed to give the narcotic medication, V2 said, I don't know. I will have to check. On 6/12/25 at 1:47 PM, V5 stated the staff did not access the pyxis system to get the narcotic medication out because that medication was out in the pyxis as well. The Physician Order Summary documents to offer pain medication 30-60 minutes prior to treatment which was dated 6/10/25. The following scheduled pain medication was ordered on 6/9/25: Tylenol 325 mg two tablets every six hours, a transdermal fentanyl patch 100mcg/hour that started on 6/12/25, and a lidocaine patch 4% to the left knee and right shoulder every morning. The narcotic pain medication (oxycodone) is ordered as needed only. Oxycodone 15 mg three tablets every four hours as needed was ordered on 6/9/25. The Medication Administration Record dated 06/2025 documents pain scores are documented once a shift and range from a zero (no pain) to a ten (severe pain). On 6/12/25, the scheduled Tylenol was administered at 6AM and 12PM. Oxycodone was administered at 4:17 AM and was not administered again until 1:42 PM. The Physical Therapy Treatment note dated 6/12/25 documents R330 rated pain a ten out of ten that was on the right upper and lower extremity and back. R330 was able to walk 15 feet to the bathroom and back but refused to walk more due to pain. R330 presented with excruciating pain during the session. The therapist spoke with the nurse that reported they are waiting for the pain medication to arrive. The Nursing admission dated 6/9/25 documents R330 had complaints of pain upon admission to the right lower extremity and right shoulder. At this time, R330 rated the pain a three out of ten and described it as an intermittent ache. R330 reported medication, rest, and ice relieve the pain. A Physician note dated 6/12/25 documents due to lupus and musculoskeletal changes R330 is on medication for chronic pain. The Care Plan dated 6/9/25 documents R330 is at risk for pain (chronic) related to lupus. Interventions include to medicate prior to therapy/treatment and provide analgesic as ordered. The policy titled, Pain, dated 1/30/25 documents, Policy Statement: It is the policy of the facility to ensure that all residents are assessed for pain in every situation where there is a potential for pain .Procedures 1. Upon admission and readmission, the nurse will assess the resident for pain. For those identified with pain upon admission/readmission assessment, an order for pain medication will be obtained from the physician. If available in the convenience box or facility house stock, the pain medication ordered will be administered to the resident as soon as possible. A policy on reordering medication was requested but was not given by the facility.

3. On 6/10/25 at 10:45AM, observed R186 lying in bed with LAL (Low air loss) mattress. V7 Agency LPN (Licensed Practical Nurse) checked the linens over the mattress. Observed linen folded in quarters and flat sheet over the mattress. R186 is wearing disposable adult brief. Surveyor asked V7 of what the setting for R186's LAL mattress. V7 said he does not know. He said that the wound care team is responsible for setting and monitoring of resident's LAL mattress. Surveyor requested for the V8 WCC (Wound Care Coordinator) and requested to observe wound care. On 6/10/25 at 10:46AM, informed V8 WCC of above observation. V8 said that resident on LAL mattress should only be on a flat sheet unless indicated in resident's care plan. On 6/10/25 at 11:10AM, observed V8 adjusting R186's LAL mattress control panel. V8 said that R186 is not on appropriate setting as manufacturer recommendation. V8 said R186 weighs 84lbs and her setting was at 110lbs. V8 said that V10 Wound Tech usually make rounds to checks all the residents in the unit with LAL mattress for appropriate setting. On 6/10/25 at 11:55AM, observed V8 WCC, V9 WCN (Wound Care Nurse) and V10 Wound Tech provide wound care to R186. During wound care, V8 WCC giving instruction and cuing V9 WCN during wound care. On 6/11/25 at 3:02PM, Informed V2 DON (Director of Nursing) of above observations and concerns. R186 is initially admitted on [DATE] with admission diagnosis listed in part but not limited to Sequelae of Cerebral Infarction, Atherosclerosis of native arteries of right leg with ulceration of other part of foot, non-pressure chronic ulcer of other part of left foot, Altered mental status, Palliative care, Diaper dermatitis, Type 2 Diabetes Mellitus. Most recent Braden scale assessment dated [DATE] indicated she is at high risk for skin impairment. Active physician order sheet indicated: Alternating pressure mattress: diagnosis vascular wound and prevention care. Treatment: Left medial ankle-Cleanse wound with normal saline solution (NSS). Xeroform secondary dressings-ABD, rolled gauze every MWF and PRN (as needed). Mid vertebrae -Cleanse wound with NSS. Skin prep. Bordered foam. Report to MD for any abnormalities, continue offloading the areas. Keep area clean and dry as needed for skin protection every TTH and PRN. Right dorsal foot- Cleanse wound with NSS. Xeroform dressings- ABD, rolled gauze every TTHS and PRN. Right hip-Cleanse wound with NSS. Apply foam dressing for protection every TTHS and PRN. Right lower back- Cleanse wound NSS. Xeroform dressing- bordered foam every TTHS and PRN. Sacrum-Cleanse wound with NSS. Calcium alginate, bordered foam dressing every day and PRN. Wound care physician visit dated 6/3/25 indicated sudden onset of pear-shaped skin breakdown and discoloration in the sacral area and right lower back area indicating a Kennedy terminal ulcer. The staff report the patient is declining in health overall, with decreased appetite and weight loss. The patient is also being seen for chronic venous wounds on the BLE. The patient was awake and resting in bed, prevalon boots in place. The patient has thin and fragile skin with history of wounds. Foley catheter in place. Comprehensive care plan indicated that she has an actual and a potential for further impairment to skin integrity due to present of comorbidities, limited mobility, fragile skin, and fracture status post fall. R186's Low air loss mattress manufacture's functions guide indicated: Pressure adjust knob adjustable by patient's weight. Turn the pressure adjust knob to see a comfortable pressure level by using the weight scale as guide. Facility's policy on Specialized mattress and appropriate layers of padding revised 8/19/23 indicated: 1. Limit the amount layers on top of specialized air mattress such as low air loss mattress according to the resident's needs and individual's condition in order to manage comfort, positioning, and moisture . 3. Use specialized air mattresses like low air loss mattress on the resident with stage 3 or 4 pressure sores to ensure moisture, heat, and friction control. Based on observation, interview and record review, the facility failed to ensure low air loss mattress devices were on the correct weight setting for residents who are at risk for developing pressure injuries. This failure has the potential to affect three (R61, R186 and R200) out of four residents reviewed for pressure injury prevention and treatment in a final sample of 35 residents. Findings Include: 1. On 6/10/25 at 12:50PM, observed R61 in bed with low air loss mattress in use. Air loss mattress is set to 7. Confirmed with V25 (Unit Nurse Manager) that the setting is on 7. V25 looked at a paper with R61's weight record and reset the mattress to 4. R61 is 116.0 lbs. dated 6/10/25. R61 Braden Scale and Clinical Evaluation dated 6/5/25, reads: High Risk 7.0 and R61 with history of healed pressure injuries to left and right buttocks and coccyx. On 6/12/25 at 10:30AM, V8 (Wound Care Coordinator) stated that R61 does not have any active pressure injury at this time, however R61 has a history of pressure injury. R61 is high risk for skin alteration and specialty mattress is being used as a preventative measure. V8 stated that they use a specialty mattress such as low air loss mattress for residents who are high risk for skin alteration, resident with multiple stage 2 pressure injuries and resident with stage 3 or higher. 2. On 6/10/25 at 10:28AM, observed R200 in bed with low air loss mattress in use. Air loss mattress is set to 150 lbs. V24 (LPN) confirmed that the setting is set to 150 lbs. V24 mentioned that R200 is 98 lbs. and needs to be set to 90 Lbs. V24 reset the specialty mattress on 90 lbs. Record reviewed. R200 is 98.0 lbs. dated 6/2/25. R200 Braden Scale and Clinical Evaluation dated 5/19/25, reads: High Risk 9.0 and R200 with a history of left elbow unstageable pressure injury healed 4/16/25. Braden Scale and Clinical Evaluation shows that above 20 is low risk and below 20 is high risk. On 6/12/25 at 10:30AM, V8 (Wound Care Coordinator) stated that the setting for the specialty mattress such as the low air loss mattress is based on resident's weight. The setting should be closer to resident weight if the increment is 30 lbs. (pounds) per dial. If resident is 98 lbs., then it should be set to 120, closer to resident's weight but not under, due to the bed will be too soft and the purpose of the bed will not be effective. V8 also stated that R200 is a hospice resident and assessed as high risk for skin alteration. R200 has history of pressure injury in which it was healed. The mattress is for comfort and preventative measures. Proactive Manual states that Weight/Pressure set up: User can adjust air mattress to a desired firmness according to patient's weight or the suggestion from health care professional. Wound Care Guidelines with a revised date of 1/24/24, reads in part: The goal of this care guidelines is to achieve compliance to regulatory requirements and provide evidence-based recommendations for the prevention and treatment of pressure injuries that can be used by the health professionals in the facility. The purpose of the prevention recommendations is to guide evidence-based care to prevent development of pressure injuries and the purpose of the treatment focused recommendations is to provide evidenced-based guidance of the most effective strategies to promote pressure injury/ulcer healing. The score from the Braden Scale and Clinical Evaluation should be interpreted/calculated to determined level of risk: Low Risk and High Risk. Each risk factor and potential cause(s) identified be reviewed individually and addressed into the resident's care plan. Facility shall develop a plan of care and implement intervention according to the resident's Braden Scale and Clinical Evaluation of identified risk factors.

Based on observation, interview, and record review the facility failed to ensure ongoing monitoring and assessment to identify suprapubic stoma site drainage and skin impairment and obtain appropriate treatment from the Physician. This deficiency affects one (R195) of three residents in the sample of 35 reviewed for Suprapubic catheter care management and quality of care. Findings include: On 6/11/25 at 9:27AM, observed R195 lying in bed with low air loss mattress. V19 CNA (Certified Nurse Assistant) lifted the top sheet and observed R195's disposable brief soaked with serosanguineous drainage on suprapubic area. V19 opened his brief and observed no dressing on suprapubic catheter site with moderate amount of serosanguineous drainage. The stoma site and surrounding skin noted with redness and irritation. The suprapubic catheter is not secured to the abdomen. The catheter is connected to the urinary drainage bag covered with privacy bag. R195 denied any pain. He said that he had a shower yesterday and did not have dressing after it was removed for the shower. R195 said that the nurses usually do his dressing twice a day. Called V7 (Agency Nurse) and showed observation made. V7 said that they do dressing to R195's suprapubic site every shift due to his drainage. V7 said that no one informed him that R195 does not have dressing on his suprapubic site. V7 called for V21 WCN (Wound Care Nurse). On 6/11/25 at 9:31AM, V20 Agency CNA said that she is the assigned CNA for R195, but she is not aware that he did not have his supra pubic catheter dressing on. She has not yet provided him with morning care. On 6/11/25 at 9:40AM, called V21 WCN and showed observation made. V21 opened his brief and observed no dressing on suprapubic catheter site with moderate amount of serosanguineous drainage. The stoma site and surrounding skin with redness and irritation. V21 said that he will assess, document and call physician for treatment orders. R195 is admitted on 5/2024 with diagnosis listed in part but not limited to Obstructive and reflux uropathy, Benign prostatic hyperplasia, Limitation of activities due to disability, need for assistance with personal care. Active physician order sheet indicated: Zinc oxide to urinary meatus topically two times a day for skin irritation/rashes. Indwelling catheter type: Suprapubic catheter, catheter size 16F, 10cc balloon reason for use: Obstructive and Reflux uropathy ordered 6/11/25 after surveyor asked for his medical records. Suprapubic catheters care every shift. Change catheter drainage bag PRN (as needed). Change foley bag, tubing, and tube holder every night shift weekly. Monitor drainage around the stoma every shift. Monitor skin integrity around the stoma every shift. Suprapubic catheter: catheter care every shift. Cleanse area with NS (normal saline) pat dry leave open to air. Apply dressing only if site is observed with drainage and sign and symptoms of infection ordered date 6/12/25 after surveyor interviewed with V21 on 6/12/25. R195's skin/wound evaluation dated 6/11/25 documented by V21 WCN indicated seen patient today for skin assessment. Staff cleaned the area and upon assessment, skin surrounding the suprapubic catheter is intact, no redness, no drainage, and no s/s of infection. Patient is not in pain. Catheter is patent and draining clear colored urine. Dressing applied as ordered. Patient tolerated the procedure well. Patient made comfortable in bed. Call light within reach. Preventive measures in place. On 6/12/25 at 9:33AM, Reviewed R195's medical records with V21WCN. Informed V21 of discrepancy with his documentation from what was observed yesterday with R195's suprapubic catheter site. V21 said that he observed R195's disposable brief on his suprapubic area was soaked with serosanguineous drainage. He said that he opened R195's brief and observed no dressing on suprapubic catheter site with moderate amount of serosanguineous drainage. The stoma site and surrounding skin with redness and irritation. He said that after he cleansed it, it did not look so bad and took picture. V21 took his phone and showed to 2 surveyors the picture he took of R195's suprapubic site. Surveyor asked V21 to describe the suprapubic site in the picture. V21 said that there is redness on the site and surrounding area. V21 said he was asked by his supervisor to take picture of R195's suprapubic site and sent the picture to her. Surveyor informed V21 that this is an invasion of resident privacy of taking picture from his personal phone. V21 said that he did not call the physician for treatment because they are putting barrier cream - Zinc oxide to the suprapubic site and they don't need physician order because it's a barrier cream. Informed V21 that R195's physician order sheet indicated Zinc oxide ointment to be applied to urinary meatus twice a day for skin irritation/rashes not for suprapubic site. Informed V21 that R195's reason for suprapubic catheter usage ordered date 6/11/25 was changed to Obstructive and reflux uropathy from BPH (Benign Prostatic Hypertrophy) after observation made with R195 and requested for documents yesterday. On 6/12/25 at 10:40AM, Informed V8 WCC (Wound Care Coordinator) of above observations and concerns. V8 said that they cannot use their own personal cell phone to take picture of resident's suprapubic catheter site. Informed V8 that the nurses are not documenting drainage and changes in suprapubic site. Informed V8 that they failed to ensure ongoing monitoring and assessment to identify suprapubic stoma site drainage and skin impairment and obtained appropriate treatment from the Physician. Facility's policy on Suprapubic Catheter reviewed 7/31/24 indicated: Policy statement: The facility shall follow nursing guidelines for safe, aseptic care, removal and change of a suprapubic catheter in order to prevent infection and help maintain catheter patency. Care guidelines: 2. Dressing around the stoma shall be changed daily and PRN. Monitor stoma site for any redness or maceration. 3. All suprapubic catheters must be secured to abdomen with an appropriate anchor device to prevent accidental dislodgement or removal. Facility's policy on Skin regimen and Treatment formulary reviewed 3/24/25 indicated: Policy statement: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown. Procedures: 1. Charge nurses must document in the electronic health record any skin breakdown upon assessment and identification. 2. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician c. other skin condition.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent serious injury to a resident. This failure affects one of three residents (R1) reviewed for falls in a total sample of six residents. This failure resulted in injuries to R1. R1 sustained facial fractures and skull fractures, acute nondisplaced fractures of bilateral sphenoid sinuses, non-displaced fractures of basilar portion of the occipital bone bilaterally, and acute nondisplaced fractures involving the postero-lateral walls of bilateral maxillary sinuses. R1 also had a small possible C6 fracture requiring a neck collar. R1 is a [AGE] year-old male. R1's diagnoses are but not limited to fracture at the base of the skull, eye bone fracture, Parkinsonism, heart disease, atrial fibrillation, history of falling, diabetes, high blood pressure, dementia, and hypothyroidism. R1's BIMS (Brief Interview for Mental Status) dated 3/18/2025, notes R1 is not very alert. R1's care plan notes R1 is at high risk for falls related to current medication use, poor safety awareness, unsteady gait, disease process: fall history, wedge compression fracture L4, paroxysmal AFIB (Atrial Fibrillation), Hypertension, Diabetes Mellitus, Dementia, Hypothyroidism, BPH (Benign Prostate Hypertrophy), and Peripheral Venous Insufficiency. R1 requires total assistance of two-person assistance using the mechanical lift with transfers due to generalized weakness, immobility, impaired mobility, and poor weight bearing control due to compression fracture superior L4, dementia & Parkinson's. On 04/05/2025, at 11:09 AM, R1 was upright in wheelchair, with a mechanical lift pad underneath him. R1 was sleeping. R1 moaned when spoken to but is not able to talk. R1 has a neck brace around his neck. There was bruising to the left lower eye. There were purple, green, and yellow colors. There were two steri-strips to the left forehead. Progress note dated 3/19/2025, notes R1 had a fall. Readmission note dated 3/22/2025, notes R1 has neck collar, and leg boots on. R1 has scattered echymotic areas, and stitches to his head. He is not in distress and does not seem to be in a lot of pain. He has black/blue discoloration to left eye, and multiple old dark blue spots. R1 is unable to verbalize pain, due to being non- verbal, but groans which is normal for him. He groans, and slow to response, but with good eye contact. Vitals are stable. Medical professional note dated 03/27/2025, notes R1 readmitted from 3/19/25-3/22/25 after fall. Imaging shows multiple facial fractures and skull fractures, acute nondisplaced fractures of bilateral sphenoid sinuses, non-displaced fractures of basilar portion of the occipital bone bilaterally, acute nondisplaced fractures involving the postero-lateral walls of bilateral maxillary sinuses. No intracranial hemorrhage. Small possible C6 fracture. Neurosurgery was consulted. Recommended Aspen collar (neck collar) for 4 weeks. R1 remains weak and was transferred back to the facility. Left peri-orbital area with purplish discoloration, stitches on left forehead intact. Aspen collar in-place. No neuro deficit. On 4/05/2025, at 11:06 AM, V1 (Certified Nursing Assistant) stated, R1 is not alert. He is a mechanical lift transfer. We are supposed to use two aides. I was told that he fell , that is why he has the neck brace. On 4/05/2025, at 11:35 AM, R2 (R1's Roommate) stated, I was getting off the elevator. I heard a page for staff to our room. I think she (Former Aide) might have pulled the pad too hard, and he fell out of bed. But I did not see it. On 4/05/2025, at 12:39 PM, V2 (Director of Nursing) stated, I believe the date was 3/19/2025, on the 3:00 PM to 11:00 PM shift. I initiated an investigation and spoke with the aide and the nurses. R1 is not alert or oriented. He is confused and wheelchair bound. He uses the mechanical lift. The aide was V4 (Former Certified Nursing Assistant) at the time. I believe the nurse was V5 (Agency Registered Nurse). The aide told me she was planning to transfer the resident from the wheelchair to the bed. She brought the patient into the room. She told the other aide that she needs help to transfer with mechanical lift. She waited. She was in front of the patient and there was a little bit of a distance away from R1. R1 had a jerky movement. He fell face down on the floor. V4 called everyone. V5 called a rapid response. Immediately, he was taken care of. There was a cut on his head. They immobilized him and sent him out. R1 has Parkinson's. He has been seen by a neurologist. He had falls at home multiple times. He is on a tapering dose by the neurologist. I believe that is why he had a jerky movement. I made them aware that he had a fall. The medication was discontinued, and he has a follow up appointment. A care plan meeting was held with the family. On 04/05/2025, at 1:09 PM, V5 stated, I was passing medication. I heard yelling from the aide. I ran into the room. The patient was on the floor. I checked the patient. He usually moans and he does not speak. I called his name. I saw he was bleeding from his head. I do not know how he fell . I immobilized him. I called a rapid response, and everyone rushed in. The ambulance came and he went to the hospital. Before he left, I gave him something for pain. R1 was laying on his side. He was on left side. I saw bleeding from his head and there was blood on his face. The aide was in there. Eventually, she said when she was trying to transfer the patient from the wheelchair to the bed; R1 had a jerky movement and he fell . The wheelchair was in the corner. To be honest, I did not go to check the wheelchair because my focus was on the patient. The aide had worked with him before and was pretty good. The wife was there before the event occurred. On 4/05/2025, at 1:33 PM, V6 (Fall Coordinator/LPN) stated, I coordinate with admissions for high fall risk patients. R1 was identified as a high fall risk before the incident occurred. Prior to admission he had already sustained a fracture. According to the aide, she was preparing R1 to be assisted to bed. I believe he requires the mechanical lift for transfers. That requires two aides. While waiting for another staff to assist her, R1 had an involuntary movement that caused the fall. There was a bed and chair alarm in place, I did not ask her the question if the wheelchair was locked. I am not aware if the wheelchair was locked but it should be to prevent it from rolling backwards, forwards, and the resident falling out. She (the aide) did not mention if the wheelchair was locked, she just stated that he had a jerky movement. According to the nurse, she was passing medication at the time. Her attention was called due to the fall. The aide was alone in the room with the resident. The root cause of the fall was tapering his medication for Parkinson's, and he had a tremor. He had sustained a fracture before and may have had poor trunk control. There should always be two aides even before preparing to transfer a resident. I would stay with the resident while waiting for assistance. I would have that patient visible and if anything happens. I would to try to prevent the fall. If there was a jerky movement, I would try to prevent the resident from hitting any hard surfaces by moving away or staying beside him or in front of him to prevent him from falling; that can cause skin breakdown and fracture. That is my opinion as a nurse. When I interviewed the aide, she was crying. This was her first time dealing with this fall. I would expect my staff to have two people when transferring. The nurse stated that she did not see anything. On 4/05/2025, at 2:01 PM, V7 (Certified Nursing Assistant) stated, I was in another room with another resident. V4 asked me if I could come help her. Usually, we transfer people with two people assisting. I told her as soon as I was done, I will join her. She went back to the room and the rapid response was called. I saw her in front of the resident. She was trying to explain to the nurse, while she was waiting, R1 had a jerky movement in the wheelchair. I heard her say that she was trying to hold him, and he had a jerky movement. He fell out of the wheelchair. He fell face down. I think I saw the wheelchair locked. The nurse called for rapid response and people rushed in. On 4/05/2025, at 2:24 PM, V9 (Nurse Practitioner) stated, the facility notified me and told me R1 had a fall. The aide was there. R1 fell forward I think; that is what they said. If there were enough people there, the injuries could have been preventable. On 4/05/2025, at 3:10 PM, V10 (R1's Wife) stated, I was not here when R1 had the fall. I usually leave here around 6:30 PM. The facility told me that he had fallen, had a bloody nose and was sent to the hospital. I went to the hospital, and I was shocked. He had the neck collar on, was bleeding from the head, but his nose was not bleeding. The hospital stated he has multiple fractures to the skull, orbital bones, C6/C7 fractures and his sinuses on the roof of his mouth. He had stitches on his head. V2 told me the following: she was so sorry this happened, it was totally our fault. V4 had R1 in the mechanical lift alone and R1 slipped out. That person no longer works for us, and we are sorry that happened. Their incident report notes that V4 was not properly trained. We have retrained and gone over proper procedures. V10 continued, V2 told the neurologist that R1 had a tremor and fell out of his wheelchair. I have gotten three different stories from V2. R2 told me that V4 was still working two weeks ago. R4, the resident council president, told me that the aide was wiping blood off the floor and was angry about it. R4 saw R1 lying on his side. On 04/05/2025, at 4:16 PM in an interview with R4 and R5, R4 stated, I am the resident council president. The facility did not notify me when R1 fell . They are supposed to. R6 told me she heard the fall. There is supposed to be two people that transfer the residents with the mechanical lift. There was only one person. No one will say if she messed up or if R1 was wiggling around and fell . R1 was on the floor and there was a lot of blood on the floor and on his head. He has several fractures: a broken neck, and stitches on his head. The aide wiped up blood off the floor. I saw her folding the mechanical lift pad. The wheelchair was away from his body, and he was laying on the floor sideways. R5 stated, I heard he was in a mechanical lift wiggling and bending and he fell out. That is what I heard. On 04/05/2025, at 4:55 PM, R6 stated, I was here in my room getting ready for bed. I went outside of my room and the door was closed. The aide opened the door and yelled for the nurse. There is no way R1 could make that loud of a thump from a wheelchair. He had to be up in the air; it was a loud crashing noise. Most of the time two people transfer residents with the mechanical lift. Agency staff try to do it on their own. If he would have fallen the distance from a wheelchair, he would not have hurt himself that bad. I saw the mechanical lift that night at the end of his bed. I'm going to tell the truth. The man was already in bad condition. I really feel bad for the man; I really do. Facility policy titled Mechanical Lift Transfers, dated 8/16/2024, notes there will always be two staff to assist the resident. One staff will control the lift as the other will guide resident and support back and neck to transfer surface.

Based on observations, interviews and record reviews, the facility failed to protect cognitively impaired residents from physical and verbal abuse; and failed to follow the facility abuse policy for two (R1 and R2) of three residents reviewed for abuse. These failures resulted in R1 and R2 being physically and verbally abused during provision of care. R1 and R2 were sent to the hospital for further evaluation and treatment and R2 sustained a right frontal hematoma and abrasion, left lateral periorbital ecchymosis and lower lip abrasion. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on [DATE] when R1 and R2 were physically and verbally abused by V5 (Certified Nurse Aide) during provision of care. V1 (Administrator), V2 (Executive Director) and V3 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 12:00 PM. The survey team confirmed by observation, interviews and record reviews that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1 is an [AGE] year old male, admitted in the facility on [DATE] with diagnoses of Delusional Disorders; Dementia In Other Diseases, Classified Elsewhere, Severe, with Psychotic Disturbance and Alzheimer's Disease, Unspecified. R1's MDS (Minimum Data Set) dated [DATE] recorded a BIMS (Brief Interview for Mental Status) score of 2 which means severe cognitive impairment. Social Services assessment dated [DATE] indicated R1 is at risk for abuse. R1's care plans documented in part but not limited to the following: Abuse (initiated [DATE]): Interventions - Provide reassurance to R1 remind him that he is safe and secure. Cognitive Loss (initiated [DATE]): Intervention - Cue, reorient and supervise him as needed. Behavior (initiated [DATE]): Interventions: Approach in a calm manner; Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. According to initial incident report dated [DATE], V16 (Family Member) notified V2 (Executive Director) that V5 (CNA Agency) assigned was verbally and physically aggressive towards R1 during care. On [DATE] at 12:25 PM, V16 was interviewed regarding R1's alleged abuse allegation. V16 stated, We installed a camera here in this room for him (R1). A camera was observed installed by the television facing R1's bed. V16 continued, I worked in healthcare management, and I know how it is if you live in a nursing home. V2 contacted me last Friday night ([DATE]) around 11:00 PM and asked if we could help her get video footage she needed. I emailed the footage at 12:14 AM, that was Saturday, and one minute later she responded that she received it. I called her back and informed her that there was an incident with R1 when a staff member brought him back to bed, that was around 9:31 PM. The staff was verbally abusive. It was caught on the video. She (V2) said she will do the investigation. During interview with V16, it was observed that a sign stated that there is an audio and video recording in R1's room posted at the door. Same sign was also posted at bedside visible to all staff and visitors. Electronic Monitoring Notification and Consent Form stipulated that V16 was permitted to conduct authorized electronic monitoring in R1's room through the use of an electronic monitoring device. It was signed and dated [DATE]. Video footage dated [DATE], time stamped 9:31 PM was seen, showing V5 was yelling, intimidating and aggressive with R1 while putting him back to bed. R1 was heard saying You stop, stop, I said I'm not stopping while V5 continued to yell telling him (R1) to lay down in bed. Video also showed R1 was pushed by V5 as she (V5) tried to make him (R1) lie down in bed. On [DATE] at 1:55 PM, V6 (Registered Nurse, RN Supervisor) was asked regarding R1. V6 stated, On [DATE] incident with V5, I was only told about the incident after V2 saw the video in the room. On [DATE] at 10:58 AM, V4 (RN) was interviewed regarding knowledge of R1's abuse allegation involving V5. V4 replied, Last [DATE], I was at the nurses' station and didn't hear V5 yelling or anything. I am not aware of any abuse incident on R1 with V5 who worked under me that night. That was my first time working with her (V5). On [DATE] at 10:17 AM, V2 was asked regarding R1's incident on [DATE]. V2 replied, When the police came in to investigate R2's abuse incident; and make a report after we called, they (police) attempted to interview R2. They noticed the sign that says video surveillance on R1. The police asked for us to contact the family of R1 to see if they are comfortable in providing them the clips related to care provided. I contacted V16 on [DATE] around 11:45 PM, to request video clips which she then provided at 12:15 AM on [DATE]. She sent the clips via email. She called me the same time regarding a concern related to care provided by a staff member to R1. The CNA in R1's video footage was identified as V5, per V2. V2 also verbalized, V16 stated, V5 appeared verbally and physically aggressive towards him (R1). At that point, I got off the phone, started the investigation. I immediately suspended her (V5). She is from staffing agency. That was the first time she (V5) picked up a shift for us. She (V5) was made aware that she is immediately suspended and will not be coming back to the facility. She (V5) was escorted out of the building and was deleted from the system. I also informed the agency to let them know that we had a serious abuse allegation on her (V5). I have had no contact with her (V5) afterwards. I attempted to interview him (R1), but he was confused and unable to provide details of what happened. He (R1) was sent to the hospital and came back with no injuries noted. Hospital records dated [DATE] recorded that R1 was brought to the emergency department for alleged physical assault. That a staff member at nursing facility was allegedly caught on camera assaulting R1. R1 stated, I hurt all over unable to point to exact location of pain. R1 was complaining of right-hand pain. There were no visible injuries noted including bruising, abrasion or lacerations; and no fractures or dislocation found. Progress notes dated [DATE] documented R1 came back to facility from the hospital. On [DATE] at 12:30 PM, R1 was observed in his room, in bed. He is alert and oriented to self, and verbal. R1 was asked regarding incident on [DATE] involving a staff member. R1 stated he does not remember any incident and has no issues with staff in the facility. On [DATE] at 2:32 PM, V19 (Unit Care Assistant) was asked regarding R1 and V5. V19 verbalized, On [DATE] around 9:32 PM, I saw V5 bringing R1 to room. I told her (V5) to handle R1 with care because there is a camera in his room. Since she (V5) does not know him, she walked him (R1) back to room, without letting him (R1) use the walker. She stood in front of him (R1), took both of his hands and guided him back to his room. She (V5) does not know R1, that he gets agitated easily, so she needs to be careful when she approached him. Police Report dated [DATE] recorded an offense Aggravated Battery on R1 by V5. The incident was dated [DATE]; and was reported to police [DATE]. In the said police report, it was documented that R1 in this case is an additional victim from the same room at the facility and two incidents took place about 15 minutes apart. V2, apparently after seeing the video provided by V16, advised police that V5 was seen pushing R1 in the chest three times while telling him to lay back in his bed; R1 was sitting up in bed when he was pushed. On [DATE] at 11:06 AM, V2 was asked regarding police report on R1. V2 replied, I called police the night of the incident, on [DATE]. They did not make the second trip because he (R1) was sent to the hospital. On [DATE] at 12:35 PM, surveyor called V22 (Local Law Enforcement Agency) to clarify R1's abuse report. V22 stated, the police report states it was reported on [DATE]. Surveyor informed V22 that facility staff stated it was reported on [DATE] with the other allegation. V22 checked records, and stated, the abuse for R1 was only reported on [DATE]. R2 is an [AGE] year old, male, admitted in the facility on [DATE] with diagnosis of Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, with other Behavioral Disturbance and Parkinson's Disease Without Dyskinesia, Without Mention of Fluctuations. MDS dated [DATE] recorded that R2 has BIMS score of 2 which means severe cognitive impairment. Social Services assessment dated [DATE] indicated R2 is at risk for abuse. R2's care plans documented in part but not limited to the following: Abuse (initiated [DATE]): Interventions - Recognize that the resident (R2) is an adult living with chronic, debilitating comorbidities in a skilled care setting and may experience feelings of lack of control and powerless; Work with the resident (R2) to overcome these feelings; advocate for expression of resident rights, autonomy and encourage independent decision making; Provide positive encouragement, support and kindness. Parkinson's Disease and is at risk for possible complications (initiated [DATE]): Intervention - Allow sufficient time for speech/communication. Cognitive loss (initiated [DATE]): Intervention - Offer cues, direction and redirection as needed. Behavior symptoms (initiated [DATE]): Interventions - Behavior-Communication. Try to ascertain what the behavior is communicating. Why is it being displayed here/now? Why in front of these people? What is the resident trying to tell us? What motivates the person to act this way? Is the behavior related to modesty/possible embarrassment? Is it related to a possible history of trauma? What message or secondary gain is the resident seeking? What message is the person sending by rejecting care? Assure the resident that safety, security and dignity are paramount. What does the resident mean by statements that blame staff for personal poor choices? Care rejection. Avoid Power Struggles. Build a relationship, rapport. Do not argue. If the present is not a good time for the resident, revisit the care situation later. It is ok to back off. Episode of increase restlessness, anxiety, impulsive, short attention (initiated [DATE]): Intervention - Monitor/record occurrence of behavior symptoms and document per facility protocol. Notify physician, family, nurse any changes. On antipsychotic medications (initiated [DATE]): Intervention - Care in pairs. Provide calm approach, explain in simple words task to be given. Allow time to understand. Initial incident report dated [DATE] documented V2 was notified that V5 reported R2 was aggressive and combative during care. R2 represented confused and unable to recall. Progress notes dated [DATE] time stamped 9:55 PM recorded that R2 was assessed, observed bleeding on the lips, bump, and scratches on forehead area. On [DATE] at 1:55 PM, V6 was interviewed regarding R2's incident on [DATE]. V6 stated, I was initially called at 9:55 PM by V4 regarding R2. V4 noted that there were scratches on his (R2) forehead, bumps on both sides of forehead and bleeding on the lips. V4 said, V5 asked for a band aid at 9:52 PM for her injured finger, like a scratch. She (V4) provided the band aid and checked on R2 and noticed the injuries. She (V4) did his (R2) initial assessment and called me right away. I went into his (R2) room, V4 and V5 were at the nurses' station. I went directly to assess R2. I also noted the injuries. I instructed V4 to supervise V5 while I do my investigation. With my investigation, there was a possible abuse on him (R2), so I called V2. I was told that she (V2) is going to come. I assigned a different CNA on R2, first aid provided, instructed V4 to inform Hospice. V2 came around 10:30 PM so she did her investigation as well. She (V2) also called local police. She (V5) was also interviewed by V2. She (V5) was supervised and took her off from the schedule. When the police arrived, they did their track on R2, interviewed me, and V4. After that, they noticed that there was a camera in R1's bed, they requested surveillance. Police interviewed V5; took pictures of R2, and injuries of V5's hand. Police cannot arrest her (V5) at the time because R2 was confused and unable to narrate the incident. He (R2) is alert and oriented to self; unable to verbalize needs and dependent on staff for all care. He (R2) is also a hospice resident. On [DATE] at 2:20pm V4 was asked regarding R2's incident on [DATE]. V4 replied, Around 9:30 PM, all residents were getting situated. CNAs are getting residents ready for bed. He (R2) was in his bed, in his room. I was at the nurses' station when V5 asked me for a band aid, said she had a scratch in her hand. I did not inspect her hand, but I gave her the band aid. I noticed that she was walking towards R2's room. I followed her and that was the time when I noticed that he (R2) had bleeding in his lips, saw bumps on his (R2) head and scratches that were starting to swell. I asked her (V5) on what happened, said he (R2) was resisting, and she (V5) was trying to get him dressed and ready when he started to kick and swung his arms and ended up hitting his head on the side rails. I told her (V5) to give me a second and will be back and that is when I contacted V6. In between that, I assessed him (R2), I cleaned his lips and forehead, assessed his range of motion and did neuro checks. V6 asked me to contact Hospice. Personally, when I worked with him (R2), he did not display any refusal to care or aggressive behavior. If a resident is refusing care at the moment, let them be, they have the right to refuse. Then come back at a later time, maybe after an hour and try to do the care. She (V5) did not tell me what happened. No, she didn't tell me about the behavior during care. She only told me when I went to the room and checked on him (R2). She (V5) should report the incident to me at the time, so I could assign another CNA to R2. Electronic Monitoring Notification and Consent Form stipulated that V20 (Family Member) signed a consent form for R2's video and audio surveillance in the room. The consent was signed on [DATE]. R2 shared the same room with R1. R1 and R2 are residents in the facility's Dementia Unit. V5 was the assigned CNA for R1 and R2 on [DATE], from 3:00 PM to 11:00 PM. In a video footage dated [DATE], time stamped 9:38 PM, it was seen in a partial angle view that R2 was sitting in the wheelchair. V5 was heard yelling, intimidating and verbally threatening R1, saying, Stop, you need to, I'll punch your face like that. Stop. In another video footage dated [DATE], time stamped 9:39 PM, V5 was seen as she aggressively pulled R2's clothing. V5 was then heard saying Stop. On [DATE] at 12:10 PM, R2 was observed in bed, alert, oriented to self, verbal. R2 was observed with multiple scratches on the forehead and a scratch on the left eye. A purplish discoloration was noted on the left eye and greenish to yellow discoloration above right eye. An abrasion was also noted to his lower lip. R2 was asked regarding injuries, stated, I don't remember what happened. R2 was also asked if he went to the hospital, stated he does not remember. On [DATE] at 10:17 AM, V2 was asked regarding R2. V2 stated, As soon as V6 notified me at 10:04 PM to report concern regarding R2's injuries, I came to facility within 20 minutes. I advised him (V6) to keep an eye on V5. She (V5) was immediately separated from the residents and another CNA was reassigned to R2. When I interviewed her (V5) that night, she received a scratch from her middle finger from R2 as he (R2) was combative and aggressive during care by kicking and scratching. I saw the scratch from her (V5) middle finger. She (V5) said she was trying to remove his (R2) shirt and he was scratching and kicking her. He was still combative when he was in bed and sustained the injuries from the side rails and headboard. I told her (V5) that if a resident says no, she is supposed to give them time and report to the nurse and that maybe a different staff or CNA should be assigned. She (V5) should have reported his (R2) behavior to the nurse. He (R2) was sent to the hospital for further evaluation and management. She (V5) was made aware that she is immediately suspended and will not be coming back to the facility. She (V5) was escorted out of the building and was deleted from the system. I contacted V15 (Staffing/Schedule Coordinator) not to schedule her (V5). I also informed the agency to let them know that we had a serious abuse allegation on her (V5). I have had no contact with her (V5) afterwards. She (V5) is from s******* agency. That was the first time she (V5) picked up a shift for us. V2 was also asked regarding police involvement during investigation. V2 continued, When the police came in to investigate and make a report after we called, they attempted to interview R2. They noticed the sign that says video surveillance on R1. The police asked for us to contact the family of R1 to see if they are comfortable in providing them the clips related to care provided. I contacted V16 last [DATE] around 11:45 PM, spoke and requested the video clips which she (V16) then provided at 12:15 AM. She sent the clips via email. R2's Hospital Records dated [DATE] recorded in part but not limited to the following: Chief complaint: Alleged Assault Visit Diagnosis: Traumatic injury of Head, Initial Encounter History of Present Illness: Presents to the emergency room brought in due to an assault. Patient (R2) was reportedly assaulted by a CNA at the nursing home prior to arrival. Patient (R2) suffered multiple head injuries after being hit in the head and face. On questioning the patient (R2), he does not recall what happened and is oriented to name only which is his baseline. Physical Exam: Head: Right frontal hematoma and abrasion, left lateral periorbital ecchymosis. ENT: lower lip outer abrasion. Emergency Department Diagnosis: Assault; Traumatic Injury of Head, Initial Encounter Police report dated [DATE] recorded an offense Battery Aggravated to Senior Citizen. Victim was R2 and V5 was the offender. Police report stated in part but not limited to the following: The incident occurred on [DATE] and was reported to police. Police responded, observed R2 with cuts on his head and lip. There was a blood stain on the wall above R2's bed and on his bed sheet. R2's hands were checked for blood or signs of injury. R2's right thumb nail appeared to have a crack in it with dried blood. Spoke with V5 who related she was preparing R2 for bed and transferring him out of his wheelchair and into bed. While doing so, V5 said R2 became agitated and flailed his arms and legs, causing a cut to her (V5) finger. V5 said she does not know how R2 got the cuts on his head and lip. V5 said he could have hit his head and lip on the bed board while he was refusing her care. The police report also documented that three video clips were uploaded from R1's camera, narrating, The first video shows V5 being aggressive with R2's roommate (R1). V5 tells him (R1) to lay his head down and she (V5) pushes him (R1) into the bed. The second video shows V5 partially out of frame and she says stop and appears to pull something out of R2's hands. The third video shows V5 partially out of frame and she says stop. On [DATE] at 1:00pm V2 was asked regarding screening and abuse orientation among agency staff working in the facility. V2 verbalized, Agency staffing is ongoing. We make sure that agency provided us background checks. Prescreening is done through agency. Agency staff picked up a shift and we do onboarding orientation with Scheduler and Nurse Manager. We also have the checklist that we go through during orientation. With agency staff - as soon as they physically come into the building, they are checked in at the front desk. The receptionist will check in with them to make sure they are on the schedule. They show photo identification. Receptionist will have them read and sign the form onboarding checklist. From there, the staff check in with Scheduler. If the Scheduler is not here, there is a designee or Nurse Manager to check where they are going. Nurse Supervisor will escort the agency staff to the assigned unit and introduced to the other staff. Regarding V5, she came in 3 PM to 11 PM shift. She should have been checked in with V6 (Nurse Supervisor). He (V6) was the one who signed her onboarding checklist. On [DATE] at 1:55pm V6, stated during interview, Usually, the agency CNA checks in at the front desk. Then they go to their assigned floor. That time, she (V5) did not look for me or Scheduler, but I saw her at 2 West. I asked her (V5) and told her that she is assigned to 3 East and should go there; and get directions from her nurse, V4. I did not do any orientation/checklist on V5 at the time. V4 was the one who gave the orientation. I only ask about password and if there are any issues to call me. On [DATE] at 2:20pm V4 was asked if she did an orientation on patients and policies with V5. V4 mentioned, V5, that was my first time working with her. When she came, I did not do any orientation regarding patient care or policies. Patient care is discussed among CNAs during shift change. On my end, I don't do any policies orientation. Management does that. Agency Nurse Onboarding Checklist showed V5 signed and dated the form [DATE]. The form was verified and signed by V6. V6 denied any knowledge on completing her (V5) onboard checklist. The date was marked wrong when it was signed. V5's Agency Orientation Checklist also showed V5 signed the form with a wrong date as [DATE]. The form was completed by V6, which he (V6) also denied that he provided the orientation to V5. In this orientation checklist, items that should be provided by agency such as dementia care training, references, background check (to name a few) were not initialed. Facility orientation items that facility should complete such as Dementia training; abuse policy (to name a few) were also not initialed. V2 stated in an interview that all items should be initialed by the one providing the orientation. On [DATE] at 12:48 PM, V10 (Special Care Unit Director) was interviewed regarding Dementia unit in the facility. V10 stated, This is the Dementia Unit, third floor. All staff assigned here are certified Dementia trained. Agency staff are not trained because they don't work full time here. When they come to the floor to work for the shift, they will be oriented to look at the Kardex, plan of care, behavior monitor and interventions. They will be able to see the plan of care for each resident they were assigned to. V10 also stated in a follow up interview, R1 is kind of stubborn and has his own way to do things. When we do care, we have to explain it to him more than five times. If not, he will not allow staff to touch him and he gets agitated. R2 does not have much behavior. During care, he becomes resistive, he will hold other staff hand. When he does that, we will give him sometimes, leave him alone for ,d+[DATE] minutes and come back. On [DATE] at 10:16 AM, V15 (Staffing/Schedule Co-Ordinator) was asked regarding background checks on agency staffing in the facility. V15 replied, We use agency staff for like 40% most of the time particularly evening and night shifts and on weekends. When they come to the facility, agency staff will check in at the front lobby and I will be directed to my Supervisor, V6, who will guide the assignment. For agency staff, I don't do the background check, it is the agency who does their own background checks. For new agency staff, I don't check the background or any paperwork because agency does that, and we trust the agency. I don't do any screening prior to agency staff working in the facility. We know for sure that the staff these agencies are giving are qualified to work. We trust the agency that their staff are screened prior to their shift. On [DATE] at 11:03 AM, V2 also mentioned during interview, For V5, I have to call agency Human Resource to verify background on or before shift starts. I have to receive those documentation. I received her (V5) papers last Friday [DATE] prior to start of shift. Facility presented V5's local state agency's health care worker registry paperwork. There were no other background or screening documentation on V5. V2 continued, They wouldn't be in the agency if they are not eligible or appropriately screened. We rely on the agencies for their staff that we use with the background check that they conduct. Everybody is screened and checked out. Agency staffing abuse knowledge and training is automatic, someone who had been working in the healthcare setting should receive training on elder abuse. For us, once they (agency staff) physically come into the facility, they are orientated verbally by Nurse Supervisor or designated Nurse. We also provide them (staff agency) with a badge with abuse emergency. On the badge, it indicates who the abuse coordinator is and the types of abuse. For our regular staff, we do abuse training upon hire, new hire orientation, quarterly and as needed, if abuse is triggered. We also have online training annually. Agency staff are included if they are in the building working, they are invited to attend. When we do abuse training, we do it per shift, normally through verbal and giving of handouts. We like to do demonstration by creating a scene and ask them to identify abuse. We reiterate that any suspicion of abuse should be reported. We have an open door policy making sure that staff continue to work comfortably with residents and other staff. V4 and V7 (RN) are agency staff and have been working with us for quite a while now. Human Resources should have their papers. V2 presented the following documents on V5 sent by agency electronically prior to start of her shift: Passport Local health agency healthcare worker registry Pre-employment physical form Tuberculosis skin test CPR (Cardiopulmonary Resuscitation) card certificate COVID (Coronavirus) vaccination card On [DATE] at 11:37 AM, V8 (Medical Director) was interviewed regarding prevention of abuse in the facility. V8 replied, Education and communication to make sure abuse would not happen again. I don't have any input on the hiring, I don't know how these staff are vetted. Nursing Supervisors need to be aware of what is going on. My role is dealing with medical issues. I can't speak to the requirements for this agency hiring. Nurses need to be educated, supervisors need to go over with nurses making sure they are comfortable in handling or dealing with this kind of population with Dementia. All patients should be protected. The fact that they have Dementia they need to be protected. On [DATE] at 12:20 PM, V17 (Human Resources Director) was asked regarding background checks and personnel files of agency staff. V17 verbalized, I don't keep the background checks and personnel files in a physical file. I saved it in the computer. For Agency staff, V15 takes care of the background checks, obtaining identification and COVID cards. She is the point person that gets the file, and she will just transfer it to me. Surveyor asked V17 to pull personnel files of V4 and V7. V4 and V7 are agency staff and are still working in the facility. During interviews, V4 stated she had been working in the facility for eight months now, while V7 is assigned to work in the facility multiple times. V17 stated, V4 and V7 are agency staff. I don't see their background checks. I believe V15 has a binder that she keeps for all background checks. V5 is new, I don't have her files. On [DATE] at 1:10 PM, after reviewing video footage provided by V2 from facility's camera, V5 arrived in the third floor Dementia Unit at 3:20 PM on [DATE]. V5 went directly to the nurses' station where V13 (Agency CNA) showed her the schedule, went over the orientation binder. V5 was just seen flipping the pages of the binder, signed a form, then went directly to get her cart in the hallway. Video time stamped 3:20 PM to 3:26 PM showed it took six minutes for V5 to do all the necessary orientation she was provided before the start of her shift. On [DATE] at 4:37 PM, surveyor was able to contact V5 after several attempts, however, V5 stated she already discussed everything related to the incident on [DATE] with the Supervisor and refused to talk further. She stated she is busy and at work. On [DATE] at 1:59 PM, V3 (Director of Nursing) was asked regarding abuse and care of residents with Dementia in the facility. V3 mentioned, We have guidelines, policies and procedures to follow regarding abuse. We do abuse in services on our staff upon hiring, orientation before they go to the unit. We do it annually, and as needed - when there is occurrence of abuse incident. For agency staff, expectation is they are being screened by the agency. When they come in here, we provide them with education about abuse, falls, like a general orientation. The orientation is given one on one with them by myself, Assistant Director of Nursing or Nurse Supervisors. The nurse on the floor provides education too. Our staff and the Supervisors are trained and aware of our guidelines when it comes to agency staff. And because the Supervisors would know the agency staff assignments, training in the care of demented residents would be included in their orientation. And floor nurses should also be educating the agency staff in the Dementia related care. On [DATE] at 2:20 PM, V1 (Administrator) stated during interview, Facility should be free from abuse. Whenever there is suspicion of abuse, residents should be safe, needs to be separated from staff if it is a staff abuse on resident or from resident if it is a resident to resident abuse. Staff has to follow abuse protocol to do what they are supposed to do. All agency staff background checks are done before they start to work and other documents were provided to facility. We need to verify that their background checks are done and prior to working here in the facility and that facility is provided with copies. Agency staffing should have 4-hour Dementia behavior training prior to work and if they don't have, then they will not be assigned to the Dementia care unit. Third floor is Dementia certified unit and staff should be trained regarding dementia. Facility's policy: Abuse and Neglect, dated [DATE]. Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. Types of Abuse and Examples: 1. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling 2. Verbal: Verbal abuse includes but not limited to the use of oral, written or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. Examples: name calling, swearing, yelling, threatening harm, trying to frighten the resident, racial slurs, etc. 7 Steps in Abuse Prevention: This facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven federal components of prevention and investigation. The seven elements of prevention and investigation include: I. Screening: Have procedures to: Screen potential employees f[TRUNCATED]

Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards of quality by a) failing to protect residents to be free from physical and verbal abuse; and failing to follow abuse policies and procedures. These failures affected two (R1 and R2) of three residents reviewed for abuse and has the potential to affect all 234 residents currently residing in the facility. Findings include: Per facility census, there are 234 residents currently residing in the facility. R1 is an [AGE] year-old, male, admitted in the facility on 02/19/24 with diagnoses of Delusional Disorders; Dementia in other Diseases, Classified Elsewhere, Severe, with Psychotic Disturbance and Alzheimer's Disease, Unspecified. R1's MDS (Minimum Data Set) dated 02/22/24 recorded a BIMS (Brief Interview for Mental Status) score of 2 which means severe cognitive impairment. Social Services assessment dated [DATE] indicated R1 is at risk for abuse. On 04/30/24 at 10:58 AM, V4 (RN) was interviewed regarding knowledge of R1's abuse allegation involving V5. V4 replied, Last 04/26/24, I was at the nurses' station and didn't hear V5 yelling or anything. I am not aware of any abuse incident on R1 with V5 who worked under me that night. That was my first time working with her (V5 CNA Agency). Hospital records dated 04/27/24 recorded that R1 was brought to the emergency department for alleged physical assault. That a staff member at nursing facility was allegedly caught on camera assaulting R1. R1 stated, I hurt all over unable to point to exact location of pain. R1 was complaining of right-hand pain. There were no visible injuries noted including bruising, abrasion or lacerations; and no fractures or dislocation found. On 04/30/24 at 12:30 PM, R1 was observed in his room, in bed. He is alert and oriented to self, and verbal. R1 was asked regarding incident last 04/26/24 involving a staff member. R1 stated he does not remember any incident and has no issues with staff in the facility. R2 is an [AGE] year-old, male, admitted in the facility on 02/14/23 with diagnosis of Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, with other Behavioral Disturbance and Parkinson's Disease Without Dyskinesia, Without Mention of Fluctuations. MDS dated [DATE] recorded that R2 has BIMS score of 2 which means severe cognitive impairment. Social Services assessment dated [DATE] indicated R2 is at risk for abuse. Initial incident report dated 04/27/24 documented V2 was notified that V5 reported R2 was aggressive and combative during care. R2 represented confused and unable to recall. Progress notes dated 04/26/24 time stamped 9:55 PM recorded R2 was assessed, observed bleeding on the lips, bump, and scratches on forehead area. R2 shared the same room with R1. R1 and R2 are residents in the facility's Dementia Unit. V5 was the assigned CNA for R1 and R2 on 04/26/24, from 3:00 PM to 11:00 PM. On 04/29/24 at 12:10 PM, R2 was observed in bed, alert, oriented to self, verbal. R2 was observed with multiple scratches on the forehead and a scratch on the left eye. A purplish discoloration was noted on the left eye and greenish to yellow discoloration above right eye. An abrasion was also noted to his lower lip. R2 was asked regarding injuries and stated, I don't remember what happened. R2 was also asked if he went to the hospital, and stated, he don't remember. On 4/29/24 at 1:00pm V2 (Executive Director) was asked regarding screening and abuse orientation among agency staff working in the facility. V2 verbalized, Agency staffing is ongoing. We make sure that agency provided us background checks. Prescreening is done through agency. Agency staff picked up a shift and we do onboarding orientation with Scheduler and Nurse Manager. We also have the checklist that we go through during orientation. With agency staff - as soon as they physically come into the building, they check in at the front desk. The receptionist will check in with them to make sure they are on the schedule. They show photo identification. Receptionist will have them read and sign the form onboarding checklist. From there, the staff check in with Scheduler. If the Scheduler is not here, there is a designee or Nurse Manager to check where they are going. Nurse Supervisor will escort the agency staff to the assigned unit and introduced to the other staff. Regarding V5, she came in 3 PM to 11 PM shift. She should have been checked in with V6 (Nurse Supervisor). He (V6) was the one who signed her onboarding checklist. On 4/29/24 at 1:55pm V6, stated during interview, Usually, the agency CNA checked in at the front desk. Then they go to their assigned floor. That time, she (V5) did not look for me or Scheduler, but I saw her at 2 West. I asked her (V5) and told her that she is assigned to 3 East and should go there; and get directions from her nurse, V4. I did not do any orientation/checklist on V5 at the time. V4 was the one who gave the orientation. I only ask about password and if there are any issues to call me. On 4/29/24 at 2:20pm V4 was asked if she did an orientation on patients and policies with V5. V4 mentioned, V5, that was my first time working with her. When she came, I did not do any orientation regarding patient care or policies. Patient care is discussed among CNAs during shift change. On my end, I don't do any policies orientation. Management does that. Agency Nurse Onboarding Checklist showed V5 signed and dated the form 4/26/2026. The form was verified and signed by V6. V6 denied any knowledge on completing her (V5) onboard checklist. The date was marked wrong when it was signed. Review of V5's Agency Orientation Checklist showed V5 signed the form with an incorrect date of 4/26/2026. The form was completed by V6, which he (V6) denied providing the orientation to V5. Orientation checklist, items provided by agency such as dementia care training, references, background check (to name a few) were not initialed. Facility orientation items that facility should complete such as Dementia training; abuse policy (to name a few) were not initialed. V2 stated in an interview that all items should be initialed by the one providing the orientation. On 05/01/24 at 11:03 AM, V2 stated (in part), For us, once they (agency staff) physically come into the facility, they are orientated verbally by Nurse Supervisor or designated Nurse. On 05/01/24 at 1:10 PM, after reviewing video footage provided by V2 from facility's camera, V5 arrived to the third floor Dementia Unit at 3:20 PM on 04/26/24. V5 went directly to the nurses' station where V13 (Agency CNA) showed her the schedule, went over the orientation binder. V5 was just seen flipping the pages of the binder, signed a form, then went directly to get her cart in the hallway. Video time stamped 3:20 PM to 3:26 PM showed it took six minutes for V5 to do all the necessary orientation she was provided before the start of her shift. On 05/06/24 at 1:59 PM, V3 (Director of Nursing) was asked regarding abuse and care of residents with Dementia in the facility. V3 mentioned, We have guidelines, policies and procedures to follow regarding abuse. We do abuse in-services on our staff upon hiring, orientation before they go to the unit. We do it annually, and as needed - when there is occurrence of abuse incident. For agency staff, expectation is they are being screened by the agency. When they come in here, we provide them with education about abuse, falls, like a general orientation. The orientation is given one on one with them by myself, Assistant Director of Nursing or Nurse Supervisors. The nurses on the floor provide education too. Our staff and the Supervisors are trained and aware of our guidelines when it comes to agency staff. And because the Supervisors would know the agency staff assignments, training in the care of demented residents would be included in their orientation. And floor nurses should also be educating the agency staff in the Dementia related care. Facility's policy: Abuse and Neglect, dated 07/14/23 (in part) Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. Types of Abuse and Examples: 1. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling 2. Verbal: Verbal abuse includes but not limited to the use of oral, written or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. Examples: name calling, swearing, yelling, threatening harm, trying to frighten the resident, racial slurs, etc. 7 Steps in Abuse Prevention: This facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven federal components of prevention and investigation. The seven elements of prevention and investigation include: How to recognize signs of burnout, frustration and stress that may lead to abuse; and to what constitutes abuse, neglect, exploitation, and misappropriation of resident property. Understanding of behavior that has an increase risk of abuse. III. Prevention: have procedures to: Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property. Deployment of sufficient and trained staff to deal with behaviors in the units. The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their bed.

Based on observations, interviews and record reviews, the facility failed to follow its abuse policy related to prevention, protection, screening, training and reporting for two (R1 and R2) of three residents reviewed for abuse. This deficiency also has the potential to affect the 234 residents currently residing in the facility. Findings include: Per census report, there are 234 residents currently residing in the facility. According to initial incident report dated [DATE], V16 (Family Member) notified V2 (Executive Director) that V5 (Agency Certified Nursing Aide, CNA) was verbally and physically aggressive towards R1 during care. R1 is an [AGE] year-old, male, admitted in the facility on [DATE] with diagnoses of Delusional Disorders; Dementia in other Diseases, Classified Elsewhere, Severe, with Psychotic Disturbance and Alzheimer's Disease, Unspecified. R1's MDS (Minimum Data Set) dated [DATE] recorded a BIMS (Brief Interview for Mental Status) score of 2 which means severe cognitive impairment. Social Services assessment dated [DATE] indicated R1 is at risk for abuse. On [DATE] at 12:25 PM, V16 was interviewed regarding R1's alleged abuse allegation. V16 stated, We installed a camera here in this room for him (R1). A camera was observed installed by the television facing R1's bed. V16 continued, I worked in healthcare management, and I know how it is if you live in a nursing home. V2 contacted me last Friday night ([DATE]) around 11:00 PM to see if we could help her get a video footage she needed. I emailed the footage at 12:14 AM, that was Saturday, and one minute later she responded that she received it. I called her back and informed her that there was an incident with R1 when a staff member brought him back to bed, that was around 9:31 PM. The staff was verbally abusive. It was caught on the video. She (V2) said she will do the investigation. During interview with V16, it was observed that a sign stated that there is an audio and video recording in R1's room that was posted at the door. Same sign was also posted at bedside visible to all staff and visitors. Electronic Monitoring Notification and Consent Form stipulated that V16 was permitted to conduct authorized electronic monitoring in R1's room through the use of an electronic monitoring device. It was signed and dated [DATE]. Video footage dated [DATE], time stamped 9:31 PM was seen, showing that V5 was yelling and intimidating and aggressive on R1 while putting him back to bed. R1 was heard saying You stop, stop, I said I'm not stopping while V5 continued to yell telling him (R1) to lay down in bed. V5 was also observed pushing R1 as she (V5) tried to make him (R1) lie down in bed. On [DATE] at 10:17 AM, V2 was asked regarding R1's incident on [DATE]. V2 replied, When the police came in to investigate R2's abuse incident; and make a report after we called, they (police) attempted to interview R2. They noticed the sign that says video surveillance on R1. The police asked for us to contact the family of R1 to see if they are comfortable in providing them the clips related to care provided. I contacted V16 on [DATE] around 11:45 PM, to request video clips which she then provided at 12:15 AM. She sent the clips via email. She called me the same time regarding a concern related to care provided by a staff member to R1. The CNA in the video footage was identified as V5, per V2. V2 also verbalized, V16 stated that V5 appeared verbally and physically aggressive towards him (R1). At that point, I got off the phone, started the investigation. I immediately suspend her (V5). She is from staffing agency. That was the first time she (V5) picked up a shift for us. She (V5) was made aware that she is immediately suspended and will not be coming back to the facility. She (V5) was escorted out of the building and was deleted from the system. I also informed the agency to let them know that we had a serious abuse allegation on her (V5). I have had no contact with her (V5) afterwards. I attempted to interview him (R1), but he was confused and unable to provide details of what happened. He (R1) was sent to the hospital and came back with no injuries noted. Hospital records dated [DATE] recorded that R1 was brought to the emergency department for alleged physical assault. Per emergency medical services, staff member at nursing facility was allegedly caught on camera assaulting R1. R1 stated, I hurt all over unable to point to exact location of pain. R1 was complaining of right-hand pain. There were no visible injuries noted including bruising, abrasion or lacerations; and no fractures or dislocation found. Progress notes dated [DATE] documented R1 came back to facility from the hospital. On [DATE] at 12:30 PM, R1 was observed in his room, in bed. He is alert and oriented to self, and verbal. R1 was asked regarding incident on [DATE] involving a staff member. R1 stated he does not remember any incident. He further stated that he has no issues with staff in the facility. On [DATE] at 2:32 PM V19 (Unit Care Assistant) was asked regarding R1 and V5. V19 verbalized, On [DATE] around 9:32 PM, I saw V5 bringing R1 to room. I told her (V5) to handle R1 with care because there is a camera in his room. Since she (V5) does not know him, she walked him (R1) back to room, without letting him (R1) use the walker. She stood in front of him (R1), took both of his hands and guided him back to his room. She (V5) does not know R1, that he gets agitated easily, so she needs to be careful when she approached him. R1's care plans documented in part but not limited to the following: Abuse (initiated [DATE]): Interventions - Provide reassurance to R1 reminded him that he is safe and secure. Police Report dated [DATE] recorded an offense Aggravated Battery on R1 by V5. The incident was dated [DATE]; and was reported to police on [DATE]. In the police report, it was documented that R1 in this case is an additional victim from the same room at the facility and two incidents took place about 15 minutes apart. V2, apparently after seeing the video provided by V16, advised police that V5 was seen pushing R1 in the chest three times while telling him to lay back in his bed; R1 was sitting up in bed when he was pushed. On [DATE] at 11:06 AM, V2 was asked regarding police report on R1. V2 replied, I called police the night of the incident, on [DATE]. They did not make the second trip because he (R1) was sent to the hospital. On [DATE] at 12:35 PM, V22 (Local Law Enforcement Agency) was called to clarify R1's abuse report. V22 stated, the police report states it was reported on [DATE]. Surveyor informed V22 that facility staff stated it was reported on [DATE] with the other allegation. V22 checked records then stated, the abuse for R1 was only reported on [DATE]. Progress notes dated [DATE] time stamped 9:55 PM documented that R2 was assessed, observed bleeding on the lips, bump, and scratches on forehead area. According to initial incident report dated [DATE], V2 was notified that V5 reported R2 was aggressive and combative during care. R2 represented confused and unable to recall. R2 is an [AGE] year-old, male, admitted in the facility on [DATE] with diagnosis of Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, with other Behavioral Disturbance and Parkinson's Disease Without Dyskinesia, Without Mention of Fluctuations. MDS dated [DATE] recorded that R2 has BIMS score of 2 which means severe cognitive impairment. Social Services assessment dated [DATE] indicated R2 is at risk for abuse. R2's care plans documented in part but not limited to the following: Abuse (initiated [DATE]): Interventions - Recognize that the resident (R2) is an adult living with chronic, debilitating comorbidities in a skilled care setting and may experience feelings of lack of control and powerless. Work with the resident (R2) to overcome these feelings; advocate for expression of resident rights, autonomy and encourage independent decision making; Provide positive encouragement, support and kindness. On [DATE] at 1:55 PM, V6 was interviewed regarding R2's incident on [DATE]. V6 stated, I was initially called at 9:55 PM by V4 regarding R2. V4 noted that there were scratches on his (R2) forehead, bumps on both sides of forehead and bleeding on the lips. V4 said that V5 asked for a band aid at 9:52 PM for her injured finger, like a scratch. She (V4) provided the band aid and checked on R2 and noticed the injuries. She (V4) did his (R2) initial assessment and called me right away. I went into his (R2) room, V4 and V5 were at the nurses' station. I went directly to assess R2. I also noted the injuries. I instructed V4 to supervise V5 while I do my investigation. With my investigation, there was a possible abuse on him (R2), so I called V2. I was told that she (V2) is going to come. I assigned a different CNA on R2, first aid provided, instructed V4 to inform Hospice. V2 came around 10:30 PM so she did her investigation as well. She (V2) also called local police. She (V5) was also interviewed by V2. She (V5) was supervised and took her off from the schedule. When the police arrived, they did their track on R2, interviewed me, and V4. After that, they noticed that there was a camera in R1's bed, they requested surveillance. Police interviewed V5; took pictures of R2 and injuries in V5's hand. Police cannot arrest her (V5) at the time because R2 was confused and unable to narrate the incident. He (R2) is alert and oriented to self; unable to verbalize needs and dependent on staff for all care. He (R2) is also a hospice resident. On [DATE] at 2:20 PM, V4 was also asked regarding R2's incident on [DATE]. V4 replied, Around 9:30 PM, all residents were getting situated. CNAs are getting residents ready for bed. He (R2) was in his bed, in his room. I was at the nurses' station when V5 asked me for a band aid, said she had a scratch in her hand. I did not inspect her hand, but I gave her the band aid. I noticed that she was walking towards R2's room. I followed her and that was the time when I noticed that he (R2) had bleeding in his lips, saw bumps on his (R2) head and scratches that were starting to swell. I asked her (V5) on what happened, V5 said he (R2) was resisting, and she (V5) was trying to get him dressed and ready when he started to kick and swung his arms and ended up hitting his head on the side rails. I told her (V5) to give me a second and I will be back and that is when I contacted V6. In between that, I assessed him (R2), I cleaned his lips and forehead, assessed his range of motion and did neuro checks. V6 asked me to contact Hospice. Personally, when I worked with him (R2), he did not display any refusal to care or aggressive behavior. If a resident is refusing care at the moment, let them be, they have the right to refuse. Then come back at a later time, maybe after an hour and try to do the care. She (V5) did not tell me what happened. No, she didn't tell me about the behavior during care. She only told me when I went to the room and checked on him (R2). She (V5) should report the incident to me at the time, so I could assign another CNA to R2. R2 shared the same room with R1. R1 and R2 are residents in the facility's Dementia Unit. V5 was the assigned CNA for R1 and R2 on [DATE], from 3:00 PM to 11:00 PM. On [DATE] at 12:10 PM, R2 was observed in bed, alert, oriented to self, verbal. R2 was observed with multiple scratches on the forehead and a scratch on the left eye. A purplish discoloration was noted on the left eye and greenish to yellow discoloration above right eye. An abrasion was also noted to his lower lip. R2 was asked regarding injuries, stated, I don't remember what happened. R2 was also asked if he went to the hospital, stated he don't remember. Police report dated [DATE] recorded an offense Battery Aggravated to Senior Citizen. Victim was R2 and V5 was the offender. There was no Police report for R1 provided for [DATE]. On [DATE] at 1:00 PM, V2 was asked regarding screening and abuse orientation among agency staff working in the facility. V2 verbalized, Agency staffing is ongoing. We make sure that agency provided us background checks. Prescreening is done through agency. Agency staff picked up a shift and we do onboarding orientation with Scheduler and Nurse Manager. We also have the checklist that we go through during orientation. With agency staff - as soon as they physically come into the building, they check in at the front desk. The receptionist will check in with them to make sure they are on the schedule. They show photo identification. Receptionist will have them read and sign the form onboarding checklist. From there, the staff check in with Scheduler. If the Scheduler is not here, there is a designee or Nurse Manager to check where they are going. Nurse Supervisor will escort the agency staff to the assigned unit and introduce to the other staff. Regarding V5, she came in 3 PM to 11 PM shift. She should have been checked in with V6 (Nurse Supervisor). He (V6) was the one who signed her onboarding checklist. On [DATE] at 1:55 PM, V6, stated during interview, Usually, the agency CNA check in at the front desk. Then they go to their assigned floor. That time, she (V5) did not look for me or Scheduler, but I saw her at 2 West. I asked her (V5) and told her that she is assigned to 3 East and should go there; and get directions from her nurse, V4. I did not do any orientation/checklist on V5 at the time. V4 was the one who gave the orientation. I only ask about password and if there are any issues to call me. On [DATE] at 2:20 PM, V4 was asked if she did an orientation on patients and policies on V5. V4 mentioned, V5, that was my first time working with her. When she came, I did not do any orientation regarding patient care or policies. Patient care is discussed among CNAs during shift change. On my end, I don't do any policies orientation. Management does that. Agency Nurse Onboarding Checklist showed V5 signed and dated the form [DATE]. The form was verified and signed by V6. V6 denied any knowledge on completing her (V5) onboard checklist. The date was marked wrong when it was signed. Review of V5's Agency Orientation Checklist showed V5 signed the form with an incorrect date of [DATE]. The form was completed by V6, which he (V6) denied providing the orientation to V5. Orientation checklist, items provided by agency such as dementia care training, references, background check (to name a few) were not initialed. Facility orientation items that facility should complete such as Dementia training; abuse policy (to name a few) were not initialed. V2 stated in an interview that all items should be initialed by the one providing the orientation. On [DATE] at 12:48 PM, V10 (Special Care Unit Director) was interviewed regarding Dementia unit in the facility. V10 stated, This is the Dementia Unit, third floor. All staff assigned here are certified Dementia trained. Agency staff are not trained because they don't work full time here. When they come to the floor to work for the shift, they will be oriented to look at the [NAME], plan of care, behavior monitor and interventions. They will be able to see the plan of care for each resident they were assigned to. V10 also stated in a follow up interview, R1 is kind of stubborn and has his own way to do things. When we do care, we have to explain it to him more than five times. If not, he will not allow staff to touch him and he gets agitated. R2 does not have much behavior. During care, he becomes resistive, he will hold other staff hand. When he does that, we will give him some time, leave him alone for 5-10 minutes and come back. On [DATE] at 10:16 AM, V15 (Staffing/Scheduling Co-Ordinator) was asked regarding background checks on agency staffing in the facility. V15 replied, We use agency staff for like 40% most of the time particularly evening and night shifts and on weekends. When they come to the facility, agency staff will be checked in at the front lobby and I will direct them to my Supervisor, V6, who will guide the assignment. For agency staff, I don't do the background check, it is the agency who does their own background checks. For new agency staff, I don't check the background or any paperwork because agency does that, and we trust the agency. I don't do any screening prior to agency staff working in the facility. We know for sure that the staff these agencies are giving are qualified to work. We trust the agency that their staff are screened prior to their shift. On [DATE] at 11:03 AM V2 stated during interview, For V5, I have to call agency Human Resource to verify background on or before shift starts. I have to receive those documentation. I received her (V5) papers last Friday [DATE] prior to start of shift. Facility presented V5's local state agency's health care worker registry paperwork. There were no other background or screening documentation on V5. V2 continued, They wouldn't be in the agency if they are not eligible or appropriately screened. We rely on the agencies for their staff that we use with the background check that they conducted. Everybody is screened and checked out. Agency staffing abuse knowledge and training is automatic, someone who had been working in the healthcare setting should receive training on elder abuse. For us, once they (agency staff) physically come into the facility, they are orientated verbally by Nurse Supervisor or designated Nurse. We also provide them (staff agency) with a badge with abuse emergency. On the badge, it indicates who the abuse coordinator is and the types of abuse. For our regular staff, we do abuse training upon hire, new hire orientation, quarterly and as needed, if abuse is triggered. We also have online training annually. Agency staff are included if they are in the building working, they are invited to attend. When we do abuse training, we do it per shift, normally through verbal and giving of handouts. We like to do demonstration by creating a scene and asked them to identify abuse. We reiterate that any suspicion of abuse should be reported. We have an open door policy making sure that staff continue to work comfortably with residents and other staff. V4 and V7 (RN) are agency staff and have been working with us for quite a while now. Human Resources should have their papers. V2 presented the following documents on V5 sent by agency electronically prior to start of her shift: Passport Local health agency healthcare worker registry Pre-employment physical form Tuberculosis skin test CPR (Cardiopulmonary Resuscitation) card certificate COVID (Coronavirus) vaccination card On [DATE] at 12:20 PM, V17 (Human Resources Director) was also asked regarding background checks and personnel files of agency staff. V17 verbalized, I don't keep the background checks and personnel files in a physical file. I save it in the computer. For Agency staff, V15 takes care of the background checks, obtaining identification and COVID cards. She is the point person that gets the file, and she will just transfer it to me. Surveyor asked V17 to pull personnel files of V4 and V7 (RN). V4 and V7 are agency staff and are still working in the facility. During interviews, V4 stated she had been working in the facility for eight months now, while V7 is assigned to work in the facility multiple times. V17 stated, V4 and V7 are agency staff. I don't see their background checks. I believe V15 has a binder that she keeps for all background checks. V5 is new, I don't have her files. On [DATE] at 1:10 PM, after reviewing video footage provided by V2 from facility's camera, V5 arrived in the third floor Dementia Unit at 3:20 PM on [DATE]. V5 went directly to the nurses' station where V13 (Agency CNA) showed her the schedule, went over the orientation binder. V5 was seen flipping the pages of the binder, signed a form, then went directly to get her cart in the hallway. Video time stamped 3:20 PM to 3:26 PM showed it took six minutes for V5 to do all the necessary orientation she was provided before the start of her shift. On [DATE] at 11:37 AM, V8 (Medical Director) was interviewed regarding prevention of abuse in the facility. V8 replied, My role is dealing with medical issues. I can't speak with the requirements for this agency hiring. Nurses need to be educated, supervisors need to go over with nurses making sure they are comfortable in handling or dealing with this kind of population with Dementia. All patients should be protected. The fact that they have Dementia they need to be protected. On [DATE] at 4:37 PM after several attempts, surveyor made contact via telephone with V5. V5 stated, she already discussed everything related to the incident on [DATE] with the Supervisor and refused to talk further. She stated she is busy and at work. On [DATE] at 1:59 PM, V3 (Director of Nursing) was asked regarding abuse and care of residents with Dementia in the facility. V3 mentioned, We have guidelines, policies and procedures to follow regarding abuse. We do abuse in-services on our staff upon hiring, orientation before they go to the unit. We do it annually, and as needed - when there is occurrence of abuse incident. For agency staff, expectation is they are being screened by the agency. When they come in here, we provide them with education about abuse, falls, like a general orientation. The orientation is given one on one with them by myself, Assistant Director of Nursing or Nurse Supervisors. The nurse on the floor provides education too. Our staff and the Supervisors are trained and aware of our guidelines when it comes to agency staff. And because the Supervisors would know the agency staff assignments, training in the care of demented residents would be included in their orientation. And floor nurses should also be educating the agency staff in the Dementia related care. On [DATE] at 2:20 PM, V1 (Administrator) stated during interview, Facility should be free from abuse. Whenever there is suspicion of abuse, residents should be safe, needs to be separated from staff if it is a staff abuse on resident or from resident if it is a resident-to-resident abuse. Staff has to follow abuse protocol to what they are supposed to do. All agency staff background checks are done before they start to work and other documents were provided to facility. We need to verify that their background checks are done and prior to working here in the facility and that facility is provided with copies. Agency staffing should have 4-hour Dementia behavior training prior to work and if they don't have, then they will not be assigned to the Dementia care unit. Third floor is Dementia certified unit and staff should be trained regarding dementia. Facility's policy: Abuse and Neglect, dated [DATE]. Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. Types of Abuse and Examples: 1. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling 2. Verbal: Verbal abuse includes but not limited to the use of oral, written or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. Examples: name calling, swearing, yelling, threatening harm, trying to frighten the resident, racial slurs, etc. 7 Steps in Abuse Prevention: This facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven federal components of prevention and investigation. The seven elements of prevention and investigation include: I. Screening: Have procedures to: Screen potential employees for a history of abuse, neglect, exploitation, misappropriation of property, or mistreating residents. This includes attempting to obtain information from previous employers and/or current employers and checking with the appropriate licensing boards and registries. The facility will also not allow contracted or temporary staff from working in the facility if the contracted or temporary staff was found by the contracting agency to be with disqualifying findings from the registry if registry check is required for the contracted staff. Similarly, prior to placement in the facility, the facility will require background check of prospective consultants, contractors, volunteers, caregivers working on behalf of the facility, and students in its nurse aide training program and students from affiliated academic institutions including therapy, social, and activity programs to care for residents to be done either the facility itself, the third-party agency or academic institution. 1. Initiate a reference from the applicant's previous employer. 2. Obtain a copy of professional licenses. The facility will check annually to ensure professional licenses are current and not expired. 3. Check with the Illinois Nurse Aide Registry now known as Healthcare Worker Registry upon hire, to determine reports of abuse, neglect and theft if staff is not a licensed staff. 4. Initiate Illinois State Police fingerprint check for non-licensed applicants or new hires within 10 days of hiring, unless the applicant had been previously finger-printed in accordance to the Illinois Background Check Act. The Illinois State Police Web Portal will automatically update convictions of those previously fingerprinted. II. Training: Have procedures to: Train employees, through orientation and on-going sessions on issues related to abuse prohibition, neglect, exploitation, misappropriation of property such as: Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. Abuse identification and recognizing signs of abuse. How staff should report their knowledge related to allegation without fear of reprisal. How to recognize signs of burnout, frustration and stress that may lead to abuse; and to what constitutes abuse, neglect, exploitation, and misappropriation of resident property. Understanding of behavior that has an increased risk of abuse. III. Prevention: have procedures to: Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property. Deployment of sufficient and trained staff to deal with behaviors in the units. The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their bed. VII. Reporting/Response: Have procedures to: If the event that results in allegation of abuse also causes the individual to suspect a crime, the facility will also report to the local law enforcement agency.

Based on observations, interviews and record reviews, the facility failed to follow its abuse policy related to prevention, protection, screening, training and reporting for two (R1 and R2) of three residents reviewed for abuse. This deficiency also has the potential to affect the 234 residents currently residing in the facility. Findings include: Per census report, there are 234 residents currently residing in the facility. According to initial incident report dated [DATE], V16 (Family Member) notified V2 (Executive Director) that V5 (Agency Certified Nursing Aide, CNA) was verbally and physically aggressive towards R1 during care. R1 is an [AGE] year-old, male, admitted in the facility on [DATE] with diagnoses of Delusional Disorders; Dementia in other Diseases, Classified Elsewhere, Severe, with Psychotic Disturbance and Alzheimer's Disease, Unspecified. R1's MDS (Minimum Data Set) dated [DATE] recorded a BIMS (Brief Interview for Mental Status) score of 2 which means severe cognitive impairment. Social Services assessment dated [DATE] indicated R1 is at risk for abuse. On [DATE] at 12:25 PM, V16 was interviewed regarding R1's alleged abuse allegation. V16 stated, We installed a camera here in this room for him (R1). A camera was observed installed by the television facing R1's bed. V16 continued, I worked in healthcare management, and I know how it is if you live in a nursing home. V2 contacted me last Friday night ([DATE]) around 11:00 PM to see if we could help her get a video footage she needed. I emailed the footage at 12:14 AM, that was Saturday, and one minute later she responded that she received it. I called her back and informed her that there was an incident with R1 when a staff member brought him back to bed, that was around 9:31 PM. The staff was verbally abusive. It was caught on the video. She (V2) said she will do the investigation. During interview with V16, it was observed that a sign stated that there is an audio and video recording in R1's room that was posted at the door. Same sign was also posted at bedside visible to all staff and visitors. Electronic Monitoring Notification and Consent Form stipulated that V16 was permitted to conduct authorized electronic monitoring in R1's room through the use of an electronic monitoring device. It was signed and dated [DATE]. Video footage dated [DATE], time stamped 9:31 PM was seen, showing that V5 was yelling and intimidating and aggressive on R1 while putting him back to bed. R1 was heard saying You stop, stop, I said I'm not stopping while V5 continued to yell telling him (R1) to lay down in bed. V5 was also observed pushing R1 as she (V5) tried to make him (R1) lie down in bed. On [DATE] at 10:17 AM, V2 was asked regarding R1's incident on [DATE]. V2 replied, When the police came in to investigate R2's abuse incident; and make a report after we called, they (police) attempted to interview R2. They noticed the sign that says video surveillance on R1. The police asked for us to contact the family of R1 to see if they are comfortable in providing them the clips related to care provided. I contacted V16 on [DATE] around 11:45 PM, to request video clips which she then provided at 12:15 AM. She sent the clips via email. She called me the same time regarding a concern related to care provided by a staff member to R1. The CNA in the video footage was identified as V5, per V2. V2 also verbalized, V16 stated that V5 appeared verbally and physically aggressive towards him (R1). At that point, I got off the phone, started the investigation. I immediately suspend her (V5). She is from staffing agency. That was the first time she (V5) picked up a shift for us. She (V5) was made aware that she is immediately suspended and will not be coming back to the facility. She (V5) was escorted out of the building and was deleted from the system. I also informed the agency to let them know that we had a serious abuse allegation on her (V5). I have had no contact with her (V5) afterwards. I attempted to interview him (R1), but he was confused and unable to provide details of what happened. He (R1) was sent to the hospital and came back with no injuries noted. Hospital records dated [DATE] recorded that R1 was brought to the emergency department for alleged physical assault. Per emergency medical services, staff member at nursing facility was allegedly caught on camera assaulting R1. R1 stated, I hurt all over unable to point to exact location of pain. R1 was complaining of right-hand pain. There were no visible injuries noted including bruising, abrasion or lacerations; and no fractures or dislocation found. Progress notes dated [DATE] documented R1 came back to facility from the hospital. On [DATE] at 12:30 PM, R1 was observed in his room, in bed. He is alert and oriented to self, and verbal. R1 was asked regarding incident on [DATE] involving a staff member. R1 stated he does not remember any incident. He further stated that he has no issues with staff in the facility. On [DATE] at 2:32 PM V19 (Unit Care Assistant) was asked regarding R1 and V5. V19 verbalized, On [DATE] around 9:32 PM, I saw V5 bringing R1 to room. I told her (V5) to handle R1 with care because there is a camera in his room. Since she (V5) does not know him, she walked him (R1) back to room, without letting him (R1) use the walker. She stood in front of him (R1), took both of his hands and guided him back to his room. She (V5) does not know R1, that he gets agitated easily, so she needs to be careful when she approached him. R1's care plans documented in part but not limited to the following: Abuse (initiated [DATE]): Interventions - Provide reassurance to R1 reminded him that he is safe and secure. Police Report dated [DATE] recorded an offense Aggravated Battery on R1 by V5. The incident was dated [DATE]; and was reported to police on [DATE]. In the police report, it was documented that R1 in this case is an additional victim from the same room at the facility and two incidents took place about 15 minutes apart. V2, apparently after seeing the video provided by V16, advised police that V5 was seen pushing R1 in the chest three times while telling him to lay back in his bed; R1 was sitting up in bed when he was pushed. On [DATE] at 11:06 AM, V2 was asked regarding police report on R1. V2 replied, I called police the night of the incident, on [DATE]. They did not make the second trip because he (R1) was sent to the hospital. On [DATE] at 12:35 PM, V22 (Local Law Enforcement Agency) was called to clarify R1's abuse report. V22 stated, the police report states it was reported on [DATE]. Surveyor informed V22 that facility staff stated it was reported on [DATE] with the other allegation. V22 checked records then stated, the abuse for R1 was only reported on [DATE]. Progress notes dated [DATE] time stamped 9:55 PM documented that R2 was assessed, observed bleeding on the lips, bump, and scratches on forehead area. According to initial incident report dated [DATE], V2 was notified that V5 reported R2 was aggressive and combative during care. R2 represented confused and unable to recall. R2 is an [AGE] year-old, male, admitted in the facility on [DATE] with diagnosis of Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, with other Behavioral Disturbance and Parkinson's Disease Without Dyskinesia, Without Mention of Fluctuations. MDS dated [DATE] recorded that R2 has BIMS score of 2 which means severe cognitive impairment. Social Services assessment dated [DATE] indicated R2 is at risk for abuse. R2's care plans documented in part but not limited to the following: Abuse (initiated [DATE]): Interventions - Recognize that the resident (R2) is an adult living with chronic, debilitating comorbidities in a skilled care setting and may experience feelings of lack of control and powerless. Work with the resident (R2) to overcome these feelings; advocate for expression of resident rights, autonomy and encourage independent decision making; Provide positive encouragement, support and kindness. On [DATE] at 1:55 PM, V6 was interviewed regarding R2's incident on [DATE]. V6 stated, I was initially called at 9:55 PM by V4 regarding R2. V4 noted that there were scratches on his (R2) forehead, bumps on both sides of forehead and bleeding on the lips. V4 said that V5 asked for a band aid at 9:52 PM for her injured finger, like a scratch. She (V4) provided the band aid and checked on R2 and noticed the injuries. She (V4) did his (R2) initial assessment and called me right away. I went into his (R2) room, V4 and V5 were at the nurses' station. I went directly to assess R2. I also noted the injuries. I instructed V4 to supervise V5 while I do my investigation. With my investigation, there was a possible abuse on him (R2), so I called V2. I was told that she (V2) is going to come. I assigned a different CNA on R2, first aid provided, instructed V4 to inform Hospice. V2 came around 10:30 PM so she did her investigation as well. She (V2) also called local police. She (V5) was also interviewed by V2. She (V5) was supervised and took her off from the schedule. When the police arrived, they did their track on R2, interviewed me, and V4. After that, they noticed that there was a camera in R1's bed, they requested surveillance. Police interviewed V5; took pictures of R2 and injuries in V5's hand. Police cannot arrest her (V5) at the time because R2 was confused and unable to narrate the incident. He (R2) is alert and oriented to self; unable to verbalize needs and dependent on staff for all care. He (R2) is also a hospice resident. On [DATE] at 2:20 PM, V4 was also asked regarding R2's incident on [DATE]. V4 replied, Around 9:30 PM, all residents were getting situated. CNAs are getting residents ready for bed. He (R2) was in his bed, in his room. I was at the nurses' station when V5 asked me for a band aid, said she had a scratch in her hand. I did not inspect her hand, but I gave her the band aid. I noticed that she was walking towards R2's room. I followed her and that was the time when I noticed that he (R2) had bleeding in his lips, saw bumps on his (R2) head and scratches that were starting to swell. I asked her (V5) on what happened, V5 said he (R2) was resisting, and she (V5) was trying to get him dressed and ready when he started to kick and swung his arms and ended up hitting his head on the side rails. I told her (V5) to give me a second and I will be back and that is when I contacted V6. In between that, I assessed him (R2), I cleaned his lips and forehead, assessed his range of motion and did neuro checks. V6 asked me to contact Hospice. Personally, when I worked with him (R2), he did not display any refusal to care or aggressive behavior. If a resident is refusing care at the moment, let them be, they have the right to refuse. Then come back at a later time, maybe after an hour and try to do the care. She (V5) did not tell me what happened. No, she didn't tell me about the behavior during care. She only told me when I went to the room and checked on him (R2). She (V5) should report the incident to me at the time, so I could assign another CNA to R2. R2 shared the same room with R1. R1 and R2 are residents in the facility's Dementia Unit. V5 was the assigned CNA for R1 and R2 on [DATE], from 3:00 PM to 11:00 PM. On [DATE] at 12:10 PM, R2 was observed in bed, alert, oriented to self, verbal. R2 was observed with multiple scratches on the forehead and a scratch on the left eye. A purplish discoloration was noted on the left eye and greenish to yellow discoloration above right eye. An abrasion was also noted to his lower lip. R2 was asked regarding injuries, stated, I don't remember what happened. R2 was also asked if he went to the hospital, stated he don't remember. Police report dated [DATE] recorded an offense Battery Aggravated to Senior Citizen. Victim was R2 and V5 was the offender. There was no Police report for R1 provided for [DATE]. On [DATE] at 1:00 PM, V2 was asked regarding screening and abuse orientation among agency staff working in the facility. V2 verbalized, Agency staffing is ongoing. We make sure that agency provided us background checks. Prescreening is done through agency. Agency staff picked up a shift and we do onboarding orientation with Scheduler and Nurse Manager. We also have the checklist that we go through during orientation. With agency staff - as soon as they physically come into the building, they check in at the front desk. The receptionist will check in with them to make sure they are on the schedule. They show photo identification. Receptionist will have them read and sign the form onboarding checklist. From there, the staff check in with Scheduler. If the Scheduler is not here, there is a designee or Nurse Manager to check where they are going. Nurse Supervisor will escort the agency staff to the assigned unit and introduce to the other staff. Regarding V5, she came in 3 PM to 11 PM shift. She should have been checked in with V6 (Nurse Supervisor). He (V6) was the one who signed her onboarding checklist. On [DATE] at 1:55 PM, V6, stated during interview, Usually, the agency CNA check in at the front desk. Then they go to their assigned floor. That time, she (V5) did not look for me or Scheduler, but I saw her at 2 West. I asked her (V5) and told her that she is assigned to 3 East and should go there; and get directions from her nurse, V4. I did not do any orientation/checklist on V5 at the time. V4 was the one who gave the orientation. I only ask about password and if there are any issues to call me. On [DATE] at 2:20 PM, V4 was asked if she did an orientation on patients and policies on V5. V4 mentioned, V5, that was my first time working with her. When she came, I did not do any orientation regarding patient care or policies. Patient care is discussed among CNAs during shift change. On my end, I don't do any policies orientation. Management does that. Agency Nurse Onboarding Checklist showed V5 signed and dated the form [DATE]. The form was verified and signed by V6. V6 denied any knowledge on completing her (V5) onboard checklist. The date was marked wrong when it was signed. Review of V5's Agency Orientation Checklist showed V5 signed the form with an incorrect date of [DATE]. The form was completed by V6, which he (V6) denied providing the orientation to V5. Orientation checklist, items provided by agency such as dementia care training, references, background check (to name a few) were not initialed. Facility orientation items that facility should complete such as Dementia training; abuse policy (to name a few) were not initialed. V2 stated in an interview that all items should be initialed by the one providing the orientation. On [DATE] at 12:48 PM, V10 (Special Care Unit Director) was interviewed regarding Dementia unit in the facility. V10 stated, This is the Dementia Unit, third floor. All staff assigned here are certified Dementia trained. Agency staff are not trained because they don't work full time here. When they come to the floor to work for the shift, they will be oriented to look at the Kardex, plan of care, behavior monitor and interventions. They will be able to see the plan of care for each resident they were assigned to. V10 also stated in a follow up interview, R1 is kind of stubborn and has his own way to do things. When we do care, we have to explain it to him more than five times. If not, he will not allow staff to touch him and he gets agitated. R2 does not have much behavior. During care, he becomes resistive, he will hold other staff hand. When he does that, we will give him some time, leave him alone for ,d+[DATE] minutes and come back. On [DATE] at 10:16 AM, V15 (Staffing/Scheduling Co-Ordinator) was asked regarding background checks on agency staffing in the facility. V15 replied, We use agency staff for like 40% most of the time particularly evening and night shifts and on weekends. When they come to the facility, agency staff will be checked in at the front lobby and I will direct them to my Supervisor, V6, who will guide the assignment. For agency staff, I don't do the background check, it is the agency who does their own background checks. For new agency staff, I don't check the background or any paperwork because agency does that, and we trust the agency. I don't do any screening prior to agency staff working in the facility. We know for sure that the staff these agencies are giving are qualified to work. We trust the agency that their staff are screened prior to their shift. On [DATE] at 11:03 AM V2 stated during interview, For V5, I have to call agency Human Resource to verify background on or before shift starts. I have to receive those documentation. I received her (V5) papers last Friday [DATE] prior to start of shift. Facility presented V5's local state agency's health care worker registry paperwork. There were no other background or screening documentation on V5. V2 continued, They wouldn't be in the agency if they are not eligible or appropriately screened. We rely on the agencies for their staff that we use with the background check that they conducted. Everybody is screened and checked out. Agency staffing abuse knowledge and training is automatic, someone who had been working in the healthcare setting should receive training on elder abuse. For us, once they (agency staff) physically come into the facility, they are orientated verbally by Nurse Supervisor or designated Nurse. We also provide them (staff agency) with a badge with abuse emergency. On the badge, it indicates who the abuse coordinator is and the types of abuse. For our regular staff, we do abuse training upon hire, new hire orientation, quarterly and as needed, if abuse is triggered. We also have online training annually. Agency staff are included if they are in the building working, they are invited to attend. When we do abuse training, we do it per shift, normally through verbal and giving of handouts. We like to do demonstration by creating a scene and asked them to identify abuse. We reiterate that any suspicion of abuse should be reported. We have an open door policy making sure that staff continue to work comfortably with residents and other staff. V4 and V7 (RN) are agency staff and have been working with us for quite a while now. Human Resources should have their papers. V2 presented the following documents on V5 sent by agency electronically prior to start of her shift: Passport Local health agency healthcare worker registry Pre-employment physical form Tuberculosis skin test CPR (Cardiopulmonary Resuscitation) card certificate COVID (Coronavirus) vaccination card On [DATE] at 12:20 PM, V17 (Human Resources Director) was also asked regarding background checks and personnel files of agency staff. V17 verbalized, I don't keep the background checks and personnel files in a physical file. I save it in the computer. For Agency staff, V15 takes care of the background checks, obtaining identification and COVID cards. She is the point person that gets the file, and she will just transfer it to me. Surveyor asked V17 to pull personnel files of V4 and V7 (RN). V4 and V7 are agency staff and are still working in the facility. During interviews, V4 stated she had been working in the facility for eight months now, while V7 is assigned to work in the facility multiple times. V17 stated, V4 and V7 are agency staff. I don't see their background checks. I believe V15 has a binder that she keeps for all background checks. V5 is new, I don't have her files. On [DATE] at 1:10 PM, after reviewing video footage provided by V2 from facility's camera, V5 arrived in the third floor Dementia Unit at 3:20 PM on [DATE]. V5 went directly to the nurses' station where V13 (Agency CNA) showed her the schedule, went over the orientation binder. V5 was seen flipping the pages of the binder, signed a form, then went directly to get her cart in the hallway. Video time stamped 3:20 PM to 3:26 PM showed it took six minutes for V5 to do all the necessary orientation she was provided before the start of her shift. On [DATE] at 11:37 AM, V8 (Medical Director) was interviewed regarding prevention of abuse in the facility. V8 replied, My role is dealing with medical issues. I can't speak with the requirements for this agency hiring. Nurses need to be educated, supervisors need to go over with nurses making sure they are comfortable in handling or dealing with this kind of population with Dementia. All patients should be protected. The fact that they have Dementia they need to be protected. On [DATE] at 4:37 PM after several attempts, surveyor made contact via telephone with V5. V5 stated, she already discussed everything related to the incident on [DATE] with the Supervisor and refused to talk further. She stated she is busy and at work. On [DATE] at 1:59 PM, V3 (Director of Nursing) was asked regarding abuse and care of residents with Dementia in the facility. V3 mentioned, We have guidelines, policies and procedures to follow regarding abuse. We do abuse in-services on our staff upon hiring, orientation before they go to the unit. We do it annually, and as needed - when there is occurrence of abuse incident. For agency staff, expectation is they are being screened by the agency. When they come in here, we provide them with education about abuse, falls, like a general orientation. The orientation is given one on one with them by myself, Assistant Director of Nursing or Nurse Supervisors. The nurse on the floor provides education too. Our staff and the Supervisors are trained and aware of our guidelines when it comes to agency staff. And because the Supervisors would know the agency staff assignments, training in the care of demented residents would be included in their orientation. And floor nurses should also be educating the agency staff in the Dementia related care. On [DATE] at 2:20 PM, V1 (Administrator) stated during interview, Facility should be free from abuse. Whenever there is suspicion of abuse, residents should be safe, needs to be separated from staff if it is a staff abuse on resident or from resident if it is a resident-to-resident abuse. Staff has to follow abuse protocol to what they are supposed to do. All agency staff background checks are done before they start to work and other documents were provided to facility. We need to verify that their background checks are done and prior to working here in the facility and that facility is provided with copies. Agency staffing should have 4-hour Dementia behavior training prior to work and if they don't have, then they will not be assigned to the Dementia care unit. Third floor is Dementia certified unit and staff should be trained regarding dementia. Facility's policy: Abuse and Neglect, dated [DATE]. Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. Types of Abuse and Examples: 1. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling 2. Verbal: Verbal abuse includes but not limited to the use of oral, written or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. Examples: name calling, swearing, yelling, threatening harm, trying to frighten the resident, racial slurs, etc. 7 Steps in Abuse Prevention: This facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven federal components of prevention and investigation. The seven elements of prevention and investigation include: I. Screening: Have procedures to: Screen potential employees for a history of abuse, neglect, exploitation, misappropriation of property, or mistreating residents. This includes attempting to obtain information from previous employers and/or current employers and checking with the appropriate licensing boards and registries. The facility will also not allow contracted or temporary staff from working in the facility if the contracted or temporary staff was found by the contracting agency to be with disqualifying findings from the registry if registry check is required for the contracted staff. Similarly, prior to placement in the facility, the facility will require background check of prospective consultants, contractors, volunteers, caregivers working on behalf of the facility, and students in its nurse aide training program and students from affiliated academic institutions including therapy, social, and activity programs to care for residents to be done either the facility itself, the third-party agency or academic institution. 1. Initiate a reference from the applicant's previous employer. 2. Obtain a copy of professional licenses. The facility will check annually to ensure professional licenses are current and not expired. 3. Check with the Illinois Nurse Aide Registry now known as Healthcare Worker Registry upon hire, to determine reports of abuse, neglect and theft if staff is not a licensed staff. 4. Initiate Illinois State Police fingerprint check for non-licensed applicants or new hires within 10 days of hiring, unless the applicant had been previously finger-printed in accordance to the Illinois Background Check Act. The Illinois State Police Web Portal will automatically update convictions of those previously fingerprinted. II. Training: Have procedures to: Train employees, through orientation and on-going sessions on issues related to abuse prohibition, neglect, exploitation, misappropriation of property such as: Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. Abuse identification and recognizing signs of abuse. How staff should report their knowledge related to allegation without fear of reprisal. How to recognize signs of burnout, frustration and stress that may lead to abuse; and to what constitutes abuse, neglect, exploitation, and misappropriation of resident property. Understanding of behavior that has an increased risk of abuse. III. Prevention: have procedures to: Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property. Deployment of sufficient and trained staff to deal with behaviors in the units. The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their bed. VII. Reporting/Response: Have procedures to: If the event that results in allegation of abuse also causes the individual to suspect a crime, the facility will also report to the local law enforcement agency.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for abuse for two (R1 and R2) of three residents reviewed for abuse. Findings include: R1 is an [AGE] year-old resident admitted to facility on 02/19/2024 with medical diagnoses including but not limited to: Dementia, Major Depressive Disorder, Generalized Anxiety, Alzheimer's Disease, and Delusional Disorder. R1's MDS (Minimum Data Set) dated 02/22/24 recorded a BIMS (Brief Interview for Mental Status) score of 2 which means severe cognitive impairment. Social Service user defined assessment (UDA) with effective date of 04/18/2024 scores resident a 2+ for abuse/neglect which means at risk for abuse/neglect. R1's care plan for abuse/neglect was initiated 04/29/24 which was three days after an abuse allegation. R2 is an [AGE] year-old resident admitted to facility on 02/14/2023 with diagnoses including but not limited to: Dementia, Generalized Anxiety and Parkinson's Disease. MDS dated [DATE] recorded that R2 has BIMS score of 2 which means severe cognitive impairment. Social Service UDA assessment with effective date of 02/28/24 scores resident a 2+ for abuse/neglect which means at risk for abuse/neglect. R2's care plan for abuse/neglect was initiated on 04/27/2024 which is one day after an abuse allegation. On 05/06/24 at 1:59 PM, V3 (Director of Nursing, DON) was interviewed regarding abuse care plan. V3 stated, I have been the DON here for almost two years. All residents should have abuse care plans. All dementia residents should have an abuse/neglect care plan initiated on admission due to cognitive impairment. Social Services does the abuse assessment upon admission. If a resident is at risk for abuse, a care plan should be developed. For R1: Abuse care plan was initiated 04/29/24. For R2: Abuse care plan was initiated 04/27/24. On 05/07/2024 at 2:13 PM, V21 (Social Services Director) was interviewed regarding abuse care plan. V21 stated, If residents are at risk for abuse, an abuse care plan should be developed. For Dementia residents, they are at risk for abuse. Its V10's (Special Care Unit Director) responsibility, the Dementia Unit Director. Interview with V10 (Special Unit Care Director) on 05/06/2024 at 2:22 PM was conducted about abuse care plans. V10 stated All Dementia residents should have abuse care plans upon admission. R2 and R1: I don't know why we don't have it. It's the responsibility of social service to develop an initial abuse care plan. In the abuse risk assessment, my responsibility is the BIMS and PHQ9. On 05/07/2024 at 2:26 PM V21 stated: Social Service does the risk assessment; the development of the abuse care plan is my responsibility. I guess, we don't have R1 and R2 initial abuse care plans. Facility's Care Plan Policy dated 11/28/2017 revised 07/27/2023 states in part but not limited to the following: Policy Statement It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations. Based on (name of regulation) a comprehensive care plan must be developed after the comprehensive assessment of the resident. Based on (name of regulation) a baseline care plan will be completed within 48 hours of admission. Procedures 1. During admission, the facility may put in place baseline care plans within 48 hours to address resident's care. 4. After the comprehensive assessment (state/federal-required MDS) is completed, the facility will put in place person-centered care plan outlining care for the resident within 7 days.

Based on interview and record review the facility failed to administer medications in a timely manner for 1 of 3 residents (R4) reviewed for medication administration in the sample of 27. The findings include: R4's Physician Order Sheet dated 11/23 showed R4 has an order of Atorvastatin (cholesterol medications), Tylenol and Tramadol (both pain medications.) R4's electronic medication administration record showed that R4 has an order of Atorvastatin 20 milligram (mg) to be given at 2100 (9 PM). R4's Tylenol order of 325 mg 2 tabs every 6 hours to be given at midnight, 6 AM, 12 PM and 6 PM. R4's Tramadol order of 60 mg, 1 tab four times a day to be given at midnight, 6 AM, 12 PM and 6 PM. On 2/23/24 at 10:15 AM, V14 (R4's granddaughter) said that on 11/6/23, R4's 6 PM medications were given very late or were not given at all. V14 said she looked for the nurse who told her he was busy taking care of so many residents and was not sure when he would be able to give R4's 6 PM medications. R4's Medication Audit Report dated 11/6/23 showed R4 got her Atorvastatin 9 PM dose at (2345) 11:45 PM which was 2 hours and 45 minutes late. R4's Tylenol 325 mg 2 tabs 6 PM dose was given at (2345) 11:45 PM which was 5 hours and 45 minutes late. R4's Tramadol 50 mg 1 tab 6 PM dose was given at (2345) 11:45 PM which was 5 hours and 45 minutes late. On 2/23/24 at 11:47 AM, V11 (LPN) said he was the nurse on 11/6/23. V11 said he was very busy that day and gave R4's PM medications late. V11 said he did not realize that R4 was on his assigned unit. On 2/23/24 at 1 PM, V10 (Nurse Supervisor) said resident's medications should be administered as ordered or an hour before or an hour after their due time. On 2/23/24 at 2:30 PM both V2 (Director of Nursing) and V20 (Asst Administrator) said the facility did not have a policy on Medication Administration.

Based on interviews and record reviews, the facility failed to follow their Privacy, Dignity and Discharge Planning and Instruction policy when a resident was discharged ; and another resident's medication was found in the discharge medication pile. This deficient practice affects one resident (R3) of three residents reviewed for privacy and confidentiality and discharge medication. Findings Include: R2 discharged from the facility on 9/29/23. On 10/5/23 at 11:00 AM, V6 (Complainant) reported that R2 received R3's one medication upon review of medication when already home. V6 was able to give the information from the medication label, such as R3's full name, medication name, direction, and prescription number (Rx # XXXXXXXX). V6 also reported that she informed the facility of this incident on 10/2/23 (Monday). Concern form dated 10/3/23, reads in part: R2 was discharged on [DATE] and was sent home with a medication which does not belong to R2. Action taken: Spoke with Nurse and education one to one was given regarding medication reconciliation during discharge. Resident/Responsible Party informed of outcome on 10/4/23. On 10/5/23 11:25AM V8 (Discharge Planner) stated that V8 received an email from V6 regarding medication that belonged to another patient (R3). I forwarded the information to V3 (DON) and V7 (Unit Nurse Manager). V8 also provided a copy of an email along with attachment of Medication (Bingo Card) pictures sent to V8 by V6. In there, the label contains the full name of R3, room number, medication name, directions and indication of use and Prescription number. On 10/5/23 at 11:15AM V7 (Unit Nurse Manager) stated that on Monday (10/2/23) she was informed by V8 because the family called and informed V8 about medication of another resident in R2's discharged medication. Pharmacy provided information of R3's one medication (Sodium Bicarbonate 650mg) for antacids with prescription number Rx # XXXXXXXX. On 10/5/23 at 11:45AM (V3) DON When I found out what happened, I talked to V10 right away and re-educated V10. V10 was busy that day and I told V10 it is not an excuse. My expectation is for the nurse is to review the list of medication and reconcile it in with the medication on hand, pack the medication and send it with resident who is being discharged . On 10/5/23 at 12:00 PM, V10 (RN) stated that he was the nurse that discharged R2. Reviewed the medication with the family and R2. One by one, handed the bingo card. However, there was a pile of bingo cards for extra medication not yet used. I just handed it to the family and did not see R3's medication was somewhere in the pile. I know I should have done better and checked all the bingo cards, but I was so busy that day. Physician order sheet reviewed and R3 has an order for Sodium Bicarbonate 650mg tablet to give 2 tablets twice a day for antacid. Privacy and Dignity policy with a revised date of 7/28/23, reads in part: It is the facility policy to ensure the resident's privacy and dignity is respected by the staff at all times. Resident health information will not be shared to anyone who is not involved in resident's care and to anyone whom the alert and oriented resident does not wish to share his and her information with. Discharge Planning and Instruction policy with the revised date of 7/26/23, reads in part: It is the policy of this facility to conduct proper discharge planning for all residents and provide appropriate discharge instructions in preparation for discharge once a discharge order is obtained from the resident attending physician. Medication will be sent with the resident being discharged to the community.

Based interviews and record reviews, the facility failed to follow their policy and procedures for providing care and services in a timely manner by not ensuring nursing staff respond to call lights in a timely manner. This failure applied to four (R343, R443, R445, R446) of four residents reviewed for assistance with activities of daily living. Findings include: On 03/06/23 at 10:44 AM R343 stated she has been at the facility with diarrhea for 3 days. R343 stated sometimes it takes 40 minutes for someone to respond to her call light when she uses it for incontinence care. On 03/06/23 at 12:50 PM R443 stated no one ever gets her out of bed other than for therapy and she stopped using her call light because no one ever responds. On 03/06/23 at 12:03 PM R445 stated he threw up on himself after eating lunch one day and pressed his call light for assistance. R445 stated it took 20-30 minutes for someone to respond to clean him up. R445 stated sometimes it takes this long for a response to his call light. On 03/06/23 at 11:00 AM R446 stated, this morning it took an hour for someone to respond to the call light. R446 stated during a shift change you can't get anyone to respond to the call light. R446 stated the night before her roommate rang the call light and she did as well, however the staff responded to her roommate but did not acknowledge that she pressed the call light for assistance as well. R446 stated she had to yell out and remind them that she needed to be changed. R446 stated she had already been waiting soiled for more than an hour but then had to wait another 30-45 minutes before being changed. On 03/07/23 at 11:17 AM R446 stated a lot of times she has to wait for assistance possibly because she's larger and needs two person assistance. On 03/08/23 at 01:44 PM V13 (Ombudsman) stated she has received multiple concerns from residents about staffing, including call light response time. Resident council meeting report dated 11/08/22 and 02/14/23 documents nursing concerns include: resident stated that sometimes their call lights at night are being answered late. Will inform night nurses and supervisor to take frequent rounds. Stand up meeting was held with staff. On 03/09/23 at 11:17 AM V3 (Director of Nursing) stated it is all nursing staff's responsibility to respond to the call lights and they should always be answered. V3 stated she is not sure what is a reasonable amount of time the call light should be responded to, however as soon as staff become aware of them. The facility's Call Light Policy reviewed 03/09/23 states: It is the policy of this facility to ensure that there is prompt response to the resident's call for assistance. Facility shall answer call lights in timely manner.

Based on observation, interview, and record review, the facility failed to provide documentation of administering a narcotic medication that was in use. This failure applied to one resident (R121) whom was reviewed during medication storage and labeling. Findings include: R121 is an [AGE] year old male who was admitted to the facility 7/1/22 with diagnoses that include Alzheimer's, Dementia. According to R121's MDS (Minimum Data Set) he exhibits severe cognitive impairments scoring a BIMS (Brief Interview of Mental Status) of 2 out of 15. According to Physicians Order Sheet (POS) dated 2/17/23 R121 has been receiving hospice services while living in the facility. On 03/08/23 3:50 PM, during medication and storage review with V19 LPN, lorazepam 1mg/ml gel narcotic sheet for this resident was found in the narcotic control book and the medication was not on the cart. V19 said that they did not know where the medication was located at that time. Surveyor and V19 checked the medication cart and the refrigerator. At 4:10PM V17 Nursing Supervisor presented the missing medication with resident label and said that it was open and had been used. V17 said, the nurses should sign out the medication immediately after the medication has been administered and it should have been on the cart. 3/9/23 at 10:13AM V17 presented with V20 LPN with the lorazepam medication and a modified control sheet which indicated 2ml were wasted on 3/8/23. This was not signed by any nurse or practitioner. V17 said this medication was discontinued on 2/8/23 and should have been removed as well as the sheet. V17 said usually, we take it and give it to the DON to destroy, but V20 LPN forgot to tell me that it was wasted, and she forgot to record it on the sheet. It was in the refrigerator, but I didn't recognize it as the medication because it is a new form of medication that we are not accustomed to using. V20 said, I noticed that the medication was discontinued and was opened after I counted with the nurse in the morning, but I forgot to sign it out before I left the facility yesterday. On 3/9/23 at 10:40AM V3 Director of Nursing said, when a medication is wasted, two nurses have to sign out and verify that the medication was wasted. R121 Physician Order Sheet was reviewed which included an order for lorazepam gel dated 2/9/23 and discontinued 2/23/23. Facility Policy titled Controlled Medications Count revised 7/27/22 states; Statement: It is the policy of the facility to maintain an accurate count of Scheduled II controlled medications. Procedure: 1. After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is taken. 2. After administration of the controlled medication, the nurse will sign off the eMAR. 3. If the controlled medication needs to be wasted, another nurse should witness the wasting of the controlled medication.

Based on interview and record review, the facility failed to accurately conduct a fall risk assessment to prevent accidental falls; failed to safely monitor a cognitively impaired resident at risk for falls and with a history of falls; and failed to train staff on fall precautions for residents. This failure affected 1 (R1) of 3 residents in the sample. This failure resulted in R1 being emergently transferred to the hospital with a femur fracture requiring surgical intervention. Findings include: R1 is a [AGE] year old cognitively impaired resident diagnosed with cerebral infarction, muscle weakness, difficulty in walking, [CONDITION(S)], and displaced fracture of base of neck of right femur. On 5/18/22 R1 was admitted to the facility by V8 (Agency Nurse) for short term rehabilitation due to ankle surgery after a mechanical fall and history of previous falls. V8 wrote in her admitting progress notes dated 5/18/22 at 6:49 PM which reads in part, A female resident of [AGE] years old was admitted into the facility on stretcher from hospital. Resident was made comfortable in the room. Head to toe assessment was done. Resident has left ankle delayed wound healing has left ankle ORIF (open reduction internal fixation) surgery. Taking antibiotics every 24 hours for left ankle wound. Transfer with one person assist. Can only move bilateral lower extremities with one person assist. V8's fall assessment showed however that R1 was assessed at a fall risk score of 3 showing no risk for falls although R1 had a history of falls and was admitted with an ankle fracture. Interview with V2 (Director of Nursing) on 6/29/22 at 10:30 AM indicated that a fall risk score of 10 or above would mean a resident is at high risk for falls and a score of 3 would indicate no risk. Surveyor asked if R1 was considered high risk for falls, V2 stated, I know she fell several times at the other facility and she fell here a month ago, so she is definitely high risk for falls. Surveyor asked if she knew who the admitting nurse was that inaccurately assessed R1 at a score of 3 meaning no risk for falls, V2 stated, It was an agency nurse but that is an incorrect score. I will find out who the agency nurse is. R1's initial care plan dated 5/18/22 reads in part, (R1) is at risk for falls related to current medical condition, weakness, decreased balance/endurance, pain. Goal: (R1) will be free of falls through the review date. Interventions: Anticipate and meet the resident's needs; call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; educate staff to assist patient to wheelchair after shower instead of sitting on toilet seat; Prepare all necessary all items before taking to shower. Interview with V8 (Agency Nurse) on 6/29/22 at 4:50 PM stated, I don't remember (R1) I work only agency there and I don't remember her. I worked different floors there (referring to the facility), but I work at a lot of different places too, so I don't know who that is. Surveyor asked if she was given any orientation to the facility's floor and units she worked on, V8 stated, I think so. Surveyor asked what kind of orientation or training she received pertaining to the facility or floor, V8 stated, They have me sign forms and stuff but not like I sit down and go through training. I bid for the slot and then I'm scheduled to work there, that is pretty much what happens. I don't get oriented to each and every resident. We kind of have to figure it out for ourselves. Surveyor asked if she could recall whether R1 was a fall risk, V8 stated, I'm not sure but most of those people there were fall risks I think. Surveyor asked if a patient came from the hospital with a fractured foot for example and had surgery on it whether that person would be at risk for falls, V8 stated, Yes that would make them high risk for falls. On 5/24/22 R1's initial fall in the facility was documented by V11 (PM Supervisor) who wrote in part at 6:10 PM: Fall note. Called by one of the nursing aide to come to the room. She was on the floor, stating that she wants to go to the bathroom and find herself on the floor. Head to toe body assessment done, range of motion within normal limits. Denies any pain at this time. Denies hitting of the head. Assisted by 2 assist to sit up in the wheelchair with the use of gait belt. Toileted. educated to use call light for assistance. On 6/17/22, R1's second fall in the facility was documented by V5 (Licensed Practical Nurse/LPN) wrote in part, Incident Summary: Prior incident around 7 PM , resident was sitting on the wheelchair comfortably. Around 7:45 PM, nurse on duty was called by certified nursing aide that resident slid down from the toilet seat on the floor in lying position. Resident stated that I was trying to get up from toilet seat without assist and I lost my balance and I slid down from the toilet seat on the floor. Resident noted alert and oriented with periods of confusion. Resident was transferred to bed via mechanical lift assisted by 2 nursing staffs. Neurological checked initiated. Resident c/o pain 4/10, and Tylenol 1000 mg given. No bump or bruises noted at that time. Doctor from on-call notified and received order to x-ray for right thigh and neurological check. Daughter notified. Supervisor notified. Around 9:45 PM while doing assessment resident noted with disorientation with small bump on the head left side of the head and resident c/o pain on the Right hip. Nurse on duty called 911 immediately and send resident to hospital for further evaluation. A written statement by V6 (Certified Nursing Aide/CNA) and taken by V5 dated 6/17/2022 at 19:45 reads Per (V6-cna), the resident (R1) slid down from the toilet seat on the floor while I was turning to grab a hair dryer. Assessed the patient and the resident was transferred back to bed using a mechanical lift. Notified MD and family. Range of motion to all extremities with her baseline. Complained of pain 4/10, immobilized area, and applied ice. MD ordered stat X-ray, given Tylenol for pain. A written and signed statement by V6 (Agency Certified Nursing Aide/CNA) dated 6/17/22 reads in part, I had given the patient a shower. After drying and dressing the patient, I went to plug in her blow dryer with my back to the patient. In a matter of untangling the cord it was a big boom. I turned to look, and the patient was on the floor. I called for the nurse while trying to tell patient not to stand. Interview with V5 on 6/28/22 at 11:00 AM stated, I was the nurse taking care of (R1) and I was at the nursing station when V6 called me over and said R1 fell in the bathroom. V6 told me that she turned around and the resident all of a suddenly slipped off the toilet on her butt. Surveyor asked what he saw when he went into the bathroom and found her on the floor, V5 stated, Her head was against the door and across from the toilet and V6 and another CNA who I can't remember the name picked her up and transferred her back to her wheelchair. Surveyor asked V5 to explain how R1 slipped off the toilet seat, but her torso and head were across from the toilet, V5 stated, I don't know but you're right she must have fallen forward not backward if her head was towards the door. Surveyor asked if he questioned V6 further to get clarification, V5 stated, No, I didn't do the investigation, but I did tell the supervisor that night. Surveyor asked when the supervisor came on to the scene to assess R1, V5 stated, I paged her, but I didn't see her till later that night maybe around 9:00. Surveyor asked when R1 fell because he documented that R1 fell around 7:45 PM, V5 stated, Sorry ,it was around 6 (PM) I think. Surveyor asked if R1 was a fall risk and what fall preventative measures he took to keep her safe, V5 stated, She is a fall risk I'm told, and I keep the bed very low and her call light by her. Surveyor asked if R1 was on any blood thinner medications, V5 stated, I'm not sure. Surveyor asked if R1 was on any blood thinners, if R1 should have been sent out immediately, V5 stated, I called the doctor-on-call that we use, and they did a video exam of her, but he only ordered stat x-rays. Surveyor asked whether he told his CNA if R1 was at risk for falls, V5 stated, I don't remember telling her that, but she should have known. Physician order sheet provided to surveyor on 6/29/22 showed R1 with two blood thinning medications. Interview with V4 (Unit Manager) on 6/28/22 at 11:00 AM stated, I talked to the CNA the next day because I wasn't working that day. I did the report because I'm the unit manager for the unit where R1 fell . V6 told me that the resident was on the toilet seat and V6 turned her back while she was trying to detangle the hairdryer and the patient suddenly got up. I think I heard the patient brought herself to the bathroom and I wasn't there. It was in the evening around 9:45 PM so I did the investigation the next day. Surveyor asked if she fell forward or backwards while on the toilet, V4 stated, I was told she slipped off the toilet and she fell on her butt and the CNA was right next to her, but she turned around and the next thing you know the resident fell to the ground. Surveyor asked whether V6 may have left R1 by herself in the bathroom and left her unattended, V4 stated, No she told me she just turned around and the resident fell . Surveyor asked if V6 actually saw R1 fall or whether the resident was already on the ground when V6 found her. V4 stated, I was told she was in the bathroom with her, but she didn't actually see R1 fall but I wrote that it was a witnessed fall. Surveyor asked if the V6 didn't actually see R1 fall, how her incident report was considered a witnessed fall, V4 stated, I thought because the CNA was still in the bathroom with R1, so we considered it a witnessed fall, but I see what you mean because V6 didn't actually see her fall but only heard a loud boom sound. Surveyor asked if she believed V6's explanation of the incident and why there were no more questions about the incident due to the nature of the fall, V4 stated, Yes I asked both the resident and the CNA. Surveyor asked if she asked V6 why anyone would blow dry someone's hair while seated on a toilet seat with a wet shower floor several feet away, V4 stated, I never thought of that. 6/28/22 interview at 11:30 AM with V6 stated, Yes I was the CNA taking care of R1 when she fell in the bathroom. She was seated on the toilet and my back was to her because I was untangling her hairdryer because I had just finished giving her a bath and sat her on the toilet seat. I didn't see her fall, all I heard was a loud boom and she was on the ground. I called the nurse (V5), and he came right away, and we carried her out of the bathroom and put her on the wheelchair. Surveyor asked if she ever left R1 unattended, V6 stated, No, like I said, my back was to her in the bathroom and the next thing you know is she was on the ground after I heard a loud boom. Surveyor asked if she was told R1 was at risk for falls, V6 stated, No. No one told me she was a fall risk resident. I never took care of R1 before, and I was told to just give her a bath. Surveyor asked why she chose to blow dry R1's hair while she was seated on the toilet, V6 stated, I don't know, she was already there. Surveyor asked if she had to obtain the dryer from the bedroom after R1 was finished showering and whether she left R1 unattended, V6 stated, No I brought in all her supplies before I started the shower. Surveyor asked if she saw R1 fall, V6 stated, Like I said all I heard was a loud boom sound and she was already on the ground. Surveyor asked how she slipped from the toilet, V6 stated, She tried to get up I think, and she slipped back on her butt. On 6/29/22 at 1:45 PM, V10 (R1's daughter) stated to surveyor, I got texts from other relatives starting at 6:00 that the facility was trying to get a hold of me. (V10 showed surveyor texts of her phone which affirmed first text came in at 6:10 PM 6/17/22.) I was at an appointment and my phone was off so as soon as I turned my phone back on, I got these series of texts and voicemail from V5 (LPN) saying my mom fell in the bathroom. I got to the facility around 8 PM and my mom was already put in bed. I talked to V5 (LPN) and the aide (V6 Certified Nursing Aide/CNA) to ask what happened. V6 was very defensive and said she didn't know my mom was a fall risk and that (V5) the nurse never told her anything. V5 said the same thing that he did tell her and blamed the CNA for the fall. They didn't know anything about my mother. Surveyor asked if she saw the nurse come in to do any assessments of her mom, V10 stated, No, V5 never did any neurological checks if that is what you're asking. I never saw that (V7-nursing supervisor) either until close to 9 (PM). I had to tell her that I wanted my mom sent out 911. Both V5 and V9 kept telling me she was okay and that they were waiting for the x-ray company to come out. Meanwhile my mother is still in pain, she kept pointing to her leg and her head; and they just kept saying they gave her Tylenol and to let it work. I said my mother is on blood thinners and I didn't want her to have a brain bleed because she just hit her head. I even pointed out the bump on her head. Both the nurse and the supervisor tell me that they didn't know she hit her head because no one saw her fall. I tell them if no one saw her fall and someone is complaining of headache wouldn't they send that patient out 911? They were clueless and I'm not even a nurse and I know that a patient should be sent out immediately. So, I said that if they didn't call 911, I would call to have my mom sent out is when they finally called the doctor again to send my mom out. Hospital records show in part: Arrival 6/17/2022 22:47 (10:47 PM) Patient presents with fall, hip pain right. (R1) is a [AGE] year old female who has a history of [CONDITION(S)] with left sided weakness with fall from nursing home. Patient had history left ankle injury status post open reduction internal fixation surgery with delayed wound healing. At nursing home for rehab and wound care. While there she had a mechanical fall while in shower today. She said she hit her head. No obvious swelling. Also complained of neck pain. Pt. is on [MEDICATION(S)] (blood thinning medication). Main complaint is her hip pain on the right. No deformity of right leg. X-ray hip 2-3 views: Result date 6/18/22. Impression: Acute subcaptital right femoral neck fracture. Recommend pinning right hip. Risks and benefits of surgery discussed, including but not limited to pain, bleeding, infection, nerve or blood vessel problems, blood clots, pulmonary embolism, catastrophic injury, loss of limb, loss of life, subsequent arthritis or need for further surgery. Patient wished to proceed with surgery. Hospitalist service is consulted by doctor for perioperative management. She was at Skilled Nursing Facility, getting out of shower, lost balance while putting on her pants, and fell . No reported loss of consciousness but she did hit the left side of her head against the wall. She reports immediate pain at the right hip. Patient is seen lying in bed with 2/10 pain at the surgery site. Policy dated September 2021 titled Fall Policy reads in part, This facility is committed to minimizing resident falls so as to maximize each resident's physical, mental and psychosocial well-being. While preventing all resident falls is not possible, it is this facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventative strategies and facilitate as safe an environment as possible. All resident falls will be assessed, and the resident's existing plan of care will be evaluated for needed changes. The information collected from all resident falls will be reviewed by the interdisciplinary team for possible changes in facility practices and procedures. Policy: a fall assessment shall be completed on each resident on admission, readmission, quarterly, any significant change, and with each occurrence of a fall. The fall risk assessment shall at a minimum include a history of falls, contributing factors, gait, balance, and medications. A resident who is identified on admission as high risk for falls will have the interdisciplinary plan of care include initial interventions to prevent injuries and falls occurrences. Procedure: For each resident fall, a facility incident report and fall risk assessment will be completed by the nurse or designee. Each resident fall episode shall be documented in the resident's clinical record. Fall investigation will be completed with the root cause analysis. The resident's plan of care shall be updated by the IDT based on the fall risk assessment and investigation if additional care interventions are necessary. If a resident fall requires the services of a physician, hospital or other service provider, the facility shall notify by telephone or fax the state department of public health within 24 hours.

A. Based on interviews and record reviews, the facility failed to have effective fall interventions in place for a resident assessed to be at high risk for falls, confused, and with poor safety awareness. This failure applied to one (R281) of one resident reviewed for accidents and supervision and resulted in R281 being emergently transferred to the hospital with a diagnosis of an acute comminuted periprosthetic fracture in the mid to distal left femur. B. Based on interviews and record reviews, the facility failed to safely assist a resident with feeding who is diagnosed as legally blind and is dependent on staff for assistance with feeding. This failure applied to one (R219) of one resident reviewed for accidents and supervision and resulted in R219 obtaining a second degree burn on the left side of the abdomen as a result of hot water being spilled on her while staff was assisting with feeding. Findings include: A. R281 is a [AGE] year old female, admitted in the facility on 03/01/2022 with diagnoses of Periprosthetic Fracture Around Internal Prosthetic Left Hip Joint, Subsequent Encounter Unspecified Fracture of Shaft of Left Femur, Subsequent Encounter For Closed Fracture with Routine Healing; Difficulty in Walking, Not Elsewhere Classified and History of Falling. According to incident report dated 03/24/2022, it was noted that at around 8:20 PM, R281 was heard calling for help and was found on the floor next to her bed. She complained of pain on the left lower extremity and was sent out to the emergency room as ordered. R281's hospital records documented the following in part but not limited to the following: 1. Orthopedic History and Physical dated 03/25/2022: History of present illness: Patient is a [AGE] year-old, female with left distal periprosthetic fracture from a fall occurring last evening. Patient states she was going to the bathroom and fell . She has recent THA (total hip arthroplasty) revision and ORIF (open reduction internal fixation) on 02/25/22. Imaging - Xray Left femur - acute comminuted periprosthetic fracture in the mid to distal left femur. Xray Left hip: 2. There appears to be an acute periprosthetic fracture in the mid to distal left femoral diaphysis. 2. Physician Discharge Summary 03/28/22: Procedures/Surgery done: Open reduction and internal fixation, left distal third femoral shaft fracture with plate and screws. On 05/17/2022 at 5:55 PM, V7 (Registered Nurse) was asked regarding R281's fall incident on 03/24/2022. V7 stated, It was right after dinner. Her room was just right next to where I was at the time. I did the rounds on her, when I checked on her, it was late, she was on the floor already. She fell . I asked her (R281) what happened and she said, 'I just want to get up.' It was very hard to deal with her, she wanted to get up all the time. I assessed her after the fall, her range of motion and vital signs. I noticed that her blood pressure was high, her range of motion in the upper extremities were fine. She had limited range of motion on lower extremities, I noticed that the left thigh was red and swollen. It was the bad leg. She was sent out to the hospital as ordered. Unfortunately, there was a fracture. She did not use her call light. She is confused. She got up and wanted to get out of bed. She has this behavior. Everyone knows about her behavior of getting up and out of bed. There was no alarm or mobility alarm on at the time. There was no alarm. R281's Care plan, initiated 03/01/2022 documented: Risk for falls related to confusion, gait/balance problems, Incontinence, poor communication/comprehension, unaware of safety needs: Intervention - Follow facility fall protocol; The resident (R281) uses chair/bed electronic alarm. Ensure the device is in place as needed. On 05/18/22 at 11:39 AM, V6 (1 West Nurse Manager) was interviewed regarding R281 and falls. V6 verbalized, On 03/24/2022, she was sent out due to a fall incident. Before the fall, V7 checked on her. Shortly after 20-30 minutes after he (V7) went in there, the fall happened. According to him (V7), she (R281) was screaming, and she was found on the left side of the bed, on the floor. She was assessed, does not remember what happened when I asked her. She was sent out for further evaluation and treatment as ordered. She had the fall because she was confused, she did not ask for help to get up. She does have a behavior of getting up and getting out of bed without calling for help. She does know how to use the call light, but she is confused. For confused residents and high risk for falls, staff needs to do frequent monitoring every one to two hours. Her room is close to the nurses' station so everybody can see her; her bed in lowest position; she has a mobility alarm on. When she had the fall, she had the mobility alarm on. Her bed alarm/chair alarms are supposed to be implemented at all times. All staff are trained regarding use of mobility alarms, even agency staff. That time of incident, she (R281) should have the mobility alarms on. Her fall was caused by poor safety awareness and confusion. Nursing Comprehensive assessment dated [DATE] reads: High risk for Falls, score 10.0 On 05/18/22 at 02:25 PM, V13 (Nurse Practitioner) was interviewed regarding R281's cause of fall. V13 replied, She is in her 90s, has a little bit of cognitive impairment. She is frail and repetitive. She needs total assist in everything. She broke her hip at home, was hospitalized , had surgery left hip repair and admitted in facility for rehab. She had a fall on 03/24/2002 - due to confusion and cognitive ability. V13 was asked on what interventions should be implemented on R281 to prevent fall incidents. V13 stated, Staff needs to follow fall prevention program. She cannot retain things, unable to use call light and couldn't retain the instructions, there should be increase supervision and follow interventions in the care plan. V2 (Director of Nursing) was also interviewed on 05/18/2022 at 3:50 PM regarding fall prevention in the facility. V2 verbalized, Staff needs to know everything about the residents' condition and needs; follow fall protocol and follow care plan interventions in placed. Facility's policy titled Fall Prevention Policy dated 10/2021 documented in part but not limited to the following: Purpose: This facility is committed to minimizing resident falls to maximize each resident's physical, mental and psychosocial well-being. While preventing all resident falls is not possible, it is this facility's policy to act in a proactive manner to identify and assess those residents that are at risk for falls, plan for preventative strategies, and facilitate a safe environment as possible. Policy: A fall assessment shall be completed on each resident on admission/readmission, quarterly, and with each occurrence of a fall. The Fall Risk Assessment shall at a minimum include history of falls, contributing factors, gait, balance, mental status, and medications. A resident who is identified on admission as high risk for falls will have an interdisciplinary plan of care, which includes initial interventions to prevent injuries and fall occurrences. At least quarterly and with each fall occurrence, the effectiveness of each resident's care plan as it relates to fall prevention shall be reviewed and updated when necessary. Facility's policy titled Fall Management Protocol dated 08/2021 stated in part but not limited to the following: Purpose: Major components of the safety and accident prevention of our residents are the determination of risk. This includes fall risk and management of resident falls. B. R219 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to [CONDITION(S)], Chronic Obstructive Pyelonephritis, [CONDITION(S)], Contracture of Muscle, and [CONDITION(S)]. According to MDS (Minimum Data Set) dated 05/01/2022 under section C, R219 has BIMS (Brief Interview of Mental Status) score of 12 indicating moderately impaired cognition. R219's eating total dependence dated 08/16/2018 reads in part, Feed resident allowing adequate time to chew/swallow food. R219's vision impairment care plan dated 07/17/2018 reads in part, Place personal items on the side so that R219 can see them; Relocate food from side of tray to center of tray during meals. On 05/16/2022 at 11:21 AM surveyor interviewed R219 regarding the incident that the resident suffered on 04/07/2022, R219 stated, V14 (CNA - Certified Nursing Assistant) placed food tray on the side table, then he put his cell phone on my bed and had his earphones in his ears. There were two cups on the tray, one with cold, one with hot water to steep my tea. I told V14 that I don't want to get burnt with the hot water, so I asked him for cold water that was next to it and then V14 knocked over the cup of hot water with his elbow. It fell on me and burnt my abdomen. V14 didn't even notice when it happened, I screamed, and another staff came in and helped me, I don't remember who it was. On 05/16/2022 at 12:37 PM surveyor interviewed V4 (three west unit manager). Surveyor asked about the incident that happened on 4/07/22 involving R219, V4 stated, The resident got burnt from the hot water spill, during breakfast time. I was told that V14 (CNA), who was feeding R219 at the time, accidentally knocked over a cup from the tray. R219 suffered burn to the left side of her upper abdomen. The resident notified V9 (RN - registered nurse) who told me about the incident. I went into the room and did an assessment. I noticed redness on her abdomen. I notified V21 (MD - Medical Doctor). I also notified wound care team and they continued the treatment. I sent V14 home for not telling me about the incident. I was also going to write him up, but he never returned to our facility. I notified the scheduler of the incident and that V14 didn't tell me directly about the incident. Progress note dated 04/07/2023 at 10:05 AM written by V9 reads in part, upon assessment, blenched redness noted to the left side of her abdomen and left breast. Complaining of pain, voiced 7/10. Tenderness upon palpitation. No open area noted. Scheduled pain medication given. V21 (MD) made aware with orders to apply ice to affected area. POA notified. Order dated 04/07/2022 at 11:59 PM written by V21 (MD) reads in part, Cold Pack - Apply to left side of abdomen topical one time for comfort and prevention of swelling. Completed 04/07/2022 R219's redness on the left quadrant of abdominal area dated 04/07/2022 reads in part, Apply Silverdine cream to left quadrant abdominal area; identify potential causative factors and eliminate/resolve when possible. Wound Care assessment dated [DATE] written by V22 (NP - Nurse Practitioner) reads in part, Burn of Second Degree of abdominal wall present; size 13cm x 26cm x 0.1cm; 25% intact blisters; 75% open dermis; light serous exudate present. Order dated 04/13/2022 written by V21 (MD) Reads in part, [MEDICATION(S)] Cream 1% - Apply to left abdomen topically everyday shift for wound cleanse with normal saline, pat dry, apply [MEDICATION(S)], apply Adaptec and dry dressing. Completed 04/22/2022, Skin and Wound Evaluation dated 04/18/2022 at 11:59 AM written by V21 (MD) reads in part, first degree burn to upper left abdomen. Wound Care assessment dated [DATE] written by V22 (NP) reads in part, burn to left abdomen intact. On 05/18/2022 at 11:45 AM V2 (DON - Director of Nursing) indicated that injury report wasn't done at the time of the incident because R219 did not acquire an actual injury, she just had some redness on her abdominal area. On 05/18/2022 at 1:30 PM surveyor interviewed V2 (DON). Surveyor asked about the incident from 04/07/2022 involving R219, V2 stated, One of the contracted staff (V14) spilled coffee over R219 and the nurse (V9) went and took care of the resident. We called wound care nurse (V22), and R219's wound assessed as was only redness. We also called physician (V21); he gave an order to ice the area. We investigated the incident internally. We called the agency to talk to V14 and do an in-service, but he did not do that and refused to sign, so we terminated him. Surveyor asked what would be the expectation to prevent [CONDITION(S)] during feedings, V2 stated, My expectation is to prevent all the incident and accidents. We do in-services, we also tell staff to be careful when handling hot liquids. Incidents that need treatment or hospital visits need to be reported. If I know cause and it's a mild injury, I can do the internal investigation. Staff needs to report all accidents and incidents. On 5/18/22 at 2:16 PM surveyor interviewed V14 (CNA) via phone. Surveyor asked V14 to clarify what happened on 04/07/2022 when he fed R219, V14 stated, I went into R219's room, I was adjusting her tray and I spilled a cup of hot water on her. R219 told me to notify the nurse. I left the room, but I didn't see any nurse on the unit. I had to go downstairs for a moment. I came back after 15 min. V4 and V9 called me, and they told me what happened and then rebuked me. I worked for the rest of the day but didn't go back to R219's room. The agency did the safety in-service for me, but I didn't work at this facility again. On 5/18/22 at 3:11 PM Surveyor interviewed V9 (RN - Registered Nurse). Surveyor asked about the incident that happened on 04/07/2022 involving R219, V9 stated, I went in to give R219 her routine morning medications. R219 told me that she got burnt to the left side of her abdomen. R219 said that V14 knocked over a cup with hot water while he was feeding her. I assessed R219; she had some blanchable redness, R219 also complained of some tenderness and pain. I called V21 (MD); he told me to put some ice at the burn site and monitor. Then I called R219's POA. I also told V4 (three west unit manager); V4 also assessed R219. I haven't worked with V14 after that. Surveyor asked who reported the incident to him, V9 stated, Nobody report the incident to me, I just came in to give R219 her medications. She was done with lunch and the tray was gone by the time I came in. 05/18/22 at 02:41 PM Surveyor interviewed V13 (NP - Nurse Practitioner). Surveyor asked about burn classification, V13 stated, Sometimes burn is just a redness, that would indicate stage 1 and stage 2. If skin comes in contact with something really hot, the skin may develop blister. Burn is a trauma. Surveyor ask what is an indication to use [MEDICATION(S)] cream, V13 stated, [MEDICATION(S)] cream is an anti-infective, promotes healing. We would use it instead of oral antibiotic, it's usually a medication for [CONDITION(S)]. Ice is also a good treatment for [CONDITION(S)]. 5/19/2022 11:38 AM Surveyor interviewed V11(Wound Care Coordinator). Surveyor asked about the incident that happened on 04/07/2022 involving R219, V11 stated, The water spilled on her abdominal area. It was just red upon an assessment, there was no skin opening at the time. V21 ordered ice pack and monitoring. Surveyor asked about V11 expectation when resident suffers a burn, V11 stated, Depends on the severity of it, if skin is open, we call the doctor and start the treatment. If the injury was superficial, and R219's was, we prescribe ice and monitor.

Based on observation, interview, and record review, the facility failed to follow their abuse prevention protocols by failing to immediately separate an alleged abuser from the resident and failing to thoroughly investigate the allegations to include potential witnesses and/or other residents under the alleged abuser's care. This failure applied to one (R3) of four residents reviewed for abuse and resulted in (R3) enduring pain, fear, mental duress, and an unplanned early discharge back to home. Findings include: R3 is an alert and oriented [AGE] year-old Polish-only speaking resident admitted to the facility on [DATE] for therapy services after being hospitalized for a fall at home and fracture of the right foot bone. R3 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MDS (Minimum Data Set) dated 5/10/21 shows R3 requiring extensive assistance with a 2-person physical assist to transfer from chair to bed. Nurse's note written by V9 (RN) on 5/12/21 at 5:05 PM stated, Received patient in wheelchair in stable condition. Noted patient was upset and crying, stated she feels cold, but refused to cover with blanket and agreed to put her shirt on. Noted patient was still upset and stated, go away from my room. Writer made sure patient was comfortable in wheelchair and call light was within reach, left room. Patient is alert and able to express self in Polish only. At lunch time, Patient transferred to wheelchair and setup tray. Around 1:30 PM, writer heard voice from patient's room that she was crying, but call light was off. CNA went to check on patient and transferred to bed as per request and made comfortable. Around 2:00 PM, writer went to check on patient again, noted patient was resting comfortably in bed and was asking for water. Writer provided ice-water, but no other concern voiced at this time. All needs attended. call light is within reach. will continue to monitor. 5/13/21 at 10:07 AM, surveyor asked V1 (Administrator) if he was the abuse prohibition coordinator and if there were any new allegations of abuse that were reported to him within the last 24 hours, V1 stated, You must be referring to R3. I was informed by my admissions people who got a call from R3's family. V22 (admissions) spoke to R3 because she can speak Polish and R3 only can speak Polish. I was told that V17(CNA-Certified Nurse's Aide) took over for R3's CNA who was on her lunch break. The resident (R3) told V22 that she wanted to be put back to bed and that V17 was rushing her back to bed and accidentally hit her feet with his leg or something like that. I'm still investigating it now and I sent the initial to your office. The resident also asked for another pillow and I was told that V17 responded to R3 that she already had 3 so he initially didn't give her another but eventually he did give her another pillow. Again, I'm still getting some final details about it from my staff, but I do think that it may have something to do with the fact that her (R3) was cut off from therapy. Surveyor asked what he did with the CNA (V17), V1 stated, Well we pretty much determined there was no abuse, so he continued on with his shift. Surveyor clarified whether V17 was sent home or was allowed back to work, V1 stated, I pretty much determined there was no abuse here so (V17) is scheduled back tomorrow. Surveyor asked V1 for copies of the facility-reported incidents sent to the local public health office. Records show on 5/12/21 V1 sent an initial facility reported allegation of abuse involving V17 against R3. Initial report showed: Date of alleged incident 5/12/21; Time of alleged incident: Around 12:30 PM. The facility has an allegation that may involve one or more of the following reportable situations: Physical Abuse, Neglect. The individual allegedly committing the offense is: Employee. Alleged victim: (R3) Age: 83. Alleged Victims diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . V1's wrote: Administrator spoke with resident's daughter to discuss the concerns she mentioned to admissions team. Resident's daughter scared that a male CNA came in to help her and rushed her and threw her on the bed. Daughter stated that he (CNA) hurt her leg and now it is worse than when she got there. She also stated that she has been sitting in her room with no TV because no one cares about her and its neglect/ Daughter stated that she asked for pillows and CNA just tossed them at her bed. Administrator then had admissions who speaks Polish get statement from resident and resident explained that it was an accident, he was just a bit hurried, and no other new pain in her leg area. Report copy provided to surveyor titled Final Incident Investigation Report Form Facility reported dated 5/13/21 showed in part (but not limited to): Based on the known facts from medical record review and interviews, the following conclusions have been determined about the original allegation: Abuse, Neglect is Unsubstantiated, as follows (summarize facts obtained during investigation): Based on interview with resident and staff it was determined that there is a large communication barrier that may have led to confusion. Resident speaks polish and does not always understand, what staff are communicating. During interview with resident, resident also that no one intentionally tried to hurt her, but staff seemed to be in a hurry. Staff educated on proper approach to care especially when communication barrier is present. This founded allegation involved an employee. See attached listing of employee's name, address, phone number, title, date of hire, and copies of previous disciplinary actions. This employee is currently: Reinstated. A full head to toe assessment was completed to assess the resident for injury. The resident's physician was notified of the allegation. This constitutes the Final Investigative Report concerning this allegation. Individual completing the report: (signed by V1), Administrator. Facility's final incident report included a statement from V22 (Admissions Director) and person who interpreted for R3 and wrote: I, (V22) Director of Admissions, went to speak with the patient (R3) after her daughter called the admissions department with a couple concerns regarding her mother's care. I went to speak to the patient in Polish her primary language at 4:30 PM on 5/12/21 on what had occurred. She mentioned that a male helper transferred her from wheelchair to the bed and was trying to transfer her quickly when he unintentionally hit her right leg with his leg. She did not claim to be in any additional pain. She expressed that she has [CONDITION(S)] and has consistent pain in her arms and legs and needs to be transferred slowly. After the male helper transferred her into bed, she had asked him for another pillow, which was sitting on the recliner, he told her she already has 3 pillows and didn't need anymore. She was begging him for another pillow to put under her arm to keep it elevated. He finally agreed and she stated that he threw the pillow at her. On 5/13/21 at 12:45 PM, interview with V22 (Admissions director) stated, My coworker got a call from R3's daughter. I got involved because I can interpret and R3 can only speak Polish. I was told that a CNA transferred R3 from wheelchair to bed and while transferring the CNA's leg made contact with R3's leg. She wasn't in any more pain I was told than normal because she had [CONDITION(S)]. Surveyor asked her to clarify, V22 stated, I'm not clinical so I'm just telling you what information I got from nursing. V22 continued, R3 asked for a pillow and the CNA told her she already had 3 pillows. When I spoke to R3 she said she had to beg for a pillow. Surveyor asked if she was present when V15 assessed R3 for any injuries, V22 stated, I went up to R3's room a second time because V15 needed an interpreter and I observed V15 take R3's socks off and she looked at her legs and toes and asked her if she was in any pain. She told me it wasn't intentional, but she was very emotional when she was talking to me. She was almost crying in fact and she did appear afraid. On 5/13/21 at 10:45 AM, surveyor approached V9 (RN) and asked about the incident that had occurred with R3. V9 stated, I was her nurse yesterday too and around 2:00 yesterday, I was doing my rounds and when I went in to see her she asked me for some ice water and she told me she had pain in her foot after V17 put her back in bed. I was later told by the admissions department (V22) that there was a complaint about abuse from the daughter and I checked out R3's foot when she complained about it, but I didn't really assess her head to toe and I should have. Surveyor asked how R3's demeanor was, V9 stated, Well she was very upset and crying and she didn't want me in her room anymore. Surveyor asked if she endorsed to the following nurse what had happened or to monitor R3 further, V9 stated, The next nurse was an agency nurse and I did not endorse the incident to him and I should have but I don't believe I did. On 5/13/21 at 11:00 AM surveyor interviewed R3 with the assistance of V18 (Occupational Therapist) who interpreted Polish during the interview. Surveyor asked R3 what had happened and R3 appeared visibly upset as she spoke Polish to V18 to answer surveyor's questions. R3 stated, This CNA man (V17) put me back in bed and he was hurrying me up and I can't move fast, I'm old and I'm in pain. Surveyor asked to describe how V17 was hurrying her up, R3 stated, He was pushing his leg and his foot and kept kicking my foot with his foot to get me moving and he hurt me. Surveyor asked which foot he was kicking, R3 stated, My right foot. Surveyor asked which foot she had a fracture on, R3 pointed to her right foot. R3 continued, He (V17) kept telling me Hurry up! Hurry up! Hurry up! He looked angry and was upset that I was too slow. Surveyor asked how it made her feel, R3 stated, How else should I feel. I was upset and I was afraid of him. Surveyor asked what else happened, R3 stated, I also asked him (V17) for another pillow and he pointed to my bed and shouted you already have 3! Surveyor asked how V17's tone was when he stated this, R3 stated, He was angry like I said, and he didn't want to give me another pillow until I had to beg for one. I just wanted one for under my arm and I was upset that he couldn't just give me another one. He finally did, and he threw it roughly at me. Surveyor asked if she told her nurse right away of what happened, R3 stated, No because no one here speaks Polish except for her (pointing at V18). Surveyor asked R3 if the facility provided her any communication board, R3 stated, No. V18 searched the room for one but could not find any communication board for R3. R3 stated, I called my daughter right away and told her what happened so she told me she will get me out of here soon because of what I told her. She talked to me today and said she will take me home today and maybe I will go somewhere else to get therapy. I don't want to stay here anymore either because I'm very afraid to stay here because of that man. On 5/13/21 at 11:55 AM, interview with V15 (MDS/Nursing Supervisor) stated, At around 4:30 PM, V2 (DON) called me to go in and see the patient for a concern and V22 came with me because she spoke Polish so she could interpret. We met the patient and she (R3) said at 1:00 PM that a guy who we later found out was (V17) put her back to bed but he was in a hurry and hit her in the right foot. He hit it with his foot with his leg because he was in a hurry, but it was accidental because he told the administrator he was in a hurry. I told R3 I will check her foot and there was no discoloration or bruising. (R3) told me that she had pain, but it was on and off. I told her it looked okay. She also said she requested a pillow so she could have it under her arm for comfort and (V17) told her she didn't need one because she already had 3 pillows. Surveyor asked if the request for another pillow was honored, V15 stated, I don't know if he gave her a pillow. Surveyor asked how her demeanor was when she assessed her, V15 stated, She looked very upset. On 5/13/21 at 1:20 PM, interview with V17 (with V23-Spanish interpreter), stated, I transferred the resident on the bed. I used my gait belt. I told her in English, but she no understands. Surveyor asked if he accidentally stepped on her feet, V17 stated, No I never touched her. Surveyor went on to clarify that if he used his gait belt to transfer, he would have to had made close contact with her. V17 responded, But I didn't step on her foot or anything. Surveyor asked if he called for any assistance as R3 required two people to transfer her and she couldn't understand English or Spanish, V17 stated, No because I was just helping her out and her regular CNA was on her lunch break. Surveyor asked if he called for anyone else to assist with translation or transfer, V17 stated, No. Surveyor asked if he was in a hurry, V17 stated, No I took my time. Surveyor asked if R3 asked him for a pillow, V17 stated, Yes and I tell her she already had 3. Surveyor asked why he didn't just give R3 another pillow, V17 stated again, Because like I say, she already had 3 pillows, so I gave her one more after she keep telling me she need one more. On 5/13/21 at 5:45 PM, records show R3 was discharged to home accompanied by daughter after being admitted to facility for rehabilitative therapy on 5/7/21. Interview on 5/13/21 at 1:15 with V1 stated, I've already counseled V17 on the phone and will do it again in person when he is scheduled back to work tomorrow. Surveyor clarified whether the incident report was final, and he concluded all his findings, V1 stated, Yes, I will give you the final report. V1 presented final report to surveyor including facility's initial and final incident investigation. Both reports show no interviews with any residents that V17 was assigned to or other potential witnesses that may have observed V17 with other residents. Facility's policy dated November 22, 2017 titled Abuse Prevention Program states in part (but not limited to): Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Abuse means any physical or mental injury inflicted upon a resident other than by accidental means. Abuse is also the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Internal Reporting: All residents, family members or others are encouraged to report their concerns or suspected incidents of potential abuse, neglect, mistreatment to the administrator or an immediate supervisor who must then immediately report it to the administrator or the designated individual in the administrator's absence. Such reports may be made without fear of retaliation. Reports will be documented, and record kept of the documentation. Protection: The facility will remove any alleged perpetrator(s) of abuse or neglect from any further contact with residents pending an investigation. If the alleged perpetrator is an employee, the employee will be sent home and/or advised not to return to work until further notice. If that employee shall be immediately suspended without pay from employment at the facility, hot having any further resident contact, pending the outcome of an investigation. Investigation: As soon as possible after an allegation of abuse, neglect, mistreatment, the administrator or designee will initiate an investigation into the allegation which may include the following elements: Interviewing all persons who may have knowledge of the alleged incident, including but not limited to: All persons who reported the suspicion, allegation or incident, the alleged victim, the alleged perpetrator, any witnesses or potential witnesses to the alleged occurrence or incident, any staff having contact with the resident during the period of the alleged incident, roommates, other residents, family or visitors.

Based on interview and record review, the facility failed to protect a resident who is dependent on staff for care from abuse by a staff member for one (R3) of four residents reviewed for abuse. This failure caused R3 to endure pain, fear, mental duress, and an unplanned early discharge back to home. Findings include: 5/13/21 at 10:07 AM, surveyor asked V1 if he was the abuse prohibition coordinator and if there were any new allegations of abuse that were reported to him within the last 24 hours, V1 stated, You must be referring to R3. I was informed by my admissions people who got a call from R3's daughter. V22 (admissions director), who knows Polish, spoke to R3 because she can only speak Polish. I was told that V17(CNA-Certified Nurse's Aide) took over for R3's CNA who was on her lunch break. The resident (R3) told V22 that she was wanted to be put back to bed and that V17 was rushing her back to bed and accidentally hit her feet with his or something like that. I'm still investigating it now and I sent the initial investigation report to your office. The resident also asked for another pillow and I was told that V17 responded to R3 that she already had 3 pillows, so he initially didn't give her another but eventually he did give her another pillow. Again, I'm still getting some final details about it from my staff, but I do think that it may have something to do with the fact that her (R3) was cut off from therapy. Surveyor asked what he did with the CNA (V17), V1 stated, Well we pretty much determined there was no abuse, so he continued on with his shift. Surveyor clarified whether V17 was sent home or was allowed back to work, V1 stated, I pretty much determined there was no abuse here so (V17) is scheduled back tomorrow. R3 is an alert and oriented [AGE] year-old Polish-only speaking resident admitted to the facility on [DATE] after hospitalization for a fall at home and fracture of foot bone. R3 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MDS (Minimum Data Set) dated 5/10/21 shows R3 requiring extensive assistance with a 2-person physical assist to transfer from chair to bed. Nurse's note written by V9 on 5/12/21 at 5:05 PM stated, Received patient in wheelchair in stable condition. Noted patient was upset and crying, stated she feels cold, but refused to cover with blanket and agreed to put her shirt on. Noted patient was still upset and stated, go away from my room. Writer made sure patient was comfortable in wheelchair and call light was within reach, left room. Patient is alert and able to express self in Polish only. At lunch time, Patient transferred to wheelchair and setup tray. Around 1:30 PM, writer heard voice from patient's room that she was crying, but call light was off. CNA went to check on patient and transferred to bed as per request and made comfortable. Around 2:00 PM, writer went to check on patient again, noted patient was resting comfortably in bed and was asking for water. Writer provided ice-water, but no other concern voiced at this time. All needs attended. call light is within reach. will continue to monitor. On 5/13/21 at 10:45 AM, surveyor approached V9 (RN) and asked about the incident that had occurred with R3. V9 stated, I was her nurse yesterday too and around 2:00 yesterday, I was doing my rounds and when I went in to see her she asked me for some ice water and she told me she had pain in her foot after V17 put her back in bed. I was later told by the admissions department (V22) that there was a complaint about abuse from the daughter and so I checked out R3's foot when she complained about it but I didn't really assess her head to toe and I should have. Surveyor asked how R3's demeanor was, V9 stated, Well she was very upset and crying and she didn't want me in her room anymore. Surveyor asked if she endorsed to the following nurse what had happened or to monitor R3 further, V9 stated, The next nurse was an agency nurse and I did not endorse the incident to him and I should have but I don't believe I did. On 5/13/21 at 11:00 AM surveyor interviewed R3 with the assistance of V18 (Occupational Therapist) who interpreted Polish during the interview. Surveyor asked R3 what had happened and R3 appeared visibly upset as she spoke Polish to V18 to answer surveyor's questions. R3 stated, This CNA man (V17) put me back in bed and he was hurrying me up and I can't move fast, I'm old and I'm in pain. Surveyor asked to describe how V17 was hurrying her up, R3 stated, He was pushing his leg and his foot and kept kicking my foot with his foot to get me moving and he hurt me. Surveyor asked which foot he was kicking, R3 stated, My right foot. Surveyor asked which foot she had a fracture on, R3 pointed to her right foot. R3 continued, He (V17) kept telling me Hurry up! Hurry up! Hurry up! He looked angry and was upset that I was too slow. Surveyor asked how it made her feel, R3 stated, How else should I feel. I was upset and I was afraid of him. Surveyor asked what else happened, R3 stated, I also asked him (V17) for another pillow and he pointed to my bed and shouted, you already have 3 pillows! Surveyor asked how V17's tone was when he stated this, R3 stated, He was angry like I said, and he didn't want to give me another pillow until I had to beg for one. I just wanted one for under my arm and I was upset that he couldn't just give me another one. He finally did, and he threw it roughly at me. Surveyor asked if she told her nurse right away of what happened, R3 stated, No because no one here speaks Polish except for her (pointing at V18). Surveyor asked R3 if the facility provided her with any communication board, R3 stated, No. V18 searched the room for one but could not find any communication board for R3. R3 stated, I called my daughter right away and told her what happened so she told me she will get me out of here soon because of what I told her. She talked to me today and said she will take me home today and maybe I will go somewhere else to get therapy. I don't want to stay here anymore either because I'm very afraid to stay here because of that man. On 5/13/21 at 11:55 AM, interview with V15 (MDS/Nursing Supervisor) stated, At around 4:30 PM, V2 (DON) called me to go in and see the patient for a concern and V22 came with me because she spoke Polish so she could interpret. We met the patient and she (R3) said at 1:00 PM that a guy who we later found out was (V17) put her back to bed but he was in a hurry and hit her in the right foot. He hit it with his foot with his leg because he was in a hurry, but it was accidental because he told the administrator he was in a hurry. I told R3 I will check her foot and there was no discoloration or bruising. (R3) told me that she had pain, but it was on and off. I told her it looked okay. She also said she requested for a pillow so she could have it under her arm for comfort and (V17) told her she didn't need one because she already had 3 pillows. Surveyor asked if the request for another pillow was honored, V15 stated, I don't know if he gave her a pillow. Surveyor asked how her demeanor was when she assessed her, V15 stated, She looked very upset. On 5/13/21 at 12:45 PM, interview with V22 (Admissions director) stated, My coworker got a call from R3's daughter. I got involved because I can interpret and R3 can only speak Polish. I was told that a CNA transferred R3 from wheelchair to bed and while transferring the CNA's leg made contact with R3's leg. She wasn't in any more pain than normal because she had [CONDITION(S)]. Surveyor asked her to clarify, V22 stated, I'm not clinical so I'm just telling you what information I got from nursing. V22 continued, R3 asked for a pillow and the CNA told her she already had 3 pillows. When I spoke to R3 she said she had to beg for a pillow. Surveyor asked if she was present when V15 assessed R3 for any injuries, V22 stated, I went up to R3's room a second time because V15 needed an interpreter and I observed V15 take R3's socks off and she looked at her legs and toes and asked her if she was in any pain. She told me it wasn't intentional, but she was very emotional when she was talking to me. She was almost crying in fact and she did appear afraid. On 5/13/21 at 1:20 PM, interview with V17 (with V23-Spanish interpreter), stated, I transferred the resident on the bed. I used my gait belt. I told her in English, but she no understands. Surveyor asked if he accidentally stepped on her feet, V17 stated, No I never touched her. Surveyor went on to clarify that if he used his gait belt to transfer, he would have to had made close contact with her. V17 responded, But I didn't step on her foot or anything. Surveyor asked if he called for any assistance as R3 required two people to transfer her and she couldn't understand English or Spanish, V17 stated, No because I was just helping her out and her regular CNA was on her lunch break. Surveyor asked if he called for anyone else to assist with translation or transfer, V17 stated, No. Surveyor asked if he was in a hurry, V17 stated, No I took my time. Surveyor asked if R3 asked him for a pillow, V17 stated, Yes and I tell her she already had 3. Surveyor asked why he didn't just give R3 another pillow, V17 stated again, Because like I say, she already had 3 so I gave her one more after she keep telling me she need one more. On 5/13/21 at 5:45 PM, records show R3 was discharged to home accompanied by daughter after being admitted to facility for rehabilitative therapy on 5/7/21. Facility's policy dated November 22, 2017 titled Abuse Prevention Program states in part (but not limited to): Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Abuse means any physical or mental injury inflicted upon a resident other than by accidental means. Abuse is also the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain and/or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation, or offensive physical contact by a licensee, employee or agent. Mental abuse is also the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, agitation or degradation. Neglect is the facility's failure to provide, or willful withholding of personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish of a resident.

Based on interview and record review the facility failed to ensure a resident was transferred using two people during a mechanical lift transfer. This failure lead to R4 falling out of the mechanical lift and sustaining a sacral fracture. This applies to 1 of 3 residents (R4) reviewed for falls in the sample of 8. The findings include: The facility's investigation report dated March 19, 2020 for R4 shows, .On 3/19/20 at 7:15 PM resident had a fall while being transferred from wheel chair to bed via mechanical lift. CNA (Certified Nursing Assistant) was present at the time and attempted to prevent the fall but was unable . Sent resident to ER (emergency room ) via 911. Called local ER at 4:30 AM talked with nurse, R4 admitted with sacral fracture . The progress note for R4 dated March 19, 2020 shows, While CNA transferring resident after dinner, from wheel chair to bed using mechanical lift, mechanical lift started tilting, CNA managed to lower her and became beyond control, resident fell with the mechanical lift . Resident is sent to local hospital by calling 911 at 7:20 PM. Resident complained about back pain after the fall. Had a small cut on the left heel, 4 mm (millimeter) long . The local hospital's history of present illness dated March 19, 2020 shows, R4 is a [AGE] year old female with past medical history of [REDACTED]. Patient says she was dropped while in mechanical lift at SNF. Patient reportedly fell a distance of 3 feet and landing on her low back . R4's ct scan of the lumbar spine with out contrast on March 19, 2020 shows, Impression: 1. Acute fractures right L2, right L3, and probably right L5 [MEDICATION NAME] processes. Questionable right L1 [MEDICATION NAME] process fracture. 2. Acute fractures involving the right sacrum. 3. Multilevel lumbar spondylosis. The facility's statement filled out by V3 CNA dated March 19, 2020 shows, Did you witness the fall? If yes, please describe how the fall happened. Yes, I was trying to put the patient (R4) to bed with mechanical lift. After lifting her up from the chair, moving her to the bed the mechanical lift swung to the side. I tried to control it but to no eval and I tried to ease the patient to the floor. Do you have any additional information that may describe how the fall occurred? Not calling for assistance with transfer . The facility's record of disciplinary action for V3 CNA dated March 20, 2020 shows, Brief description of incident/problem/misconduct: Failed to follow facility protocol on mechanical lift transfer to use two person assistance. On January 6, 2021 at 10:04 AM, V5 CNA stated, mechanical lifts are always done with 2 people. We train new CNAs to make sure there is 2 people no matter what. On January 6, 2021 at 11:38 AM, V4 Nursing Supervisor stated, It happened on PM shift. R4 was transferred by CNA (V3) and then heard she was dropped on the floor. The mechanical lift should have 2 persons for transfers. I don't know why she did the transfer by her self. We train them to use 2 persons. R4's Minimum Data Set, dated dated dated [DATE] shows, she is total dependence for transfers of 2 persons. R4's care plan initiated on June 27, 2018 shows, Focus: Self care- R4 has an ADL (activities of daily living) self care performance deficit related [MEDICAL CONDITION] left side weakness, status [REDACTED]. Interventions: Transfer with 2 person total assist, use mechanical lift.

Based on interview and record review, the facility failed to apply R2's wheelchair footrests, which resulted in R2's feet touching the ground and falling forward. This failure resulted in R2 being sent to local hospital due to a [MEDICAL CONDITION] which required stitches. This affected 1 resident (R2) of 3 residents reviewed for falls in a total sample of 6. Findings include: On 8-27-19 at 12:56 PM, V1 (Administrator) stated ex-employee was counseled (post incident) on applying footrests when resident is in wheelchair. On 8-27-19 at 11:04 AM, V2 (Director of Nursing/DON) stated footrests keep legs elevated and prevent feet from touching the ground. V2 would apply footrests to wheelchair when pushing a resident for safety reasons and comfort. On 8-28-19 at 8:53 AM, V6 (Restorative Director) stated footrests maintain proper position in wheelchair and prevents the feet from touching the ground. Restorative nurse would have applied footrests to the wheelchair to maintain safety and prevent accidents. The facility instructs new staff that if the resident is unable to propel or unable to lift their feet from the floor, foot rests should be applied. If the resident is unable to maintain their posture in the wheelchair, foot rests should be applied. R2's Final Narrative Summary of Incident (Final Reportable), dated 8-7-19, documents CNA explained that while he was pushing resident, she suddenly put down her foot which caused her to fall forward. R2 was sent to local hospital and returned to facility with 5 sutures intact. R2's Nursing Progress Note, dated 8-6-19 at 10:40 PM, documents R2's laceration was fixed with 5 sutures which have to come out in 5 days. Wheelchair User Manual, dated (YEAR), documents proper positioning is essential; for your safety. When reaching, leaning, or bending forward, it is important to use the front casters as a tool to maintain stability and balance.

Based on interviews and record reviews, this facility failed to meet professional standards of quality care for one resident (R5) out of three residents reviewed for an acute change in condition and timeliness of transport in a sample of 14. This failure resulted in a delay in R5 receiving intensive monitoring and hospital-level treatment for [REDACTED]. Findings include: Review of the medical record notes R5 was admitted to this facility on 8/6/17 with [DIAGNOSES REDACTED]. On 2/15/18 at 1:45pm, V9 LPN stated that the resident's gastrostomy tube should be checked by auscultation with stethoscope for correct placement and also for gastric residual volume before administering any feeding, water, or medication. V9 stated that residents with gastrostomy tubes should be monitored for nausea, vomiting, abdominal distention, abdominal pain, and aspiration of tube feedings. On 2/15/18 at 2:45pm, V10 RN stated that the resident's gastrostomy tube should be checked by auscultation with stethoscope for correct placement and also for gastric residual volume before administering any feeding, water, or medication. V10 stated that residents with gastrostomy tubes should be monitored for nausea, vomiting, abdominal distention, abdominal pain, and aspiration of tube feedings. On 2/16/18 at 6:50am, V8 RN stated that residents that receive intermittent feeding via gastrostomy tube, the gastrostomy tube should be checked for any gastric residual volume at the beginning of each shift and before each use. Review of R5's POS (physician order [REDACTED]. Review of R5's medical record, dated 8/8/17, notes: At 2:55pm, R5 complained of abdominal pain/tenderness which is evidenced by R5's reaction to touch upon abdominal palpation. Pain medication given with no relief. V3 NP (nurse practitioner) assessed R5, ordered abdominal x-ray immediately and bladder scan x 1 due to poor urine output. Bladder scan showed 57ml in R5's bladder. Outside diagnostic company notified of R5's need for urgent abdominal x-ray. At 9:30pm, R5 still complaining of abdominal pain, 5 out of 10,, skin cool and clammy, blood pressure 82/54, heart rate 104 beats/minute, respirations 20, oxygen saturation 90% on HHTC (high humidity [MEDICAL CONDITION] collar) with oxygen at 3 liters. As needed pain medication given and pushed fluid via gastrostomy tube. Indwelling catheter with 20ml output. At 10:10pm, blood pressure 80/60, heart rate 113 beats/minute, respirations 30/minute, oxygen saturation 84% HHTC oxygen 3 liters. At 10:35pm, blood pressure 85/61, heart rate 105 beats/minute, respirations 30/minute, oxygen saturation 86% HHTC oxygen 5 liters. R5 complained of abdominal pain 5 out of 10. 911 emergency medical services called. R5 transported to hospital at 11:05pm. There is no documentation found that R5's feeding was held at any time on 8/8/17 between 2:55pm and 11:05pm when R5 was complaining of abdominal pain unrelieved by pain medication or exhibiting signs of distress (low blood pressure, rapid heart rate, increased respirations, decreasing oxygen saturation with oxygen). Review of R5's abdominal x-ray result, dated 8/8/17 at 8:40pm, notes gastrostomy tube tip overlies the region of the stomach, proper positioning within the stomach of the gastrostomy tube cannot be positively confirmed without installation of positive contrast material followed by x-rays, and should be considered prior to gastostomy tube utilization. Review of V23's ( Nurse Practitioner) progress note, dated 8/8/17, R5 seen and examined at bedside. R5 verbalizes via whiteboard pain in abdomen. Denies nausea, vomiting. Abdomen distended and tender throughout all quadrants with palpation. Abdominal x-ray result noted. Plan: continue feeding via gastrostomy tube, monitor for shortness of breath, fever, chills. Review of R5's MAR (medication administration record), dated 8/7-8/9, notes R5 received feeding via gastrostomy tube from 8/7 until R5 left facility 8/8 at 11:05pm. Review of R5's hospital medical record, dated 8/8/17, notes peritonitis/septic shock likely secondary to tube feeding contents seeping into intra-abdominal cavity. CT (computerized topography) scan of R5's abdomen/pelvis demonstrating displaced gastrostomy tube with large amount of intra-abdominal fluid. This facility's enteral tube feeding via continuous pump policy, dated 07/2016, notes report complications (gastric distention, respiratory distress) promptly to the supervisor and the attending physician.

Based on interviews, and record reviews, this facility failed to use a gait belt while transferring a resident to a wheelchair for one of five residents reviewed for transfers in a sample of 10. This failure resulted in R1 sustaining a lumbar spine fracture during a transfer while in this facility. Findings include: R1's medical record notes R1 was admitted to this facility on 5/25/15 status [REDACTED]. R1 sustained an L2 (lumbar spine second vertebrae) fracture on 6/8/15. On 6/16/15 at 10:45am, R1 stated that R1 has had multiple falls (at least 10) since January 2015 and that this is the reason for the spinal surgery on 5/20/15. R1 stated on admission to this facility, R1 did not have feeling in both legs and feet. R1 stated that R1 wears a left leg brace due to foot drop and the TLSO (thoracolumbosacral orthotic) brace for back support after recent surgery. R1 stated that feeling is just now returning to both feet. R1 stated on 6/8/15 R1 was standing up from wheelchair in bathroom when both knees buckled, and then R1 abruptly sat down again in wheelchair. R1 stated that R1 had participated in a lot of therapy that day and was tired. R1 stated that R1 has increased anxiety due to fear of falling and injuring self again. During interview on 6/17/15 at 2:45pm, E11 LPN (licensed practical nurse) stated that she admitted R1 to this facility on 5/25/15. E11 denies being aware that R1 had fallen multiple times prior to admission to this facility. E11 stated that she was not aware that R1 wears an AFO splint for left foot drop, wears a TLSO brace status [REDACTED]. E11 stated that she was aware that R1's gait was unsteady and that R1 could not transfer self, but did not think R1 was a fall risk. During interview on 6/16/15 at 12:15pm, E4 (director of restorative therapy) stated that gait belts are to be used by staff at all times when assisting residents. E4 stated that this facility insists on gait belts usage on all residents. E4 stated that each resident's care plan is individualized indicating how much assistance is needed for transfers, toileting, and ADLs (activities of daily living). E4 stated that the staff are expected to review the care plan at beginning of their shift and note if resident needs one or two staff members to assist with transfers, toileting, and ADLs. During interview on 6/16/15 at 2:49pm, E5 CNA (certified nurse assistant) stated that she was holding onto R1's left arm while R1 stood in bathroom when R1 sat down too fast in wheelchair. E5 stated that R1 was wearing AFO brace and TLSO brace at the time this occurred. E5 denies using a gait belt when assisting R1 stating that she knows R1 and did not need to use gait belt. During interview on 6/16/15 at 4:10pm, E1 (administrator) stated that the gait belt is part of the staff uniform and that staff are expected to use the gait belt when transferring and toileting residents. During interview on 6/17/15 at 11:00am, Z1 (nurse at R1's neurosurgeon's office) stated that she does not know how hard R1 hit the seat of wheelchair when R1 sat down, but spinal fractures just don't happen. Z1 stated that R1 was seen by Z2 (neurosurgeon) on 6/9/15 and complained of persistent severe back pain and numbness to lower extremities; R1 informed Z1 and Z2 that R1's knees buckled and R1 fell back into wheelchair. Z1 stated that if a gait belt had been used at that time, it could have softened the impact to R1's spine possibly preventing R1's spinal fracture. Z1 stated that R1 was admitted to an acute care facility after appointment on 6/9/15 due to L2 (lumbar spine second vertebrae) fracture and increased pain. Review of Z2's consultation note dated 6/9/15 notes R1 is three weeks status [REDACTED]. R1 was walking a lot with physical therapy throughout the day on 6/8/15 and became tired at the end of the day. R1 was being brought to the bathroom in a wheelchair when R1 stood up from the wheelchair, R1's knees buckled and R1 fell back into the wheelchair. Immediately, R1 felt increased pain in the back and could not walk secondary to the pain. R1 was admitted to an acute care facility for pain control due to L2 fracture. Review of R1's lumbar spine CT (computerized tomography) scan dated 6/9/15 notes an acute fracture of R1's left L2 transverse process and a subtle, complete non-displaced right L5 pedicle/transverse process fracture.

Based on interview and record review, the facility failed to notify the physician regarding a resident's change in condition for one resident (R28) of 18 residents reviewed for receiving quality care and treatment of [REDACTED]. This deficient practice resulted in R28's medical treatment for [REDACTED]. Findings include: R28's Face Sheet indicates that she was admitted to the facility on [DATE]. R28's admitting [DIAGNOSES REDACTED]. R28's Clinical Notes Report documents that she was admitted into room [ROOM NUMBER] bed 2 at 2:45pm. R28's Clinical Notes Report dated 12/17/14 at approximately 5:00pm documents that her lungs were CTA (clear to auscultation) bilaterally. Z3 (Nurse Practitioner) performed R28's initial History and Physical Assessment on 12/18/14. Z3 documents: Respiratory normal, No dyspnea. CTA anteriorally and posteriorally. On 12/21/14, E16 (LPN-Licensed Practical Nurse) documented that R28 had a temperature of 102 degrees Fahrenheit on 12/20/14 at 5:00pm. There is no documentation that the physician or family member was notified. On 2/4/15 at 1:16pm, E16 stated, "I did not notify the family or doctor regarding the fever. I gave her two Tylenol and a sponge bath and the temperature came down." E16 continued, "I don't know the facility protocol. I was inserviced and she told me that above 100.5 degrees, call the doctor. I did not look at the physician's orders [REDACTED]." A Physician order [REDACTED]. The order was written by Z2 (Physician). R28's Clinical Notes dated 12/21/14 through 12/22/14 indicate that she continued to spike temperatures on and off. Her temperatures ranged from 99.6 to 101.1. There is no documentation that her family or physician were notified. On 2/5/15 at 8:07am, Z4 (Family Member) stated, "I was at the facility every day from 8:00am to 1:00pm and then a caregiver would come in and take care of her. I kept telling the nurses that she had a cough and runny nose. They would just give her Tylenol. She started the cough on 12/20/14, Saturday, during the day. The first day I told (E18) (LPN). The second day I told (E17)RN-Registered Nurse)." R28's Medication Administration Record [REDACTED]. R28's Clinical Notes dated 12/21/14 at 8:39pm indicates that R28 had a fever of 101.1. On 2/4/15 at 3:00pm, E17 stated, "The doctor was not notified of the temperature of 101.1. The doctor was not notified until 12/22. But, we only talked about her elevated blood pressures. Don't think we talked about her temperatures." On 2/5/15 at 10:12am, E18 indicated that he did not call the doctor regarding temperatures. E18 indicated that he cared for (R28) two-three times. On 2/4/15 at 12:40pm, E20 (Nurse Manager) stated, "I've been the nurse manager for two years. She was in room [ROOM NUMBER] bed 2. I reviewed (R28's) record. The patient had a temperature. Any change in status, we call family and let them know. The physician not notified regarding the 102 degree fever. I inserviced (the nurse) to notify the physician with changes. The family was not notified regarding the temperature. I caught that when I reviewed the chart. All nurses are instructed to call the physician if temperature is higher than 100.5 degrees. Our doctors are very good at ordering diagnostic tests. But the temperature of 102, the doctor wasn't notified. He definitely should've been notified." R28's Resident Master Information Sheet documented Z4 as the Emergency Contact. R28's Face Sheet documented Z4 as the Responsible Party. On 12/22/14, R28 was admitted to a local hospital after an abnormal CT (Computerized Tomography) scan of the head. In the emergency room , Z4 (Family Member) gave the physician an account of R28's temperatures and cough/runny nose. A sputum culture was performed. RESULT: positive for Moraxella. A single view chest x-ray was performed. IMPRESSION: Mild vascular congestion. R28 was diagnosed with [REDACTED]. R28's Ct of the head showed persistent paranasal sinus [MEDICAL CONDITION] changes, mainly ethmoid air cells visualized on this exam. On 2/4/15 at 1:30pm, Z3 (Nurse Practitioner) indicated that she was not notified regarding R28's temperature. Z3 stated, "If I was notified regarding the temps, I would have seen her and medically assessed her. Just the whole clinical picture of temps for three days, cough and her increased risk, I would've started to check oxygen saturations and vital signs more frequently. Get a better clinical picture." On 2/4/15 at 2:22pm, Z2 (Physician) stated, "With a temperature of 102, I would expect to be notified. I was not notified at this time. Pneumonia-won't spike temperature right away. The patient would be more lethargic. Fever when infection spreads to the blood. If I was notified, I would have done basic labs, order vital signs more frequently and do x-rays. Do more diagnostics. If cough, a chest x-ray for sure. Or I would have the NP (nurse practitioner) see the patient for assessment. I don't remember being notified. If not documented, than I wasn't. If breakdown in communication happens repeatedly, it can definitely be potential for harm to the resident. If the temps goes undiagnosed , can end up with pneumonia. If notified, we could have started treatment to prevent worsening condition. Moraxella pneumonia is a bacterial pneumonia. It is community acquired and a nursing home can be considered a community. I'm sure the pneumonia happened before 12/22. If she already had fever, then she had the infection in blood." An undated facility policy titled, "Vital Signs Assessment Policy" documents: PURPOSE: Inform Physician any significant change. An undated facility policy titled, "Change in Resident Status Notification (Non-Emergent) documents: PURPOSE: To notify appropriate persons when there is a significant change in a resident's condition. POLICY: Physician, family and/or guardian are notified when there is a significant change in a resident's condition. PROCEDURE: 1. When a significant change in a resident's condition has been observed, care will be rendered immediately and the physician, family member and/or guardian will be notified.

Based on interview and record review, the facility failed to notify the physician and the responsible family member regarding a change in medical condition for one resident (R28) of 18 residents reviewed for notification of changes in a sample of 30. This deficient practice resulted in R28's medical treatment for [REDACTED]. Findings include: R28's Face Sheet indicates that she was admitted to the facility on [DATE]. R28's admitting [DIAGNOSES REDACTED]. R28's Clinical Notes Report documents that she was admitted into room [ROOM NUMBER] bed 2 at 2:45pm. R28's Clinical Notes Report dated 12/17/14 at approximately 5:00pm documents that her lungs were CTA (clear to auscultation) bilaterally. Z1 (Nurse Practitioner) performed R28's initial History and Physical Assessment on 12/18/14. Z1 documents: Respiratory normal, No dyspnea. CTA anteriorally and posteriorally. On 12/21/14, E16 (LPN-Licensed Practical Nurse) documented that R28 had a temperature of 102 degrees Fahrenheit on 12/20/14 at 5:00pm. There is no documentation that the physician or family member was notified. On 2/4/15 at 1:16pm, E16 stated, "I did not notify the family or doctor regarding the fever. I gave her two Tylenol and a sponge bath and the temperature came down." E16 continued, "I don't know the facility protocol. I was inserviced and she told me that above 100.5 degrees, call the doctor. I did not look at the physician's orders [REDACTED]." A Physician order [REDACTED]. The order was written by Z2 (Physician). R28's Clinical Notes dated 12/21/14 through 12/22/14 indicate that she continued to spike temperatures on and off. Her temperatures ranged from 99.6 to 101.1. There is no documentation that her family or physician were notified. R28's Clinical Notes dated 12/21/14 at 8:39pm indicates that R28 had a fever of 101.1. On 2/4/15 at 3:00pm, E17 (RN-Registered Nurse) stated, "The doctor was not notified of the temperature of 101.1. The doctor was not notified until 12/22. But, we only talked about her elevated blood pressures. Don't think we talked about her temperatures." On 2/5/15 at 10:12am, E18 (LPN) indicated that he did not call the doctor regarding temperatures. E18 indicated that he cared for (R28) two-three times. On 2/4/15 at 12:40pm, E20 (Nurse Manager) stated, "I've been the nurse manager for two years. She was in room [ROOM NUMBER] bed 2. I reviewed (R28's) record. The patient had a temperature. Any change in status, we call family and let them know. The physician not notified regarding the 102 degree fever. I inserviced (the nurse) to notify the physician with changes. The family was not notified regarding the temperature. I caught that when I reviewed the chart." On 2/5/15 at 10:12am, E18 indicated that he did not call the doctor regarding temperatures. E18 indicated that he cared for (R28) two-three times. On 2/4/15 at 12:40pm, E20 (Nurse Manager) stated, "I've been the nurse manager for two years. She was in room [ROOM NUMBER] bed 2. I reviewed (R28's) record. The patient had a temperature. Any change in status, we call family and let them know. The physician not notified regarding the 102 degree fever. I inserviced (the nurse) to notify the physician with changes. The family was not notified regarding the temperature. I caught that when I reviewed the chart. All nurses are instructed to call the physician if temperature is higher than 100.5 degrees. Our doctors are very good at ordering diagnostic tests. But the temperature of 102, the doctor wasn't notified. He definitely should've been notified." R28's Resident Master Information Sheet documented Z4 as the Emergency Contact. R28's Face Sheet documented Z4 as the Responsible Party. On 12/22/14, R28 was admitted to a local hospital after an abnormal CT (Computerized Tomography) scan of the head. In the emergency room , Z4 (Family Member) gave the physician an account of R28's temperatures and cough/runny nose. A sputum culture was performed. RESULT: positive for Moraxella. A single view chest x-ray was performed. IMPRESSION: Mild vascular congestion. R28 was diagnosed with [REDACTED]. R28's Ct of the head showed persistent paranasal sinus [MEDICAL CONDITION] changes, mainly ethmoid air cells visualized on this exam. On 2/4/15 at 1:30pm, Z3 (Nurse Practitioner) indicated that she was not notified regarding R28's temperature. Z3 stated, "If I was notified regarding the temps, I would have seen her and medically assessed her. Just the whole clinical picture of temps for three days, cough and her increased risk, I would've started to check oxygen saturations and vital signs more frequently. Get a better clinical picture." On 2/4/15 at 2:22pm, Z2 (Physician) stated, "With a temperature of 102, I would expect to be notified. I was not notified at this time. Pneumonia-won't spike temperature right away. The patient would be more lethargic. Fever when infection spreads to the blood. If I was notified, I would have done basic labs, order vital signs more frequently and do x-rays. Do more diagnostics. If cough, a chest x-ray for sure. Or I would have the NP (nurse practitioner) see the patient for assessment. I don't remember being notified. If not documented, than I wasn't. If breakdown in communication happens repeatedly, it can definitely be potential for harm to the resident. If the temps goes undiagnosed , can end up with pneumonia. If notified, we could have started treatment to prevent worsening condition. Moraxella pneumonia is a bacterial pneumonia. It is community acquired and a nursing home can be considered a community. I'm sure the pneumonia happened before 12/22. If she already had fever, then she had the infection in blood." An undated facility policy titled, "Vital Signs Assessment Policy" documents: PURPOSE: Inform Physician any significant change. An undated facility policy titled, "Change in Resident Status Notification (Non-Emergent) documents: PURPOSE: To notify appropriate persons when there is a significant change in a resident's condition. POLICY: Physician, family and/or guardian are notified when there is a significant change in a resident's condition. PROCEDURE: 1. When a significant change in a resident's condition has been observed, care will be rendered immediately and the physician, family member and/or guardian will be notified.