Every finding on record at Sunset Home

Based on interview and record review, the facility failed to ensure that safe operating equipment was maintained for nine of nine residents (R1, R2, R3, R4, R5 R6, R7, R8 and R9) reviewed for mechanical lifts in a sample of nine.Findings include:The Maintenance Service policy dated 12/2009, documents Maintenance service shall be provided to all areas of the building, grounds, and equipment. 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 5. Maintenance personnel shall follow the manufacturer's recommended maintenance schedule. 10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.The Safe Lifting and Movement of Residents policy dated 7/2017 documents In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 10.Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order.The Mechanical Lift Service Manual dated 6/7/24 documents At one-year intervals, attach a load equivalent to or within 100 lbs. (pounds) of the rated capacity of the lift to the unit. Do not exceed the rated weight capacity. Raise and lower the load with the lift. Listen for any unusual noises while operating the unit. With the test load applied to the lift, check all structural welds for any signs of stress or fatigue cracks. If any unusual noises or cracks are found, stop using the lift and call the (Manufactures Service Department) immediately! On 8/3/26 at 10:05 AM, V1/Administrator provided a resident roster highlighted with residents (R1 - R9) who require a mechanical lift for transfers. V1 verified at this time that only R1- R9 required a mechanical lift for transfers in the facility.On 8/3/26 at 11:35 AM, R1 stated that he was being transferred from his wheelchair to his bed with a mechanical lift. He was about a foot above his wheelchair seat when the lift broke and R1 fell hitting his back on the arm of the chair.On 8/3/26 at 11:46 AM V3/Maintenance Assistant stated I have never done a load bearing lift on the mechanical lift. I do monthly checks to see if it goes up and down but that is all.On 8/3/26 at 12:27 PM, V4/Certified Nursing Assistant/CNA stated that V5/CNA was helping V4 transfer R1 from the wheelchair to bed with a mechanical lift. They had R1 raised above the seat of his wheelchair and the lift broke. R1 fell back into the seat of his wheelchair hitting his back on the arm of the wheelchair. On 8/3/26 at 12:55 PM, V5/CNA stated that while transferring R1 from the wheelchair to the bed by a mechanical lift the lift broke and R1 fell back into his chair.On 8/3/26 at 1:45 PM, V1/Administrator stated that all the mechanical lifts should have been tested yearly for weight loads up to at least 400 pounds per the Mechanical Lift Service Manual.

Based on observation, interview, and record review, the facility failed to provide timely toileting assistance and failed to honor a resident's dignity and self determination for one (R53) of three residents reviewed for resident rights in a sample of 39. These failures resulted in R53 becoming incontinent of urine on multiple occasions and lying in her own urine for over two hours, which resulted in R53 experiencing embarrassment and disgust.Findings include:The facility's Certified Nursing Assistant job description reviewed 2/14/13, documents the primary purpose of your job description is to provide your assigned residents with routine daily nursing care procedures, and as may be directed by your supervisor. Record all entries on flow sheets, notes, charts, ect., in an informative and descriptive manner. Assist resident with bowel and bladder functions (i.e., take to bathroom, offer bed pan/urinal, portable commode, etc.). Maintain intake and output records as instructed. Keep residents dry (i.e., change gown, clothing, linen, etc., whenever it becomes wet or soiled). Keep incontinent residents clean and dry.R53's current care plan documents R53 will have reduced episodes of incontinence. This same care plan documents R53 requires assistance of two staff members for toileting.R53's Minimum Data Set (MDS) assessment dated [DATE] documents R53 requires two assist for toilet transfers.R53's medical record does not contain documentation of toileting R53, or if R53 is continent or incontinent when staff assist R53 with toileting.On 11/18/25 at 9:15 AM, R53 was sitting in her wheelchair in the hallway outside of the communal resident bathroom. On 11/18/2025 at 9:25 AM V9 (R53's Family Member) stated the facility does not have enough people to take the residents to the bathroom especially after breakfast in the morning. All the staff are in dining room, and nobody is on the floor to assist residents so by the time R53 can use the toilet she has already soiled herself. This upsets R53 a lot because she does not want to soil herself and understands she needs to use the restroom. V9 stated she has spoken with V1 (Administrator) several times who says, we are trying to get people trained, but nothing changes. Instead, they keep giving R53 medications to keep her quite because she gets upset about not receiving the correct care. Over the weekend they (facility staff) didn't put an adult brief on her at bedtime and when R53 woke up, she was wet and had to lay in urine for two hours before anyone helped her. On 11/18/25 at 9:45 AM, R53 stated The staff are not taking me to the bathroom. They tell me 'I'll take you in a minute.' I must wait 30 minutes to an hour normally to go to the restroom. This weekend the staff didn't put an adult brief on me, and I laid in bed for a couple of hours needing to go to the bathroom. I had my call light on, and I pounded on my bedside table with the call light, and nobody came. I don't pee the bed. I am not that person, but I couldn't help it, so I had to pee the bed and lay in my urine for over two hours. I was embarrassed and it was disgusting. On 11/18/25 at 11:00 AM, V22 (Ombudsman) stated V22 has had complaints of call lights not being answered and the lights are being turned off every right at 8:00 PM and after that the call lights are not answered. On 11/18/25 at 10:42 AM, V14 (CNA/Certified Nursing Assistant) stated R53 lets us know when she needs to use the restroom. R53 will get someone or let us know. R53 is continent and only is incontinent if she must wait too long to use the restroom. V14 stated we do not have enough staff here to provide cares especially after breakfast. The past two weeks we have two aides after 2:00 PM. Thursday and Friday of last week it was only (V14) and V19 (CNA) as the only aides on the floor and it was very hard to get all the residents toileted and laid down in between meals. On 11/18/25 at 11:50 AM, V2 (Director of Nursing) stated that the facility does not have documentation whether a resident was continent or incontinent and they only paper document resident bowel movements. V2 stated we used to document in electronic charting but V1 (Administrator) prefers to document. V2 confirms she has no documentation of R53's toileting record. V2 further stated R53 will verbalize to staff when she needs to use the restroom and will wheel herself to the resident bathroom in the hallway and wait for assistance. V2 stated that staff is expected to answer call lights timely and assist residents with toileting.

Based on record review and interview the facility failed to thoroughly investigate an allegation of abuse for one resident (R1) and determined it unsubstantiated and failed to protect R1 from further abuse. This failure resulted in an Immediate Jeopardy Findings IncludeThe Immediate Jeopardy began on 10/09/25 at 6 AM when V4 (Certified Nurse Aide) was allowed to return back to work with all residents and specifically R1. On 10/16/25 at 9:30 AM V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 10/4/25 around 6:30 PM. While the Immediacy was removed on 10/16/25 the facility remains out of compliance at a severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of their removal plan. The Facility's Abuse and Neglect policy dated July 2023 documents It is the policy of (this facility) to provide each resident with an environment free from abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of resident property, exploitation and physical or chemical restraint not required to treat the resident's symptom, as defined below. The Facility's Abuse and Neglect policy dated July 2023 documents should an incident or suspected incident of resident abuse, neglect, or injury of an unknown source be reported, the administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. The person in charge of the investigation will be provided a completed copy of the abuse report form, witness statement, and or information regarding the alleged incident. The individual conducting the investigation will, at a minimum: i. review the resident's medical record to determine events leading up to the incident ii. interview the person reporting the incident iii. interview any witnesses to the incident iv. interview the resident (as medically appropriate) v. interview the resident's attending physician to determine the resident's current mental status vi. interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident vii. interview the resident's room mate, family members, and visitors viii. interview other residents to whom the accused employee provides care or services ix. review all events leading up to the alleged incident. The Facility's Abuse and Neglect policy dated July 2023 documents Employees accused of participating in the alleged abuse will be immediately suspended until the finding of the investigation have been reviewed by the administrator. If it is after regular office hours, the house supervisor will remove the accused employee from the facility immediately.R1's Medical Record documents that she was admitted to the facility on [DATE] with diagnosis to include but not limited to Alzheimer's Disease, Depression and Hypertension. R1's MDS (Minimum Data Set) dated 9/5/25 documents that she is rarely/never understood.Throughout the survey R1 became verbally aggressive when spoken to and did not answer any questions appropriately.On 10/14/25 at 10:00 AM V4 (CNA) stated that on 10/4/25 R1 had been crazy all day. V4 stated that at the end of her shift she saw R1 by the door with V3 (RN). V4 stated R1 was arguing with V3 (RN) and attempting to exit the door. V4 confirmed that she walked up behind R1 and hooked her arm up under R1's arm and turned her around and started walking towards (R1)'s room. V4 confirmed that R1 did not want to go. V4 repeatedly answered I do not recall to most other questions asked such as where any other staff members were at the time, how she knew that R1 did not want to go down the hallway and whether or not V4 cursed during this interaction as was documented in another interview.On 10/14/25 at 1:30 PM V9 (Licensed Practical Nurse) stated that on 10/4/25 during shift change around 6:30 PM she was waiting to get report from V3 (Registered Nurse) but V3 (RN) was at the door with R1 attempting to get R1 to go down the hall away from the door and R1 was resisting leaving the area. V9 (LPN) stated that V4 (CNA) walked up to V3 (RN) and R1 and said we aint doing this sh*t today and hooked her arm under R1's arm and marched her back up the hallway and yelled for help from another V5 (CNA) who was just walking out of another resident's room. V9 stated that both she and V3 (RN) felt very uncomfortable with V4 (CNA)'s actions.On 10/14/25 at 2:00 PM V3 (RN) stated on 10/4/25 during shift change R1 was by the doors that led out of the unit. V3 stated she was attempting to redirect R1 to back away from the doors. (R1) was slapping at my arms and yelling, but she does that all the time. She had been doing it all day. V3 stated that V4 (CNA) swooped in and hooked (R1) under the arm and dragged her down the hallway. V3 denied requesting help or needing help. (R1) had been having behaviors all day, it felt like (V4/CNA) just decided that (R1) was not going to be acting like that anymore. (V4/CNA) was visibly angry during this interaction. V3 (RN) stated that at the time of the incident both she and V9 (LPN) felt that the interaction was not appropriate and aggressive on V4 (CNA)'s part.On 10/14/25 at 3:00 PM V8 (Certified Nurse Aide) stated that on 10/4/25 he heard a commotion and turned the corner to see R1 being dragged down the hallway while she was fighting and yelling. V8 stated that V4 stated here you take her. V8 stated he was able to hold his hand out to R1 and she took it calmly and was cooperative once let go. That is not the way we should be treating a confused person. (V4/CNA) was noticeably upset and frustrated with (R1). R1 acted scared and followed me around all night. I for sure think she was traumatized by the whole thing even if she couldn't say it. The Facility's Abuse Investigation dated 10/9/25 documents that on 10/4/25 V4 (CNA) was immediately suspended. The Abuse Investigation dated 10/9/25 documents that the allegation was considered unsubstantiated as of 10/9/25 and V4 was allowed to return to work.The Facility's schedule documents that V4 (CNA) worked on 10/09/25 and 10/14/25. On 10/14/25 V4 (CNA) was the staff member responsible for R1's direct care. On 10/14/25 at 1:30 PM V1 (Administrator) confirmed that all statements from staff members on 10/4/25 indicated that V8 (CNA) was the staff member who took R1 from V4 (CNA) during the incident. V1 confirmed that she had not interviewed or spoken with V8 as of 10/14/25. I just haven't had problems with (V4/CNA) I wasn't that worried about it. The facility's schedule for 10/4/25 documents that 3 staff members that were present on the hallway that incident took place on and V2 confirmed she has not interviewed them: V8 (CNA), V11 (CNA) and V12 (CNA).On 10/16/25 V1 (Administrator) provided an amended Abuse Investigation dated 10/15/25 that declared the abuse allegation on 10/4/25 as substantiated abuse. The Facility's Resident Bedsheet census form dated 10/4/25 documents that 88 residents reside in the facility.Immediate Jeopardy Removal Plan:The Facility submitted it's original Abatement plan on 10/16/25 at 2:50 PMRegional Office returned the Abatement for corrections at 3:39 PMThe Facility submitted the Abatement plan with corrections on 10/16/25 at 3:42 PMRegional Office returned the Abatement plan for corrections on 10/17/25 at 9:04 AM.The Facility submitted the Abatement plan with corrections at 10:00 AMRegional Office returned the Abatement plan for corrections at 11:05 AMThe Facility submitted the Abatement plan at 11:21 AMRegional Office accepted the Abatement plan on 10/17/25 at 11:43 [NAME] 10/16/25 and 10/17/25 this surveyor confirmed through interview and record review that the facility took the following steps to remove the immediacy 1. On10/16/25 Administrator, DON, and ADON reviewed Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating.2. On 10/16/2025 staff were educated on Abuse Prevention Policy by V2 (DON) and V3 (ADON) 3. On 10/16/2025 Staff not working dayshift were called by (V1) Administrator, V2(DON), and V3 (ADON) were given education via phone of Abuse Prevention policy.4. Remainder of the staff not working or reached by phone will be required to receive the education prior to working their next shift by V2 (DON) and/or V3 (ADON) or designee and will be required to sign the education sign-in sheet. 5. On 10/16/25 An Emergency QAPI (Quality Assurance Performance Improvement)discussion was held with Medical Director, V1(Administrator,)V2(DON), V3(ADON) and V32(Social Service Director) to review the investigation findings and conclusion and review the QA audit tools for ongoing audit plan. QA Audit for thorough investigation will be conducted with each allegation investigation. These audit findings will be reported monthly on the QAPI scorecard and reported at the quarterly Quality assurance meeting.6. V1 ( Administrator) and V2 (DON)will meet monthly to review all audit findings and discuss, if any, possible further training/education or policy review changes need to occur. 7. R1's Care Plan was updated with at risk for abuse/harm and interventions by Social Service Director on 10/16/2025.Date of completion10/16/2025

Based on interview and record review the facility failed to ensure one resident (R1) was free from abuse of three residents reviewed for abuse in a total sample of nine. Based on V8's statement R1 acted scared and followed me around all night. I for sure think she was traumatized by the whole thing even if she couldn't say it., it can be determined that the reasonable person in this resident's position would have experienced psychosocial harm (e.g., embracement, humiliation, anxiety) as a result of this abuse. This failure resulted in an Immediate Jeopardy. Findings include: The Immediate Jeopardy began on 10/4/25 around 6:30 PM when R1 was forcibly moved down the hallway against her will while she was fighting and yelling. On 10/16/25 at 9:30 AM V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 10/4/25 around 6:30 PM. While the immediacy was removed on 10/17/25, the facility remains out of compliance at a severity Level 2 to evaluate the implementation and effectiveness of their removal plan. The Facility's Abuse and Neglect policy dated July 2023 documents It is the policy of (this facility) to provide each resident with an environment free from abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of resident property, exploitation, and physical or chemical restraint not required to treat the resident's symptoms, as defined below. The Facility's Abuse and Neglect policy dated July 2023 documents Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. This includes deprivations by an individual, including a caretaker, of goods or services necessary to attain or maintain physical, mental, or psychosocial well-being. This presumes instances of abuse of all residents, even those in a coma, cause physical harm, or pain mental anguish. Physical Abuse- includes but not limited to, hitting, slapping, pinching, and corporal punishment. a. resident to resident abuse with or without injury b. staff to resident abuse with or without injury c. other (visitor, relative) to resident abuse with or without injury.R1's Medical Record documents that she was admitted to the facility on [DATE] with diagnosis to include but not limited to Alzheimer's Disease, Depression and Hypertension. R1's MDS (Minimum Data Set) dated 9/5/25 documents that she is rarely/never understood. R1's current undated care plan documents the resident is/has potential to demonstrate physical behaviors related to Dementia. R1's care plan documents the intervention for this this resident tolerates 1 to 2 people at a time. The resident needs personal space. The resident does not like to be touched by anybody. When resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to calmly walk away and approach later.On 10/14/25 at 11:00 AM V7 (R1's Health Care Power of Attorney) stated that he did not think the facility is used to having someone so mobile and confused. I don't think they know what they are doing with her. She can be difficult but their approach is a lot of the problem. When I get phone calls about (R1)'s behaviors staff say things like '(R1) has been off the chain today' or 'she's been crazy all day.' Throughout the survey R1 did not answer any questions appropriately and became verbally aggressive when spoken to.The Facility's Abuse Investigation dated 10/9/25 documents that on 10/4/25 around shift change/approximately 6:30 PM R1 was at the end of the hallway near a door and V3 (Registered Nurse) approached R1 and attempted to redirect her away from the door. The investigation documents that R1 was redirected from the door by V4 (Certified Nurse Aide). Staff Interviews dated from 10/4/25 through 10/9/25 document that R1 had been having combative behaviors and been resistive to cares for most of the day and became combative when V4 (Certified Nurse Aide) attempted to redirect her away from V3 (Registered Nurse) and the door. The Investigation dated 10/9/25 documents that the abuse allegation was unfounded and that it was believed that V4 (CNA) was intervening due to a behavior. On 10/14/25 at 10:00 AM V4 (CNA) stated that on 10/4/25 R1 had been crazy all day. V4 stated that at the end of her shift she saw R1 by the door with V3 (RN). V4 stated R1 was arguing with V3 (RN) and attempting to exit the door. V4 confirmed that she walked up behind R1 and hooked her arm up under R1's arm and turned her around and started walking towards (R1)'s room. V4 confirmed that R1 did not want to go. V4 repeatedly answered I do not recall to most other questions asked such as where any other staff members were at the time, how she knew that R1 did not want to go down the hallway and whether or not V4 cursed during this interaction as was documented in another interview.On 10/14/25 at 1:30 PM V9 (Licensed Practical Nurse) stated that on 10/4/25 during shift change around 6:30 PM she was waiting to get report from V3 (Registered Nurse) but V3 (RN) was at the door with R1 attempting to get R1 to go down the hall away from the door and R1 was resisting leaving the area. V9 (LPN) stated that V4 (CNA) walked up to V3 (RN) and R1 and said we aint doing this sh*t today and hooked her arm under R1's arm and marched her back up the hallway and yelled for help from another V5 (CNA) who was just walking out of another resident's room. V9 stated that both she and V3 (RN) felt very uncomfortable with V4 (CNA)'s actions.On 10/14/25 at 2:00 PM V3 (RN) stated on 10/4/25 during shift change R1 was by the doors that led out of the unit. V3 stated she was attempting to redirect R1 to back away from the doors. (R1) was slapping at my arms and yelling, but she does that all the time. She had been doing it all day. V3 stated that V4 (CNA) swooped in and hooked (R1) under the arm and dragged her down the hallway. V3 denied requesting help or needing help. (R1) had been having behaviors all day, it felt like (V4/CNA) just decided that (R1) was not going to be acting like that anymore. (V4/CNA) was visibly angry during this interaction. V3 (RN) stated that at the time of the incident both she and V9 (LPN) felt that the interaction was not appropriate and aggressive on V4 (CNA)'s part.On 10/14/25 at 3:00 PM V8 (Certified Nurse Aide) stated that on 10/4/25 he heard a commotion and turned the corner to see R1 being dragged down the hallway while she was fighting and yelling. V8 stated that V4 stated here you take her. V8 stated he was able to hold his hand out to R1 and she took it calmly and was cooperative once let go. That is not the way we should be treating a confused person. (V4/CNA) was noticeably upset and frustrated with (R1). R1 acted scared and followed me around all night. I for sure think she was traumatized by the whole thing even if she couldn't say it. On 10/14/25 at 2:30 PM V1 (Administrator) stated I am now hearing more of the story about the incident on 10/4/25 with (R1) and (V4/CNA). I am reopening the investigation and interviewing more staff.On 10/16/25 V1 (Administrator) provided an amended Abuse Investigation dated 10/15/25 that declared the abuse allegation on 10/4/25 as substantiated abuse. Immediate Jeopardy Removal Plan:The Facility submitted it's original Abatement plan on 10/16/25 at 11:31 AMRegional Office returned Abatement plan for corrections on 10/16/25 at 2:06 PMThe Facility submitted the Abatement plan with corrections on 10/16/25 at 2:21 PM, then V1 (Administrator) stated that she noticed a mistake and re-submitted another version of the Abatement plan at 2:27 PM. Regional Office submitted the Abatement plan with more corrections on 10/17/25 at 9:04 AMThe Facility submitted the Abatement plan with corrections on 10/17/25 at 10:00 AMRegional Office submitted the Abatement plan with more corrections at 11:05 AMThe Facility submitted the Abatement plan with corrections at 11:21 AMThe Facility's Abatement plan was accepted on 10/17/25 at 11:43 AM.On 10/16/25 and 10/17/25 this surveyor confirmed through interview and record review that the facility took the following steps to remove the immediacy1.On 10/16/25: V1 (Administrator),V2 (Director of Nursing) and V3 (Assistant Director of Nursing) reviewed Abuse Policy and intervening and reporting with quiz; Stress and Burnout Handout, Coping with Workplace Stress, Training and Tips for Spotting Stress or Burnout with all on duty staff in person. All staff not working on at the time were reached by phone and were educated. Any staff who were not reachable will not be able to clock in for their next shift until V2 (DON) or V3 (ADON) provide the education and handouts.2. The Abuse policy and intervening and reporting with quiz, Stress and Burnout Handout, Coping with Workplace Stress, Training and Tips for Spotting Stress or Burnout specific to intervention of preventing abuse and recognizing stress and burnout in co-workers and intervening was added to the orientation packet for new staff.3.On 10/16/25 An emergency QAPI (Quality Assurance and Performance Improvement) discussion was held with the Medical Director, V1 (Administrator),V2 (DON), V2 (ADON) and V32 (Social Service Director) to review the investigation findings and conclusion and review the QA audit tools for ongoing audit plan. QA Audit will be conducted of 5 residents and 5 staff per month by V2 (DON), V3 (ADON), V32 (Social Services Director) and/or designees about Abuse, Stress, and Burnout and concerns regarding any cares. These audit tools will be reported monthly on the QAPI scorecard and reported at the QA meeting; 4.On 10/17/25 All residents with Alzheimer's Disease/Dementia were reviewed for At Risk for Abuse/Harm and any identified, care plan was be added and/or updated by V32 (SSD) .5. V1 (Administrator) and V2 (Director of Nursing) will meet monthly to review all audit findings for discussion for need, if any, for further training/education and/or policy review changes.Completion date 10/17/25

Based on interview and record review the facility failed to ensure that Certified Nursing Assistant staff have had required 12 hours of in-service education. This failure has the potential to affect all 88 residents residing in the facility. Findings include: The facility policy titled, Abuse and Neglect, dated July 2023, documents not in its entirety, 3.) Aversion And Intervention of Abuse, a. Preventing resident abuse is a primary concern for Sunset Home. It is our goal to achieve and maintain an abuse free environment. B. Our abuse/intervention program may include but is not limited to: i. Conducting conflict resolution training classes for all staff. vii. Regularly scheduled in-service training programs designed to teach staff how to better understand the resident's abusive actions. Facility Town Hall meeting in-service sign in sheet for abuse training dated 3/13/25 documents V5, V6, V13, V15, and V16 (all Certified Nursing Assistants) attended, Town Hall meeting in-service sign in sheet for abuse training dated 4/17/25 documents V4, V5, V13, V17, V18, V19, V20, V21, V22, V23, V24, V25, V26, V27, and V28 (all Certified Nursing Assistants) attended, Town Hall meeting in-service sign in sheet for abuse training dated 9/18/25 documents V4, V5, V11, V12, V13, V14, V15, V19, V20, V21, V22, V23, V27, V29, V30, and V31 (all Certified Nursing Assistants) attended. On 10/15/25 at 1:10 PM V2 (Director of Nursing/DON) stated she is not sure about dementia training for the Certified Nursing Assistants/CNA, but the abuse training is done in the Town Hall meetings, and she (V2/DON) stated she does skills in-services on various topics at the monthly CNA meetings. On 10/15/25 at 1:15 PM V1 (Administrator) stated that she was not sure if there is proof that the CNAs (Certified Nursing Assistant) have had the required 12 hours of yearly in-servicing/education but will check with Human Resources. V1 also stated she does not think there has been any dementia training in the one and half years she has been with the facility. On 10/15/25 at 2:20 PM V1 (Administrator) stated, I'm going to be honest with you we do not have any proof to show that the CNA (Certified Nursing Assistant) staff have had their 12 hours of training and unable to prove they all have had abuse and dementia training.

Based on interview and record review, the facility failed to report an injury of unknown origin to the state agency for one of three residents (R1) reviewed for bruises in a sample of three. Findings include: The facility's Abuse and Neglect Policy, dated 7/2023, documents Identifying and Recognizing signs and symptoms of abuse: a. The following are examples of actual abuse/neglect and signs and symptoms of abuse/neglect which should be promptly reported. This listing is not all inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. When in doubt, reported immediately. i. Signs of/actual physical abuse: 1. Welts or bruises. State Agencies: Purpose- to assure all serious bodily injuries and reasonably suspected crimes against resident's, resulting in serious bodily injuries, are reported to IDPH (Illinois Department of Public Health) immediately, all serious incidents and accidents, and allegations of abuse, including injuries of unknown sources, and reasonably suspicion of a crime against a resident are reported to IDPH in an appropriate fashion immediately with a final report sent to the department within five days. R1's Progress Note, dated 2/25/25 and signed by V4/LPN (Licensed Practical Nurse), documents During transfer from wheelchair to stretcher this nurse observed a large circular red/purple bruise to (R1's) left mid back. Emergency Medical Technicians were made aware that (R1) has been on Eliquis (blood thinning medication) but it was placed on hold per (V6/Nurse Practitioner) and that (R1) experienced no recent falls that this nurse was aware of other than the one on 2/7/25. This same progress note documented V4 notified V2/DON (Director of Nursing) of the bruise located to R1's left mid back. On 5/2/25 at 2:15PM V4/LPN stated she observed a large purplish/red bruise approximately six inches in diameter to R1's left mid back for the first time when sending R1 out to the hospital. V4 stated she was unable to measure the bruise to R1's back because R1 was being transferred out to the local hospital. V4 stated, I reported the bruise to (V2/Director of Nursing) because it had appeared overnight, and I did not know what caused it. I let (V2) know I did not believe it was due to (R1's) fall, because the fall had occurred two to three weeks prior to the bruise appearing. There was no rhyme or reason to the bruise appearing to (R1's) back. As of 5/2/25, the facility's reports to the local State Agency did not contain documentation of R1's 2/25/25 injury of unknown origin as being reported. On 5/2/25 at 2:28 PM V2/DON stated V4 did report R1's bruise (injury of unknown origin) to V2. V2 stated R1's injury of unknown origin was not reported to the local State Agency and should have been. On 5/3/25 at 10:03 AM V1/Administrator verified the bruise to (R1's) left mid back was not reported to the local State Agency and should have been.

Based on record review and interview, the facility failed to ensure a thorough investigation was completed following a bruise of unknown origin for one of three residents (R1) reviewed for bruises in a sample of three. Findings include: The facility's Abuse and Neglect Policy, dated 7/2023, documents an injury should be classified as an injury of unknown source when the injury was not observed by any person, could not be explained, and the injury is suspicious because of the extent of the injury or the location. This same policy also states, VI. Abuse Investigations. All reports of resident abuse, neglect, and injuries of unknown origin shall be promptly and thoroughly investigated by the organization management. c. The individual conducting the investigation will, at a minimum: i. review the resident's medical record to determine events leading up to the incident. ii. Interview the person(s) reporting the incident. iii. Interview any witnesses of the incident. iv. Interview the resident (as medically appropriate). v. Interview the resident's attending physician to determine the resident's current mental status. vi. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. vii. Interview the resident's roommate, family members, and visitors. viii. Interview other residents to whom the accused employee provides cares or services and ix. Review all events leading up to the alleged incident. k. The results of the investigation will be documented. R1's Progress Note, dated 2/25/25 and signed by V4/LPN (Licensed Practical Nurse), documents During transfer from wheelchair to stretcher this nurse observed a large circular red/purple bruise to (R1's) left mid back. Emergency Medical Technicians were made aware that (R1) has been on Eliquis (blood thinning medication) but it was placed on hold per (V6/Nurse Practitioner) and that (R1) experienced no recent falls that this nurse was aware of other than the one on 2/7/25. This same progress note documented V4 notified V2/DON (Director of Nursing) of the bruise located to R1's left mid back. On 5/2/25 at 2:15PM V4/LPN stated she observed a large purplish/red bruise approximately 6 inches in diameter to R1's left mid back for the first time when sending R1 out to the hospital. V4 stated she was unable to measure the bruise to R1's back because R1 was being transferred out to the local hospital. V4 stated, I reported the bruise to (V2/Director of Nursing) because it had appeared overnight, and I did not know what caused it. I let (V2) know I did not believe it was due to (R1's) fall, because the fall had occurred like two to three weeks prior to the bruise appearing. There was no rhyme or reason to the bruise appearing to (R1's) back. As of 5/2/25, the facility's investigations for allegations of abuse did not contain documentation that R1's 2/25/25 injury of unknown origin was investigated as potential abuse. On 5/2/25 at 2:28 PM V2/DON stated V4 did report R1's bruise (injury of unknown origin) to V2. V2 stated an investigation was never initiated for the bruise/injury of unknown origin located on R1's left mid back and should have been. On 5/3/25 at 10:03 AM V1/Administrator verified an investigation was never initiated for the bruise/injury of unknown origin to R1's left mid back and should have been.

Based on interview and record review the facility failed to follow treatments as ordered by the physician and failed to implement pressure relieving interventions for one resident (R5) of four residents reviewed for pressure ulcers in the sample of nine. These failures resulted in R5 developing a facility acquired stage 4 pressure ulcer to her coccyx that became infected and caused R5 pain. Findings include: The Prevention of Pressure Injuries policy dated 4/2020 documents The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Mobility/Repositioning 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. 2. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. The Administering Medications policy not dated documents that medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame. 18. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR (Medication Administration Record) space provided for that drug and dose. 19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 21. Topical medications used in treatments must be recorded on the resident's treatment record (TAR) (Treatment Administration Record). 28. If a medication error is noted to have occurred, immediately assess the resident for adverse reactions and notify the physician for any additional orders. Place the resident on the 24-hour report book, notify the POA (Power of Attorney) and fill out a medication error form and turn into the nursing office. R5's Face Sheet documents R5 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses which included Spinal Stenosis, Lumbar Region without Neurogenic Claudication, Prolapsed Uterus, Essential (Primary) Hypertension, Unspecified Urinary Incontinence, Vitamin D Deficiency, Other Abnormalities of Gait and Mobility, Chronic Diastolic (Congestive) Heart Failure, Weakness, and Chronic Kidney Disease, Stage Three. R5's Progress Notes dated 12/21/24 at 12:48 AM document that R5 passed away on 12/20/24. R5's Brief Interview for Mental Status/BIMS dated 11/20/24 documents a BIMS of 10 (moderate cognition). R5's MDS (Minimum Data Set) assessment dated [DATE] documents R5 required substantial assist for bed mobility, was dependent on staff for toileting and transfers, R5 had an indwelling urinary catheter, and R5 was always incontinent of bowel. R5's Care Plan dated 12/5/24 documents that R5 had impaired skin integrity related to Immobility and a Prolapsed Uterus and a Pressure Ulcer to the Coccyx dated 12/5/24. Interventions Administer treatments as ordered and monitor for effectiveness. Avoid positioning (R5) on coccyx. Follow facility policies/protocols for the prevention and treatment of skin breakdown. This same Care Plan documents R5 had ADL (activities of daily living) self-care needs, was dependent on staff for bed mobility, and required one staff to turn and reposition R5 in bed. R5's Nursing Note written by V2/Director of Nursing dated 9/18/24 at 3:00 PM, documents that R5 has two new pressure ulcers. Skin issue # (number) 1 is a stage one pressure injury on R5's left buttock that measures 0.7 cm/centimeters x 0.8 cm x 0.1 cm. Skin issue # 2 is a stage two pressure ulcer on R5's coccyx that measures 1.1 cm x 1 cm x 0.1 cm. There is no wound odor or tunneling on either wound. R5's Physician Order dated 9/18/2024 documents Cleanse coccyx open area with NS (Normal Saline) and apply calcium alginate and (absorbent foam dressing) daily. Start date 9/18/2024. Cleanse open area to L (left) buttocks with NS and apply (moisture barrier ointment) TID (three times a day) and PRN (as needed). Start date 9/18/24. R5's Physician Order dated 10/19/2024 documents Cleanse coccyx and R (right) buttock open areas with NS and apply calcium alginate four x (by) four gauze and (absorbent foam dressing) daily until healed. Start date 10/19/24. R5's Braden Evaluation dated 11/20/24 at 3:52 PM, documents Sensory Perception: very limited. Moisture: Constantly moist. Activity: Chair fast. Resident is Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Nutrition: Probably inadequate. Braden score of 10 (High Risk). R5's Progress Notes written by V4/Nurse Practitioner/NP for 12/2/24 service, documents R5 is a [AGE] year-old female who is seen today due to worsening wound to the coccyx. Last week the on-call NP was paged with concerns for progression of the wound. The wound measures 2.5 cm/centimeters by 3.5 cm by 1.2 cm with tunneling, sloth, and foul odor (indicates infection). Orders were given for Santyl, calcium alginate and dressing, change daily. I (V4) am following up today. At my previous visit in early November, wounds to the coccyx and right buttocks were superficial without any slough tissue, depth, or tunneling. The area is painful for (R5). Wound care to coccyx: Cleanse with 1/4 (Diluted sodium hypochlorite solution) 0.125% (percent) solution. Apply Santyl to slough tissue in wound bed. Pack with (Diluted sodium hypochlorite solution) soaked four X four gauze, ensuring packing extends through the tunneling. When removing old dressings, MUST be sure old gauze is removed!!! This dressing must be changed daily. Start Oxycodone 2.5 mg/milligrams oral daily; give 30 minutes prior to wound care in the AM. Turn every 2 (two) hours while in bed. (Pressure relieving) cushion at all times when in wheelchair. R5's Physician Order dated 12/3/2024 documents (Diluted sodium hypochlorite solution) (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite) Apply to coccyx topically one time a day for wound care. Cleanse wound with (Diluted sodium hypochlorite solution), apply Santyl to slough tissue in wound bed. Pack with (Diluted sodium hypochlorite solution) soaked four X four gauze, ensure packing extends through tunneling. Upon removal make sure old gauze is removed. Dressing must be changed daily. Start date 12/4/24. Oxycodone HCI Oral Tablet 5 MG (milligrams) Give 0.5 tablet by mouth every night shift for wound prior to wound care. Start date 12/3/24. R5's Nursing Note written by V6/LPN dated 12/3/24 at 1:57 PM, documents Per (V4/Nurse Practitioner) on 12/3/24 at 1:00 PM: Orders for wound care as follows: Cleanse with 1/4 (Diluted sodium hypochlorite solution) 0.125% solution. Apply SANTYL to slough tissue in wound bed. Pack with (Diluted sodium hypochlorite solution) soaked 4x4 gauze, ensuring packing extends through the tunneling. When removing old dressings, MUST be sure old gauze is removed!!! This dressing must be changed daily. Currently waiting on (Diluted sodium hypochlorite solution) from the pharmacy. Faxed pharmacy to ensure (Diluted sodium hypochlorite solution) is delivered tonight. R5's Medication Administration Note written by V6/Licensed Practical Nurse/LPN dated 12/3/24 at 2:41 PM, documents (Diluted sodium hypochlorite solution) (1/4 strength) External Solution 0.125 % Apply to coccyx topically one time only for Wound care for 1 (one) Day 1 dose No supplies available from pharmacy at this time. R5's Physician Order dated 12/5/2024 documents (Diluted sodium hypochlorite solution) (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite) Apply to coccyx topically every day and night shift for wound care. Cleanse wound with (Diluted sodium hypochlorite solution), apply Santyl to slough tissue in wound bed. Pack with (Diluted sodium hypochlorite solution) soaked four x four gauze, ensure packing extends through tunneling. Upon removal make sure old gauze is removed. Dressing must be changed daily. Start date 12/5/24. Turn every two hours while in bed, side to side, avoid laying on back. Must use pillows between knees. Every shift to prevent further breakdown. Start 12/5/24. R5's Progress Notes written by V4/NP for 12/13/24 service, documents that R5 is a [AGE] year-old female who is seen today for follow up wound care to the coccyx. Physical Exam Stage four, now with deep tissue injury to surrounding tissue at 12 O'clock. Wound bed: 2.5 cm x 3.5 cm x 1.2 cm with slough/foul odor (indicated in fection) and tunneling at 5-6 O'clock, approx. 3 of tunneling. Cleanse with 1/4 (Diluted sodium hypochlorite solution) 0.125% solution. Apply Santyl to slough tissue in wound bed. Pack with (Diluted sodium hypochlorite solution) soaked 4 x 4 gauze, ensuring packing extends through the tunneling. When removing old dressings, MUST be sure old gauze is removed!!! Changed dressings twice daily. Turn every two hours while in bed, side to side, avoid laying on back. Must use pillows between knees to prevent further breakdown. R5's Medication Administration Note written by V17/Licensed Practical Nurse dated 12/17/24 at 4:52 AM, documents (Diluted sodium hypochlorite solution) (1/4 strength) External Solution 0.125 % Apply to coccyx topically every day and night shift for wound care Cleanse wound with (Diluted sodium hypochlorite solution), apply Santyl to slough tissue in wound bed. Pack with (Diluted sodium hypochlorite solution) soaked 4x4 gauze, ensure packing extends through tunneling. Upon removal make sure old gauze is removed. Dressing must be changed daily. Unable to complete due to there being no (Diluted sodium hypochlorite solution) available to complete this treatment. R5's Skin Check dated 12/18/24 at 5:38 AM, documents that R5 has a Stage four Pressure Ulcer, full thickness skin and tissue loss on her right coccyx that was acquired in-house. R5 is unable to describe pain. R5 says It hurts during dressing change. Length 7 cm/centimeters, width 5.5 cm, depth 3 cm, with undermining and tunneling. Granulation 50 % (percent), slough 50 %, with purulent heavy exudate and moderate odor after cleansing. Skin issue 2, left breast Excoriation Pressure ulcer staging: Stage 2 Pressure ulcer/injury - partial thickness skin loss with exposed dermis. Wound acquired in-house. Length 6 cm, Width 1.3 cm, Depth 1.2 cm. Skin issue 3, Right medial forefoot, Eschar Pressure ulcer staging: Stage 2 Pressure ulcer/injury - partial thickness skin loss with exposed dermis. Wound acquired in-house. Other pain description: Unable to describe, says It hurts when doing dressing change. Length 1.5 cm, Width 1.6 cm, Depth 1.2 cm, Area 9.3 cm. R5's Treatment Administration Records/TAR for September 2024 through December 2024 documents Cleanse coccyx open area with NS (normal saline) and apply calcium alginate and (absorbent foam dressing) daily. This same TAR documents R5's treatment was not signed as being done on 9/22, 9/23, 9/24/24. Cleanse open area to L (left) buttocks with NS and apply (moisture barrier ointment) TID (three times a day) and PRN (as needed) every shift for Wound care. This same TAR documents R5's treatment was not signed as being done on day shift 10/5, 10/20, 11/7, evening shift 9/20, 9/21, 9/24, 9/29, 11/6, 11/12, 11/26, 11/27, 11/28/24, and night shift 9/22, 9/23, and 9/24, 10/21, 10/23, 11/22, 11/24 Cleanse coccyx and R (right) buttock open area with NS and apply calcium alginate four x four gauze and (absorbent wound dressing) daily until healed. This same TAR documents R5's treatment was not signed as being done on 11/6, 11/22, and 11/24/24. (Diluted sodium hypochlorite solution) (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite) Apply to coccyx topically every day and night shift for wound care. Cleanse wound with (Diluted sodium hypochlorite solution), apply Santyl to slough tissue in wound bed. Pack with (Diluted sodium hypochlorite solution) soaked 4 X 4 gauze, ensure packing extends through tunneling. Upon removal make sure old gauze is removed. Dressing must be changed daily. This same TAR documents R5's treatment was not signed as being done on days 12/10/24 and nights 12/11/24. Turn every 2 (two) hours while in bed, side to side, avoid laying on back. Must use pillows between knees. Every shift to prevent further breakdown. This same TAR documents R5's treatment was not signed as being done on the evening of 12/12/24. On 3/13/25 at 11:20 AM, V4/NP stated, I took care of (R5) for five years. For most of that time (R5) was stable with advanced Dementia. (R5) was up to activities then started having age related decline that led to her being bed bound. (R5) was not getting up at all at that time. (R5's) wound were caused by pressure. (R5's) wounds started out simple and treatments were ordered. From what I knew the treatments were working for (R5's) wounds and they were getting better. Then I was notified that I needed to look at (R5's) wound. I was totally floored by how huge it was. It was foul smelling and infected. It looked like there was also a deep tissue injury. I told (R5's) family that unfortunately this wound is bad, and we can't do surgery and all we can do is to try to manage pain and odor because the odor was so bad. We were doing symptom control until the end of (R5's) life. Once bed bound, (R5) should have been turned, and I should not have to explain it to staff and put that in the orders. It is nursing 101 that a resident should be turned and repositioned. (R5's) wound was nasty. I don't think (R5's) wound care was being done as ordered. I do the treatments at times and the supplies are not always available. I have had to request that they (the facility) get supplies that I have ordered. If treatments are not done as ordered the wound will get worse. On 3/13/25 at 4:51 PM V3/Previous MDS Coordinator stated There are a lot of reasons that (R5's) pressure ulcer got worse. (R5) was not turned like she should have been. The staff are not good about turning and repositioning the residents. (R5) had a small pressure ulcer that healed then (R5) got another one. The dressings were not changed like it should have been either because we would run out of supplies. On 3/14/25 at 11:34 AM, V16/R5's Power of Attorney/POA stated I came to the facility about once a week and talk to (R5) every day. (R5) had dementia but she knew what was going on. I went in more once (R5) was moved to the fourth floor from the first floor. The care just wasn't as good on the fourth floor. Most of the time (R5) was laying on her back. There was a sign in her room that (R5) was to be on her side. (V4/NP) made it known that (R5) should be on her side. I am putting the blame on the aids not all of them but some. (R5) had no use of her legs and could not move herself. (R5) was dependent on staff. I saw the wound and it was disgusting. I wish I had never seen it. It had a bad smell and was nasty. (V4/NP) had been brought in to take care of it. (V4) told me that inside the wound was bigger than the outside. It was on (R5's) lower back towards the buttock. On 3/15/25 at 1:23 PM, V12/LPN stated that she took care of R5. R5 did have a pressure ulcer that got worse and had a bad odor to it. There were times there were no supplies to do the dressing. R5 was supposed to be kept off her back while in bed but that didn't always happen. On 3/15/25 at 1:36 PM, V13/LPN stated I am not at the facility often because I work as needed. The first time I saw the skin issue on (R5) it looked like a bruise. About a week later the area had opened and had a foul smell to it. On 3/15/25 at 3:59 PM, V15/Registered Nurse/RN stated (R5) had a pressure ulcer that got worse from laying on her back. The CNAs (Certified Nursing Assistants) don't turn the residents like they are supposed to. On 3/17/25 at 1:43 PM, V1/Administrator verified that according to R5's TAR, R5's dressings were not done daily as ordered. V1 stated If it is not marked it is not done. On 3/18/25 at 10:18 AM, V4/NP stated R5 was a high risk for developing a pressure ulcer but the severity of the wound did not need to happen. Better care would have minimalized the severity of it.

Based on interview and record review the facility failed to transcribe a physician's order accurately, administer the correct physician's ordered insulin for 45 days, and notify the physician once a residents' blood sugar dropped below normal parameters for one resident of three residents (R1) reviewed for significant medication errors in the sample of nine. These failures resulted in R1 experiencing hypoglycemia and lethargy on two occasions that required glucagon injections. Findings include: The Administering Medications policy not dated documents that medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame. 18. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR (Medication Administration Record) space provided for that drug and dose. 19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 21. Topical medications used in treatments must be recorded on the resident's treatment record (TAR) (Treatment Administration Record). 28. If a medication error is noted to have occurred, immediately assess the resident for adverse reactions and notify the physician for any additional orders. Place the resident on the 24-hour report book, notify the POA (Power of Attorney) and fill out a medication error form and turn into the nursing office. R1's current computerized medical record documents R1 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which include Type 2 Diabetes Mellitus without Complications, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Trifascicular Block, Occlusion and Stenosis of Unspecified Carotid Artery, Lymphoid Leukemia, Unspecified Not Having Achieved Remission, Hyperlipidemia, Essential (Primary) Hypertension, Presence of Cardiac Pacemaker, Acute Diastolic (Congestive) Heart Failure, and Chronic Kidney Disease, Stage 3. R1's Brief Interview for Mental Status/BIMS dated 12/25/24 documents a BIMS of 2 (cognitively impaired). R1's current Care Plan documents that R1 has Diabetes Mellitus. Interventions Diabetes medication as ordered by doctor. R1's Physician's Notes/Orders written by V31/R1's Physician dated 11/4/24, documents Subjective: Clarify Orders (Sliding scale insulin needs addressed as (V28/R1's Power of Attorney/POA) states (R1) is bottoming out. Prescription has been updated. Insulin Aspart, w (with)/Niacinamide, (Fiasp) 100 UNIT/ML Inject 6-8 units into the skin 3 (three) times daily after meals. Inject per sliding scale: 100-150 2 units, 151-199 4 units, 200-250 6 units, 251-400 8 units. Lantus SoloStar 100 UNIT/ML SOPN Injection-pen Inject 30 (thirty) units 3 ML into the skin daily. Plan: Follow up in 6 (six) months (around 5/4/2025). R1's Nursing Note written by V20/Agency Licensed Practical Nurse/LPN dated 11/4/24 at 1:25 PM documents (R1) returned from doctors' appointment with some new orders. Please see MAR (Medication Administration Record) for the orders. R1's Medication Administration Record dated 11/1/24 - 12/19/24 documents Insulin Glargine-yfgn Subcutaneous Solution Pen Injector 100 UNIT/ML (Insulin Glargine-yfgn) Inject as per sliding scale. Start date 11/4/24 at 4:00 PM. R1's Nursing Note written by V25/Registered Nurse/RN dated 12/13/24 at 7:05 AM, documents Glucagon Emergency Injection Kit 1 (one) MG Inject 1 vial subcutaneously as needed for hypoglycemia. Blood sugar 44. R1's Medication Administration Note written by V3/LPN dated 12/18/24 at 7:52 AM, documents Glucagon Emergency Injection Kit 1 MG (milligram) Inject 1 vial subcutaneously as needed for hypoglycemia. R1's Nursing Note written by V3/LPN dated 12/18/24 at 7:54 AM, documents Blood sugar 37. Glucagon 1 mg given in left thigh. R1's Progress Notes written by V4/Nurse Practitioner/NP dated 12/19/25 at 4:35 PM documents (R1) is an [AGE] year-old male who is evaluated today for follow-up hypoglycemic episode. The nurse tells me (R1) required an injection of Glucagon again yesterday. Sugars are occasionally low in the morning. I reviewed (R1's) sugars and medication orders. I wrote previous orders about (R1's) sliding scale insulin although it appears these orders were not carried out when reviewing the MAR (Medication Administration Record). I also noted that the order for SSI (Sliding Scale Insulin) is entered as Basaglar, which is Glargine, which is incorrect. This is a long-acting insulin. STOP the incorrect order for sliding scale Basaglar. START insulin Aspart (Novolog) 100 units/ml and give according to the sliding scale. R1's Nursing Note written by V2/Director of Nursing/DON dated 12/19/24 at 2:37 PM, documents Clarified orders from (V4/NP) at this time. (V4) ordered to stop sliding scale of Basaglar which is (R1's) insulin Glargine-yfgn per insurance. (V4) is ok with using the current long-acting insulin. Start Aspart insulin which (R1) has Fiasp and (V4) is ok with continuing using that short acting insulin. R1's Medication Administration Record dated 12/19/24 - 12/31/24 documents Fiasp Flex Touch Subcutaneous Solution Pen- Injector 100 UNIT/ML (Insulin Aspart (with Niacinamide) Inject as per sliding scale. Start date 12/19/24 at 4:00 PM. R1's Progress Notes written by V4/NP for 12/16/24 service, documents, Labs reviewed. (R1) is awake and alert this morning. Labs show (R1's) sugar was 24 this morning. Glucometer read in the 50's. By late in the morning (R1) was in the 200 range. On call NP or myself was not notified of the Glucometer reading this morning. On 3/13/25 at 11:20 AM, V4/NP stated I was notified by nursing staff that (R1's) blood sugars had dropped for the second time in a week that required Glucagon to be given. It prompted a visit from me. I was like what is happening. I looked through the medical record and found the problem. I notified (V2/DON) that the incorrect insulin was being given. The order given on 11/4/24 was ordered by (V31/R1's Physician). I just looked the order up and the order from (V31) was correct. They were giving long-acting insulin as the sliding scale instead of the short acting and (R1) was bottoming out. I brought it to (V2/DON) to fix the order. (R1) didn't die but he was hypoglycemic, and I believe he bottomed out a couple of times and Glucagon needed to be used so I would say yes it did (R1) harm. I witnessed (R1) extremely lethargic from hypoglycemia. On 3/13/25 at 1:31 PM, V2/DON stated that R1's insulin order was changed on 11/4/24 and the new order got put in incorrectly. (V4/NP) asked me to check to see what happened. I found that the order was put in wrong. I don't remember how long it was wrong. It may have been a couple of weeks. On 3/13/25 at 4:51 PM V3/Previous Minimum Data Set/MDS Coordinator stated (V4/NP) asked me to check to see what insulin (R1) was getting. I sent a picture to (V4) then took the bottle to (V4). (R1) was not getting the correct insulin. (R1) was supposed to be getting fast acting insulin for sliding scale but instead was getting a slow acting insulin. (V20/Agency LPN) put the order in wrong for (R1). (R1) got the wrong medication for over a month. I was working on 12/18/24 when R1's blood sugar dropped so low that he passed out and I had to give (R1) Glucagon. On 3/14/25 at 10:28 AM V2/DON stated (R1) had his insulin corrected on 12/19/25. (R1) took a sliding scale fast acting insulin and a slow acting insulin. (R1's) order was changed and when (V20/Agency LPN) made the change on 11-4-24, (V20) transcribed the order wrong and put in the wrong insulin order to the pharmacy and on (R1's) MAR. (R1) took the wrong insulin from 11/4/24 - 12/19/24. On 3/14/25 at 12:29 PM, V22/Pharmacist stated The insulin that was ordered on 11/4/25 for (R1) was a long-acting insulin. The insulin that (R1) should have got is completely different then what (R1) got. It was to be given before meals and that should have been questioned back to the doctor to see if that was correct because it is not usually given like that. That was not a normal order. Hypoglycemia is very serious, and you don't want that to happen. It could be very dangerous especially for the elderly. On 3/15/25 at 3:07 PM, V2/DON stated The pharmacy filled what we ordered for (R1) on 11/4/24 and that insulin was given until 12/19/24. Then on 12/19 (V4/NP) thought there was a problem with (R1's) insulin because (R1's) blood sugar had bottomed out. (V4) asked me to look into what was happening. I then realized that the wrong insulin had been ordered. (R1) was getting a slow acting insulin for sliding scale instead of the fast-acting insulin. (V4) doesn't usually give a verbal order. The order should have been double checked. On 3/18/25 at 1:23 PM, V1/Administrator stated, When that insulin order was put in for (R1) we (the facility) did not have checks in place to make sure the orders were correct.

Based on interview and record review the facility failed to send the correct medication on a home visit for one resident of three residents (R2) reviewed for home medications in the sample of 9. Findings include: The Administering Medications policy (not dated) documents Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame. The Dispensing Medications to Residents on Leave/Pass dated 4/2007, documents The facility shall provide residents with necessary medication(s) when they leave the facility temporarily. 1. Residents who are away from the facility during medication passes will be given scheduled and essential PRN (as needed) medication(s) to take with them. They will only be given the amounts and dosages needed for the length of the anticipated absence. R2's current computerized medical record documents R2 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which include Essential (Primary) Hypertension, Fibromyalgia, Spondylosis, Chronic Obstructive Pulmonary Disease, Hyperlipidemia, Unspecified Atrial Fibrillation, Hypertensive Chronic Kidney Disease, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, and Peripheral Vascular Disease. R2's MDS (Minimum Data Set) assessment dated [DATE] documents R2 has a Brief Interview for Mental Status/BIMS of 15 (cognition intact). R2 requires set up help for eating, supervision for bed mobility, and is dependent on staff for transfers. R2's Care Plan documents I have Diabetes Mellitus. Intervention Administer diabetes medication as ordered by doctor. R2's Nursing Note written by V8/Unit Coordinator dated 12/21/24 at 10:49 AM, documents (R2) went out with family Noon meds and 7 PM med's sent with (R2). (R2) is planning to return around 7 PM this evening. On 3/13/25 at 10:56 AM, V1/Administrator stated that she remembers a conversation about R2 going on a home visit and having the wrong insulin with her. Either R2 or her family were called and told it was the wrong insulin and for R2 not to take it. V1 does not know whose medication it was or why R2 was given it. On 3/13/25 at 4:51 PM V3/Previous MDS Coordinator stated (R2) was going on a home visit and (V7/Unit Coordinator) got (R2's) medication ready to send with (R2). When it was time for (R2) to leave (V6/Previous Licensed Practical Nurse/LPN) gave the medication to (R2). Later (V7) said that (V6) gave (R2) the wrong insulin. (R2) and her family were called and told the insulin was wrong and not to take it. On 3/14/25 at 1:42 PM, V1 stated (V7/Previous Unit Coordinator) got (R2's) medication ready for (R2) to take on her home visit and had them in the medication cart. (V7) then left the floor. While (V7) was gone (R2) was ready to leave the facility. (V6/Previous LPN) gave (R2) the insulin syringe that was in the cart with (R2's) other med's that were ready. Then (V7) returned to the floor and (V6) told (V7) that (R2) had left with her insulin and medication. (V7) told (V6) that was not (R2's) insulin. V1 also stated I have no idea of whose insulin that was. I don't know who it would have been for. On 3/14/25 at 1:50 PM, V2/Director of Nursing stated, There was no insulin that was supposed to go home with (R2). I don't know why the nurse had a syringe with insulin in it laying in the med cart. That shouldn't have happened. On 3/14/25 at 3:07 PM, R2 stated I went on a home visit on 12/21/24. I was gone from about 10:30 AM to 6:30 PM. Shortly after leaving the facility, I got a call and was told not to take the insulin the facility had sent with me because it was not my insulin. On 3/19/25 at 12:44 PM, V1/Administrator stated We do not have a policy on medication storage that I can find. I know the insulin should not have been left in the drawer like that.

Based on interview and record review the facility failed to notify a resident's family of a medication error and failed to notify the physician of a change in condition for one resident of three residents (R1) reviewed for insulin in the sample of 9. Findings include: The Administering Medications policy not dated documents Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame. 28. If a medication error is noted to have occurred, immediately assess the resident for adverse reactions and notify the physician for any additional orders. Place the resident on the 24-hour report book, notify the POA (Power of Attorney) and fill out a medication error form and turn into the nursing office. R1's current computerized medical record documents R1 is a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses which included Type 2 Diabetes Mellitus without Complications, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Trifascicular Block, Occlusion and Stenosis of Unspecified Carotid Artery, Lymphoid Leukemia, Unspecified Not Having Achieved Remission, Hyperlipidemia, Essential (Primary) Hypertension, Presence of Cardiac Pacemaker, Acute Diastolic (Congestive) Heart Failure, and Chronic Kidney Disease, Stage 3. R1's Progress Notes written by V4/Nurse Practitioner/NP for 12/16/24 service, documents (R1) is a [AGE] year-old male who is evaluated today for follow-up edema/blistering to the legs. Labs show (R1's) sugar was 24 this morning. Glucometer read in the 50's. By late in the morning (R1) was in the 200 range. On call NP or myself was not notified of the Glucometer reading this morning. On 3/14/25 at 10:28 AM V2/Director of Nursing stated (R1) had his insulin corrected on 12/19/25. (R1) took a sliding scale fast acting insulin and a slow acting insulin. (R1's) order was changed and when (V20/Agency Licensed Practical Nurse) made the change she put in the wrong insulin. I think that (V20) discontinued the right medication but then added the wrong medication. The correct medication is a short acting insulin Fiasp and the incorrect insulin was Glargine-yfgn. (R1) took the wrong medication from 11/4/24 - 12/19/24. On 3/17/25 at 10:56 AM, V1/Administrator stated I don't find any documentation that (V28/R1's Power of Attorney) was notified of the medication error for (R1). They should have been. On 3/18/25 at 10:27 AM, V4/NP stated I was reviewing (R1's) medical records and saw that (R1's) blood sugar had dropped. I was not notified when the incident happened. It is important I'm notified of a significant change when it happens instead of finding out about it later from reviewing medical records. On 3/19/25 at 1:02 PM, V1/Administrator stated that she does not have a specific policy about physician notification or family notification. V1 also stated (V4/NP) should have been told about (R1's) drop in blood sugar.

Based on interview and record review the facility failed to take vitals or do a resident's assessments in a timely manner for one resident of four residents (R3) reviewed for vitals and assessments in the sample of 9. Findings include: The Admitting the Resident: Role of the Nursing Assistant dated 9/2013, documents The following information should be recorded in the resident's medical record: 4. The resident's vital signs. 5. The resident's height and weight. The Admission Assessment and Follow Up: Role of the Nurse dated 9/2012, documents The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS (Minimum Data Set). 9. Conduct supplemental assessments following facility forms and protocol including a. Activity level; b. Pain assessment; c. Fall risk assessment; d. Neurological assessment; e. Skin assessment; f. Functional assessment ability to perform ADLs; and g. Behavioral assessment. The following information should be recorded in the resident's medical record: 3. Assessment data obtained during the procedure. R3's current computerized medical record documents R3 is a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses which included Secondary Malignant Neoplasm of Other Parts of Nervous System, Malignant Neoplasm of Right Kidney, Except Renal Pelvis, Acute Embolism and Thrombosis of Unspecified Deep Veins of Lower Extremity, Bilateral, Other Pulmonary Embolism without Acute Cor Pulmonale, Thrombocytopenia, Other Pancytopenia, Chronic Systolic (Congestive) Heart Failure, Cardiac Arrhythmia, Dehydration, Secondary Malignant Neoplasm of Bone, Shortness of Breath, Hyperlipidemia, Spondylosis without Myelopathy or Radiculopathy, Lumbar Region, Acute Embolism and Thrombosis of Deep Veins of Left Upper Extremity. R3's electronic Medical Record documents R3's assessments were done on 12/10/24 as follows: Elopement Evaluation at 6:41 AM, Braden Scale (Pressure Ulcer Risk) Evaluation at 2:24 PM, Skin Check at 2:26 PM, AIMS (Abnormal Involuntary Movement Scale) Evaluation at 3:17 PM, and Fall Risk Evaluation at 3:18 PM. R3's Weight and Vitals Summary dated 3/14/25 at 2:54 PM for 12/6/24 -12/20/24, documents the first vitals for R3 were recorded on 12/10/24 at 10:05 AM, four days after admission. On 3/13/24 at 1:33 PM V2/Director of Nursing/DON verified that R3 was admitted to the facility on [DATE] and there were no vitals recorded on the vitals log until 12/10/24. V2 stated I have no idea what happened. The vitals should have been taken and recorded. No idea why there are no vitals. The nurses are supposed to put them in the they put a lot on paper, and it doesn't always get recorded in the system. On 3/15/25 at 3:07 PM, V2/DON stated 'The assessments are the same for everybody. It doesn't matter if they are Private Pay, Medicare, or Medicaid. When a resident is first admitted vitals should be done every shift for at least the first three days to get a baseline. On 3/19/25 at 1:02 PM, V1/Administrator stated I can't find that any of the required assessments for (R3) were done when (R3) admitted on [DATE]. On 12/10/24 the Elopement Assessment, Skin Assessment, Fall Assessment, AIMS Assessment, and Braden Evaluation were all done but they should have been done sooner. V1 also stated I can't find a policy that clearly defines when vitals should be done.

Based on Observation, Interview and Record Review, the facility failed to keep the kitchen and resident dining areas free from cockroaches. This failure has the potential to affect all 96 residents residing in the facility. Findings include: The facility's Sanitation policy, dated 11/2022, documents The food service area is maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. All utensils, counter, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. The facility's Pest Control policy, dated 5/2008, documents Our facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. The facility's pest control Service Slip/ Invoice, dated 11/6/24, documents the facility's kitchen and surrounding areas were treated for roaches (cockroach insects). The facility's pest control Service Slip/ Invoices, dated 12/27/24, 1/10/25, 1/24/25, documents on each of these dates' areas of the facility, including the kitchen, dining halls, interior walls and basement were treated for cockroaches. The facility's pest control Service Slip/ Invoice, dated 1/31/25, documents the facility's kitchen, ice machine and third and fourth floor dining hall areas were treated. This invoice documents Four river (dining hall) was showing a lot of roaches. The facility's pest control Service Slip/ Invoice, dated 2/7/25, documents the facility was treated in the basement and the kitchen for cockroaches. On 2/10/25 at 11:40 AM, V8 (Certified Nursing Assistant, CNA) stated she worked in the facility's fourth floor Riverside hall on 1/27/25 and saw cockroaches in the dining area. V8 stated I did see roaches on resident trays in the fourth floor dining room. The counter by the sink and the ice machine is where they seem to be. They (staff) will put trays up there and that is where the roaches were seen. One of the aides (unknown), told me the ice had roaches in the past too. I have heard there have been issues with roaches for a long time. On 2/10/25 at 12:15 PM, a live cockroach was observed crawling on the floor beneath the sink and counter in the Riverside fourth floor dining area. A non-living cockroach was observed on the microwave stand above the dining room's sink. At this time V10 (CNA) confirmed the insect on the floor was a live cockroach and stated They (pest control) usually come spray to treat them. I've seen maybe a couple lives ones today, but nothing big. At this time the counter near the sink and microwave contained a plastic container with loaves of bread inside. This container had a broken piece of lid which created an approximate three inch hole in the container's top lid. A resident tray was sitting on the counter with food under a warmed lid. This same counter also contained three column containers with holes in them which each stored forks, knives and spoons. V11 (CNA) confirmed that the silverware in the columns on this counter is clean and for resident use. On 2/10/25 at 12:45 PM, V15 (Dietary Assistant) stated I mostly work in the main dining room, outside of the kitchen area. I am not in the kitchen as much. I have seen roaches in the main dining room. This morning, I opened the cabinet under the juice machine and there were several live roaches. The only things stored in that cabinet is bags of sealed coffee. They (cockroaches) are usually less than an inch in size. I have killed larger ones myself too. This issue of roaches has been going on for several months. We get sprayed but it never seems to help or work fully. On 2/10/25 at 12:50 PM, V16 (Dietary Manager) confirmed the facility has cockroaches in the kitchen and dining areas. V16 stated They are better, but I still see them occasionally but it's usually just one or two. I have seen them on counters, and we wipe down the area and then I send a work order to maintenance when I see them. About six months ago we did a deep clean of the entire kitchen and food storage, one time. Then a new pest control company took over and it's gotten better since then, but not all the way gone. On 2/11/25 at 9:55 AM, V17 (Director of Housekeeping) confirmed the facility has had infestation issues with cockroaches. V17 stated Housekeeping cleans the dining rooms three times a day on each floor. But when they clean, they are not responsible for removing trays. That is dietary's responsibility. Roaches used to be found in all of the dining rooms. We still see them in dining room on fourth floor. Staff are leaving the food sitting on the counter overnight. No matter how much we clean, we still see them. Everything needs deep cleaned more often. Trays of food get left on the counter would be what's feeding the bugs. Dietary should be taking all the trays back, not leaving them in the dining area. There was a big tray with food and bowls from last night's supper or lunch on the counter this morning in the fourth floor dining room. Then in the sink there was about eight plates, some cups and bowls, all with food on them. When I lifted the tray this morning, there was one live roach and I killed it. I have seen them around the ice machine in the past, not today. On 2/11/25 at 11:00 AM, V1 (Administrator) confirmed the facility has been having pest control visits to address cockroaches in the facility's kitchen and dining areas. V1 stated The problem has gotten better but they are still present. They (pest control) just came last Friday but I am not sure if there has been further investigation as to the source or location of the infestation. A resident room roster dated 2/10/25 and provided by V3 (Assistant Director of nursing), documents there are 96 residents residing in the facility.

Based on Observation, Interview and Record Review, the facility failed to ensure nursing assistants provided a resident at risk for falling with supervision, failed to provide residents with dining assistance, and failed to document meal and fluid intakes and episodes of incontinence for three of three residents (R1, R2, R3) reviewed for nursing care in the sample of four. Findings include: The facility's Assistance with Meals policy, dated 3/2022, documents Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. All residents will be encouraged to eat in the dining room. Facility staff will serve resident trays and will help residents who require assistance with eating. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals; keeping interactions with other staff to a minimum while assisting residents with meals. The facility's Certified Nursing Assistant job description, dated 4/16/20, documents The primary purpose of your job position is to provide your assigned residents with routine daily nursing care procedures, and as may be directed by your supervisors. Record all entries on flow sheets, notes, charts, etc. (etcetera), in an informative and descriptive manner. Use the Care Plan to identify residents before serving meals, transferring, etc., as necessary. Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift. Maintain intake and output records as instructed. Keep incontinent residents clean and dry. Serve food trays. Assist with feeding as indicated (example; cutting foods, feeding, assist in dining room supervision, etc.). Assist residents with identifying food arrangements (example; informing residents with sight problems, what foods are on the tray, where it is located, if it is hot/cold, etc.). Record the residents' food/fluid intake. Report changes in the resident's eating habits. The facility's Behavioral Programs and Toileting Plans for Urinary incontinence policy, dated 10/2010, documents The purpose of this procedure is to provide guidelines for the initiation and monitoring of behavioral interventions and/or a toileting plan for the resident with urinary incontinence. Monitor, record and evaluate information about the resident's bladder habits, and continence or incontinence, including: voiding patterns (frequency, volume, time, quality of stream, etc.); associated pain or discomfort; type of incontinence (stress, urge, mixed, overflow, functional, etc.); level of incontinence; and response to specific interventions. If the resident does not respond and does not try to toilet, or for those with such severe cognitive impairment that they cannot either point to an object or say their own name, staff will use a check and change strategy. A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin. R1's current Care Plan, dated 1/30/25, documents R1 has diagnoses including but not limited to Glaucoma, Dry Eye Syndrome, Dysphagia and Muscle Weakness. This Care Plan documents I have vision impairment and require glasses. ADL (Activities of Daily Living) self care needs; Eating, (R1) requires set up assistance by one staff to eat. I am incontinent of bladder related to Impaired Mobility, Loss of peritoneal tone, Poor toileting habits. Staff manage my urinary incontinence, and I am able to alert them to my wants/needs. I have impaired skin integrity related to immobility and bowel and bladder incontinence. Monitor nutritional status. Serve diet as ordered, monitor intake and record. R1's Weight Summary, dated 2/11/25, documents R1's weight on 1/7/25 was 129.8 pounds. This same record documents R1's weight on 2/4/25 was 121.8 pounds, indicating R1 has suffered a six percent weight loss in one month. R2's current Care Plan, dated 11/13/24, documents I have impaired cognitive function/dementia or impaired thought processes related to Alzheimer's. ADL (Activities of Daily Living) self care needs; Eating, (R1) requires extensive assistance by one staff to eat. (R2) is approaching end of life. Family has decided to enroll him in (Hospice Program). He has a diagnosis of Alzheimer's Disease with calorie malnutrition. R2's Minimum Data Set assessment, dated 1/1/25, documents R2 has severe cognitive impairment and is frequently incontinent of bowel and bladder. R3's current Care Plan, dated 12/4/24, documents (R3) is incontinent of bladder (related to) Confusion, Dementia, Impaired Mobility, Loss of peritoneal tone. The resident uses disposable briefs. Change per schedule and PRN (as needed). Anticipate and meet the resident's needs. (R3) is High risk for falls related to Deconditioning, Gait/balance problems. (R3) has had an actual fall: 3/21/23 no injury, 3/31/23 no injury, 8/5/23 lowered to floor, 9/10/24 slid out of wheelchair, 9/13/24 fall no injury, 12/12/24 lowered to floor no injury, 1/12/25 lowered to floor no injury. On 2/10/25 at 12:05 PM, R3 was observed in the entry way to the fourth floor River-view dining room. R3 was slouched down in her wheelchair and appeared to have slid far enough that she could not reposition herself. R3 stated Can you help me? at which time V13 (Certified Nursing Assistant, CNA) was observed walking from the hallway into the dining room towards R3. At this same time V10, V11 and V12 (CNAs) were all observed sitting together, side by side at a table in the fourth floor dining room. V10 was eating a container with deli meat, crackers and cheese and was drinking a carbonated beverage. V10 confirmed she is a CNA who works in the facility and is not on break. V11 got up from the table at this time. V10 and V12 both stood from the table and began removing trays from the dining tables. Several residents remained in the dining room at this time including R1 and R2 who both were seated at the table where V10, V11 and V12 were just sitting. R1 was staring forward and took an occasional bite of his cake. Less than 25% of his noon meal had been consumed, approximately half of his cake and no more than two bites of a grilled sandwich were eaten. R1's vegetables and sides were untouched. R1 did not engage in conversation and was not observed being encouraged to eat any more than he had consumed. R2 was sitting at the other end of the table and was sleeping upright in his wheelchair. Less than 50% of his meal was eaten. R1 and R2's trays were both collected by 12:15 PM, without any further consumption or encouragement of consumption from staff. On 2/10/25 at 12:30 PM, V14 (Registered Nurse) confirmed that R3 does have a history of falling and has fallen from her wheelchair by sliding out of it before. V14 then stated Typically, CNA staff do not eat in the dining room during resident meals because they are in there to watch and assist residents. On 2/10/25 at 12:35 PM, V12 (CNA) stated If we (nursing assistants) do incontinence care or turning and positioning, we just put it on a paper. We don't chart in the computer. I guess the nurse enters that in the computer, I don't know. On 2/11/25 at 11:00 AM, V1 (Administrator) stated CNAs should not be eating in the dining room during resident mealtimes. They should be assisting residents and supervising the meal, especially not sitting all together. R1, R2 and R3's medical records do not document meal intake percentages, incontinence cares provided or incontinent urinary output recordings. On 2/11/25 at 1:30 PM, V3 (Assistant Director of Nursing) stated We do not have anywhere that we document meal intakes in R1, R2 or R3's records. (R2) falls asleep during meals a lot, so he sometimes just needs cues. I did see where (R1) just triggered this month for weight-loss. CNAs don't chart intakes of meals anywhere though. (R3) does fall from her wheelchair sometimes. It sounds like (nursing assistant) staff yesterday were not doing what they're supposed to be. The expectation of CNA's assisting at mealtimes is much more than what was being done. They should not all be sitting at the same table together when residents are in there for supervision and meal assistance. On 2/11/25 at 2:20 PM, V3 confirmed R1, R2 and R3 have not had bladder incontinent episodes documented in their medical records for the past two months. V3 stated I do not have documentation to show if (R1, R2 or R3) had any episodes of incontinence or output with urination. CNAs should be documenting the incontinent episodes so that they can prove it was done and taken care of. I don't have any other place for them to chart (besides paper) and we no longer have them chart in the computer. The last of the paper incontinence charting I can find is from October 2024. On 2/12/25 at 2:40 PM, V1 confirmed there is a lack in CNA charting and stated these are all things that are going to have to change. V1 stated There's no way to prove they (residents) are or are not receiving incontinence care if they are not documenting it.

Based on observation, interview and record review, the facility failed to ensure a chemical dishwasher was monitored for safe sanitizer concentration, failed to ensure opened bags of freezer kept food items were labeled with dates of opening, and failed to record cool down temperatures for soups that were prepared ahead and stored in the freezer for future use. This failure has the potential to affect all 87 residents living in the facility. Findings include: The facility Dishwashing Machine Use policy, dated 3/2010, documents Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. Dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Quaternary Ammonium- minimum concentration 150-200 parts per million (PPM). Concentrations will be recorded in a facility approved log. If hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machine immediately until temperature or PPM are adjusted. On 10/21/24 at 10:30 AM, V7 (Dietary Manager) performed a test to check concentration of the dishwasher's chemical level during a cycle. V7 stated the facility uses a chemical dishwasher and the sanitation checks should be completed twice daily. Once in the morning and once in the evening. V7 stated the concentration should fall between 100-200 PPM with a testing strip for measurement and the facility staff should document the checks on the Dish Machine Sanitizer log. The facility's Dish Machine-PPM Sanitizer Record log dated September 2024 documents the dish machine sanitation checks were not completed on three mornings and not completed on 17 evenings throughout the month of September. This same record also documents October 1-21st 2024 checks were not completed on two mornings and 18 evening sanitation checks were not completed. The facility's Refrigerators and Freezers policy, dated 12/2014, documents This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked in cases and on individual items removed from cases for storage. Use by dates will be competed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. The facility's Food Preparation and Service policy, dated 10/2017, documents Food and nutrition's services shall prepare and serve food in a manner that complies with safe food handling practices. The danger zone for food temperatures is between 41 degrees and 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. This policy also documents Rapid Cooling. Potentially hazardous foods should be cooled rapidly. This is defined as cooling from 135 degrees Fahrenheit to 70 degrees within two hours and then to a temperature of below 41 degrees Fahrenheit within the next four hours. The total cooling time between 135 degrees and 41 degrees is not to exceed six hours. Large or dense foods may need special interventions in order to meet the time and temperature requirements for cooling. On 10/21/24 at 10:20 AM, the facility's walk-in freezer contained several opened plastic bags on shelves. These bags contained frozen french fries, onion rings, pork fritters and chicken strips. All four bags were without label indicating a date opened or a use by date. V7 (Dietary Manger) stated the kitchen staff should be putting those bags back in the boxes they came in and conformed they should all be labeled with dates for expiration purposes. This same freezer also contained multiple quart sized bags of frozen soup with various October dates on them. V7 confirmed the variety of soups were made in the kitchen this month and then frozen and will be used for the facility's Fall menu options. On 10/21/24 at 10:45 AM V7 provided the facility's October 2024 cool down logs for food prepared in the kitchen that needed cooling. This log did not document any cool down temperatures for the soups in the facility's freezer. On 10/21/24 at 10:50 AM, V9 (Cook) confirmed she made the soups that are in the freezer and stated, I didn't even think about doing cool down logs for those. On 10/21/24 at 10:52 AM, V7 confirmed V9 made the following soups that are stored in the freezer: Vegetable on 10/15/24, Potato on 10/17/24, Chili on 10/15/24, Broccoli Cheese on 10/16/24, and Taco Soup on 10/15/24. V7 also confirmed that V8 (Assistant Dietary Manager) made Oriental Soup on 10/18/24 and stored in the freezer. V7 verified she has no documentation to show temperatures of the soups during their cool down process and stated Cool down temperatures should have been done and documented. I will discard the bags of soup today. The facility's Long Term Care Application for Medicare and Medicaid dated 10/21/24 and signed by V1 (Administrator) documents 87 residents reside in the facility.

Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and indwelling urinary catheters for 10 of 10 residents (R1, R6, R20, R29, R49, R50, R54, R73, R81, and R143) reviewed for EBP in the sample of 36. Findings include: The facility's EBP (Enhanced Barrier Precaution) policy, undated, documents Policy Statement: EBPs are utilized to prevent the spread of MDROs (multi-drug resistant organisms) to residents. Policy Interpretation and Implementation: 1. EBPs are used as an infection prevention and control intervention to reduce the spread of (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. A. gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. PPE (Personal Protective Equipment) is changed before caring for another resident. C. Face protection may be used if there is also a risk of splash or spray. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etcetera); and h. wound care (any skin opening requiring a dressing). 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 11. PPE is available outside of the resident rooms. On 10/21/24 from 9:25 AM to 9:40 AM a tour was done of the facility. During this tour, no EBP signs were on any resident's door indicating they were in EBP. On 10/21/24 at 10:13 AM R6 was in his room sitting in his wheelchair with a urinary catheter bag attached underneath R6's wheelchair. No EBP sign was observed on R6's door or inside of R6's room, nor any PPE was noted inside or outside of R6's room. R6 stated, The staff do not wear gowns when provided catheter care to me or at any time. On 10/21/24 at 9:57 AM R49 was in her wheelchair in her room with a catheter bag secured underneath R49's wheelchair. No EBP sign was observed on R49's door or inside of R49's room, nor any PPE was observed inside or outside of R49's room. 32875 R54's current computerized medical record, documents R54 was admitted to the facility on [DATE] with a diagnosis of Urinary Tract Infection and Neuromuscular Dysfunction of Bladder. R54's MDS (Minimum Data Set) dated 7/31/24 documents a BIMS (Brief Interview for Mental Status) Score of 15/15, indicating (cognitively intact). R54 has an indwelling catheter. On 10/21/24 at 1:00 PM, V10/Licensed Practical Nurse/LPN stated that there is no-one on the second floor that requires Personal Protective Equipment/PPE to be worn when entering a resident's room or providing care. On 10/21/24 at 1:07 PM, there was no Enhanced Barrier Precaution/EBP sign on R54's door or inside of R54's room. There was no PPE available inside or outside of R54's room. On 10/21/24 at 1:07 PM, R54 stated that the staff do not wear any gowns when they do catheter care. 31682 On 10/21/24 at 10:54 AM R1 was in his room and had an indwelling urinary catheter draining yellow urine into a bag attached to the bottom of his wheelchair. R1 did not have EBP signs on his door, nor any PPE was noted inside or outside of R1's room. R1 stated, The staff do not ever wear a mask or gown when they are cleaning my catheter. On 10/23/24 at 10:18 AM V4/ADON/Infection Preventionist provided a list of residents who should have been placed in EBPs but were not. The list included the following residents: R1, R6, R20, R29, R49, R50, R54, R73, R81, and R143. V4 stated, None of these residents were placed on EBP on 10/21/24. On 10/23/24 at 10:25 AM V3/Assistant Director of Nursing (ADON)/Infection Preventionist stated she has been attempting to implement EBP for the past couple of months but has not been ensuring the EBPs are being implemented to residents who require EBP. V3 stated, I should be monitoring at least weekly residents who require EBP to ensure the signs are being put up, PPE is available inside or outside of the resident's rooms, and that staff are following the EBPs. I have not been doing this.

Based on observation, interview, and record review the facility failed to ensure oxygen tubing and humidification bottles were dated and oxygen tubing was stored in a bag between uses for four of four residents (R64, R140, R147, and R290) reviewed for respiratory care in a sample of 36. Findings include: The facility's Oxygen administration Policy/Procedure by Nasal Cannula/Mask (un-dated) documents Purpose: To deliver a low to moderate concentration of oxygen when oxygen use is indicated. Action To Be Performed By: Licensed medical personnel as designated in their job description. 3- Assemble equipment: Oxygen cylinder, tank, or canister. Cannula/Mask & (and) tubing (Change tubing/mask Q (every) 7 days & PRN (as needed). 1. R64's current POS (Physician Order Sheet) documents an order to change oxygen tubing, date oxygen tubing, and place in a bag when not in use one time a day every Sunday for oxygen protocol. This same POS also documents an order for oxygen at one liter as needed for dyspnea. On 10/21/24 at 9:40 AM R64 was sitting in a high back wheelchair in her room. R64's nasal cannula oxygen tubing was laying on the floor and undated and unbagged. R64's oxygen humidification bottle was also undated. 2. R290's current POS documents an order for three liters of oxygen per nasal cannula continuous. On 10/21/24 at 10:02 AM R290 was sitting in her recliner with oxygen flowing at three liters via nasal cannula. R290's oxygen tubing and humidification bottle was undated. On 10/21/24 at 10:04 AM V5/Agency Licensed Practical Nurse verified R64 and R290's oxygen tubing and humidification bottles were undated and R64's oxygen tubing were not placed in a bag while not in use. 31682 3. On 10/22/24 at 12:13 PM R140's oxygen nasal cannula tubing was lying on top of R140's oxygen concentrator. R140's oxygen nasal cannula tubing was not labeled with the date or stored within a bag and R140's humidifier bottle was not labeled with the date. 4. On 10/21/24 at 10:36 AM R147's oxygen nasal cannula tubing was hanging on R147's right side rail. R147's oxygen tubing was not labeled with the date and was placed within a bag while not in use. On 10/23/24 at 11:03 AM V2 (Director of Nursing) stated, All oxygen tubing and humidifier bottles should be dated and stored in plastic bags when not in use.

Based on observation, interview, and record review the facility failed to ensure call lights were placed within reach for three of 18 residents (R30, R37, and R64) reviewed for accommodation of needs in the sample of 36. Findings include: The Call Light Policy (undated) documents All residents of (the facility) should have a working and reachable call light. Call Lights are available for residents to request assistance for a wide variety of reasons. Call lights are to be placed within reach no matter where the resident is located in their rooms. Examples of where call lights can be placed include clipped to the recliner, clipped around side rails (if the resident uses them), placed over bedside table as long as bed side table is in reach of the resident. 1. R37's MDS (Minimum Data Set) assessment dated [DATE] documents R37 is severely cognitively impaired, requires staff assistance for activities of daily living, and has a high risk for falls. On 10/22/24 from 9:45 AM through 10:40 AM R37 was lying in bed on her left side sleeping. R37's call light was on the top of her side table, out of R37's reach, during this time. On 10/22/24 at 10:40 AM V11 (CNA/Certified Nursing Assistant) verified R37 uses a call light and that her call light was not in reach. 32875 2. R30's current computerized medical record, documents R30 was admitted to the facility on [DATE] with diagnoses which included Spinal Stenosis, Lumbar Region with Neurogenic Claudication, Essential (Primary) Hypertension, Acute Respiratory Failure with Hypoxia, and Localization-Related (Focal) (Partial) Symptomatic Epilepsy and Epileptic Syndromes with Simple Partial Seizures, Not Without Status Epilepticus. R30's MDS (Minimum Data Set) dated 8/21/24 documents a BIMS (Brief Interview for Mental Status) Score of 3/15, indicating (severe cognitive impairment). R30 requires partial assistance for activities of daily living and transfers. R30 is frequently incontinent of bowel and bladder. On 10/21/24 at 10:32 AM R30's was sitting in her wheelchair in her room without a call light. The call light was clipped to the recliner and not in reach. On 10/21/24 at 10:32 AM R30 stated I use the call light, but I don't know where it is. On 10/21/24 at 11:50 AM V1, R30's Power of Attorney, stated that R30 uses her call light. 49187 3. On 10/21/24 at 9:40 AM R64 was sitting in her room in a high back wheelchair. R64's call light was hanging over R64's bedside table on her left side out of reach. R64 stated that most of the time the call light is out of reach, and she cannot always get help when needed. On 10/21/24 at 9:45 AM V6/Certified Nursing Assistant verified R64's call light was out of reach. V6 stated, The call light should be attached to (R64) or (R64's) wheelchair when she is in it, not laying on her bedside table. (R64) is dependent with cares, so she would not be able to get to her call light if it is out of reach. On 10/23/24 at 11:03 AM V2 (Director of Nursing) stated, All calls lights should be placed within reach at all times.

Based on Observation, Interview and Record review, the facility failed to ensure a resident with a diagnosis of Dementia and a history of falling was adequately supervised to prevent a fall for one of three residents (R51) reviewed for Falls in the sample of 36. Findings include: The facility's Falls Management Program policy, dated 7/21/23, documents Fall prevention takes a combination of medical treatment, rehabilitation, and environment changes. Prevention tools may include assessments, education, medication reviews, environmental changes, and the use of fall mats and alarms. In order to maintain a successful falls prevention program, all staff members are responsible for seeking out, removing, and reporting potential fall hazards. This policy also documents Psychotropic Drugs: Know which residents take a benzodiazepine (antianxiety medication) or an antipsychotic (medication). Watch residents who are on these drugs for side effects such as confusion, drowsiness, dizziness, changes in gait (walking), loss of balance, and changes in mental status. On 10/21/24 at 11:30 AM R51 was observed in the dining room, sleeping in her wheelchair. R51's wheelchair contained a string pull alarm attached to the chair and R51's shirt. R51's current care plan, dated 10/22/24, documents R51 has diagnoses including but not limited to, Dementia, Anxiety, Parkinson's Disease, Complete Traumatic Amputation at level Between Right Hip and Knee, Phantom Limb Syndrome with Pain, and Communication Deficit. This same care plan documents R51 takes Risperidone (antipsychotic medication) and a care plan for falls that document I am high risk for falls related to impaired cognition, poor safety awareness, poor vision and a history of falls. 5/1/19 (R51) fell trying to put herself to bed. This care plan also documents R51 suffered falls on 9/29/19, 1/16/2020, 7/17/2020, 7/9/21, 7/22/21, 9/10/21,1/17/22 and 7/23/24. R51's Fall Investigation, dated 7/23/24, and signed by V2 (Director of Nursing) documents (R51) was found outside of the building lying in the front drive. (R51) appeared to have tried to go off the curb and the wheelchair tipped. On 10/23/24 at 10:00 AM, V16 (Activity Aide) confirmed she was the one who took R51 to the lobby on 7/23/24. V16 stated When we have an outdoor activity no one is allowed to go outside without staff. So, we put residents in the lobby and gather other residents. We (activity staff) put (R51) in the lobby that day and went to gather other residents. The other staff member was (V17, activity aide). No one from activities was down there when (R51) was able to go out behind another staff member without their knowledge. When (activity aides) came back down they were bringing (R51) back in from outside. This wasn't out of the normal for her to act in that way. (R51) can be strong willed and if she wants to do something she will. If I would've known she was having a bad day I wouldn't have left her unattended. On 10/23/24 at 10:28 AM V2 (Director of Nursing) confirmed that on 7/23/24, R51 was left in the facility lobby with other residents and was not being supervised by trained staff when she got out of the building and fell . V2 stated We knew with (R51's) fall that an employee had went out the door and (R51) had gotten through before the alarm would sound. I am not positive who the employee was, I believe it was someone working in maintenance. The receptionist down there was (V20) and she saw (R51) slip out the door and called the nursing office. By the time I got down there (R51) had already gotten herself off of the curb and fallen.

Based on Observation, Interview and Record review the facility failed to ensure a physician ordered hand splint was in place daily and a resident's limitations in range of motion were care planned for one of two residents (R73) reviewed for limitations in range of motion in the sample of 36. Findings include: The facility's (undated) Rehabilitation/Restorative Programs policy documents Upon admission or onset of a decline in Activities of Daily Living functions, a resident will be evaluated for individual status, and as potential candidate for Rehabilitation/Restorative program developed specifically for that individual. The goal/approaches of the individual's care plan shall be re-evaluated at least quarterly for any necessary revisions or modifications. R73's Minimum Data Set assessment, dated 9/4/24, documents R73 has Range of Motion impairments on one side for both upper and lower extremities. R73's Physician Order Sheet, dated 10/22/24, documents Patient to wear left upper extremity splint during daytime hours. Splint wear schedule: Donn (apply) with AM (morning) care, can wear up to 8 hours. This order has a start date of 3/8/24. R73's current care plan does not include a plan of care addressing R73's limits in range of motion or the use of a splint for R73's left hand. On 10/21/24 at 11:15 AM, R73 was sitting in a wheelchair in his room. R73's left hand was balled into a tight fist contracture and resting on the wheelchair. V18 (R73's Power of Attorney) stated that R73 is not currently in therapy and hasn't been since about April. V18 stated (R73) is supposed to have a splint on that left hand but they (facility) never put it on him. He has not had any device, wash cloth or splint placed in his left hand since being here. He went out of the facility and got (injectable neurotoxins) in that hand about three weeks ago. The nurse who went to give the injection had to clean his hand and remove yeast growth on his skin, from the tight contracture. On 10/22/24 at 12:15 PM, R73 was in the dining room sitting at table. R73 did not have a splint on his left hand which was resting in his lap. On 10/22/24 at 12:20 PM V13 (Licensed Practical Nurse/Restorative Nurse) confirmed R73 has an order for a left-hand splint. V13 stated He sometimes wears a splint, also he refuses a lot. The use of his splint isn't documented on an administration record. We might sometimes document refusals on the behavior tracking sheets. R73's Restorative Care logs dated September 2024 and October 2024 do not document any administration or refusals of R73's splint being worn/offered. R73's October 2024 Behavior Management Program does not document any refusals of wearing the hand splint and only documents 10/14/24- No Behaviors. On 10/23/24 at 10:30 AM, V2 (Director of Nursing) stated I wasn't aware that (R73) had a splint. (R73's) care plan does not reflect his limits in range of motion or the order for his splint. It should be on there so that staff are also aware of the need to address his deficits.

Based on observation, interview, and record review, the facility failed to provide supervision to a resident with severely impaired cognition and a known wanderer, failed to respond to door alarms at the door and at the main alarm panel, and failed to thoroughly investigate an elopement for one of three residents (R1) reviewed for accidents in the sample of ten. These failures resulted in R1, a severely cognitively impaired resident with a diagnosis of Dementia, eloping from her unit through an open double door that is normally closed, approximately 80 feet, to an unoccupied area of the building, getting through an alarmed door that leads to a stairway and being found on a landing after descending 8 steps. R1's wheelchair was tipped backwards in front of her on the landing. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 4/2/24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: The Facility's Safety of Residents/Procedure for Missing Residents policy (undated), states A light panel on 2 Riverview Nursing station will indicate if a door alarm has been activated. This includes internal doors with alarms as well as outside doors with alarms. A staff member will be dispatched to check out the alarm. After staff member reaches the alarmed door and assesses the situation, they will return to the unit to discuss with charge nurse or house supervisor. The alarm is to stay on until staff has checked the reason for the door alarm. On 3/29/24 at 11:10 a.m., R1 was observed up in her wheelchair and independently propelling the wheelchair with her feet. R1 was confused and visiting with peers and staff. R1's current electronic medical record, documents R1 is an [AGE] year-old that was admitted to the facility on [DATE] with diagnoses which included but not limited to, Dementia without behavioral disturbances, History of Falls with Fractures, Age-Related Osteoporosis, Hypertension, Long-Term use of Anticoagulants, Major Depressive Disorder, and Protein-Calorie Malnutrition. R1's Minimum Data Set assessment dated [DATE], documents R1 has severely impaired cognition; has a behavior of wandering on a daily basis; requires substantial/maximal assistance with transfers; is unable to ambulate; and propels wheelchair independently with supervision. R1's current Care Plan states, (R1) moves about the unit in her (wheelchair) at times going in and out of other's rooms; this occurs daily most of the time; (R1) is usually easily redirected; (R1) has dementia and will get self-up and down from chair, bed, etcetera, repeatedly at times. She does not remember to ask for assist. Restless movements occur daily. On 3/29/24, R1's Care Plan had not been updated to reflect R1's elopement on 2/23/24 or R1's increased risk for elopement and interventions. R1's Incident Report dated 2/23/24 at 5:00 p.m., completed by V6 (Licensed Practical Nurse/LPN) states (V6) came up to the nurse's station to pass 4:00 p.m. medications around 4:35 p.m. (R1) was wandering around the nurse's station and talking to others. (V6) noticed around 4:50 p.m. (that R1) was no longer around and I had medication to give her. (V6) asked the (Certified Nurse Aides/CNA's) if they knew where (R1) was and they said, she was just right here and that they didn't know where she was. (V6) checked the dining room and resident's room, (R1) was not present. (V6) alerted other staff on unit that (R1) was missing. Between myself (V6), CNAs, and other nurse on duty we looked in all of the other resident's rooms and bathrooms, the shower room, dining room and 4 City View (adjoining unit that is not occupied). (R1) was not in any of those places. We continued to look for (R1). (V6) returned to the nurse's station. (V5/LPN) called the (second floor nurse's station) to ask if any of the stairwell alarms had gone off recently and was told 'no.' (V5) went to continue searching for (R1). (V5) returned to (R1's unit/4 River View) only a couple of minutes later and said that she needed help and that she found (R1). This nurse (V6) immediately followed (V5) and told the CNAs to call 911. (R1) was observed at the bottom of the stairs on 4 (City View South). (R1) was sitting on the bottom stair and wheelchair was to her right and the wheelchair was tipped over on its back wheels. (R1) denied injury but stated her left leg hurt. (R1) was attempting to move herself and get up. (V6 and V5) advised (R1) to not move. (R1) could not say how she got there. The facility's investigation of R1's Elopement dated 2/28/24, does not document any information regarding the staffs' lack of response to the door alarm sounding where R1 exited from or the main door alarm panel at the time of R1's elopement on 2/23/24. R1's medical record does not document an updated Elopement Risk Assessment was completed after R1's elopement on 2/23/24. On 3/28/24 at 10:10 a.m., V2 (Director of Nursing) stated on 2/23/24, R1's nurse could not find R1 to give her 4:00 p.m. medications. V2 stated all staff immediately started searching for R1. V2 stated there was a period of approximately 10-15 minutes when R1's location was not known. V2 stated staff found R1 and her wheelchair in a stairwell on the south side of the adjoining unit. V2 stated I have no idea how she got down that set of steps. Her wheelchair was next to her tipped over. V2 stated an alarm has been added to the set of double doors that leads to R1's adjoining unit. V2 stated R1 had a small bruise above her left eye but was sent to the local hospital for evaluation and returned with no new injuries. V2 stated R1 has a history of falls with fractures, and she was shocked that R1 had no fractures from this incident on 2/23/24. On 3/28/24 at 1:44 p.m., V8 (Certified Nurse Aide) stated she was working the evening that R1 was missing and found at the bottom of the stairwell. V8 stated R1 was found on the fourth floor on the unit 4 City instead of R1's unit 4 Riverview. V8 stated 4 City View is unoccupied and no one was in that area at the time of R1's elopement on 2/23/24. V8 stated R1 was on the move (2/23/24) and wanting to go somewhere. V8 stated She wanders constantly when she is in her wheelchair, but she stays close to us because she likes to visit. She thought there was dinner that needed to be cooked. She had increased behaviors that day. She thought the kids were waiting on her. She wanders up and down the halls and goes in other resident rooms, so we have to keep an eye on her. We try to keep her occupied with food and activities. I'm not sure who saw her last. I wasn't on the floor when they realized she was missing. When I came back up, they said they couldn't find (R1). I don't think it was very long before they missed her. We are always watching for her. She can walk short distances if she is in the right mood. When I went to the stairwell, I saw the wheelchair at the bottom flipped backwards and she was sitting on the bottom step trying to get herself up. She kept saying she wasn't hurt; she was just trying to get up. (R1) had no injuries other than a small bump over her eye. No bleeding or obvious fractures. On 3/29/24 at 9:10 a.m., V5 (Licensed Practical Nurse) stated she was working on R1's unit (4 Riverview) on 2/23/24 when R1 eloped from the unit. V5 stated she did not hear any alarm sound on the door that R1 opened and descended to the bottom of the stairs to the first landing. V5 stated I had just talked to (R1) up by the nurse's station and then went on to finish my medication pass. I heard staff looking for (R1) and I immediately assisted in the search. We looked everywhere on the unit and then went over to 2 City View (the adjoining unit that is not occupied) and also sent staff to other floors to look for her. I finally went to the 4 south stairwell and found her and went to get help. After we got (R1) sent to the emergency department for evaluation, I called down to the nurse on second floor V14/Licensed Practical Nurse) that has the door alarm panel for the entire facility. At first, she told me that she silenced an alarm that she thought was the back door. I proceeded to inform her that (R1) had gotten down the 4 south stairwell and we did not hear an alarm and ask her why she didn't call us to see what was going on. (V14) then changed her story and said she had not silenced any alarms. The door alarm was working so I know that is what happened. We just couldn't hear the alarm. Had she called to check on the door alarm we would have found (R1) quicker. I did not have anyone from administration question me about the door alarms. On 3/29/24 at 9:30 a.m., V1 (Administrator) stated she was aware of R1's elopement on 2/23/24 but she did not assist V2 with the investigation or know of any issues with the alarms being silenced at the main panel. On 3/29/24 at 9:40 a.m., V6 (Licensed Practical Nurse) stated she was R1's nurse on 2/23/24. V6 stated I remember seeing (R1) sometime between 4:30-4:45 p.m. after the (Certified Nurse Aides) got her out of her recliner and into her wheelchair for supper. We had a resident on the unit that was actively dying, and I had gone to check on that resident. When I came back up by the nurse's station (R1) wasn't up there. My first thought was the staff must have already taken (R1) to the dining room for supper. I continued to pass more medications. I remember asking a couple of the (Certified Nurse Aides) if (R1) was in the dining room and they told me she was not in the dining room. I started checking other resident rooms because it is not uncommon for (R1) to go into other resident rooms. She was nowhere to be found. We checked 4 City View (adjoining unoccupied unit) because the double doors that separates the two units had been open all day. Those double doors are usually shut. All staff on unit were searching the entire facility for her. We did not receive any calls from second floor staff to say we had an alarm sounding that needed to be checked. (V5) finally found (R1) down the first set of stairs of the 4-south stairwell. The alarm was working when we went to go assess her. I have no idea how (R1) got down those stairs, but she had no major injuries. Her wheelchair was sitting on its back in front of her, so I believe it went down first. I don't think she was in it, or she wouldn't have been sitting on the stairs. She couldn't have climbed over the wheelchair. She can't walk much but I wonder if she held on to the railing and scooted or walked down the steps. We will never know because she has no memory of the incident. She had a small bruise over her eye and no other noted injuries, but we kept her there until the ambulance came to get her in case, she had internal injuries or fractures. She came back with no major injuries noted at the emergency room . No one from administration interviewed me about this elopement. No one asked anything about the door alarms. On 3/29/24 at 10:15 a.m., V14 (Licensed Practical Nurse) stated she was working on 2/23/24 when R1 went missing and was later found in the stairwell. V14 stated the main panel for all facility door alarms, is located at the second-floor nurse's station. V14 stated when an alarm is activated it sounds on the panel and the location of the door is identified. V14 stated usually staff clear the door and the alarm panel shuts off with no action from second floor staff. V14 stated if for any reason a door alarm continues to sound the second-floor staff are supposed to call the identified unit on the alarm panel and tell them there is an alarm sounding and ask if all residents are accounted for. V14 verified that the second-floor staff are not supposed to turn the alarm on the panel off until they receive an all clear from the unit assessing the door alarm. V14 stated around the time that R1 went missing on 2/23/24, V14 recalls an alarm going off for 5-10 minutes and she was trying to listen for her own unit residents, so she silenced the alarm on the main panel. V14 stated I thought it was the back door that was going off, so I didn't call anyone. Once the alarm is silenced the door will reset and stop alarming. V14 stated after R1's staff had found R1, one of the nurses on R1's unit called and asked about the alarm sounding but I couldn't see for sure what door was alarming. V14 stated No one from administration interviewed me or in-serviced me on door alarms and elopement. On 3/29/24 at 11:33 a.m., V9 (Certified Nurse Aide) stated V9 was working R1's unit when she eloped on 2/23/24. V9 stated R1 is usually around the nurse's station and talking to everyone. V9 stated I had gotten everyone down to the dining room for supper and we all realized (R1) was not in sight. We searched everywhere for her. 4 City View is the unit adjoining 4 Riverview (R1's unit) and it is currently not occupied. The double doors that separate these two units are always kept closed but it is not alarmed. For some reason, it was open on day shift. I don't know who opened them up. They are able to stay open with the magnets on the wall. Finally, one of us said we needed to check the stairwells. I did not hear an alarm sound but the alarm on the door she went through was working because it sounded when we went through it to find her. The staff from the second floor have the main panel for all the alarms. They are supposed to call us if we have an alarm sounding and they didn't do that. I think it was shut off on the second floor, so we never did hear it. On 3/29/24 at 11:40 a.m., V2 (Director of Nursing) stated through her investigation of R1's elopement on 2/23/24, she did not identify any issues regarding door alarms. V2 stated she did not educate/in-service staff on elopement or door alarms. The Immediate Jeopardy was identified to have started on February 23, 2024, when the facility failed to provide adequate supervision to R1 to prevent her from eloping from her unit and failed to respond to door alarms heard at the main alarm panel around 4:45 p.m., resulting in R1 being found approximately 80 feet away from her unit, to a unoccupied area of the building, getting through an alarmed door that leads to a stairway and being found on a landing after descending 8 steps. V2 (Director of Nursing/DON) was notified of the Immediate Jeopardy on 4/1/24 at 12:45 p.m. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. All facility staff were educated by V2 on the facility's Safety of Residents policy and the facility's door alarm system including the importance of not silencing/shutting off the alarm at the main panel until the alarm has been assessed by staff and clearance is received to shut the alarm off. 2. V2 (Director of Nursing) submitted an addendum to the investigation report regarding R1's elopement after a more thorough investigation was completed. 3. V1 (Administrator) and V2 (Director of Nursing) were in-serviced by V46 (Human Resources) on completing a thorough investigation. 4. V2 (Director of Nursing) updated R1's elopement risk/interventions and updated R1's elopement care plan. 5. All residents currently assessed at high risk for elopement risk were reviewed for Care Planned interventions and identifying information in the elopement binder. All newly assessed high risk individuals will be added to the facility elopement binder and have this risk addressed in their Care Plans. 6. The facility will complete ongoing monitoring through the quarterly QAPI process.

Based on interview and record review, the facility failed to notify the physician of a significant change in condition for one of three residents (R4) reviewed for change in condition in the sample of ten. These failures resulted in R4 being diagnosed with a Severe Urinary Tract Infection (UTI), Sepsis, and being hospitalized for five days. Findings include: The Facility's Change in a Resident's Condition or Status policy dated 12/18/23, states Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician in a timely manner when there has been: a. An accident or incident involving the resident; b. A discovery of injuries of an unknown source; c. A reaction to medication; d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly; f. Refusal of treatment or medications (two or more consecutive times); g. A need to transfer the resident to a hospital/treatment center; h. A discharge without proper medical authority; and/or i. Instructions to notify the physician of changes in the resident's condition. 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normalyl resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. 3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative when: b. There is a significant change in the resident's physical, mental, or psychosocial status. 4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition/status. R4's electronic medical record documents R4 was admitted to the facility on [DATE] and discharged to the hospital on 3/15/24. R4 was admitted with diagnoses which included but not limited to, Nontraumatic Intracerebral Hemorrhage, Dementia with Altered Mental Status, History of Urinary Tract Infections, and Urinary Retention. R4's Minimum Data Set assessment dated [DATE], documents R4 had severely impaired cognition and was frequently incontinent of bowel and bladder. R4's Admission Progress Note dated 2/7/24, documents R4 was admitted to the facility on an antibiotic medication for a diagnosis of Urinary Tract Infection (UTI). R4's Progress Note dated 3/9/24 at 1:49 p.m., written by V20 (Licensed Practical Nurse/LPN), documents 600 milliliters (ml) of urine was drained via straight catheterization; R4's urine had a foul odor and had mucus discharge. R4's Progress Notes dated 3/9/24 do not document that R4's physician was notified of her abnormal urinary symptoms. R4's Progress Notes dated 3/10/24 at 4:14 p.m., written by V20, states Straight cathed (catheterized) (R4) per sterile technique, 500 (milliliters) immediate return of foul-smelling urine. At the end of draining again was thick mucus, foul strong odor, so thick it had difficulty draining through the tube. R4's Progress Note dated 3/15/24 at 12:12 p.m., states (V27/R4's family) called insisting that (R4) is sent to the (emergency room ) for potassium. (V27) stated he has seen this before and she is need of this. This same progress note documents R4's physician/nurse practitioner was notified, and orders were received to send R4 to the hospital via ambulance. R4's Hospital Records dated 3/15/24, document R4 was admitted to the hospital with diagnoses of Severe Urinary Tract Infection, Sepsis, and Metabolic Encephalopathy. These same hospital records document R4 was discharged to another facility on 3/20/24. On 4/2/24 at 10:57 a.m., V27 (R4's family) stated he had noticed R4 had a decline in her overall condition a week or so before she was sent to the hospital (on 3/15/224). V27 stated he would try to talk to staff about R4's condition and they blew me off and thought I didn't know what I was talking about. V27 stated I had even talked to (V18/Physical Therapist) on 3/14/24 and V18 thought R4 was being treated with an antibiotic for a UTI. Come to find out she was not on an antibiotic and that is how she ended up so sick and hospitalized on [DATE]. If they had reported her symptoms and decline sooner, she wouldn't have gotten so bad. V27 stated on 3/15/24, he went to visit R4 before lunch and she didn't respond to V27 like she normally would. V27 stated he lifted her head up while she was sitting in her wheelchair, and it was limp. V27 stated one of the staff members sitting in the dining room stated R4 had just gotten up and was not in a good mood. V27 stated he was so upset at the lack of concern for R4's poor condition that he had to leave the building and go sit in his truck and call R4's nurse to tell her to send R4 to the hospital. V27 stated I think it was (V20/LPN) that I told about (R4) needing to go to the hospital because something was wrong. (R4) has had potassium level issues in the past and has acted like she was that day. I knew she wasn't right, and they were just acting like she was just tired. I told (V20) that I wanted to talk to the Unit Coordinator (V17) so I could tell her what was going on and that no one was doing anything for (R4). It wasn't a few minutes later that I received a text message from (V17) telling me they called an ambulance to take (R4) to the hospital. She was so sick by the time she got to the hospital with a UTI that she had become septic and had metabolic Encephalopathy. If they had treated her sooner with an antibiotic, she wouldn't have been so sick. On 4/2/24 at 2:35 p.m., V2 (Director of Nursing) stated there is no documented evidence that R4's physician or nurse practitioner were notified of R4's abnormal urine (foul odor and mucous) that was first documented on 3/9/24. V2 stated R4's physician should have been notified of that change in condition. V2 stated R4 ended up hospitalized with diagnoses of UTI, Sepsis, and Metabolic Encephalopathy. On 4/3/24 at 10:09 a.m., V20 (Licensed Practical Nurse) stated R4's progress notes dated 3/9/24 and 3/10/24 were both shifts that V20 noticed R4's abnormal urine output during a straight catheterization procedure. V20 stated she recalls the urine having a foul odor and very thick mucus. V20 stated V20 did not notify R4's physician or nurse practitioner according to R4's progress notes. V20 stated I was working on 3/15/24 when (V27) called and said R4 needed to be sent to the hospital because he thought she needed some potassium by the decline in her condition. I reported this information to (V17/Unit Coordinator) who took over from there and had R4 sent to the emergency room . (R4) ended up being septic from a UTI if I remember correctly. On 4/3/24 at 11:13 a.m., V36 (R4's Nurse Practitioner) stated Anytime we get a call or fax from a nursing home our secretaries put a note in our computer system so we can see what is going on with the residents at all times. There is nothing documented in (R4's) record that we were notified of foul odor or purulent drainage in (R4's) urine. She was feisty with the staff during cares, but she had moments that she was alert and would eat or drink. I personally witnessed the family giving her food and drinks when they visited. If I would have been notified of R4's signs of a UTI I would have ordered a UA (Urinalysis) and started her on an antibiotic while we waited on the culture results. I am confident that (V37/Nurse Practitioner) would have ordered a urinalysis and antibiotic if she knew about (R4's) signs and symptoms of a UTI. If (R4) had been treated when her infection symptoms first started, it's very unlikely that she would have been admitted to the hospital with a severe UTI and sepsis.

Based on record review and interview, the facility failed to ensure the licensed nurse provided care and services to the 32 residents residing on the 3rd floor, when V4 (Licensed Practical Nurse) was found sleeping during her shift from approximately 9:15 pm on [DATE] to 5:00 am on [DATE]. V5 and V10 (Certified Nursing Assistants) observed V4 sleeping throughout the night and were unable to wake her. V5 and V10 failed to report to Administrative Staff that V4 had been sleeping, until 4:40 am on [DATE], despite having a resident (R3) actively dying on Hospice, a resident (R2) requesting pain medication and another resident (R1) on Hospice that was experiencing a decline in her health. V4 failed to administer R1's nighttime dose of insulin and staff failed to monitor and assess R1 every two hours during the night. This resulted in V12 (R1's Family) finding R1 at 5:45 am on [DATE], with her head hanging over the side of the bed, verbally non-responsive and experiencing a hyperglycemic episode. Video surveillance confirms that staff did not go into R1's room between 9:09 pm on [DATE], when V4 obtained R1's blood glucose level, and 5:45 am on [DATE]. These failures resulted in an Immediate Jeopardy and had the potential to affect all 32 residents residing on the 3rd floor. The Immediate Jeopardy began on [DATE] when V4 failed to provide nursing care to residents of the 3rd floor of the facility, including two residents on Hospice (R1, R3) and in the end stages of life, because she was sleeping for approximately eight hours of her shift. V1 (Acting Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 11:00 am. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 as the facility continues to investigate the events of [DATE]-[DATE] to determine if any other residents were affected by the events on those days, in-service staff regarding identifying potential neglect and proper procedures and timeframes for reporting it. Findings include: The facility Abuse and Neglect Policy (revised [DATE]), documents Policy: It is the policy of Sunset Home to provide each resident with an environment free from abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of resident property, exploitation and physical or chemical restraint not required to treat the resident's symptoms, as defined below. Sunset Home shall follow the procedure for reporting and investigation of alleged resident abuse and neglect as outlined below, and in accordance with Skilled Nursing and Intermediate Care Facilities Code (77 Ill. Adm. Code 300.3240). Purpose and Scope: The purpose and scope of this policy and procedure is to inform all individuals of the proper protocol for preventing, reporting and investigating allegations of abuse and neglect as specified in the corporate policy above. The facility policy documents, 'Neglect refers to the failure to provide goods and/or services necessary to avoid physical harm, mental anguish, or mental illness. The Staff Nurse Job Description (Revised [DATE]) documents, The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such Supervision must be in accordance with the current Federal, State, and local standards, guidelines and regulations that govern our facilities, and as may be required by the Director of Nursing or Charge Nurse to ensure that the highest degree of quality care is maintained at all times. The Job Description includes, under Major Duties and Responsibilities: Direct the day to day function of the nursing assistants in accordance with current rules, regulations and guidelines that govern the long-term care facility. Ensure that the nursing procedures manual is followed rendering nursing care. The policy advises that the licenses nurse is to, Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the residents' response to the care. Give/receive the nursing report upon beginning and ending shift duty hours. Provide leadership to nursing personnel assigned to your unit/shift. Under Nursing Care Functions, it documents that the Staff Nurse is to Make periodic checks to assure that prescribed treatments are being properly administered by nursing assistants and to evaluate the resident's physical and emotional status. Administer professional services such as: catheterization, tube feeding, suction, applying and changing dressings/bandages, packs, colostomy care, range of motion exercises, care of the dead/dying, etc., as required, within the Nurse Practice Act for the State of Illinois. Provide and/or assist other staff with nursing care including performing the duties listed in the Certified Nursing Assistant job description as necessary. Monitor seriously ill residents. On [DATE] at 4:47 pm, V2 (Director of Nursing) provided a Resident Bedsheet to reflect the midnight census on [DATE], which was 32 residents (R1-R32). A Resident Bed Sheet, dated [DATE], was provided by V2 (Director of Nursing) on [DATE] at 4:47 pm. V2 confirmed that was the accurate midnight census of [DATE] and it identifies 32 residents 1. R1's electronic medical record documents R1 was admitted to the facility on [DATE] and has the current diagnoses of Chronic Pain, Type II Diabetes Mellitus with Hyperglycemia, History of Diabetic Ketoacidosis, Acute Ischemic Heart Disease, Muscle Weakness, Muscle Wasting and Atrophy, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease and was placed on Hospice on [DATE]. R1's current Plan of Care documents R1 has chronic back pain with instructions for staff to monitor for signs/symptoms of pain and administer Percocet (Narcotic) four times a day. R1's current Plan of Care also documents, I am high risk for falls (related to) gait/balance problems and instructs staff to provide a working and reachable call light, the bed in low position at night; personal items within reach, and Be sure my call light is within reach and encourage me to use it for assistance when needed. A Minimum Data Set assessment dated [DATE] documents R1 had a BIMS (Brief Interview of Mental Status) of 14, which indicates no cognitive impairment. However, Hospice Admission documentation, dated [DATE], indicates R1 was placed on Hospice Services due to a physical decline related to malnutrition and cites R1 has experienced increased confusion over the last six months. R1's Hospice Plan of Care, dated [DATE], documents under Mobility/Safety that R1/Caregivers will demonstrate safe, effective use of equipment. Interventions: Instruct Patient/Caregiver on fall prevention and safety precautions. (R1) requires assistance of two for transfer but has not been out of bed for 2 days prior to Hospice enrollment. Patient is (a) fall risk. Education to keep bed in low position and call light within reach. R1's Nursing Progress Notes document no Nursing Assessments/Notes from [DATE] through [DATE] by the facility's licensed nursing staff. The next documented Nursing Note is on [DATE] at 6:15 am and reads (R1) is not opening eyes or responding to staff at this time. Upon checking the blood sugar, it is reading high. (V14/Medical Director) called and order received to give 20 (Units) Humalog now. After this, blood sugar came down 495, hospice called again. At this time the hospice nurse informed me she has heard from the daughters, and they are planning on taking (R1) out of here (as soon as possible) today. Discharge paperwork gathered, medications gathered, and (medical supply company) will be delivering her bed at noon today, ambulance to be scheduled once bed is delivered. Nursing documentation indicates R1 left the faciity on [DATE] at 12:43 pm with her family in the care of Hospice services. On [DATE] at 3:04 pm, V12 (Family/Healthcare Power of Attorney) stated that R1 has a video camera in her room that is triggered to record with motion or movement. According to V12, on [DATE] at 5:25 am, she could see Mom (R1) dangling over the side of the bed. I tried calling there (facility) to notify the staff and no one answered, it rang and rang. I only live 10 minutes away, so I just drove over there. When I got to Mom's floor, it was a ghost town. There were no staff to be seen. I went into her room, and she was still hanging over the side of the bed and her call light was on the floor. So, I went running down the hall looking for someone to help. The Aides came into her room and set her upright. Mom is not waking up and is lethargic. The Aides left and I tried to get (R1) to drink some water. Around 6:00 am, I started thinking that maybe (R1's) blood sugar was off, she's a Diabetic, so I went to find a nurse. The nurse tried to get a reading of her blood sugar, but it just registered high. The nurse called the doctor, and she got some fast acting insulin in (R1), but she still wasn't responsive. The nurse said they could send to (R1) the hospital, but she would have to come off of Hospice if they did. I looked at the video footage and saw that no one had been in (R1's) room since 9:09 pm ([DATE]). The nurse came in then to check her blood sugar and I can see Mom's call light on the floor then. The nurse says (R1's) blood sugar is over 200 and she needs insulin. The nurse never came back in (R1's) room. I could see at 1:13 am (on [DATE]), Mom raises the head of her bed up with the button on the bed rail and her call light is still on the floor. I couldn't tell what (R1) was trying to do then. Nobody comes in her room at all after 9:09 pm ([DATE]). I was so upset, I just had them discharge her to my house on Hospice. This was not something we planned, but I could not leave her there. Mom died two days later. I heard the nurse working was escorted out of the building for not checking on residents that night. On [DATE] at 7:40 am, V12 stated, Not sure how you put a price on time with a loved one, but I sure wish there was a way to quantify that, as we should have had more time with our mom (R1). I personally moved to [NAME] on [DATE]st to spend more time with her, though I got an amazing 2 months with her, I definitely thought I would have more, we all did. Video surveillance of R1's room, submitted by V12, from [DATE] and [DATE] was reviewed. The videos from R1's room are in segments, due to the surveillance camera being utilized only records when motion is detected in the room. The video surveillance recorded the following: On [DATE] at 9:09 pm, V4 (Licensed Practical Nurse) is at R1's bedside with her back to the camera. R1 is lying in bed and the call light is hanging from the wall, over the nightstand and on the floor. V4 states, Your accucheck is 291. I'm going to grab your insulin. I'll be back. V4 turns off the light as she leaves the room. Motion is not detected in R1's room again until [DATE] at 1:13 am. At that time, R1 is positioned on her right side in bed, facing the right bed rail. R1's call light remains on the floor in the same spot. R1 raises the head of the bed with the button on the bed rail to approximately a 70-degree angle. At 5:25 am, (Which was when V12 woke up and checked on R1 through the video camera. This allowed V12 to save the footage she had just viewed even though there was no motion at that time.) R1's head of the bed is in the same upright position, two pillows are on top of R1's lower to mid back, and R1's head is over the right side of the bed towards the ground. R1's upper body is partially against the bed rail. R1 is motionless and R1's call light is still on the floor in the same position. Between 5:26 am and 5:45 am, R1 remained in the same position over the right side of the bed. R1's left arm can be seen moving on two occasions and muffled, inaudible noises are coming from R1. At 5:46 am, V12, V5 (Certified Nursing Assistant) and V10(Agency Certified Nursing Assistant) enter R1's room, R1 is in the same position over the right side of the bed. V5 lowers the head of R1's bed and V10 assists V5 to get R1 positioned back to the center of the bed on her back. V12 is crying and states, Why has nobody been in here? V5 responds, I have been. I walked by all night checking on her. I promise. V12 replies, She's been like this since one in the morning. It's on camera. By 6:25 am, a licensed nurse has yet to be in R1's room to assess her and V12 remained at R1's bedside. R1 remains unresponsive. V12 states to R1 that she is going to go get a nurse to check R1's blood sugar. At 6:26 am, V7 (Licensed Practical Nurse) enters R1's room to obtain R1's blood sugar. V12 clearly tells V7 that staff have not been in R1's room since 9:00 pm (on [DATE]). V7 responds, Yeah, that's horrible. The Director of Nursing will be down to talk to you. V7 then tells V12 that R1's blood sugar reading was high, so off the charts. At 6:29 am, V12 can be seen showing V7 video surveillance of R1 from the night before and V7 questions V12 if she observed R1 in any distress. At 6:44 am, V3 (Assistant Director of Nursing) enters R1's room as V12 remains at R1's bedside to administer R1's insulin. V12 states to V3, She (R1) hasn't been responsive since I've been here. That was about five something, but no one has been in here since 9:00 (pm). I got up after 5:00 (am). I'll show you the picture of the snapshot of the camera of how (R1) was and I called up here and no one answered, and I came over here. V12 then showed V3 video footage of R1 on her phone. At 6:45 am, V3 states to V12, The nurse down here was escorted out of the building last night. V12 replies, Because of this, or because of something else? V3 then stated, Just kind of in general. She's been here more than once. She's not one of our employees, but that doesn't mean anything, because she's not coming back. I apologize, also. I had not gotten report since she wasn't here, and I was not aware she went home. On [DATE] at 1:05 pm, V5 (Certified Nursing Assistant) stated the early morning of [DATE], she heard someone running and yelling down the hallway. V5 indicated she was in a resident room at the time, so she came out and saw V12 was who was yelling. V12 told her R1 had fallen. V5 stated she and V10 (Certified Nursing Assistant) immediately went into R1's room, where she saw R1 slumped over, the head of the bed was really high up, like at a ,d+[DATE] degree angle. Part of (R1) was leaning into the bed rail, but she was not on the floor. I didn't notice where her call light was, but she didn't use it all night. It should have been clipped to her or tied to the rail. We got (R1) upright into bed and she wasn't really awake but seemed ok. I told the girls in report what happened. (V12) was really upset and said nobody had been in to check on (R1) all night. (R1) was already in bed when I came on shift at 6:00 pm ([DATE]). Around 7:00 pm was the first time I saw her, and she was resting. They told me she had just went on Hospice. I went by her room again around 2:30 am ([DATE]) and she was lying flat in the bed, not with her head of the bed way up like we found her. I just peeked into her doorway; I didn't step into the room. We were really busy that night. The Nurse on the floor had been sleeping all night. From around 9:00 pm to 2:00 am, (V4/Licensed Practical Nurse) was sleeping at the nurses' station. Then (V4) got up, went into the common area and slept there from 2:15 am until 5:15 am ([DATE]). I tried to let her know when residents needed something, but she wouldn't wake up. V5 indicated the closer it got to 5:00 am and she could not get V4 to wake up, she knew she needed to notify someone. V5 stated, I had called (V6/Licensed Practical Nurse) just before 5:00 am, because (V6) was the House Supervisor, but she was working on another floor. I knew the 5:00 am meds were going to need to be passed and I could not get (V4) to wake up. (V6) came up and had to shake (V4) to get her to come around. V5 was questioned as to why she didn't notify management earlier that V4 had slept through the majority of her shift and V5 stated I didn't want to get anyone in trouble. On [DATE] at 5:50 pm, V10 (Agency Certified Nursing Assistant) stated she started her 12 hour shift on [DATE] at 6;00 pm. V10 stated V4 was late coming in to start the shift and as soon as V4 got there, she sat down at the nurses' station and ate her dinner. V10 stated, After that, (V5) left to get (V4) something from the gas station. (V4) passed her evening (medication) and after that she went to sleep. It was probably around 9:00 - 9:15 pm, she went to sleep at the nurses' station. (V5) and I split up the residents to do their check and change every two hours. I did help (V5) with (R3), just to reposition him. (R3) was in the process of dying that night, his breathing had changed, and he was making some sounds. (V5) and I did our last rounds around 4:00 am. (V4) was sleeping in another spot, in a chair then. I never saw (R4) go into a resident room after she did her 9:00 pm med (medication) pass. Near the end of the shift, (R1's) daughter was yelling in the hallway that (R1) was on the floor. (V5) and I went into (R1's) room right away. (R1) was hanging halfway off the bed with her head towards the floor. The head of the bed was way high up and the bed was in the highest position. I don't know how it go that way; I didn't go into to her room that night. (V5) and I got (R1) up in the bed, but she seemed asleep. I don't know (R1) well, so I wasn't sure if that was how she normally was. I've worked with (V4) before and she tends to sleep during her shift and not help, but CNAs (Certified Nursing Assistants) do their thing and Nurses do theirs. On [DATE] at 12:15 pm, V6 (Licensed Practical Nurse) stated on [DATE] at about 4:40 am, V5 called her and said the nurse on the 3rd floor was sleeping. V6 indicated she finished her tasks on her floor and got to the 3rd floor about 5:00 am. V6 stated, I found (V4) sleeping in the chair and out cold. I tried to wake her and shook her by her shoulders. She finally came around. I got her keys and asked her to leave the building. (V5) told me that (V4) had been sleeping all night. I was concerned because there were two residents on Hospice that hadn't been checked on by a Nurse throughout the night. It was (R1) and a male resident (R3). V6 stated she called V3 (Assistant Director of Nursing) after V4 left the building and informed V3 she had to make a nurse leave for sleeping while on duty. V6 stated, (V5) called because the morning meds (medication) needed passed, but I was more concerned about checking the two residents dying (R1 and R3). V6 stated, around 5:45 am, I heard (R1's) daughter in the hall, very upset saying her Mom was on the floor or almost on the floor. I called (V3) again and told her (R1) daughter was upset. (V3) was walking into the building at that time and said she would check on (R1). There were some other residents on that floor I was concerned about, ones that need nursing attention during the night. (R1) is a very brittle diabetic and a fall risk, so she was one. (R4) needs a lot of attention at night, too. I had heard on occasion from day shift staff that (V4) would do her morning med pass late, like she would still be doing it when they came in at 6:00 am, but I didn't' witness that so I never reported it. On [DATE] at 2:06 pm, V3 (Assistant Director of Nursing) stated she was on call the weekend of [DATE]. V3 indicated she received a call on [DATE] at approximately 4:30 am from V6, who advised her there was an issue on the 3rd floor and she sent the nurse (V4) home for sleeping on duty. V3 stated, (V6) told me the Aides tried to wake (V4) and couldn't, so she went to the floor and had to physically shake (V4) to wake her up. I was coming in to work the floor at 6:00 am and I wasn't sure what (V4) had done or had not done the prior shift. I just knew another nurse was covering the morning med pass. When I got to the floor, (V7/Licensed Practical Nurse) said she had checked (R1's) blood sugar, which was just reading high. I called (V14/Medical Director) who ordered 20 (Units) of fast acting insulin. After giving it, (R1's) blood sugar was 495. I contacted the on call doctor and the Hospice staff, but the hospice staff informed me (R1's) family was taking her home that day. I know the daughter was upset with her mom's care during the night and said staff didn't monitor her as they should have. The aides should have been checking on R1 at least every two hours. We did apologize and advised (V4) would not be returning to work there. (V5) told me that (R1's) family thought (R1) had fallen on the floor, but she hadn't. (V5) told me she checked in on (R1) between 3:30 and 4:00 am ([DATE]). I did question (V6) why (V4) was left to sleep for so long. (V6) said the CNAs (Certified Nursing Assistants) were very frustrated with the fact that they couldn't get the nurse to function, but they reported it was essentially a normal night. I was told (V4) showed up late and had a pillow and blankets where she was sleeping. V3 was questioned if (V4) sleeping throughout the night on her shift could have led to a neglectful situation and V3 stated she did not consider resident neglect at that time, so it wasn't reported as such to the Administration. V3 concluded that if resident's didn't get medication or assessed properly during the night, it would be neglect. On [DATE] at 1:47 pm, V7 (Licensed Practical Nurse) stated she was on day shift [DATE]. V7 stated when she started the shift, I was asked to check (R1's) blood sugar because she was lethargic. When I saw (R1), she wasn't talking, but she was awake. (R1) had a blank stare and definitely was not as alert as usual. The Aides told me to let (V3) know, since she was her actual nurse for the day. (V3) told R1's daughter they could not send (R1) to the ER (emergency room ) because she was on Hospice. I was told that (V4) had slept all night and didn't check on the residents. I heard the Aides tried to wake her that night and couldn't and (V6) had to actually shake (V4) to get her to wake up. I've worked as an Agency nurse with (V4) at other facilities. (V4's) been known to sleep on the job and has been caught using drugs in the bathroom while working other places. (V4) sleeps on shift all of the time and she's done it at numerous facilities. When she's on the schedule, she's a body and that's all. On [DATE] at 7:53 am, V16 (Nurse Practitioner) stated R1 had been progressing downhill medically. V16 stated, On [DATE]st (2023), (V12) expressed to me she was having issues with staff not toileting (R1) routinely. So, I told (V6/Licensed Practical Nurse) that I wanted someone checking on her (R1) every two hours. (R1) should have been on a every two hour check and change. (R1) was a brittle Diabetic and was not the most compliant, but (V4) not returning to give (R1) her insulin is a huge problem. Staff not checking on (R1) every two hours is a huge problem. Someone should have been in that room during the night. 2. The Electronic Medical Record documents R3 was admitted to the facility on [DATE] for Hospice services related to Malignant Neoplasm of the Colon. A [DATE] Pain Evaluation documents R3 as experiencing daily moderate pain in his back related to metastatic cancer and he receives narcotics. R3's Hospice Care Plan, dated [DATE], documents R3 was experiencing a significant decline and identifies the following: Goal is for pain to be controlled with R1's desired comfort level, Initiate comfort medications for symptom management, Staff are to collaborate with the Primary Nurse regarding R1's condition and Ensure and coordinate provision of care and services meet R1's needs. On [DATE], Physician's Orders document Hospice changed R3's medication orders to the following: Lorazepam 0.5 mg every four hours for end stage restlessness, Atropine Sulfate 1% two drops orally every two hours for oral secretions, Morphine 20mg/ml 0.75 ml (milliliters) every four hours for pain and instructed staff to continue to assess and document R3's pain level twice per day on day shift and night shift. On [DATE] at 8:49 am, Nursing Progress Notes document, Sponge bath given in bed, area to hips cleaned with (normal saline) all even covering. (R3) actively dying, turned every couple hours, air mattress on bed, area on feet and shoulders pinkish in color not open at this time. There are no documented Nursing Progress Notes for R3 during the afternoon or night of [DATE] or the morning of [DATE]. On [DATE] at 5:50 pm, V10 (Agency Certified Nursing Assistant) stated (V4) passed her evening (medication) and after that she went to sleep. It was probably around 9:00 - 9:15 pm, she went to sleep at the nurses' station. (V5) and I split up the residents to do their check and change every two hours. I did help (V5) with (R3), just to reposition him. (R3) was in the process of dying that night, his breathing had changed, and he was making some sounds. (V5) and I did our last rounds around 4:00 am. On [DATE] at 12:50 pm, V5 (Certified Nursing Assistant) stated she was aware the evening of [DATE] that R3 was on Hospice and in the end stages of life. V5 stated, We did turn (R3) every two hours as much as we could. He had a wound that he needed to stay off of. (R3) was on Hospice and actively dying that night, so we focused on keeping him comfortable. He had a lot of stuff in and around his mouth, so we tried to clean that up. I never saw (V4) go into his room during the night. Like I said, she was sleeping the whole time. On [DATE] at 12:15 pm, V6 (Licensed Practical Nurse) stated on [DATE], at about 4:40 am, V5 called her and said the nurse on the 3rd floor was sleeping throughout the night. V5 indicated she was aware that there were Hospice patients on the 3rd floor, and she was concerned they hadn't been checked on by a Nurse throughout the night. V6 stated, (V5) called because the morning meds (medication) needed passed, but I was more concerned about checking the two residents dying (R1 and R3). I went to the gentleman's room first (R3). The gentleman passing (R3) was having extreme air hunger and lots of oral secretions. His eyes were fixed, and he seemed to be just hanging on. I wouldn't want to die like that. I immediately gave him Atropine, Morphine and Ativan. I had another nurse pass the morning meds. At that time, V6 was questioned regarding a documented Pain Assessment in R3's Medication Administration Record on the evening of [DATE], where V6 initialed R3's pain was at a 7 on a scale of ,d+[DATE]. V6 confirmed at that time, she back dated that pain assessment on R3 to [DATE] and that was actually R3's level of pain when she arrived to his room on [DATE] at approximately 5:15 am. On [DATE] at 12:30 pm, V3 (day shift Nurse/Assistant Director of Nursing) stated V5 did report to her the morning of [DATE] that R3 had increased secretions throughout the night and V6 did not pass on any information regarding the condition she found R3 in that morning ([DATE]). Medication Administration Records document V4 charted she administered Lorazepam 0.5 mg and Morphine 0.75 ml to R3 at midnight on [DATE], when V5 and V10 had observed V4 to be sleeping all night. On [DATE] at 7:53 am, V16 (Nurse Practitioner) stated a patient on Hospice and near the end of life should be assessed by the Licensed Nurse frequently, we want these people to be comfortable, oral care needs to be given, assessed for pain. The nurse (V4) not checking on (R3), making sure his medical needs are met in the dying stages is 100% neglect. The next Nursing Progress Note is on [DATE] at 5:26 pm, Family has been here with (R3) most of the day, Hospice nurse was just in and (saw) resident, she doesn't feel like he will transition over tonight, our goal is to keep him comfortable, he keeps his lips pierced together when giving morphine and Ativan, but this nurse was able to administer it, turned and repositioned often, fingers are cool to touch, his feet are mottling somewhat, will continue to monitor and note changes accordingly. Nursing Progress Notes document R3 expired on [DATE] at 9:33 am. 3. The Electronic Medical Record documents R2 has the current diagnoses of Low Back Pain, Pain in the Left Hip and Repeated Falls. R2's Current Plan of Care documents, I have chronic pain (related to) Low Back Pain. (Complaint of) pain even after scheduled pain meds, this occurs almost daily. The Plan of Care advises staff of the following: Nursing is to anticipate need for pain relief and respond immediately to any complaint of pain, (R1's) pain is alleviated/relieved by as needed Tylenol, Evaluate the effectiveness of pain interventions every shift, R2 is able to call for assistance when in pain, ask for medication, tell you how much pain is experienced, Nursing staff is to monitor/document for side effects of pain medication, monitor/record pain characteristics every shift and as needed, and monitor/record/report to Nurse R2's complaints of pain or requests for pain treatment. R2's current physician orders, dated [DATE] document R2 can received Tylenol 500 mg (milligrams) every ,d+[DATE] hours for breakthrough pain and instructs staff to assess R2's pain in the morning and at night. A Minimum Data Assessment, dated [DATE], documents R2 has a BIMS (Brief Interview of Mental Status) of 11, suggesting R2 has moderate cognitive impairment, but is able to make her needs known. On [DATE] at 1:05 pm, V5 (Certified Nursing Assistant) stated she recalled R2 asking for pain medication during the night of [DATE]. V5 stated she could not recall what kind of pain R2 was having, but she tried to notify V4 (Licensed Practical Nurse) of R2's request for pain medication; however, V4 would not wake up at that time. V5 stated I know (R2) didn't' get it (pain medication). On [DATE] at 10:52 am, R2 was questioned about her pain and if she had recently gone without pain medication after requesting it. Due to R2's cognition, she was unable to cite anything specific, but stated, There are times it gets missed. R2 stated she will often ask for additional pain medication during the night because she had pain in her hip. R2 stated, I get pain there (pointing to her hip) when I lay in bed, it's like an ache and the Tylenol will help me go back to sleep. The Electronic Medication Administration Record documents staff failed to assess R2's pain level on the night of [DATE] and R2 did not receive any PRN (as needed) Tylenol 500 mg on [DATE] or [DATE]. On [DATE] at 2:30 pm, V2 (Director of Nursing) stated V3 and V1 (Assistant Administrator) were in charge of the building that weekend, as she was off. V2 stated she didn't find out anything about what happened that weekend until Monday ([DATE]). V2 indicated she heard (R1's) Daughter was upset over her Mom's care and (V3) was handling it. I'm just now hearing the whole story. V2 stated she would have expected the Aides to let someone know well before 4:40 am that V4 had been sleeping on shift. V2 concluded, if residents were not getting proper care or receiving medication that night, she would consider that patient neglect. On [DATE] at 2:42 pm, V1 (Acting Administrator) stated the only thing she was notified of that weekend, was on the evening of [DATE]. V1 stated she was told a Hospice patient was going home with family and that very early in the morning staff had found an Agency Nurse sleeping and she was immediately sent home. V1 stated, I was told nothing more. On Monday, I contacted the Staffing Agency and told them (V4) was found sleeping and was difficult to arouse. I asked for (V4) to be put on a Do Not Return list for our facility. V1 was unaware if anyone in management had officially spoken with or interviewed the CNAs that found V4 sleeping that night. V1 stated, I am just learning all of the details from that night and had I been aware, it would have been looked into for Neglect. On [DATE] at 10:15 am, V1 con [TRUNCATED]

Based on record review and interview, the facility failed to obtain an order for use of bed rails, assess bed rails for safety when used with a low air loss mattress, obtain informed consent and review risks/benefits of bed rail use with the resident's representative for one of one resident reviewed for bed rails in a sample of 32. The facility failed to develop a system for notifying Maintenance of mattress changes when bed rails are being used, so a new Entrapment Risk Assessment could be completed to ensure safety prior to resident use. This failure resulted in R1 rolling out of her bed on 6/08/23 and her head becoming entrapped between the mattress and the bed rail. Facility staff continued to use R1's bed rails in the upright position after R1 became entrapped. On 6/10/23, R1 was found with her upper body hanging over the side of the bed against the bed rails. R1 continued to have bed rails on her bed until she discharged to home on hospice 6/10/23. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy began on 6/06/23 when V11 failed to have Maintenance conduct an entrapment risk assessment to ensure R1 was safe to have bed rails with the installation of a new mattress. V1 (Acting Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 11:26 am on 7/06/23. While the immediacy was removed on 07/07/2023, the facility remains out of compliance at a Severity Level 2 as the facility continues to audit resident records for the completion of bed rail assessments, according to residents' Minimum Data Set assessment schedule, going forward. V24 (Minimum Data Set Coordinator) will ensure that the assessments are completed timely and consistent with the residents' current medical status. V24 will also make sure that there is a physician's order and consent for all bed rail use. V24 will track any discrepancies found and report quarterly to QAPI committee. Findings include: The Recommendations for Health Care Providers Using Adult Bed Rails by the United States Food and Drug Administration (https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails) include the following, When installing and using bed rails: Select an appropriate bed rail for age, size and weight of the person using the bed rail. Be aware that not all bed rails, mattresses, and bed frames are interchangeable and not all bed rails fit all beds. Check with the manufacturers to make sure the bed rails, mattress, and bed frame are compatible. Follow the health care facility's procedures and manufacturer's recommendations and specifications for installing and maintaining bed rails for the particular bed frame and bed rails used. If the bed rail includes a safety strap or bed rail retention system, ensure these are attached to the rail and secured to the bed frame according to the manufacturer's instructions. Use caution when using bed rails with a soft mattress as this may increase risk of entrapment between the mattress and bed rail. Inspect and regularly check the mattress and bed rails to make sure they are still installed correctly and for areas of possible entrapment and falls. Regardless of mattress width, length, and depth, the bed frame, bed rail, and mattress should leave no gap wide enough to entrap a patient's head or body. Regularly assess that bed rails remain appropriately matched to the equipment and to the patient's needs, considering all relevant risk factors. Inspect, evaluate, maintain, and upgrade equipment (beds, mattresses, and bed rails) to identify and remove potential fall and entrapment hazards. Re-assess the person's needs and re-evaluate the equipment if an episode of entrapment or near-entrapment occurs, with or without serious injury. This should be done immediately because fatal 'repeat' events can occur within minutes of the first episode. Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement or bed position, or by using a specialty mattress, such as an air mattress, mattress pad or waterbed. When in doubt, call the manufacturer of the bed rails for assistance. The facility policy, titled Policy and Procedure for Safe Use of Bedrails (no date) documents, The purpose of this guidance is to provide a uniform set of recommendations for caregivers in Sunset Home care settings to use when assessing their patients' need for possible use of bed rails. Bed rails can facilitate turning and repositioning within the bed or transferring in or out of a bed. Procedures: 1. The use of bed side rails must first be evaluated for their appropriateness upon admission in relation to the resident's condition. 2. The request for half or full bed rails must be made by either the Physician/resident &/or POA (Power of Attorney) and clearly documented in the service plan. The facility must obtain a physician's order which needs to be kept on file in the resident's chart. 3. The resident &/or POA must be advised of the risks of bed side rails, including the possible dangers associated with their use prior to the implementation. 4. The continued use of bed side rails must be assessed for appropriateness quarterly as part of updating the resident's service plan, or more often as necessary, with significant changes. R1's electronic medical record documents R1 was admitted to the facility on [DATE] and has the current diagnoses of Chronic Pain, Type II Diabetes Mellitus with Hyperglycemia, History of Diabetic Ketoacidosis, Muscle Weakness, Muscle Wasting and Atrophy. A Consent for Use of Side Rails form was signed by R1 on 10/06/21 and a Maintenance Bed Rail Assessment was documented as being completed that same day. Bed Rail evaluations, on 1/09/23 and 4/13/23, document R1 as a fall risk, that bed rails would only provide R1 with a sense of security, and that bed rails were not indicated at that time as neither R1 or R1's family was requesting the use of bed rails. R1's current Plan of Care documents, I am high risk for falls (related to) gait/balance problems and instructs staff to provide a working and reachable call light, the bed in low position at night; personal items within reach. R1's current Physician's orders, dated 6/01/23, do not contain an order for the use of bed rails. Per interview with V3 (Assistant Director of Nursing), on 6/29/23 at 2:41 pm, R1's mattress was changed to a Low Air Loss Mattress due to her decline in health, with no change in R1's bed frame. Hospice Admission documentation, dated 6/08/23, indicates R1 was placed on Hospice Services due to a physical decline related to malnutrition and cites R1 has experienced increased confusion over the last six months. R1's Hospice Plan of Care, dated 6/08/23, documents under Mobility/Safety that R1/Caregivers will demonstrate safe, effective use of equipment. Interventions: Instruct Patient/Caregiver on fall prevention and safety precautions. (R1) requires assistance of two for transfer but has not been out of bed for 2 days prior to Hospice enrollment. Patient is (a) fall risk. Education to keep bed in low position and call light within reach. On 6/26/23 at 3:04 pm, V12 (Family) stated that R1 has a video camera in her room that is triggered to record with motion or movement. According to V12, on 6/10/12 at 5:25 am, she could see Mom (R1) dangling over the side of the bed. I tried calling there (facility) to notify the staff and no one answered, it rang and rang. I only live 10 minutes away, so I just drove over there. When I got to Mom's floor, it was a ghost town. There were no staff to be seen. I went into her room, and she was still hanging over the side of the bed and her call light was on the floor. So, I went running down the hall looking for someone to help. The Aides came into her room and set her upright. Mom is not waking up and is lethargic. V12 indicated she went back and reviewed video footage to try to determine how long R1 had been hanging over the side of the bed or if she had any other issues, like a fall. V12 stated on 6/08/23 she observed video surveillance of R1's lower body sliding off the bed and her head getting stuck between bed rail and the mattress. V12 concluded, No one ever called me to even tell me that (had occurred). V12 was asked if the facility had ever informed her of the risk and benefits of using bed rails prior to installing them on R1's bed and V12 stated a discussion about bed rails was never had with anyone at the facility. Video surveillance from R1's room, dated 6/08/23 at 10:38 am captured the following on 6/08/23 at 10:38 am: R1 is lying on her left side, positioned on the far left side of the bed. R1 is on a low air loss mattress with both 1/4 bed rails in the upright position. R1's legs begin to slowly slide off the left side of the bed towards the ground, pulling her upper body into the bed rail. R1 attempts to sit up, but her lower body is over the side of the bed, this brings her head and upper body and further into the space between the mattress and bed rail. R1 is in this position for approximately 25 seconds, when V13 (Certified Nursing Assistant) enters R1's room and says toward the hallway, Get the Nurse. She's (R1) on the floor. V13 attempts to move R1 by herself but is unsuccessful. At 10:41 am, V15 (Certified Nursing Assistant) enters the room to assist V13 and V13 states, Her (R1) head's stuck between there. V11 (Licensed Practical Nurse/Unit Coordinator) enters the room and lowers the head of the bed, which allows the staff to get R1 out of the space between the mattress and bed rail and R1 is then fully lowered to the ground. V11 briefly assesses R1 and then V11 and V13 assist R1 back to bed. R1's Electronic Medical Record contains no documentation (Nursing Progress Note, Care Plan Revision, Incident Report, Physician Notification, etc.) of R1 sliding out of bed on 6/08/23, causing her head to become entrapped between the mattress and bed rail. On 6/28/23, V1 (Acting Administrator) and V2 (Director of Nursing) were asked if they had any incident reports for R1 from June 2023, and they both indicated they did not. On 6/29/23 at 12:49 pm, V13 (Certified Nursing Assistant) stated she just happened to be walking by R1's room (on 6/08/23), doing rounds, and saw R1 hanging from the bed. V13 stated, I was the first one in the room. (R1's) head and shoulder was wedged between the air mattress and side rail. (R1's) legs were on the ground. I could see (R1's) face was pressing up against the side rail. It took three staff to get (R1) out and lower her to the ground. V13 stated R1's bed rails were not lowered for her safety after the incident. On 6/29/23 at 12:10 pm, V11 (Licensed Practical Nurse) stated she was called in to help V13 after R1 had slid out of the bed and onto her knees. V11 stated she didn't see R1 by the bed rail or entrapped between the bed rail and the mattress. V11 stated R1 was not injured or complaining of pain. V13 stated (R1) typically doesn't try to get out of bed and she always uses her call light. After that happened, I had a tab alarm placed on (R1) and told the aides to put foam noodles on both sides of the bed. V11 stated she did not discontinue R1's bed rails. V11 stated she did a report in Risk Watch to tell management what happened with the fall and myself or the MDS (Minimum Data Set) Coordinator would have been responsible for updating R1's care plan with fall interventions. V11 stated she was working when R1 received the new air loss mattress (6/06/23) and stated R1 had a regular mattress prior to that. V11 stated she did not think there was any reason why R1 couldn't have bed rails with the low air loss mattress. V11 then concluded, The Maintenance Department does routine entrapment risk assessments on all beds with side rails. But I didn't request a new one from Maintenance when (R1's) new mattress was put in place (on 6/06/23). On 6/29/23 at 10:15 am, V1 (Acting Administrator) confirmed again that Management had not been notified of R1 experiencing any recent falls from bed or that R1 had become entrapped in the bed rails. At that time, the video of R1 on 6/08/23 falling was reviewed with V1. After reviewing the full video of R1's incident, V1 agreed that it should have been investigated as a fall from bed with entrapment. V1 stated R1 should have had a physician's order for the side rails and an accurate bed rail risk assessment completed prior to using bed rails with the low air loss mattress. On 7/06/23, V2 (Director of Nursing) she was unaware of R1 had slid off the bed or become entrapped between the bed rail and mattress until it was brought to their attention during the survey. V2 stated the Maintenance Department is to be doing Entrapment Risk Assessments, which included gap measurements, on all beds with bed rails, quarterly and they do monthly rounds to check for any residents that might be new and using bed rails. V2 stated there is no policy or routine practice of staff requesting maintenance to measure for entrapment risk when a resident has a mattress change. V2 indicated she had reviewed R1's Bed Rail evaluations from 1/09/23 and 4/13/23 and noted that those assessments did not support R1's use of bed rails and that R1 did not have a physician's order for the use of bed rails. V2 stated, (R1) was at one point alert and oriented enough to use (bed rails) for mobility and transfers, but I'm not sure about the end when she had declined. V2 then stated, V11 had completed a paper Incident Report on 6/08/23, but V11 never entered the information into the computer for V1 to be notified of what had occurred. V2 stated V11 should have completed a Nursing Note in the electronic medical record, which would have notified Risk Management, but that information wasn't entered, which is why she wasn't alerted to do an investigation. At that time, V2 provided the paper Incident Report completed by V11 on 6/08/23. This Resident Incident Report, dated 6/08/23 at 10:00 am, by V11 documents R1 was found at 9:15 am on 6/08/23 and Describe: found (R1) sliding out of bed. The report documents R1 sustained no injury, was assessed and returned to bed. The report also documents V12 and V16 (Nurse Practitioner) as being notified of the incident. This report fails to document that R1's head was between the bed rail and mattress. Additional video surveillance was reviewed and on 6/10/23 from 5:26 am and 5:46 am R1 can be seen with her head over the right side of the bed towards the ground and both bed rails are in the upright position. R1's upper body is partially against the bed rail. R1 is motionless and R1's call light is on the floor. At 5:46 am (6/10/23), V12, V5 (Certified Nursing Assistant) and V10 (Certified Nursing Assistant) enter R1's room and she is assisted to an upright position. On 7/07/23 at 7:53 am, V16 (Nurse Practitioner) stated she was not notified of R1's 6/08/23 fall and entrapment and indicated she was on vacation that week. V16 stated she did not find out about the incident until after R1 had passed away. V16 stated, if she had been notified of the incident immediately after it happened, she would have told staff to discontinue using the bed rails. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. A new Bed Safety Policy has been created, effective 7/06/23. 2. All staff will receive an in-service on the dangers of using bed rails and entrapment risk using the updated Bed Safety Policy. Nurses will be educated on how to appropriately fill out the bed rail assessment for residents needing them and the orders and measurements required for use. If Hospice or any other agency gives an order for a mattress change or bed rails, facility's updated policy must be followed. This education/in-service will be completed by V1, V2 and V3 by end of day 7/7/2023. 3. V11 and V14 will receive in-servicing on the facility's fall policy and change in resident condition policy. V2 will provide the in-service by end of day 7/7/2023. 4. V2 and V3 will review bed rail assessments for all residents in the facility to ensure they are up to date and correct. Any discrepancies will be addressed as they are found by the end of the day 7/07/23. 5. Maintenance technicians will conduct entrapment measurements on all beds with bed rails by end of day 7/7/2023. 6. V24 (Minimum Data Set Coordinator) will monitor for completion of side rail assessments according to residents' Minimum Data Set schedule going forward. V24 will ensure that the assessments are complete and accurately reflect the current medical condition of the resident. V24 will monitor records to ensure there is a physician's order and consent for bed rail use. V24 will track any discrepancies found and report quarterly to the QAPI committee.

Based on record review and interview, the facility failed to ensure resident care was delivered in a manner that met the resident's physical and emotional needs after experiencing a decline in health and follow the comprehensive individualized care plan when delivering care, for two of three residents (R1, R3) reviewed for nursing care, in a sample of 32. This failure resulted in R3 experiencing physical distress during the end stages of life. Findings include: The Staff Nurse Job Description (Revised [DATE]) documents, The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such Supervision must be in accordance with the current Federal, State, and local standards, guidelines and regulations that govern our facilities, and as may be required by the Director of Nursing or Charge Nurse to ensure that the highest degree of quality care is maintained at all times. The Job Description includes, under Major Duties and Responsibilities: Direct the day to day function of the nursing assistants in accordance with current rules, regulations and guidelines that govern the long-term care facility. Ensure that the nursing procedures manual is followed rendering nursing care. The policy advises that the licenses nurse is to, Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the residents' response to the care. Give/receive the nursing report upon beginning and ending shift duty hours. Provide leadership to nursing personnel assigned to your unit/shift. Under Nursing Care Functions, it documents that the Staff Nurse is to Make periodic checks to assure that prescribed treatments are being properly administered by nursing assistants and to evaluate the resident's physical and emotional status. Administer professional services such as: catheterization, tube feeding, suction, applying and changing dressings/bandages, packs, colostomy care, range of motion exercises, care of the dead/dying, etc., as required, within the Nurse Practice Act for the State of Illinois. Provide and/or assist other staff with nursing care including performing the duties listed in the Certified Nursing Assistant job description as necessary. Monitor seriously ill residents. The Job Description indicates, under Specific Requirements that staff Must have patience, tact, cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents. Must be able to relate information concerning a resident's condition. Must be willing to seek out new methods and principles and be willing to incorporate them into existing practices and Must function independently, have flexibility, personal integrity, and the ability to work effectively with residents, personnel and support agencies. Must be in good general health and demonstrate emotional stability. Must be able to relate to and work with ill, disabled, elderly, emotionally upset and at times hostile people within the facility. The facility policy titled Quality of Life (no date), documents Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation: 1. Residents shall be treated with dignity and respect at all times. 2. 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. The policy also documents, 9. Staff shall speak respectfully to residents at all times and 13. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: Promptly responding to the resident's request for toileting assistance. 1. The Electronic Medical Record documents R3 was admitted to the facility on [DATE] for Hospice services related to Malignant Neoplasm of the Colon. A [DATE] Pain Evaluation documents R3 as experiencing daily moderate pain in his back related to metastatic cancer and he receives narcotics. R3's Hospice Care Plan, dated [DATE], documents R3 was experiencing a significant decline and identifies the following: Goal is for pain to be controlled with R1's desired comfort level, Initiate comfort medications for symptom management, Staff are to collaborate with the Primary Nurse regarding R1's condition and Ensure and coordinate provision of care and services meet R1's needs. On [DATE], Physician's Orders document Hospice changed R3's medication orders to the following: Lorazepam 0.5 mg every four hours for end stage restlessness, Atropine Sulfate 1% two drops orally every two hours for terminal/oral secretions, Morphine 20mg/ml 0.75 ml (milliliters) every four hours for pain and instructed staff to continue to assess and document R3's pain level twice per day on day shift and night shift. On [DATE] at 8:49 am, Nursing Progress Notes document that R3 is actively dying. There are no further documented Nursing Progress Notes or nursing assessments for R3 during the afternoon or night of [DATE] or the morning of [DATE]. On [DATE] at 12:15 pm, V6 (Licensed Practical Nurse) stated on [DATE], at about 4:40 am, V5 (Certified Nursing Assistant) called her and said the nurse (V4/Licensed Practical Nurse) on the 3rd floor was sleeping throughout the night. V5 indicated she was aware that there were Hospice patients on the 3rd floor, and she was concerned they hadn't been checked on by a Nurse throughout the night. V6 stated, (V5) called because the morning meds (medication) needed passed, but I was more concerned about checking the two residents dying (R1 and R3). I went to the gentleman's room first (R3). The gentleman passing (R3) was having extreme air hunger and lots of oral secretions. His eyes were fixed, and he seemed to be just hanging on. I wouldn't want to die like that. I immediately gave him Atropine, Morphine and Ativan. I had another nurse pass the morning meds. V6 confirmed that R3's pain was at a 7 on a scale of ,d+[DATE], when she arrived to R3's room that morning. On [DATE] at 5:50 pm, V10 (Agency Certified Nursing Assistant) stated (V4) passed her evening (medication) and after that she went to sleep. It was probably around 9:00 - 9:15 pm, she went to sleep at the nurses' station. (V5) and I split up the residents to do their check and change every two hours. I did help (V5) with (R3), just to reposition him. (R3) was in the process of dying that night, his breathing had changed, and he was making some sounds. (V5) and I did our last rounds around 4:00 am. On [DATE] at 12:50 pm, V5 (Certified Nursing Assistant) stated she was aware the evening of [DATE] that R3 was on Hospice and in the end stages of life. V5 stated, We did turn (R3) every two hours as much as we could. He had a wound that he needed to stay off of. (R3) was on Hospice and actively dying that night, so we focused on keeping him comfortable. He had a lot of stuff in and around his mouth, so we tried to clean that up. I never saw (V4) go into his room during the night. Like I said, she was sleeping the whole time. Medication Administration Records document V4 charted she administered Lorazepam 0.5 mg and Morphine 0.75 ml to R3 at 8:00 pm and midnight on [DATE], when V5 and V10 had observed V4 to be sleeping all night. Documentation indicates R1 did not receive any Atropine Sulfate 1% for terminal/oral secretions on [DATE] or [DATE]. However, On [DATE] at 2:40 pm, V2 (Director of Nursing) stated she completed a narcotic count as a part of her investigation into resident neglect due to V4 sleeping throughout her shift on [DATE]-[DATE]. V2 stated she was able to confirm that V4 did not administer Lorazepam 0.5 mg and Morphine 0.75 ml to R3 at midnight on [DATE], even though V4 documented in the Medication Administration Record that she did. On [DATE] at 7:53 am, V16 (Nurse Practitioner) stated a patient on Hospice and near the end of life should be assessed by the Licensed Nurse frequently, we want these people to be comfortable, oral care needs to be given, assessed for pain. The nurse (V4) not checking on (R3), making sure his medical needs are met in the dying stages is 100% neglect. V16 stated she would expect the nurse to be completing and charting ongoing pain assessment and if the medications being administered at the end of life are being effective or not. V16 stated, if R3 did not receive medication as ordered at midnight on [DATE], that could account for why he was experiencing air hunger and pain when V6 assessed him after 5:00 am on [DATE]. Nursing Progress Notes document R3 expired on [DATE] at 9:33 am. 2. R1's electronic medical record documents R1 was admitted to the facility on [DATE] and has the current diagnoses of Chronic Pain, Type II Diabetes Mellitus with Hyperglycemia, History of Diabetic Ketoacidosis, Acute Ischemic Heart Disease, Muscle Weakness, Muscle Wasting and Atrophy, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease and was placed on Hospice on [DATE]. R1's current Plan of Care also documents, I am high risk for falls (related to) gait/balance problems and instructs staff to provide a working and reachable call light, the bed in low position at night; personal items within reach, and Be sure my call light is within reach and encourage me to use it for assistance when needed. R1's current Care Plan also documents R1 is an Extensive assist of one (person) with a gait belt and roller walker when transferring and R1 requires the extensive assistance of one staff member to move between surfaces and to toilet. A Minimum Data Set assessment, dated [DATE], documents R1 requires the extensive assistance of one staff member for Activities of Daily Living, including toileting, is only occasionally incontinent of urine, and has a BIMS (Brief Interview of Mental Status) of 14, indicating R1 has minimal cognitive impairment. Video surveillance from R1's room on [DATE] at 7:13 pm recorded the following: V17 (Licensed Practical Nurse) enters R1's room, responding to R1's call light being on. R1 is sitting in her recliner. V17 states to R1, Your call light was on. What do you need? R1 states something inaudible. V17 then states, No, that's not your medicine. What do you need? I came to answer your call light. What do you need? R1 replies, I need to go to the bathroom. V17 stated, Well, I'll have someone come and take you in a little bit, OK? V17 leaves the room before R1 responds. Thirteen minutes later, at 7:26 pm, V17 enters R1's room, accompanied by V18 (Certified Nursing Assistant). V17 states to R1, OK. (R1) you know how to go to the bathroom. I have this aide that's gonna help you to the bathroom. (R1 remains sitting in recliner and says nothing) Please let her help you. Stand up. You know how to stand up. Put your hands on this and stand up. (R1 has the wheeled walker in front of her but is struggling to stand independently. Neither V17 or V18 have a gait belt or are assisting R1 to stand) Show her how you can do it. On the count of three, STAND UP. (R1 can be seen still struggling to stand up independently and is unsure of where to put her hands to help herself stand. R1 is not verbalizing anything and appears confused.) You gotta help yourself, OK? You stand up for those therapists, you can stand up for us. You know how to do it. Push up on the chair and stand up. (R1 continues to struggle with no assistance from V17 or V18) Do you need to go to the bathroom now? Or do you want to wait? (No response from R1 who is sitting and still appears confused) I'm not gonna force you to do this. Do you need help to go to the bathroom? (V17 does not wait for R1 to respond) Do you need to go to the bathroom? R1 quietly states, no. V17 then states, YOU DON'T? Alright. You don't need to go to the bathroom, obviously. Alright (inaudible). Now if you have to go, I have this aide to help you to go to the bathroom. When you need to go, press your call light and we'll come help you. I have to say, you told me you needed to go to the bathroom. I said I was gonna go set some help. She was going to help you. Did you change your mind. R1 responds something that is too quiet to be heard and V17 and V18 leave the room without assisting R1 to the toilet. Video surveillance from R1's room on [DATE] at 8:42 pm recorded the following: V17 enters R1's room as R1 is sitting in her recliner. V17 states, Yes, what do you need (R1)? R1 replies, I need to go to the bathroom. V17 states, (R1) you're gonna have to wait for a little bit. I'm sorry. (V17 then turns off R1's call light) I'm the only person on the floor at the moment. I got a few more people to do and I'll help you to the bathroom. V17 leaves R1's room and no one returns until 10:05 pm, when V17 enters to check R1's blood sugar. Video surveillance with audio indicates R1's blood sugar was low at that time and V17 requests a health shake for R1 to drink. At 10:09 pm, V17 pours a health shake into a cup and gives it to R1, who appears to be lethargic. V17 tells R1 she will be back to recheck R1's blood sugar in 30 minutes. Video surveillance shows R1 alone in her room, sipping on the health shake and at 11:01 pm R1 is slowly slumping towards the left side of the recliner, spilling her drink. V17 does not return to R1's room until 11:07 pm. V17 states R1's name three times and then, Wake up. Really. You need to wake up. You should let them put you to bed. If you are that worse ., do you want me to send you to the hospital? (R1 is not responsive) You gotta wake up. I'm not mad at you, but something is wrong. Did you even drink that stuff? I'm not mad, I'm just worried about you. V17 leaves the room to get R1 a Glucagon injection. By 11:36 pm, R1's blood sugar is back to normal. V17 states to R1, Ok, we are going to get you up in bed now and change you (referring to her incontinence brief). R1 was never toileted after her initial request at 8:42 pm. Video surveillance from R1's room on [DATE] at 8:30 pm recorded the following: V21 (Certified Nursing Assistant) enters R1's room. R1 states, I've had my call light on for an hour. V21 replies, I'm sorry, but I'm the only one running the floor right now. R1 states, Well, the thing is, I don't know what I'm doing. I have to go to the bathroom. V21 states, Do you need to go? R1 replies, Yes, well there's no green pads in here. V21 states, I'll have to go to another unit to get some. V21 leaves without toileting R1 and does not return. On [DATE] at 12:29 pm, V2 (Director of Nursing) reviewed the video surveillance from [DATE], [DATE] and [DATE]. V2 stated R1 seemed defeated in the [DATE] video, after staff repeatedly told her to get up on her own without assistance when she needed to toilet. V2 indicated it was as if R1 gave up on trying to be toileted. V2 stated she expects more from the staff, that staff clearly need education on customer service and not making residents wait to toilet. On [DATE] at 7:53 am, V16 (Nurse Practitioner) stated It doesn't matter where staff are in their education, they can do things for the residents, like pass ice and toilet them, get them what they need. V16 stated V12 (R1's Healthcare Power of Attorney) had expressed to her on [DATE] that she was having issues with staff not toileting R1. V16 stated she informed V6 (Licensed Practical Nurse) that same day that she wanted staff checking on R1 every two hours to either be toileted or see if she needed incontinence care. V16 concluded that R1 had been progressing downhill and staff often don't understand that residents decline and can't do the things they used to do for themselves independently anymore.

Based on interview and record review the facility failed to ensure a resident was properly transferred which affected one of three residents (R1) reviewed for accidents/incidents in a sample of three. This failure resulted in R1 being lowered to the floor during an improper transfer causing significant bruising, a hematoma, and requiring hospitalization in the Intensive Care Unit for a contusion of unspecified front wall of thorax and a large left anterior chest wall hematoma. Findings include: R1's list of current diagnoses includes Dementia, Psychotic Disturbance, Anxiety, Morbid (Severe) Obesity, and General Muscle Weakness. R1's Minimum Data Set (MDS) assessment dated [DATE] documents that R1 is totally dependent on two staff for transfers, does not walk, and uses a wheelchair for mobility. In addition, this MDS documents that when R1 goes from a sit to stand position, meaning R1's ability to come to a standing position from sitting in a chair, wheelchair, or the side of the bed, R1 is dependent on staff to do all the effort where R1 does none of the activity or requires two or more staff to assist R1 to complete the activity. R1's care plan dated 1/19/23 documents that R1 requires the use of a full mechanical lift (A device to transfer a resident who is laying down) with two people for transferring but may use a sit stand mechanical lift, where R1 must hold on to handles, stand, and maintain body weight on his legs during the transfer, for toileting. In addition, R1's care plan documents R1 is at high risk for falls because of incontinence, and gait and balance problems. This same fall care plan documents for staff to use the full mechanical lift due to R1's inability to stand for long. R1's fall prevention focus dated 3/15/23 documents that R1 was lowered to the floor on that date and that the intervention of staff reeducated on appropriate lift use for resident's level of care was added. R1's Investigation Report Form with interviews dated 3/21/23 documents that on 3/15/23 at 5:30a.m. V4 (Certified Nurse Aide/CNA) and V5 (CNA) entered R1's room to get R1 up for the day. V4 and V5 noted that R1's full mechanical lift sling was wet, so they obtained a sit/stand mechanical lift and sling then proceeded to stand R1. While pulling up R1's pants, R1's knees began to buckle at which time V4 and V5 lowered R1 to the floor with no injuries noted at that time. This investigation documents that during the night of 3/15/23, R1 began complaining of pain to R1's left upper arm and a large bruise was found upon R1's assessment. On 3/18/23 R1 was sent emergently to the hospital because R1's bruising had increased in size and because R1 was experiencing increased pain. In V4's written statement, V4 explained that V4 and another CNA were attempting to get R1 up for the day but were unable to find a full mechanical lift sling to transfer R1. V4 stated that she and the other CNA used a sit/stand mechanical lift, where the sling fits around R1's chest and lifts R1 into a standing position, to stand R1 up to transfer. V4 stated that while the CNAs were pulling up R1's pants, R1's legs gave out and R1 was lowered by the CNAs to the floor. In V5's written statement, V5 explained that V5 and another CNA were getting R1 up for the day. V5 stated that R1's full mechanical lift sling was soiled from urine from the previous night and the CNAs could not find another sling to use for R1. V5 stated that she and the other CNA decided to use the sit/stand mechanical lift to stand R1 because R1 was on their list of residents who needed to get up during their shift. V5 explained, The (other) aide and I decided to use the (sit/stand) lift. At times, day shift and other night shift aides have used the (sit/stand) lift on (R1) due to no clean slings in (R1's) room or even on the unit. V5 continued to explain that once V4 and V5 stood R1, R1 became weak, and his knees began to buckle so V4 and V5 lowered R1 to the floor. In addition, R1's fall investigation documents that V4 and V5 were interviewed by V6 (Human Resources) who documented that, Both of them was put (through) transfer training and received a final warning. On 3/27/23 at 1:24p.m. V5 verified that R1 was lowered to the floor on 3/15/23 when V4 and V5 used the sit/stand standing mechanical lift to transfer R1 instead of the full mechanical lift. V5 stated that she and V4 used a regular sit/stand sling around R1 but that R1 is a very large resident who should have a larger sling to fit him. V5 stated that during R1's transfer on 3/15/23, she and V4 placed the sit/stand sling around R1's chest below his breast area so it would stay in place. V4 stated that when R1's knees began to buckle, the sit/stand sling began to slide up as R1's arms went up in the air and that's when V4 and V5 lowered R1 to the floor. R1's progress note dated 3/15/23 at 5:30a.m., late entry, documents that R1's legs became weak during a mechanical lift transfer and was lowered to the floor. R1's progress note dated 3/16/23 at 2:03a.m. documents that R1 complained of pain to his left upper arm at which time a large dark blue bruise was noted. Upon further inspection, the nurse noted R1's bruise was becoming firm to the touch. R1's progress note dated 2/16/23 at 9:27a.m. documents R1's left chest bruise was hard to the touch and that R1 was anxious and yelling out for staff, which this note states, is unusual for (R1) during the day. This same note documents that R1 complained that he Hurt all over, and was administered as needed Acetaminophen for pain which was not effective. R1's progress note dated 3/18/23 at 3:26a.m. documents R1's bruising to his front left chest had spread around to R1's left back at which time R1 was sent to the ER for treatment. R1's progress note dated 3/18/23 at 1:33p.m. documents that R1 was admitted to the Intensive Care Unit of the hospital for close monitoring for active bleeding. R1's hospital emergency room (ER) physician's note dated 3/18/23 states, Started having spontaneous bruising. Eliquis discontinued couple of days ago. May have fallen out of (mechanical) lift recently. Comes in today with significant soft tissue (Hematoma/pooling of blood under the skin due to injury). Large chest wall bruise on the left side. Left leg is swollen. This same note documents under assessment and plan that the hospital physicians would be addressing concerns including soft tissue hematoma, traumatic from fall, and Anemia from acute blood loss. On 3/19/23 R1's Complete Blood Count laboratory (Lab) findings document that R1's HGB (hemoglobin) was extremely low with a reading of 6.8 g/dL (grams per deciliter) with the normal range listed as 12.5 - 16.9 g/dl and R1's HCT (hematocrit) was also low with a reading of 24.2 % (percent) with the normal range listed as 38.0 - 50.0%. As a result of R1's low blood count, R1 was ordered to be transfused with 1 (one) unit of blood. R1's Computed Tomography (CT) angiogram report dated 3/18/23 states, There is a large hematoma in the anterior left chest wall. Large component deep to the left pectoralis major muscle measures 14.9 cm (centimeters) x 10.2 cm x 8.3 cm. There is also intramuscular component of the left pectoralis major muscle which measures approximately 12.3 cm x 1.8 cm x 5.7 cm there is also a smaller hematoma in the inferior left anterior chest wall at the inferior lateral aspect of the pectoralis major muscle which measures approximately 5.8 cm x 3 0.6 cm x 4.1 cm x 2.2 cm x 1.5 cm. No extravasation of contrast is seen to suggest active hemorrhage. Note the extreme lateral aspect of the hematomas are excluded from the image. On 3/27/23 at 9:55a.m., 2:12p.m. and 2:25p.m. V3 (Director of Nurses) stated that she investigates falls and reports falls with injuries to the State Agency. V3 verified that R1 fell during a transfer using the sit/stand mechanical lift instead of the full mechanical lift on 3/15/23. V3 also verified that because of that fall, R1 developed a large bruise and hematoma to the left chest which continued to increase in size. V3 stated that R1 was sent emergently to the hospital for treatment for that bruise and hematoma on 3/18/23 where R1 remains as of this date, 3/27/23.

Based on interview and record review the facility failed to ensure a fall prevention pressure alarm was in working order for one of four residents (R86) reviewed for falls in a sample of 29. This failure resulted in R86 sustaining a fall with a fractured left hip when R86's pressure alarm failed to sound and alert staff that R86 was ambulating without assistance. Findings include: A Falls Management Program dated 7/2017 states, Interdisciplinary Team: An interdisciplinary team will meet on a regular basis to discuss individuals who have had a history or are at high risk of falling and develop a plan to lower the risk potential for future falls. This policy states, Prevention tools may include assessments, education, medication reviews, environmental changes, and the use of fall mats and alarms. An Alarm Reduction Program policy states, Alarms may malfunction, be removed, or lose their effectiveness over time. 1. R86's 8-3-22 Minimum Data Set (MDS) assessments documents R86 is moderately cognitively impaired and requires extensive assistance of one person for bed mobility, transfers, walking in room, dressing, toileting, and personal hygiene. R86's Fall Risk assessment dated [DATE] documents R86 is at risk for falls. R86's care plan for transfers dated 7/26/22 documents R86 requires the extensive assistance of one person with a transfer belt and a wheeled walker. R86's fall investigation report dated 8/20/22 to 8/23/22 documents that on 8/20/22 while R86 was in her room sitting in a chair, R86 stood up without calling for assistance, walked to the door without using her walker, then turned around to walk back when R86 fell to the floor causing her left leg to rotate out. This report documents that R86 was using a pressure alarm in her chair to alert staff when R86 gets up without assistance, however, on 8/20/22 this pressure alarm was not functioning, and staff were not alerted. The report documents that staff did not know R86 was ambulating without assistance until after R86 fell and was heard yelling for help. This report documents R86 was sent emergently to the hospital where she was diagnosed with a fractured left hip. R86's hospital X-ray report dated 8/20/22 documents R86 sustained a Comminuted mildly angulated intertrochanteric fracture of the proximal left femur. On 10/25/22 at 12:24 PM V4 (Unit Manager) stated that R86 has a history of falls. V4 stated that as a fall prevention measure, the IDT placed a pressure alarm in R86's chair which alarms each time R86 gets up without assistance. V4 stated if R86's alarm sounds, staff rush to R86's room to make sure they assist R86, so she doesn't fall. V4 verified that on 8/20/22, R86's pressure alarm did not sound when R86 got up from the chair to walk around her room. V4 stated there is no documentation for when staff last verified that R86's pressure alarm was properly functioning. V4 stated the facility did not have a policy for staff to regularly check the functioning of residents' pressure alarms on a per shift or even a daily basis.

Based on observation, interview, and record review, the Administrator (V1) and Director of Nursing (V2) failed to immediately act upon and follow-up on numerous resident allegations alleging physical, verbal, and mental abuse sustained from Registered Nurse (V4) for eight of nine residents (R1, R2, R4, R5, R6, R7, R8, R9) reviewed for abuse in the sample of nine. These failures resulted in R1, R2, R4, R5, R6, R7, R8, and R9 living in on-going fear and retaliation of V4 in their own home. These failures had the potential to affect all 90 residents within the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 4-27-22, the facility remains out of compliance at Severity level II as the facility continues to interview residents on abuse quarterly based on their MDS (Minimum Data Set) assessment schedule, review these responses monthly, and if an allegation of abuse is detected during an interview, this will be reported to V1 immediately. Staff grievances/abuse allegations will be reviewed by V1 and V2 when they are reported and a log will be kept of staff grievances/abuse allegations, which will be reviewed monthly to assure resolution of incidents. Results of this review along with allegations of abuse from resident and staff members along with grievances will be reported and reviewed by the QAPI (Quality Assurance and Performance Improvement) committee quarterly. Findings include: The facility's Administrator/Chief Executive Officer Job Description Policy, revised 2/14/13, documents, The primary purpose of your job position is to direct the day-to-day operations and functions of the facility in accordance with current Federal, State, and local laws, standards, guidelines, and regulations that govern the long-term care facility to assure that the highest degree of quality care can be provided to the resident at all times. For such purpose, and in dealing with all government regulatory agencies, you are Administrator of (the facility). Major Duties and Responsibilities: Assure that all employees, residents, visitors, and the general public follow established policies and procedure. Create and maintain an atmosphere of warmth, personal interest, and positive emphasis, as well as a calm environment throughout the facility. Personnel Functions: Recruit and select competent department directors, supervisors, consultants, and other auxiliary personnel. Consult the department directors concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services. Terminate employees when necessary, documenting and coordinating such actions with the Human Resources Director. Resident Rights: Ensure that resident's rights to fair and equitable treatment, self-determination, individually, privacy, property and civil rights, are well established and maintained at all times within the administration guidelines. Review residents' complaints and grievances and make written reports of action taken. Miscellaneous: Assure that all residents receive care in a manner and in an environment that maintains or enhances their quality of life without abridging the safety and rights of other residents. Assure that each resident receives the necessary nursing, medical, and psychosocial services to attain and maintain the highest possible mental and physical functional status, as defined by the comprehensive assessment and care plan. Working conditions: Is involved with residents, family members, personnel, visitors, government agencies/personnel, etc., under all conditions/circumstances. Maintains a liaison with residents, their families, support personnel, etc., to assure that the residents' needs are continually met. Specific Requirements: Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines pertaining to long-term care administration. V1's Hiring Authorization Form documents V1 was hired as the Administrator of the facility on 12-27-2018. The facility's Director of Nursing Job Description Policy, Revised 3/2017, documents, The primary purpose of your job description is to plan, organize, develop and direct the overall operation of the Nursing Department in accordance with current Federal, State, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care for our Residents is maintained at all times. Administrative Functions: Plan, develop, organize, implement, evaluate and direct the Nursing Department in accordance with current rules, regulations and guidelines that govern the long-term facility. Personnel Functions: Determine staffing needs for Nursing Department to assure the highest level of care attainable for our Residents. Review grievances and complaints made or filed by nursing personnel. Safety and Sanitation: Promote a safe environment for the Residents and staff. Resident Rights Functions: Ensure that all Nursing Services personnel are knowledgeable of the Residents' Rights and Responsibilities. Monitor Nursing Services to assure that all Residents are treated fairly and with kindness, dignity and respect. Coordinate and direct the Quality Assessment and Assurance program to enhance the quality of life for the Residents in accordance with current rules, regulations, and guidelines that govern the long-term care facility. Responsible for the identification, review, investigation, determination and necessary actions to be taken with Resident complaints and grievances. V2's Personnel Action Change Form documents V2 was hired as the Director of Nursing on 3-15-2017. The facility's Daily Census Sheet dated 4-20-22 documents 90 residents reside within the facility. On 4-21-22 at 9:45 AM, R6 was sitting in her recliner in her room. R6 stated, A while ago (2-24-21), (V4, Registered Nurse), the nurse, jerked me out of my chair, stomped on my feet, and punched me in the stomach. I told (V4) my feet were bleeding and (V4) said 'good.' (V4) then swung me around and threw me on my bed. I am lucky (V4) didn't throw me through the window. I feared for my life. (V4) was always mean to me and would cuss me out. I haven't been able to walk since (V4) stomped on my feet. On 4-20-22 at 9:45 AM, R1 was sitting in her recliner in her room. R1 was alert and oriented to time, place, and name. R1 had tears in her eyes, and R1 stated, A couple weeks ago in the middle of the night around 2:30 AM, I was sleeping in my recliner with the television on. (V4, Registered Nurse) came into my room, ripped the covers off of me, and told me, 'Get up. You are going to the bathroom.' I told her that I did not have to go to the bathroom. (V4) said yes you are and made me go to the bathroom. I looked at (V4) and said, 'Why are you so mean.' I do not know why (V4) was being so hateful to me. (V4) told me to shut my television off and go to bed. I did not want to go to bed. I was crying and (V4) told me to, 'Shut up.' I have told everybody about this and do not like that (V4) still takes care of me. I feel scared when she is on duty. (V4) is nothing but a bully. I can hear her out in the hallway yelling at other residents at times. She is just like Nurse Ratchet. V22's (CNA/Certified Nursing Assistant) written statement dated 3/30/21 and signed by V22, documents, (R9) has made numerous complaints about (V4) and the way she treats her and talks to her. (R9) said that she is in her right mind and that she would never talk to someone the way that (V4) talks to the residents. (R9) said (R8) has cried to (R9) numerous times because (R8) says (V4) is rough and mean with her. This is an ongoing thing and it's to the point to where the majority of the residents have complained about (V4) or are scared of (V4). An Employee Warning Report dated 4/21/21 and signed by V25/Human Resources, documents, Employee name as (V4), Type of warning as Final Warning, Type of Offense as Violation of company policies. Description of Violation: We continue to receive multiple complaints from residents and staff that you are rude to residents, yelling and cursing at them. We also receive complaints from staff that constitute as bullying and intimidation. This warning was signed by V4, Registered Nurse, on 4/21/21. This warning also has documented that V2 was present. V11's (President of the Board of Directors) Email (Electronic Mail) dated 1-17-22 and sent to V1 (Administrator) and V2 (Director of Nursing/DON) documents, (R5) says (R7) has Dementia or limited mental abilities and has a repetitive verbal tick where she says, 'the-the-the' frequently. (R5) witnessed (V4/Registered Nurse) mock and repeat this tick to (R7) and to other staff in the lunchroom. Other incidents that (R5) didn't witness firsthand was (V4) had told a male resident (R2) that everybody hated him, and nobody wanted him there. (R5) heard that this male resident was going around to other residents in tears, asking if it was true that everyone hated him. (R5) also heard from (R6) that (V4) dragged (R6) out of her armchair at night onto the floor and stomped on her stomach. This would of course be a very serious incident if true. (R5) feels that other staff and residents are fearful of (V4) and concerned about retribution if they were to report her. (R5) feels certain staff have quit as a result of (V4's) presence. (R5) has been advised by other residents (and staff, as I understand it) to watch her medicines very closely at night because some people are truly fearful that (V4) would harm them. I feel it is very important that we address this phone call in our executive meeting and that we move forward with investigation into (V4's) conduct and/or termination. V4's Time and Attendance Report dated 2-4-22 through 4-19-22 documents V4 has worked full time hours within the facility. On 4-20-22 at 9:35 AM, V26 (LPN/Licensed Practical Nurse) stated R1, R4 and R9 have made abuse allegations regarding (V4) to her and she reported those allegations to V2 (Director of Nursing). On 4-20-22 at 11:25 AM V7 (Nurse Resource Coordinator) stated, One night in March 2022, (V5/Service Attendant) called me and told me that (V4, Registered Nurse) grabbed (R4's) penis and told (R4) that if he doesn't quit masturbating, she (V4) was going to break it off. I did not report this allegation to (V1/Administrator). I wasn't thinking. I put a written statement in (V2's) office box about the allegation on Monday (March 14). On 4-20-22 at 1:05 PM V8 (Registered Nurse) stated, (V4) has been abusing residents for years. (R2) was crying one morning to me that (V4) told him nobody can stand (R2), and she (V4) hates him (R2). (R2) was crying for days asking the staff if they like him. This happened several months ago. I submitted statements to (V2) and notified (V2) immediately. (V4) mocks (R7) in the dining room and I know (R6) had to be moved off of 400-hallway due to (R6) reporting that (V4) beat her up and yelled at her. On 4-20-22 at 12:15 PM, V11 (President of Board of Directors) stated, I would have expected (V1, Administrator) to have investigated all of these allegations as abuse. On 4-21-22 at 9:30 AM, V12 (R6's Power of Attorney) stated, About a year ago in February 2021 when (R6) lived on the fourth floor, (R6) had told me that (V4) had beaten her and stomped on her feet. I reported this to Social Services (V9) and (V2/Director of Nursing). (V2) made the decision to move (R6) down to the first floor so (V4) would no longer care for (R6). I know (V4) did take care of (R6) after that a couple of nights, even though (V2) said she would not let (V4) take care of (R6). On 4-21-22 at 10:20 AM, V27 (Social Worker) stated that she has reported abuse allegations that R1 and R6 made against (V4) to (V2) and has not reported the allegations to (V1). On 4-22-22 at 9:55 AM, V19 (Registered Nurse) stated that multiple residents (R5, R6, R7, R8, and R9) have had numerous reports of (V4) abusing them either physically, mentally, or verbally. V19 stated she has made (V2) aware of all of the allegations, and (V4) has continued to be allowed to take care of these residents. V19 stated, I never notified (V1) of any of these allegations. Every time I would call (V1) with concerns he would tell me, 'What do you want me to do about it?' I did not even know that (V1) was the abuse coordinator. On 4-20-22 at 12:15 PM, V11 (President of Board of Directors) stated, (V1, Administrator) has never gotten back to me with the outcome or what has been done regarding all of the resident's allegations of abuse from (V4). I thought (V1) would have taken care of it. On 4-20-22 at 9:45 AM V1 (Administrator) stated, I have had no staff to resident abuse allegations made to me in the last six months. On 4-21-21 at 8:45 AM V3 (ADON/Assistant Director of Nursing) stated, (R1, R2, R4, R5, R6, R7, R8, and R9's) allegations of abuse regarding (V4) have never been reported to the State, investigated, and (V4) has not been suspended pending investigation. None of these allegations have been documented in the resident's clinical records. (V1) was made aware of the allegations regarding (R1) and (R4). (V4) is able to work all floors with all residents. On 4-22-22 at 9:30 AM (V2) stated, I cannot find that an investigation was done regarding (R8 and R9's) allegations of abuse from (V4). I cannot find where (V4) has ever been suspended or removed from resident care for abuse allegations pending investigation. On 4-20-22 at 1:00 PM, V1 (Administrator) stated, I trusted that (V2) would do the reports to the state and the investigations (regarding V4's abuse allegations). I did not have anything else to do with them once I turned them over to (V2) and (V3). I am the abuse coordinator. I do not recall any other allegations of abuse made to me about (V4) regarding (R1, R2, R4, R5, R6, R7, R8, or R9). (V4) has never been suspended pending an abuse investigation. An Immediate Jeopardy was identified on 4-25-22 at 10:00 AM. The Immediate Jeopardy began on 2-24-21 when R6 reported to administration physical, verbal, and mental abuse she had sustained by V4 and V4 was allowed by the facility Administration to continue to work in the facility resulting in (R1, R2, R4, R5, R7, R8, and R9) being verbally, physically, and mentally abused by V4. V1 and V2 received emailed statements and written statements by staff and residents alleging abuse of the residents, and V1 failed to ensure all of these allegations were investigated thoroughly and that residents remained protected from V4 (Registered Nurse) throughout the course of the investigation. On 4-26-22 at 10:30 AM V1 (Administrator) and V3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V1 and V3 were in-serviced by V25 (Human Resource Director) on their job duties and roles related to prevention of abuse and fear of the residents. 2. V1 and V3 were in-serviced by V30 (Ombudsman) regarding abuse allegations and procedures. 3. A tool incorporating questions regarding staff to resident abuse and resident to resident abuse was developed and used with all residents follow up interviews. Social service staff interviewed all residents emphasizing that they can report allegations/occurrences of abuse without fear of retaliation from the staff member. 4. Mental health services were offered to (R1, R2, R4, R5, R6, R7,R8, and R9). Completion date 4-27-22

Based on interview and record review, the facility failed to immediately remove the alleged perpetrator (V4, Registered Nurse) after allegations of verbal, physical, and mental abuse were made, thoroughly investigate these allegations of abuse by (V4) and failed to report these allegations to the State agency for eight of nine residents (R1, R2, R4, R5, R6, R7, R8 and R9) reviewed for abuse in the sample of nine. These failures resulted in V4 remaining in the facility and working directly with R1, R2, R4, R5, R6, R7, R8, and R9 which resulted in these residents suffering continual abuse, fear, retaliation, and bullying from V4. These failures have the potential to affect all 90 residing within the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 4-27-22, the facility remains out of compliance at Severity level II as the facility continues to keep a reportable occurrences log that will be audited and reviewed monthly by the V1 (Administrator), V3 (Assistant Director of Nursing) and V9 (Social Services Coordinator) to assure that any instances of abuse have been reported to the State, families and physicians of residents involved, as well as the elder abuse officer as appropriate. Upon completion of any new abuse investigations, V3 will forward the findings on to the State agency. The facility will also continue to educate staff and all new staff on the abuse policy. Findings include: The facility's Abuse and Neglect Policy revised on July 2017 documents, Identifying and Recognizing Signs and Symptoms of Abuse: 1.) The following are examples of actual abuse/neglect and signs and symptoms of abuse/neglect which should be promptly reported. This listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. When in doubt, REPORT IT IMMEDIATELY. i. Signs of/Actual Physical Abuse: A.) Welts or Bruises; B.) Abrasions or lacerations; C.) Fractures, dislocations, or sprains of questionable origin; D.) Black eyes or broken teeth; E.) Sexually exploited, G.) Rape; H.) Excessive exposure to heat or cold; I.) Involuntary seclusion; J.) Multiple [CONDITION(S)] or human bites. ii. Signs of/Actual Physical Neglect A.) Malnutrition and dehydration (unexplained weight loss; B.) Poor hygiene; C.) Inappropriate clothing (soiled, tattered, poor fitting, lacking, inappropriate for season); D.) Decayed teeth; E.) Improper use/administration of medication; F.) Inadequate provision of care; G.) Caregiver indifferent to resident's personal care and needs; H.) Failure to provide privacy I.) Left alone but needs supervision. iii. Signs/Symptoms of psychological abuse/neglect; A.) Resident clings to abuser/caretaker; B.) Paranoia; C.) Depression; D.) Confusion; E.) Disorientation; F.) Withdrawal; G.) Inconsistent injury explanation; H.) Low self-esteem or self-worth; I.) Anger; and/or J.) Suicidal. VI. Abuse Investigations: All reports of resident abuse, neglect, and injuries of unknown origin shall be promptly and thoroughly investigated by the organization management. The administrator shall be notified immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator along with the (State agency), and adult protective services, if necessary. 1.) Should an incident or suspected incident of abuse, neglect, or injury of an unknown source be reported, the administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. 2.) The person in charge of the investigation will be provided a completed copy of the abuse report form, witness statement, and or information regarding the alleged incident. 3.) The individual conducting the investigation will, at a minimum: i. Review the resident's medical record to determine events leading up to the incident; ii. Interview the person(s) reporting the incident; iii. Interview any witnesses to the incident; iv. Interview the resident (as medically appropriate), v. Interview the resident's attending Physician to determine the resident's current mental status; vi. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; vii. Interview the resident's roommate, family members, and visitors; viii. Interview other resident's roommate, family members, and visitors; ix. Interview other residents to whom the accused employee provides care or services, and x. Review all events leading up to the alleged incident. 5.) Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports. 6.) While the investigation is being conducted, accused individual not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the administrator. 7.) Employees of the organization who have been accused of resident abuse shall be suspended from duty pending the results of the investigation which shall be reviewed by the Administrator. 8.) The individual in charge of the investigation will consult with the administrator on a daily basis concerning the progress/findings of the investigation. 9.) The administrator or designee shall keep the resident and his/her representative informed of the progress of the investigation. 10.) The results of the investigation will be documented. 11.) A copy of the completed investigation shall be provided to the Administrator within five working days of the reported incident. 12.) The Administrator or designee shall inform the resident and his/her representative of the results of the investigation and corrective action taken within five days of the completion of the investigation. 13.) Should the investigation reveal that abuse occurred; the administrator or designee shall report such findings to the ombudsman, the state licensing agency, and others, as may be required by state or local laws immediately. 15.) Allegations of abuse are reported to the state survey agency immediately. The administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency within five days of the reported incident. VII. Protection of Resident During Abuse Investigations: 1.) During abuse investigations, residents will be protected from harm by the following measures: i. Employees accused of participating in the alleged abuse will be immediately suspended until the findings of the investigation have been reviewed by the administrator. VIII. Reporting Abuse: Facility Management, it is the responsibility of all employees, consultants, attending physicians, family members, etc., to immediately report any incident, suspected incident, or allegation of neglect or resident abuse, including injuries of unknown origin, and theft or misappropriation of resident property to the Administrator. 2.) Employees, consultants, and/or attending Physicians must report any suspected abuse, allegations of abuse, or incidents of abuse to the Administrator immediately. 3.) The Administrator must be immediately notified of suspected abuse, allegations of abuse, or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator shall be contacted immediately. vi. The Resident's Attending Physician; and/or vii. The Facility Medical Director. 5.) Notices to the above agencies/individual may be submitted via United States mail, special carrier, facsimile, electronic mail, or by telephone. Such notices will include, as minimum: i. The name of the resident; ii. The number of the room in which the resident resides; iii. The type of abuse committed (i.e., verbal, physical, sexual, neglect, etc.): iv. The date and time the alleged incident occurred, v. The name(s) of all persons involved in the alleged incident, and. Vi. Describe immediate action taken by the organization. 7.) Any individual observing an incident of resident abuse or suspecting resident abuse must move resident from harm and immediately report such incident to the home Administrator. 9.) A completed copy of the abuse report and written statements from witness, if any, must be provided to the Administrator within 24 hours of the reporting of such incident. An immediate investigation shall be made and a copy of the findings of such investigation shall be provided to the Administrator within five working days of the reporting of such incident. 10.) When an incident of resident abuse is suspected or determined, such incident must be report to facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy. State Agencies: To assure all serious bodily injuries and reasonably suspected crimes against a resident resulting in serious bodily injuries are reported to the (State Agency) by phone immediately, and all serious incidents and accidents, and allegations of abuse, including injuries of unknown source, and reasonable suspicion of crime against a resident are reported to the (State Agency) in an appropriate fashion immediately with a final report sent to the department within five days. The facility's Daily Census Sheet dated 4-20-22 documents 90 residents reside within the facility. V22 (CNA/Certified Nursing Assistant) written statement dated 3/30/21 and signed by V22, documents, (R9) has made numerous complaints about (V4) and the way she (V4) treats her and talks to her. (R9) said that she is in her right mind and that she would never talk to someone the way that (V4) talks to the residents. (R9) said (R8) has cried to (R9) numerous times because (R8) says (V4) is rough and mean with her. This is an ongoing thing and it's to the point to where the majority of the residents have complained about (V4) or are scared of (V4). An Employee Warning Report dated 4/21/21 and signed by V25/Human Resources, documents, Employee name as (V4, Registered Nurse), Type of warning as Final Warning, Type of Offense as Violation of company policies. Description of Violation: We continue to receive multiple complaints from residents and staff that you are rude to residents, yelling and cursing at them. We also receive complaints from staff that constitute as bullying and intimidation. This is also a Category 1 offense page 23 of your employee handbook #28 Threatening, intimidating, or coercing fell ow employee, resident, visitors, or other people affected with (the facility). Category 1 offenses are most serious and subject an employee to immediate discharge in the absence of mitigating circumstances. Consequences of Further Violations: Follow (the facility's) policies and procedures. Any further violations of this policy will result in termination from employment depending on the offense. This warning was signed by V4 on 4/21/21. This warning also has documented that V2 (Director of Nursing) was present. V11's (President of the Board of Directors) Email (Electronic Mail) dated 1-17-22 and sent to V1 (Administrator) and V2 (Director of Nursing/DON) documents, I spoke to (V1) regarding a phone call I received yesterday from (R5) and would like to provide you both with the details of that conversation. (R5) personally witnessed an incident where (V4) was openly mocking a resident (R7) at mealtime. (R5) says (R7) has Dementia or limited mental abilities and has a repetitive verbal tick where she says, 'the-the-the' frequently. (R5) witnessed (V4) mock and repeat this tick to (R7) and to other staff in the lunchroom. Other incidents that (R5) didn't witness firsthand was (V4) had told a male resident (R2) that everybody hated him, and nobody wanted him there. (R5) heard that this male resident was going around to other residents in tears, asking if it was true that everyone hated him. (R5) also heard from (R6) that (V4) dragged (R6) out of her armchair at night onto the floor and stomped on her stomach. This would of course be a very serious incident if true. (R5) feels that other staff and residents are fearful of (V4) and concerned about retribution if they were to report her. (R5) feels certain staff have quit as a result of (V4's) presence. (R5) has been advised by other residents (and staff, as I understand it) to watch her medicines very closely at night because some people are truly fearful that (V4) would harm them. I feel it is very important that we address this phone call in our executive meeting and that we move forward with investigation into (V4's) conduct and/or termination. On 4-20-22 at 9:35 AM V26 (LPN/Licensed Practical Nurse) stated, About a week or two ago, (R1) told me that (V4) had went into her room in the middle of the night, jerked her covers off of her, and told (R1) to get the hell up and out of the chair. I reported this immediately to (V27/Social Services). (R1) continued to be very mad that day and would say, 'I am not going to let that b***h (V4) talk to me that way.' I have had a lot of residents complain in the past and have been told that if it is not in writing, it didn't happen. (R9) is very scared of (V4) and tells me that all the time. I know there was an abuse allegation turned into (V2/Director of Nursing) regarding (V4) and another resident (R4) in the past. On 4-20-22 at 11:25 AM V7 (Nurse Resource Coordinator) stated, One night in March 2022, (V5/Service Attendant) called me and told me that (V4, Registered Nurse) grabbed (R4's) penis and told (R4) that if he doesn't quit masturbating, she (V4) was going to break it off. I did not report this allegation to (V1/Administrator). I wasn't thinking. I put a written statement in (V2's) office box about the allegation on Monday (March 14). On 4-20-22 at 1:00 PM V5 (Service Attendant) stated, I was sitting at the nurse's station on (3-9-22) around 6:30 PM and (R4) was masturbating in the little room connected to the nursing area. (V4/RN) went up to (R4), grabbed (R4's) by the penis, and screamed at (R4), 'If you don't stop that I am going to rip that thing off.' (R4) had his penis outside of his pants. Later that night, around 8:30 PM, (R4's) door to his room was closed and I could hear (V4) yelling at (R4), 'You son of a b***h.' I then heard a slap and heard (R4) yell back at (V4), 'ouch.' I was too scared to go in (R4's) room. I am scared of what (V4) might have done to me. I did not report this to (V1/Administrator) or (V2/Director of Nursing). I called and reported this to (V7/Nurse Resource Coordinator) later that night. I did give (V2) a written statement later the next week. On 4-20-22 at 2:25 PM V9 (Social Service Director) stated, I met with (R5) on 12-29-21 to talk to her about concerns she had with (V4). (R5) did not like how (V4) was treating her. (R5) said (R5) told (V4) that she was not taking a shower due to doctor's orders, and that she was to only have a sponge bath. (R5) said that (V4) called her a 'liar' and said (V4) tried to force (R5) to take a shower and was telling (R5) she refused to wear her foam boot. (R5) was very upset and felt like (V4) was very rude. (R5) also told me that she saw (V4) mocking another resident (R7) repeatedly in the dining room and laughing about it. (R7) tends to repeat 'the, the, the, the, there' repeatedly and (R5) said (V4) kept making the same sounds as (R7) and laughing about it. (R5) said this made her feel very uncomfortable and felt it was cruel and unnecessary. I reported this all in an email to (V2/Director of Nursing) and left a message on (V1's) voicemail regarding the allegations. I let both (V1) and (V2) know that I felt like these allegations need to be treated as abuse. On 4-20-22 at 1:05 PM V8 (Registered Nurse) stated, (V4) has been abusing residents for years. (R2) was crying one morning to me that (V4) told him nobody can stand (R2), and she (V4) hates him. (R2) was crying for days asking the staff if they like him. This happened several months ago. I submitted statements to (V2) and notified (V2) immediately. (V4) mocks (R7) in the dining room and I know (R6) had to be moved off of 400-hallway due to (R6) reporting that (V4) beat her up and yelled at her. On 4-20-22 at 12:15 PM V11 (President of Board of Directors) stated, On 1-17-22 I contacted (V1) and (V2) about concerns (R5) had reported to me. (R5) had concerns with a nurse (V4). (R5) also said (V4) was trying to force (R5) to take a shower, even though (R5) had a doctor's order to only take sponge bathes. (R5) felt like she was not treated or respected very well by (V4). (R5) also said she witnessed (V4) mocking a resident (R7) during meals that had a known 'tick.' (R5) also reported (V4) told a resident (R2) that everyone hated him and caused (R2) to have tears. On Monday (4-18-22), (R5) told me (R4) had been assaulted by (V4) and had been slapped by (V4). I notified (V1) by phone of this allegation immediately on Monday (4-18-22). I would have expected (V1) to have investigated all of these allegations as abuse. On 4-21-22 at 9:45 AM, R6 was sitting in her recliner in her room. R6 stated, A while ago (2-24-21), (V4, Registered Nurse), the nurse, jerked me out of my chair, stomped on my feet, and punched me in the stomach. I told (V4) my feet were bleeding and (V4) said 'good.' (V4) then swung me around and threw me on my bed. I am lucky (V4) didn't throw me through the window. I feared for my life. (V4) was always mean to me and would cuss me out. I haven't been able to walk since (V4) stomped on my feet. On 4-21-22 at 9:30 AM, V12 (R6's Power of Attorney) stated, About a year ago in February 2021 when (R6) lived on the fourth floor, (R6) had told me that (V4) had beaten her and stomped on her feet. I reported this to Social Services (V9) and (V2/Director of Nursing). (V2) made the decision to move (R6) down to the first floor so (V4) would no longer care for (R6). I know (V4) did take care of (R6) after that a couple of nights, even though (V2) said she would not let (V4) take care of (R6). On 4-21-22 at 10:20 AM, V27 (Social Worker) stated, I have reported the allegation that (R1) made about (V4) to (V2). I have been notified of multiple resident allegations of verbal abuse from (V4) and have reported all of them to (V2). I have not documented any of these allegations in the resident's Social Service notes or progress notes. I know (R6) had made several allegations about (V4). I have not reported any of these allegations to (V1). On 4-22-22 at 9:55 AM V19 (Registered Nurse) stated, (R5) was scared of (V4) and said she was afraid (V4) would try to overdose her. When I first started there around December 2020 (V4) was orientating me. One night during this time around 7:00 PM to 9:00 PM, (R6) was weak and trying to sit down while she was walking. (V4) started yelling and cussing at her to keep going and made her walk the rest of the way to her chair. (R6) was angry and upset and was yelling back at (V4). (V4) was very verbally abusive to (R6). (R6) would get so upset with (V4) and tell me that (V4) 'hates her.' I know (R6) got so upset that (R6's) psychiatrist called the facility and said it would be in (R6's) best interest to not have to be around (V4) at all. (R6) was then moved from 400-hallway to 100-hallway and (V4) was not supposed to work with (R6). Later on, (V4) had so many complaints filed against her from residents on 400-hallway, that the supervisors decided to move her to 100-hallway for a few months. I thought that was ridiculous to just move (V4) to another hallway and let (R6) have to be cared for by (V4) again. Around November 2021, (R2) would tell me almost every night that I worked that he was afraid of (V4) and would thank me for working there. (R2) would say on the nights that (V4) would work with him, he would get yelled at by (V4). (R9) is a very sweet little old lady that would not cause any trouble with anybody. (R9) would tell me that she doesn't like (V4) and has heard (V4) 'belittling' (R7) in the dining room. (R9) would tell me that she was scared of (V4). (R8) would whisper to me that (V4) yells at her and to not tell anybody because it would get back to (V4). (R8) would say she was afraid of (V4) and would not tell my why. I have reported all of these allegations to (V7/Nurse Coordinator) and (V7) would report them to (V2). I never notified (V1) of any of these allegations. Every time I would call (V1) with concerns he would tell me, 'What do you want me to do about it?' I did not even know that (V1) was the abuse coordinator. On 4-20-22 at 12:15 PM, V11 (President of Board of Directors) stated, (V1) has never gotten back to me with the outcome or what has been done regarding all of the resident's allegations of abuse from (V4). I thought (V1) would have taken care of it. On 4-20-22 at 9:45 AM V1 (Administrator) stated, I have had no staff to resident abuse allegations made to me in the last six months. On 4-21-21 at 8:45 AM V3 (ADON/Assistant Director of Nursing) stated, (R1, R2, R4, R5, R6, R7, R8, and R9's) allegations of abuse regarding (V4) have never been reported to the State, investigated, and (V4) has not been suspended pending investigation. None of these allegations have been documented in the resident's clinical records. (V1) was made aware of the allegations regarding (R1) and (R4). (V4) is able to work all floors with all residents. On 4-22-22 at 9:30 AM (V2, Director of Nursing) stated, I cannot find that an investigation was done regarding (R8 and R9's) allegations of abuse from (V4). I cannot find where (V4) has ever been suspended or removed from resident care for abuse allegations pending investigation. On 4-20-22 at 1:00 PM V1 (Administrator) stated, I got a call from V11 (President of the Board) on Monday (4-18-22) informing me that she had got a report of (V4) grabbing (R4's) 'crotch' and telling (R4) she was going to break it off about a month ago that was witnessed by (V5/Service Attendant). I did not report this or investigate this as abuse. I guess a staff member grabbing a man's penis could be considered abuse. (V4) has not been suspended because as of yesterday I did not feel like this allegation rose to the level of abuse. I also have received an email in January 2022 from (V11) regarding multiple resident concerns regarding (V4). I turned all of this over to (V2) and (V3/Assistant Director of Nursing/ADON) to investigate. I trusted that (V2) would do the reports to the State and the investigation. I did not have anything else to do with it once I turned it over to (V2) and (V3). I am the abuse coordinator. I do not recall any other allegations of abuse made to me about (V4) regarding (R1, R2, R4, R5, R6, R7, R8, or R9). (V4) has never been suspended pending an abuse investigation. An Immediate Jeopardy was identified on 4-21-22 at 3:00 PM. The Immediate Jeopardy began on 2-24-21 when R6 reported she had sustained physical, verbal, and mental abuse by V4 and V4 was not removed from direct care of the residents residing within the facility, the facility did not thoroughly investigate the allegation, and the facility did not report the allegation of abuse to the State agency or V1, resulting in V4 continuing to have access to all residents in the facility and verbally, physically, and mentally abusing R6 and other residents (R1, R2, R4, R5, R7, R8, and R9). On 4-25-22 at 11:00 AM V1 (Administrator) and V3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V9 (Social Services Coordinator) contacted the Elder Abuse Officer on 4/25/2022 to report all abuse allegations against V4. 2. V1 (Administrator) made an initial report to the State Agency regarding the abuse allegations for residents R1, R2, R4, R5, R6, R7, R8, and R9. 3. V4 (RN) was terminated from her position at the facility on 4/25/2022 at 12:15 pm. 4. V9 (Social Services Coordinator) along with other Social Services staff interviewed all residents in the facility regarding any further abuse allegations and all allegations found during these interviews were reported to V1. 5. Full investigations of all allegations of abuse will be completed by V3 (Assistant Director of Nursing and V9 (Social Services Coordinator). 6. All department heads and all other staff were in-serviced on the Abuse policy regarding reporting abuse, protecting the residents, removal of the perpetrator and thorough investigation. 7. V3 kept a log of all reportable incidents ensuring all instances of abuse have been reported to State, families and Physicians of residents involved, as well as the elder abuse officer as appropriate. Completion Date 4-27-22

Based on observation, interview, and record review, the facility failed to prevent mental, verbal, and physical abuse from a Registered Nurse (V4) to eight of nine residents (R1, R2, R4, R5, R6, R7, R8, R9) reviewed for abuse in the sample of nine. These failures resulted in R1, R2, R4, R5, R6, R7, R8 and R9 having increased on-going feelings of anxiety, crying, and fearfulness, R4 and R5 sustaining physical abuse, and R7 sustaining bullying/disparaging comments regarding her disease. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 4-27-22, the facility remains out of compliance at Severity level II as the facility continues to interview residents on a quarterly basis according to their MDS (Minimum Data Set) assessment schedule and implement a tool incorporating questions regarding staff to resident abuse and resident to resident abuse, emphasizing a resident can report allegations/occurrences of abuse without fear of retaliation from the staff. The responses of these interviews will be reviewed monthly by V1 (Administrator), V3 (Assistant Director of Nursing) and V9 (Social Services Coordinator) and if an allegation of abuse is detected during an interview of a resident, this will be reported to the Administrator immediately. All new staff will be in-serviced on the Abuse policy and procedures including reporting abuse, removal of the perpetrator, and thorough investigation on their first day of orientation. Findings include: The facility's Abuse and Neglect Policy revised on July 2017 documents, It is the policy of (the facility) to provide each resident with an environment free from abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of resident property, exploitation and physical or chemical restraint not required to treat the resident's symptoms, as defined below. The facility shall follow the procedure for the reporting and investigation of alleged resident abuse and neglect as outlined below, and in accordance with Skilled Nursing and Intermediate Care Facilities Code. Abuse refers to the willful infliction of injury, reasonable confinement, intimidation, punishment with resulting physical harm, pain, or mental anguish. Deprivation by an individual, including a caretaker, of goods or services which are necessary to attain or maintain physical, mental, and psychosocial well-being is also defined as abuse. Instances of abuse, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Physical Abuse includes, but is not limited to, hitting, pinching, slapping, kicking, and controlling behavior through corporal punishment, this also includes resident to resident physical contact in the dementia unit. An Employee Warning Report dated 4/21/21 and signed by V25/Human Resources, documents, Employee name as (V4/Registered Nurse), Type of warning as Final Warning, Type of Offense as Violation of company policies. Description of Violation: We continue to receive multiple complaints from residents and staff that you are rude to residents, yelling and cursing at them. We also receive complaints from staff that constitute as bullying and intimidation. It was also found that (V4) trained a staff member that if a resident is not allergic to Benadryl, that you can give it to them to help them sleep. This is a Category 2 Offense page 24 of your employee handbook #18, Discourtesy to the residents, residents' family, or fell ow employees. Category 2 offenses should require disciplinary action but may not in all incidents result in immediate discharge in the absence of mitigating circumstances. This is also a Category 1 offense page 23 of your employee handbook #28 Threatening, intimidating, or coercing fell ow employee, resident, visitors, or other people affected with (the facility). Category 1 offenses are most serious and subject an employee to immediate discharge in the absence of mitigating circumstances. Consequences of Further Violations: Follow (the facility's) policies and procedures. Any further violations of this policy will result in termination from employment depending on the offense. This warning was signed by V4 on 4/21/21. This warning also has documented that V2 (Director of Nursing) was present. V4's Training Transcript documents V4 was in-serviced on Abuse and Neglect, Types of Abuse, and Preventing, Reporting, and Recognizing Abuse 3-4-16, 6-23-16, 7-13-17, 7-9-18, 8-7-19, 8-13-19, 6-15-21, and 4-10-22. 1. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively intact. R1's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4-20-22 at 9:45 AM R1 was sitting in her recliner in her room. R1 was alert and oriented to time, place, and name. R1 had tears in her eyes and R1 stated, A couple weeks ago in the middle of the night around 2:30 AM, I was sleeping in my recliner with the television on. (V4, Registered Nurse) came into my room, ripped the covers off of me, and told me 'Get up. You are going to the bathroom.' I told her that I did not have to go to the bathroom. (V4) said, 'Yes, you are' and made me go to the bathroom. I looked at (V4) and said, 'Why are you so mean.' I do not know why (V4) was being so hateful to me. (V4) told me to shut my television off and go to bed. I did not want to go to bed. I feel like I should have the right to stay up and watch television. I take myself to the bathroom, so I do not know why (V4) felt the need to rip my covers off and make me go. I do not think (V4) likes herself very much. I was crying and (V4) told me to, 'Shut up.' I have told everybody about this and do not like that (V4) still takes care of me. I feel scared when she is on duty. (V4) is nothing but a bully. I can hear her out in the hallway yelling at other residents at times. She is just like Nurse Ratchet. On 4-20-22 at 9:35 AM, V26 (LPN/Licensed Practical Nurse) stated, About a week or two ago, (R1) told me that (V4) had went into her room in the middle of the night, jerked her covers off of her, and told (R1) to get the hell up and out of the chair. I reported this immediately to (V27/Social Services). (R1) continued to be very mad that day and would say, 'I am not going to let that b***h (V4) talk to me that way.' I have had a lot of residents complain in the past and have been told that if it is not in writing, it didn't happen. (R9) is very scared of (V4) and tells me that all the time. Also, I know there was an abuse allegation turned into (V2/Director of Nursing) regarding (V4) and (R4) in the past. I am not sure what the allegation regarding (R4) was about. On 4-20-22 at 3:26 PM V15 (R1's Family Member) stated, (R1) called me two weeks ago on a Thursday and told me (V4, Registered Nurse) came into her room, jerked the covers off of her, and made her go the restroom and then to bed. (R1) said (V4) was mean to her. I have cameras in her room, but that night they were unplugged for some reason. (R1) has never complained or made accusations about staff at the facility before. (R1) has been really upset. (R1) has called me at work at least three to four times a day since this incident and has had very bad anxiety. I have talked to (V2/Director of Nursing) about (R1's) accusations. 2. R2's MDS (Minimum Data Set) assessment dated [DATE], documents R2 has moderately impaired cognition. R2's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 4-20-22 at 12:45 PM, R2 was sitting in his wheelchair. R2 stated, There is a nurse on third shift. I do not know her name. She has blonde hair and has worked here awhile. She is hateful and yells at us (the residents). She has yelled at me a couple times before and I did not like it. On 4/21/22 at 2:24 PM, V18 (CNA/Certified Nursing Assistant) stated, (R2) refused his shower because he was in too much pain. (V4, Registered Nurse) came in his room and said You (R2) wanted out of your room, now get up and take a shower. V18 then stated, I stepped in and asked (R2) if he just wanted a bed bath and (R2) said, 'Yes.' I then gave him a bed bath and (V4) was mad at me. (V4) was taken off the floor for a while and moved to another hall but then put back on the 400-hall. 3. R4's MDS assessment dated [DATE], documents R4 has moderately impaired cognition. R4's POS dated 4/20/22, documents, R4 has Major Depressive Disorder. R4's current plan of care documents, Inappropriate Behavior, (R4) has exhibited inappropriate, rude, sexual behaviors and fondling self. Fondling or pleasuring self a total of three times during the quarter. Interventions include: R4 to masturbate as long as he does it in his room where others cannot see. Staff needs to knock prior to entering if he is masturbating return later. When R4 is in the common area and is being inappropriate, verbally or pleasuring himself, quietly caution him that he is in the common area, and it's inappropriate in the common area around staff and peers. V5's (Service Attendant) undated Written Statement documents, (R4) was sitting in the chair at the nurse's station. (R4) was trying to get our attention by pleasuring himself. (V4, Registered Nurse) told (R4) to stop. (R4) continued on laughing, thinking it was funny. (V4) rushed over there and grabbed (R4) by the penis and told (R4), 'If you don't stop that, I am ongoing to rip that thing off.' (R4) screamed because she (V4) grabbed (R4) so hard. (V4) continued to yell at him for the rest of the night. On 4-20-22 at 11:45 AM R4 stated, I am always getting yelled at by (V4) at night. (V4) is very mean! On 4-20-22 at 10:45 AM V28 (CNA) stated, (V4, Registered Nurse) is very disrespectful to the residents and yells at them. I personally have heard (V4) yell at (R4). (R4) will yell, 'hey, hey, hey.' (V4) yelled at him to stop or will take him to his room. (V4) made (R4) go to his room. I have heard that (V5, Service Attendant) witnessed (V4) slap (R4) before. On 4-20-22 at 1:00 PM V1 (Administrator) stated, I got a call from V11 (President of the Board) on Monday (4-18-22) informing me that she had got a report of (V4) grabbing (R4's) 'crotch' and telling (R4) she was going to break it off about a month ago that was witnessed by (V5/Service Attendant). I gave this to (V25/Human Resources) on Tuesday (4-19-22) to look into. I guess a staff member grabbing a man's penis could be considered abuse. I also have received an email in January 2022 from (V11) regarding multiple resident concerns regarding (V4). On 4-20-22 at 11:25 AM V7 (Nurse Resource Coordinator) stated, A lot of residents do not like (V4). (V4) comes off as abrasive. One night in March 2022, (V5/Service Attendant) called me and told me that (V4) grabbed (R4's) penis and told (R4) that if he doesn't quit masturbating, she (V4) was going to break it off. On 4-20-22 at 1:00 PM V5 (Service Attendant) stated, I was sitting at the nurse's station on (3-9-22) around 6:30 PM and (R4) was masturbating in the little room connected to the nursing area. (V4, Registered Nurse) went up to (R4), grabbed (R4) by the penis, and screamed at (R4), 'If you don't stop that I am going to rip that thing off.' (R4) had his penis outside of his pants. Later that night, around 8:30 PM, (R4's) door to his room was closed and I could hear (V4) yelling at (R4), 'You son of a b***h.' I then heard a slap and heard (R4) yell back at (V4), 'ouch.' I was too scared to go in (R4's) room. I am scared of what (V4) might have done to me. 4. R5's MDS assessment dated [DATE], documents R5 is cognitively intact. R5's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Face Sheet/Census Report documents R5 was admitted to the facility on [DATE] and discharged home on 1-30-22. This same Face Sheet/Census Report documents R5 is responsible for herself. V11's (President of the Board of Directors) Email (Electronic Mail) dated 1-17-22 and sent to V1 (Administrator) and V2 (Director of Nursing/DON) documents, I spoke to (V1) regarding a phone call I received yesterday from (R5) and would like to provide you both with the details of that conversation. I don't know how much detail was provided in her formal grievance. (R5) is someone I know personally through another organization. (R5) is recovering from surgery at (the facility). I am confident in her mental faculties. Some of what (R5) shared with me is information that she has heard, so I know it can be difficult to sort through information that is not first-hand. Her specific grievance was with nurse (V4, Registered Nurse) failing to follow (R5's) doctor's orders. (R5) was advised that she should have absolutely no showers. Only sponge baths due to the need to keep her foot dry to promote scabbing. When (V4) told (R5) it was time for a shower, (R5) relayed this information to (V4) and was told (by V4) that she, 'Knew how to do her job' and that she could give her a shower without getting her foot wet. (R5) refused and felt she was treated disrespectfully as a result. I am not sure that this additional information was included in (R5's) formal grievance but she felt it needed to be shared with me. (R5) personally witnessed an incident where (V4) was openly mocking a resident (R7) at mealtime. (R5) says (R7) has Dementia or limited mental abilities and has a repetitive verbal tick where she says 'the-the-the' frequently. (R5) witnessed (V4) mock and repeat this tick to (R7) and to other staff in the lunchroom. Other incidents that (R5) didn't witness firsthand was (V4) had told a male resident (R2) that everybody hated him, and nobody wanted him there. (R5) heard that this male resident was going around to other residents in tears, asking if it was true that everyone hated him. (R5) also heard from (R6) that (V4) dragged (R6) out of her armchair at night onto the floor and stomped on her stomach. This would of course be a very serious incident if true. (R5) feels that other staff and residents are fearful of (V4) and concerned about retribution if they were to report her. (R5) feels certain staff have quit as a result of (V4's) presence. (R5) has been advised by other residents (and staff, as I understand it) to watch her medicines very closely at night because some people are truly fearful that (V4) would harm them. I feel it is very important that we address this phone call in our executive meeting and that we move forward with investigation into (V4's) conduct and/or termination. V9's (Social Service Director) Email (Electronic Mail) dated 12-29-21 at 3:13 PM and sent to (V2/Director of Nursing) documents, Hi (V2). I spent a long time with (R5). I have attached (R5's) statement. All of (R5's) concerns show unprofessionalism by (V4), but I feel the one with (R7) in the (dining room) actually needs to be treated as abuse. I left a message on (V1's) voice mail to be official. Met with (R5) today (12-29-21) to speak with her about concerns with (V4). (R5) explained to me (V9) she had gone to see the orthopedic doctor on Tuesday. He removed (R5's) cast and gave her a boot. (R5) said she received instruction that boot was to remain on at all times and she was not to get leg/dressing wet. (R5) said he specifically told her no showers and she was to only have sponge baths for the time being. (R5) said (V4) came into her room last night at bedtime and said, 'We are taking a shower.' (R5) told (V4) 'no' because of doctor's instructions. (R5) says that (V4) replied that she was a professional and knew how to give a shower without getting her leg wet. (R5) refused again and said that (V4) then told (R5) it was in her 'directives' that she was to take a shower and said (V4) was calling (R5) a 'liar.' (R5) voiced being upset that (V4) was rude and not listening to what (R5) said the doctor told her and felt (V4) was trying to force her to do something she knew wasn't right and which also went against her doctor's orders. (R5) says there have been other issues with (V4) that have upset her, and one is (V4) accused her of not wearing a foam boot one day. (R5) explained that she had removed it when she put the call light on because she figured it would save staff time and trouble in getting her to the bathroom. Staff had told (R5) that (V4) had told them that she was 'refusing' to wear a foam boot. (R5) says, 'I am upset that a nurse would go out of their way to lie about me.' (R5) also reports that (V4) was mocking another resident (R7) repeatedly in the unit dining room and laughing about it. (R5) says (R7) tends to repeat 'the, the, the, there' repeatedly. (R5) said (V4) came into the dining room and told (R7) to stop because she needed to eat and then began making the same sounds (as R7) and laughing. (R5) says (V4) did this several times while walking around the dining room. (R5) said this made her feel very uncomfortable and felt it was cruel and unnecessary. On 4-20-22 at 12:30 PM, R5 stated, I lived at the facility in December 2021 for therapy after having three surgeries. I was not supposed to get my foot wet and was given orders to get a sponge bath only. (V4) told me I was liar, and she was a professional and knew how to give me a shower without getting my foot wet. I am [AGE] years old and told (V4) that I am not a liar, I would not be taking a shower, and I would be reporting her to my doctor's office. I called my doctor's office the next day and the doctor was very upset. The doctor called the facility the next day and told them that I 'am not' to have shower. (V4) also accused me of not wearing my foam purple boot as ordered. That same night around 11:00 PM, (V4) came into my room and said, 'What are you still doing up! You need to turn the television off and go to sleep.' I refused. I also witnessed (V4) mocking (R7) in the dining room. (R7) repeats, 'the, the, the, there' repeatedly and (V4) kept mocking (R7). (V4) was just bullying (R7). I would talk back to (V4) and not put up with her rudeness. The CNAs would tell me to watch my back. I was worried every night when I lived there that (V4) would do something bad to me. I asked that (V4) not take care of me, but she still continued to take care of me. I was worried that she would try to kill me by overmedicating me. I also watched (V4) yell at (R4) in the dining room and told (R4) that she hated him. I have reported all of this to (V9, Social Service Director). (V4) is very hateful and should not be a nurse. On 4-20-22 at 2:25 PM V9 (Social Service Director) stated, I met with (R5) on 12-29-21 to talk to her about concerns she has with (V4). (R5) did not like how (V4) was treating her. (R5) said (R5) told (V4) that she was not taking a shower due to doctor's orders, and that she was to only have a sponge bath. (R5) said that (V4) called her a 'liar' and said (V4) tried to force (R5) to take a shower and was telling (R5) she refused to wear her foam boot. (R5) was very upset and felt like (V4) was very rude. (R5) also told me that she saw (V4) mocking another resident (R7) repeatedly in the dining room and laughing about it. (R7) tends to repeat, 'the, the, the, the, there' repeatedly and (R5) said (V4) kept making the same sounds as (R7) and laughing about it. (R5) said this made her feel very uncomfortable and felt it was cruel and unnecessary. I let both (V1) and (V2) know that I felt like these allegations need to be treated as abuse. 5. R6's MDS assessment dated [DATE] documents R6 is cognitively intact and ambulates in her room with staff assistance of one. R6's MDS assessment dated [DATE], documents R6 is cognitively intact and never ambulates even with staff assistance. R6's progress notes dated 2/24/21, documents, R6 was being moved to another unit (100) due to behaviors and accusations R6 made of staff. On 4-21-22 at 9:45 AM, R6 was sitting in her recliner in her room. R6 stated, A while ago (2-24-21), (V4, Registered Nurse), the nurse, jerked me out of my chair, stomped on my feet, and punched me in the stomach. I told (V4) my feet were bleeding and (V4) said 'good.' (V4) then swung me around and threw me on my bed. I am lucky (V4) didn't throw me through the window. I feared for my life. (V4) was always mean to me and would cuss me out. I haven't been able to walk since (V4) stomped on my feet. On 4-21-22 at 9:30 AM, V12 (R6's Power of Attorney) stated, About a year ago in February 2021 when (R6) lived on the fourth floor (R6) had told me that (V4) had beaten her and stomped on her feet. I reported this to Social Services (V9) and (V2/Director of Nursing). (V2) made the decision to move (R6) down to the first floor so (V4) would no longer care for (R6). I know (V4) did take care of (R6) after that a couple of nights, even though (V2) said she would not let (V4) take care of (R6). I think because of staffing shortages (V4) was allowed to work with (R6). (R6) is still scared and upset with (V4). Just yesterday, (R6) told her urologist that she was beat up and yelled at by (V4). (R6) has refused to bear weight or walk since this allegation. (R6) is very smart and would know if somebody is abusing her. (R6) is truthful and has never made any false allegations in the past. This nurse (V4) has really caused (R6) a lot of suffering. On 4/21/22 at 10:25 am., V13 (RN/Registered Nurse) stated, (R6) told me that (V4) hit her and stomped on her foot and that was why she was moved from 400-hall to 100-hall. On 4/21/22 at 10:40 am., V16 (CNA/Certified Nursing Assistant) stated, (R6) told me multiple times (V4) ran over (R6's) feet several times with a wheelchair and would beat her up. On 4/21/22 at 10:10 am., V14 (CNA) stated, When (R6) moved to 100-hall around February 2021, (R6) complained about (V4) being mean to (R6) frequently. (R6) said that (V4) stomped on her feet and (R6) would give me notes written on menu papers about the accusations of (V4). (R6) also told me (V4) told (R6) she needed to get in her bed and get to sleep. (R6) complained to me later that (V4) was working on 100-hall and was not supposed to, so I informed (V2). 6. R7's MDS assessment dated , 3/30/22, documents R5 has moderately impaired cognition. R7's POS dated 4/20/22, documents R7 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R7's current plan of care documents, (R7) has an alteration in neurological status due to Dementia, Repetitive verbalizations. (R7) has impaired recall and decision-making skills secondary to Lewy Body Dementia. At times, (R7) has chanted Oh God or other verbalizations repeatedly. On 4-20-22 at 11:45 AM, R9 was sitting in her room. R9 stated, (V4) has mocked a resident (R7) in the dining room. I felt really sorry for (R7). (R7) cannot help her disease. 7. R8's 3-31-21 MDS Assessment documents R8 was cognitively intact. V23's (CNA) written statement dated 3/30/21 and signed by V23, documents, I got the resident (R8) up this morning, and she was happy. I left the room to answer a call light and staff (V24/CNA) came to me saying (R8) was crying face red and stated (V4) yelled at her and was being mean to her. At that time (V27/Social Service) was walking by. I asked (V27) to talk to (R8) and when (V27) came in, I left the room. On 4-20-22 at 9:55 AM, R8 was sitting in her room. R8 stated, I am not going to tell you anything about who has been mean to me. If I do not tell, then I do not get in trouble. If I told you what she had done to me, she would just make my life worse. 8. R9's MDS assessment dated [DATE] documents R9 is cognitively intact. V22's (CNA) written statement dated 3/30/21 and signed by V22, documents, (R9) has made numerous complaints about (V4, Registered Nurse) and the way she treats her and talks to her. (R9) said that she is in her right mind and that she would never talk to someone the way that (V4) talks to the residents. (R9) said (R8) has cried to (R9) numerous times because (R8) says (V4) is rough and mean with her. This is an ongoing thing, and it's to the point to where the majority of the residents have complained about (V4) or are scared of (V4). V24's (CNA) written statement dated 3/30/21 and signed by V24, documents, I went to get (R9) up for a shower, and she asked me what nurse was on shift tonight. I told (R9) (V19/RN) was the nurse tonight. (R9) said, 'Oh thank you I was scared it was (V4).' (V4) came in here and was rude and told me to take my pills in pudding. I got choked up on them and spit it out. (V4) is never nice when she comes in. (R9) also stated that she was very scared of (V4). On 4-20-22 at 11:45 AM, R9 was sitting in her room. R9 stated, I do not like to get anybody in trouble. (V4) is mean to me and a lot of other residents. (V4) yells at us a lot. I don't know if (V4) has a bad home life and she takes it out on us. On 4-21-21 at 8:45 AM, V3 (Assistant Director of Nursing) stated, I cannot find any documentation in (R1, R2, R4, R5, R6, R7, R8, and R9's) medical records regarding their allegations of abuse regarding (V4). On 4-20-22 at 1:05 PM, V8 (Registered Nurse) stated, (V4, Registered Nurse) has been abusing residents for years. (R2) was crying one morning to me that (V4) told him nobody can stand (R2), and she (V4) hates him. (R2) was crying for days asking the staff if they like him. This happened several months ago. I submitted statements to (V2) and notified (V2) immediately. (V4) mocks (R7) in the dining room and I know (R6) had to be moved off of 400-hallway due to (R6) reporting that (V4) beat her up and yelled at her. On 4-20-22 at 12:15 PM, V11 (President of Board of Directors) stated, I have a friend that was a resident at the facility (R5). (R5) is now residing at home. On 1-17-22, I contacted (V1) and (V2) about concerns (R5) had reported to me. (R5) had concerns with a nurse (V4). (R5) also said (V4) was trying to force (R5) to take a shower, even though (R5) had a doctor's order to only take sponge bathes. (R5) felt like she was not treated or respected very well by (V4). (R5) also said she witnessed (V4) mocking a resident (R7) during meals that had a known 'tick.' (R5) also reported (V4) told a resident (R2) that everyone hated him and caused (R2) to have tears. On Monday (4-18-22), (R5) told me (R4) had been assaulted by (V4, Registered Nurse) and had been slapped by (V4). On 4/21/22 at 2:45 PM, V2 (DON/Director of Nursing) stated, (V4) was taken off 400-hall for about six months due to many complaints from staff and residents on that hall. V2 stated she can't remember the residents but did provide the staff names (V19/RN, V20/CNA, V21/CNA) that had the complaints. On 4-22-22 at 9:55 AM V19 (Registered Nurse) stated, (R5) was scared of (V4) and said she was afraid (V4) would try to overdose her. When I first started there around December 2020, (V4, Registered Nurse) was orientating me. One night during this time around 7:00 PM to 9:00 PM, (R6) was weak and trying to sit down while she was walking. (V4) started yelling and cussing at her to keep going and made her walk the rest of the way to her chair. (R6) was angry and upset and was yelling back at (V4). (V4) was very verbally abusive to (R6). (R6) would get so upset with (V4) and tell me that (V4) hates her. I know (R6) got so upset that (R6's) psychiatrist called the facility and said it would be in (R6's) best interest to not have to be around (V4) at all. (R6) was then moved from 400-hallway to 100-hallway and (V4) was not supposed to work with (R6). Later on, (V4) had so many complaints filed against her from residents on 400-hallway, that the supervisors decided to move her to 100-hallway for a few months. I thought that was ridiculous to just move (V4) to another hallway and let (R6) have to be cared for by (V4) again. (R2) was very friendly and always visit with me while I was passing my medications. Around November 2021, (R2) would tell me almost every night that I worked that he was afraid of (V4) and would thank me for working there. (R2) would say on the nights that (V4) would work with him, he would get yelled at by (V4). (R9) is a very sweet little old lady that would not cause any trouble with anybody. (R9) would tell me that she doesn't like (V4) and has heard (V4) 'belittling' (R7) in the dining room. (R9) would tell me that she was scared of (V4). (R8) would whisper to me that (V4) yells at her and to not tell anybody because it would get back to (V4). (R8) would say she was afraid of (V4) and would not tell my why. Every time I would call (V1) with concerns he would tell me, 'What do you want me to do about it?' I quit there because I could not take it anymore hearing the abuse that the residents were receiving from (V4, Registered Nurse) and nothing being done about it. An Immediate Jeopardy was identified on 4-21-22 at 3:00 PM. The Immediate Jeopardy began on 2-24-21 when R6 reported she had sustained physical, verbal, and mental abuse by V4 (Registered Nurse) and V4 was allowed to continue employment within the facility, resulting in V4 continuing to verbally, physically, and mentally abuse R6 and other residents (R1, R2, R4, R5, R7, R8, and R9). On 4-25-22 at 11:00 AM V1 (Administrator) and V3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. (V4) was terminated from her position at the facility on 4/25/2022 at 12:15 PM. 2. V1 and V3 were in-serviced regarding abuse allegation procedures including reporting, removal of the perpetrator and thorough investigations of all abuse allegations by V30 (Ombudsman). All other staff were in-serviced regarding abuse policy and procedures including reporting abuse, removal of the perpetrator and thorough investigation of all abuse allegations by V3 (Assistant Director of Nursing) and other nursing administration. 3. V9 (Social Services Coordinator) along with other social services staff interviewed all residents in the facility regarding any further abuse allegation. 4. V9 and Social Services staff updated R1, R2, R4, R5, R6, R7, R8, and R9's Care Plans with interventions to address behavior problems related to physical, mental, and verbal abuse. 5. V31 (Unit Coordinator) contacted R1, R2, R4, R5, R6, R7, R8, and R9's families and physicians regarding abuse allegations made by these residents. 6. The Social Services department interviewed residents about abuse and who they can report allegations/occurrences of abuse without fear of retaliation from the staff member. Completion Date 4-27-22

Based on observation, interview and record review, the facility staff failed to report known symptoms of COVID-19 and continued to care for residents. The facility also failed to follow the Centers for Disease Control and Protection guidance and the Facility's COVID-19 policy to identify and prepare a designated space with dedicated staff to care for and monitor residents with confirmed COVID-19. These failures have the potential to impact all 113 residents residing in the facility. This failures resulted in an Immediate Jeopardy situation. While the immediacy was removed on 10/20/2020, the facility remains out of compliance at a severity level two. The facility is still in the process of monitoring the effectiveness of of staff training and adherence to COVID policies. Findings include: The Facility's Interim Policy for Suspected or Confirmed Coronavirus (COVID-19) policy dated 7/23/20, states All healthcare personnel (HCP) will be correctly trained and capable of implementing infection control procedures and adhere to requirements. This policy also states Screening Employees: Facility will actively verify absence of fever and respiratory symptoms when employees report to work-beginning of their shift as well as mid shift. Document temperature, absence of shortness of breath, new or change in cough and sore throat and other criteria as identified by State guidance. If employee is ill, employee will put on a facemask, immediately leave the facility and self-isolate at home. Employees who develop symptoms to COVID-19 (fever, cough, shortness of breath or sore throat and other criteria as identified by State guidance) will be instructed to not report to work and referred to public health authorities for testing, medical evaluation recommendations and return to work instructions. Employees who develop symptoms on the job will be: Instructed to immediately stop work, provided with a facemask and immediately leave the facility, instructed to self-isolation at home. The Infection Preventionist and/or designee will work with the employee to identify individuals, equipment and locations the employee came in contact with. The Centers for Disease Control and Protection (CDC) recommendations dated 5/13/20, states People with COVID-19 have had a wide range of symptoms reported-ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: Fever or chills; Cough; Shortness of breath or difficulty breathing; Fatigue; Muscle or body aches; Headache; New loss of taste or smell; Sore throat; Congestion or runny nose; Nausea or vomiting; Diarrhea. This list does not include all possible symptoms. CDC will continue to update this list as we learn more about COVID-19. The Centers for Disease Control and Protection recommendations dated 6/25/20, states Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Identify HCP (Healthcare Personnel) who will be assigned to work only on the COVID-19 care unit when it is in use. Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive). The Facility's Interim Policy for Suspected or Confirmed Coronavirus (Covid-19) policy dated 7/23/20, states Residents suspected or confirmed with COVID-19 that remain in facility upon advice of local/State public health agency, will be assessed and evaluated for a minimum of 14 days for potential change in condition or additional signs or symptoms; In the event of a facility outbreak, (an outbreak is defined as 1 positive case in either a resident or a staff member and one person, resident or staff member that is symptomatic) institute the outbreak management protocols: Define Authority (Infection Preventionist, Director of Nursing, Administrator, Medical Director, etc.); Immediate reporting/notification and consultation with the Local/State Public Health Department for specific directions to include, for example: Place residents in private rooms on standard, contact, droplet (airborne if available) precautions, Cohort residents identified with same symptoms/COVID-19 confirmation, Implement consistent assignment of employees, Only essential staff to enter rooms/wings; Limit only essential personnel to enter the room with appropriate PPE (Personal Protective Equipment) and respiratory protection. Appropriate PPE includes, gown, gloves, N95 respirator or approved KN95, face shield or goggles; PPE worn in room where resident is suspected, positive, or new/re-admit may not be worn outside of that room. On 10/15/20 at 9:28 a.m., V12 (Certified Nurse Aide) stated I was the first one (residents and staff) to get (COVID-19). I had not been feeling good for several days (8/24/20-8/26/20) and was experiencing sinus pressure. I continued to work because I did not have a fever. Then I lost my taste and smell (8/25/20 or 8/26/20) and did not know that was a sign of (COVID-19). I do not recall being educated on that being a symptom. I did not report my symptoms to anyone because I thought I just had a sinus infection. Then I was off for a few days (8/27/20-8/30/20) and my mom told me that the loss of taste and smell were a symptom of (COVID-19) and she told me to go to the doctor. I went to the doctor on my days off and was tested for COVID-19. I returned to work on 8/31/20 (prior to receiving results of COVID-19 test) with the same symptoms and worked approximately half of my shift before the clinic called me and told me I was positive (for COVID-19). I immediately reported to a supervisor and they sent me home. I was being screened for (COVID-19 symptoms) prior to every shift but loss of taste and smell was not one of the questions that they asked me, so I continued to work. The Facility's Inservice records dated 6/22/20, documents V12 was educated on the symptoms of COVID-19 per CDC guidance dated 5/13/20, which included the symptom of New loss of taste or smell. V2 (Director of Nursing) stated The Inservice dated 6/22/20, educated the staff on the symptoms of COVID-19 and the list of symptoms was also posted at the time clock where all staff could frequently see it. V12's assignments dated 8/16/20 through 8/31/20, provided by V2 (Director of Nursing), document V12 worked on the following floors: 8/13/20- 4th floor, 8/17/20- 2nd floor; 8/18/20- 2nd floor; 8/24/20-2nd floor; 8/25/20-4th floor, 8/26/20- 2nd floor; 8/31/20- 2nd floor. On 10/15/20 at 12:13 p.m., V3 (Infection Preventionist) stated (V2/Director of Nursing) and I were not aware of (V12) having any symptoms of (COVID-19) or that she was tested for (COVID-19) until she received her positive test results during her shift on 8/31/20. She was re-educated by Human Resources about making sure that any symptoms of (COVID-19) are immediately reported or called in to the facility. V12's Employee Symptoms Evaluation dated 8/31/20, documents V12 did not report any symptoms of COVID-19, including new loss of taste or smell. Facility documentation dated 9/2/20, completed by V20 (Human Resources), documents that V12 was educated on the importance of not coming to work when sick and reporting any illnesses or symptoms to facility management immediately. On 10/10/20, 10/12/20, and 10/14/20, R5 was observed in her room on the 2nd floor, R6 was observed in his room on the 1st floor, and R7 was observed in her room on the 4th floor. On 10/10/20 at 12:18 p.m., V2 (Director of Nursing) stated the facility has had a Covid-19 outbreak that first started with a staff member on 8/31/20. V2 stated the facility currently has three residents that have tested positive for COVID-19. V2 stated R5 tested positive for COVID-19 on 9/30/20 and resides on the second floor; R6 tested positive for COVID-19 on 10/7/20 and resides on the first floor; and R7 tested positive for COVID-19 on 10/7/20 and resides on the fourth floor. V2 stated the facility does not have a dedicated wing/area set up for the resident with confirmed COVID-19 or dedicated staff to care for and the residents with confirmed COVID-19. On 10/12/20 at 1:43 p.m., V2 (Director of Nursing) stated the facility has not implemented a dedicated area or wing for the residents with COVID-19 because it would be against resident rights to move residents out of their rooms if they didn't want to. V2 stated We could technically force them (to move) if we get to an emergency situation. On 10/12/20 at 10:25 a.m., V3 (Infection Preventionist) stated V3 is the facility Infection Preventionist. V3 stated the facility has an outbreak of COVID-19 which includes three residents with confirmed COVID-19 (R5, R6, R6). V3 stated The only way to make a dedicated (COVID) wing is by closing a wing down because we have residents on every wing right now. V3 verified that the facility's census is down, and they have empty rooms to move residents into in order to free up a wing for residents with confirmed COVID-19. V3 stated the facility does not have it set up where dedicated staff are caring for the residents with confirmed COVID-19. V3 stated the staff that are caring for the COVID residents are also taking care of the other residents that reside on their assigned unit that do not have confirmed COVID-19. On 10/14/20 at 11:10 a.m., V3 stated the facility is following the CDC guidance for development of policies and procedures regarding COVID-19. V3 stated the facility has no plans at this time to make a designated area for the residents with confirmed COVID-19. V3 stated she would have to look back through emails received from the Local Health Department to see what the guidance was regarding the facility identifying a dedicated space for residents with COVID-19 and also regarding dedicated staff. V3 stated We have received so much guidance that it's hard to keep straight. It's really a catch 22 to move the resident's out of their own rooms. It could be more detrimental mentally on them. I have not spoken to (R5, R6, or R7) about potentially moving to another room. We have not reached out to the local health department for guidance on cohorting (R5, R6, and R7). On 10/13/20 at 1:54 p.m., V11 Local Health Department (LHD) Infectious Disease Nurse stated V11 has not received any phone calls or correspondence from the facility asking for guidance on room placement of the residents with confirmed COVID-19 or about how to set up a COVID unit. V11 stated the local health department has sent out guidance on what the facility is to do as far as housing residents and dedicated staff in the event of a COVID outbreak and they should be following that guidance. V11 stated the LHD expects them to make every effort to cohort residents with confirmed COVID-19 and also to have dedicated staff that will care for them. V11 stated they should not have staff that are taking care of a resident with COVID also taking care of a non-COVID resident. V11 stated COVID-19 is highly contagious and the facility should be making every effort to keep it from spreading in such a vulnerable environment. V11 stated it was sometime in April 2020 that the facility received guidance from the LHD regarding the need to have a plan and identifying a designated space for a potential COVID-19 outbreak. On 10/15/20 at 8:30 a.m., V11 stated the facility emailed the LHD late yesterday afternoon and reported the current location, in the facility, of the three residents (R5, R6, R7) with confirmed COVID-19 and basically asked permission to break the rules of the CDC guidance and I told them absolutely not. V11 stated she re-sent the CDC guidance to the facility regarding having a designated space and designated staffing for a COVID-19 outbreak. V11 stated that should have been set up before the facility ever had a confirmed COVID-19 case. On 10/15/20 at 12:20 p.m., V3 (Infection Preventionist) stated I emailed (the LHD) yesterday asking if we needed to have a dedicated space and dedicated staff for our residents with (COVID-19). We were directed by (the LHD) that we did need to have a dedicated space and dedicated staff. We are going to be working on moving residents today. On 10/15/20 at 10:30 a.m., the facility's computerized room listing noted R5 continued to reside on the 2nd floor, R6 continued to reside on the 1st floor and R7 continued to reside on the 4th floor. The Centers for Medicare and Medicaid Services, Resident Matrix dated 10/12/20, documents 113 residents reside in the facility. An Immediate Jeopardy situation was identified on 10/17/20. The Immediate Jeopardy was identified to have begun on 8/31/20 when V12 (Certified Nurse Aide) came to work and cared for residents with known symptoms of COVID-19. The facility also failed to prepare a designated space and dedicated staff to care for residents that had confirmed COVID-19 starting with R5 on 9/30/20. On 10/17/20 at 10:29 a.m., V1 (Administrator) was notified of the Immediate Jeopardy situation. On 10/20/20 at 10:00 a.m., the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V2 (Director of Nursing) verified that all staff had been educated on 10/18/20, regarding the signs and symptoms of COVID-19 and the importance of not coming to work and immediately reporting such signs and symptoms to a supervisor. V2 provided a list of all staff employed by the facility with a list of employees who received the above education. 2. V2 verified that all staff and residents were tested and were negative for COVID-19 on 10/14/20. V2 verified that R5, R6, and R7 were all out of isolation by 10/17/20. V2 stated the next weekly COVID-19 testing for all staff and residents will be on 10/21/20. V2 stated no staff or resident have any signs or symptoms of COVID-19 at this time. 3. V2 verified that the facility has a designated area for residents with confirmed COVID-19 and a plan that includes who the designated staff will be in the case of a resident(s) testing positive for COVID-19. V2 verified the designated area is set up and ready to be utilized if needed. V2 verified that plastic sheathing is in place to isolate the designated area from the hallway of the unit. 4. V2 stated V2 would be responsible for auditing the weekly COVID-19 testing results to ensure the facility's COVID-19 policy is being followed.

Based on observation, record review, and interview, the facility failed to ensure resident safety during repositioning for one of three residents (R1) reviewed for injuries in a sample of three. This failure resulted in a bruising and a laceration to a lower extremity which required suturing in a local Emergency Department. Findings include: R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 has short and long term memory problems and is moderately cognitively impaired. R1's current care plan accessed electronically on 3/15/19 indicates R1 is totally dependent on staff for bed mobility, transfers, dressing, toileting, personal hygiene, and movement about the facility. A facility report to the State Agency documents on 3/11/19 at approximately 8:00 a.m. R1 sustained a large laceration to R1's right lower leg and was sent to the local emergency room for treatment. A Resident Abuse Investigation Report Form completed by V5 (RN - Registered Nurse/Unit Coordinator) states, (R1) moved her legs and they were covered up by a blanket. When staff attempted to sit (R1) up properly (for meal service) (R1's) leg was in the wrong spot and sustained a laceration. On 3/19/19 at 8:40 a.m., V6 (CNA - Certified Nursing Assistant) stated, The nurse asked for a chair for (R1) to keep (R1's) feet from coming out. (R1) was scooting down in the chair too. I got (R1) a wide recliner (geri chair) out of the storage room about three weeks to a month before (R1's 3/11/19 injury). (R1) sat on a (air) cushion and (non-slip sheet of material) to keep (R1) from sliding. We mainly kept (R1) reclined. It (R1's geri chair) was hard to recline up to a sitting position. I couldn't get it to sit up. I tried one, two, maybe three times and I couldn't get it to sit up. (V7 LPN - Licensed Practical Nurse) was in the dining room serving drinks and I asked (V7 LPN) to help me. (R1) had a blanket over (R1's) legs so you couldn't see her legs. I went out of the dining room to bring up another resident and when I got back there (V7 LPN) did get it (geri chair) out of the reclining position and another resident said there was blood on the floor. (R1) didn't yell or say anything and didn't act like (R1) was in pain. (R1) didn't even say anything when the paramedics got there. (R1) has dementia and once in a while will say something but really doesn't have conversation. When I got back to the dining room, the blanket (covering R1's legs) was in place. (R1) was reclined back at some point. I don't really remember when. It was an awful gash (the laceration to R1's right lower leg). I ran and got bath towels and we (V6 CNA and V7 LPN) wrapped it up tight. I regret that both of us (V6 CNA and V7 LPN) should have removed the blanket (over R1's legs) to see where (R1's) legs were. I didn't see (R1) get her legs off of (R1's geri chair). On 3/19/19 at 12:48 p.m., V7 (LPN) stated, I was in the dining room setting up drinks and breakfast and (V6 CNA) was having trouble getting (R1's) chair up (from a reclining position). I didn't see (V6 CNA) trying but (V6) asked if I could help. I was busy at the time and (V6) left the room. I don't know if I acknowledged (V6) but I think I told (V6) I would help. After (V6) left I tried and the first time it (R1's geri chair) didn't go up but the second time it did. It was a little difficult, the chair was older. Then I pushed (R1) toward the table and another resident alerted me to there being blood on the floor. (R1) had a blanket on (R1's) legs. I came up from behind (R1) to put the (geri) chair up (from reclining to sitting position). (R1) had a wound to her (right lower) leg. It was a gaping wound. We applied pressure with towels and pulling it together. (R1's) leg was obviously pinned behind the foot rest and the metal part of the geri chair. On 3/19/19 at 3:55 p.m., V5 (RN-Unit Coordinator) presented a blue colored Geri chair parked near the elevator in a nearby empty unit as the Geri chair R1 was using when injured on 3/11/19. The mechanism to raise or lower the foot rest is a notch and peg bar that has to be kicked off of the peg located on the Geri chair frame before the footrest can be raised or folded up under the Geri chair seat. On 3/19/19 at 3:30 p.m., V5 (RN Registered Nurse-Unit Coordinator) stated, (Staff) shouted 'Bleeding come quick!' (V14 LPN) took off and responded to help. (V14 LPN) was the one that wrapped R1's leg in towels to get it to stop bleeding. I didn't get to see (R1's) leg until they brought (R1) up to me (at the nurses' station). It had stopped bleeding by then. I looked at it and rewrapped it. The wound was gaping. I applied pressure and redressed it. I thought at first something may have been wrong with the chair, but looking at the chair I didn't see blood on it. I couldn't figure out what caused it unless (R1) had got (R1') leg caught in between (the chair and the foot rest). On 3/19/19 at 4:00 p.m., V14 (LPN) stated, They called for help. When I got there, there was blood on the floor. (R1's) foot rest was down. (V7 LPN) was in there (the dining room) and a CNA was there but I don't remember who. We weren't sure at first what happened. I used the towels to help stop the bleeding. A hospital Transfer Report Form dated 3/11/19 states, In geri chair, cut to right leg on chair, unable to control bleeding. A emergency room Note dated 3/11/19 states, Large, 20 cm full thickness laceration to medial right lower (right) extremity. A hospital Procedure Note dated 3/11/19 states, Closure was achieved with 20 sutures. R1's 3/11/19 hospital discharge orders state, Keep clean with topical antibiotic ointment and daily dressing changes. Suture removal 10 to 14 days. On 3/15/19 at 2:09 p.m., R1 was lying in bed making no verbal response or eye contact with care givers, V11 (LPN - Licensed Practical Nurse) and V12 (RN- Registered Nurse) who were present to perform R1's wound treatment. V11 (LPN) removed R1's right lower leg dressing. R1 had 20 largely spaced (1 to 1.5 centimeter (cm) in width joining the wound together and approximated 1 cm apart along the length of the wound) sutures in a wide v-shaped wound which covered R1's lower right leg. R1's wound also had dark purple bruising from the center of the wound toward the distal edges of the wound.

Based on observation, interview, and record review the facility failed to provide supervision and assistance to a resident totally dependent for toileting for one of three residents (R42) reviewed for falls. These failures resulted in R42 self-transferring to the toilet, losing balance and falling which resulted in R42 sustaining a left wrist fracture. Findings include: The facility's Falls Management Program policy dated 07/2017 documents, Muscle weakness and walking or gait problems are the most common cause of falls among nursing home resident. A Fall refers to unintentionally coming to rest on the ground, floor, or other lower level. An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. Resident's Transfer and Mobility: Know which residents need assistance during transfers and walking. Give help when needed. Provide toileting, food, drink, and activity based on the resident's individual schedule. Check the resident often. R42's MDS (Minimum Data Set) Section C Cognitive Status documents R42 is cognitively intact, and Section G Functional Status, documents R42 is totally dependent on two staff for transfers and toilet use. This same MDS documents R42 is continent of bowel and bladder. R42's current Fall Care Plan documents: 6-7-17 Staff will offer to take R42 to the bathroom after meals and every two to three hours. 6-13-18 R42 requires the mechanical lift for all transfers and no longer ambulates. R42's current Kardex (Nursing Medical Information Document) documents: Toileting offer the bathroom every two hours. The facility's Nursing Unit Assignment Schedule dated 8-6-18, documents V4 (Licensed Practical Nurse/LPN) and V5 (Certified Nursing Assistant/CNA) were the two staff scheduled on 8-6-18 from 6:00 PM to 10:45 PM to care for resident's on R42's hallway, including R42. R42's Incident Report dated 8-6-18 at 8:31 PM, documents, (R42) yelled out for help. CNA found resident on the floor in the bathroom. (R42) on her back. Left wrist hanging at unnatural position. Appears to cause (R42) significant pain. Skin tear noted on the left wrist. (R42) could not hold urine any longer attempted to put self on toilet. Slipped. Sent to emergency room for evaluation and treatment due to pain and possible fracture to the left wrist. R42's Left Wrist X-Ray dated 8-6-18, documents, Impression: Distal radial [MEDICATION NAME] oriented impacted fracture with ulnar and dorsal angulation of distal fracture fragments. V5's (CNA's) written statement dated 8-6-18 documents, I was coming out of (another resident's room) from giving a shower. I came around the corner and heard a call light and someone yelling, 'Help.' in (R42's room). I ran in to see R42 laying on the floor in the bathroom seeming to have a very swollen left wrist. I ran to (another floor) to get help. V4's (Licensed Practical Nurse) written statement dated 8-6-18 documents, (R42) needed to use the restroom. As I came down the hall with the (mechanical lift), I was stopped by a delivery guy. (The delivery guy) said the second floor nurse was busy and needed him to get the nurse on first floor (V4) to trade out the narcotic box. I went to the second floor (a different floor) from where I was working. I went up to second floor. I was off of the unit less than five minutes, when a fall occurred in (R42's room). (R42) has attempted to transfer self to the toilet and fell . On 10/02/18 at 10:49 AM, R42 was sitting in a wheelchair with a splint on her left wrist and left hand. R42 stated, (On 8-6-18) I turned on my call light and no one answered it for a long time. When the call light was answered the staff told me they would right back. No one came back, so I tried to get up to go to the bathroom. When I stood up from the toilet I lost my balance. I tried to steady myself with the hand rail, but my hand went between the hand rail and the wall and broke. I had to go to the bathroom real bad and got tired of waiting on someone to help me, so I went myself. There was no one on the floor to help me and I was yelling that I needed to go to the bathroom, but no one came. On 10/03/18 at 10:44 AM, V5 (CNA/Certified Nursing Assistant) stated, It was the first night I had worked (R42's) floor since my orientation. I had came out of giving another resident a shower that had took around twenty minutes. I heard someone hollering for help. I found (R42) on the bathroom floor with a broken arm. I was the only CNA on (R42's) floor. I was in the shower room and the nurse was off of the floor, so no one was left on the floor to answer call lights or supervise other residents. (R42) said she had to go to the bathroom really bad and got herself up. (R42) is supposed to be a (mechanical) lift with two staff members for transfers. (R42) uses her call light whenever I work the floor. I had not toileted her before the fall. I was the only CNA and had not toileted (R42) since 6:00 PM that night. I was trying to get showers done. The nurse would have answered call nights when I was in the shower room, but she was on another floor. That left (R42's) floor unsupervised. On 10/03/18 at 11:31 AM, V4 (Licensed Practical Nurse) stated, I float between floors. (V5/CNA) was working with me. I was bringing a (mechanical) lift in to help (R42) to the bathroom because (R42) had to urinate. I told (R42) that I would be back to help her and a delivery guy stopped me. I then had to go to the second floor. I was off the floor for five or ten minutes. (V5/CNA) was the only staff left on the floor. When I got back, (V5) was yelling that (R42) fell . I could tell (R42's) wrist was broken. I had not offered (R42) the toilet prior to the fall. I started my shift at 6:00 PM. I am not sure how often (R42) is suppose to be toileted. On 10/03/18 at 12:37 PM, V6 (Registered Nurse) stated that V4 should have toileted R42 before leaving the floor and attending to the delivery guy. V6 also stated that V4 should have asked another staff member to supervise R42's floor while V4 was on another floor and V5 was giving a shower. V6 stated, Resident care should always come first. On 10/03/18 at 12:02 PM, V7 (R42's Physician) stated, The nurse should have toileted (R42) before attending to a delivery man. This would have prevented (R42) from transferring herself and ultimately falling and breaking her wrist. Resident cares should have came first. If the nurse left the floor, and the CNA was giving a shower, then the nurse should have made sure the residents were supervised by somebody.

Noncompliance resulted in two deficient practices. A. Based on record review and interview, the facility failed to to follow the Fall Policy and Gait Belt Policy requiring residents to have accessible call lights and safely transfer a resident to bed using a gait belt for one of seven residents (R19) reviewed for falls in the sample of 24. These failures resulted in R19 falling twice and sustaining a right elbow fracture and multiple lumbar spine fractures. B. Based on observation, interview, and record review, the facility failed to analyze resident falls for root cause, failed to implement effective fall interventions, failed to supervise a resident, failed to follow care plan fall interventions, and failed to identify side rail entrapment for one of seven residents (R10) reviewed for falls, in the sample of 24. Findings include: A. 1. A Falls Management Program policy dated 7-8-16, documents, In order to maintain a successful falls prevention program, all staff members are responsible for seeking out, removing, and reporting potential fall hazards. A fall checklist includes that staff are to keep the call light, water pitcher, glass, and any personal items within arm's length of the resident. R19's Minimum Data Set (MDS) Assessment Section G Functional Status dated 4-7-16, documents R1 requires extensive assistance of one staff physical assist for walking in the room, transferring, and toileting. R19's MDS dated [DATE] also documents R19 is cognitively intact. R1's Transfer Care Plan dated 1-7-16 to 6-24-16, documents R1 requires extensive assistance of one staff and a roller walker to ensure safety with transfers. R19's Incident Report dated 5-5-16 at 10:45 p.m., documents Resident was found lying on the floor on her right side after a CNA (Certified Nursing Assistant) called a nurse for help. R19's Fall Care Plan dated 7-5-16, documents a post fall intervention on 5-5-16 of, Educate staff about leaving a call light with a resident at all times while they (residents) are alone in their room. R19's Investigation Report dated 5-6-16 and signed by E2 (Director Of Nursing/DON), documents, On the evening of 5-5-16 at approximately 11:00 p.m., (R19) was being ambulated with a roller walker to the bathroom. The nurse on the unit was called to (R19's) room and found (R19) on the floor between the bed and bathroom with a gait belt on. The staff member (E6/CNA) reported (R19) has slipped off the roller walker she was sitting on. During the assessment, (R19) reported that her right arm hurt around the elbow, and the right elbow had a bruise On 5-6-16, (R19) still complained of mild discomfort and (R19) required a right elbow x-ray .(R19) has a fracture to the radial head of the right elbow and was transferred to the hospital for a splint. R19's right elbow x-ray report dated 5-6-16, documents R19 has a probable non-displaced medial radial head fracture. R19's written statement dated 5-6-16 and signed by E2 (Director of Nursing), documents R19 reported that on 5-5-16 E6 (CNA) assisted R19 to the bathroom. E6 put the roller walker in front of R19 and assisted R19 up. R19 then stated, (E6) continued to comment to me that I was ambulating wrong and I was not putting my feet in the right manner. She (E6) really upset me. We were almost to the bathroom and I told (E6) I needed to sit down. I was getting weak. (E6) left me standing there in the doorway and yelled down the hall for another staff. When they (other staff) got to the room I had already fallen down This same statement documents R19 reported that E6 did not leave a call light with R19 before (E6) left the room. E6's (CNA) Termination Report dated 5-9-15, documents, Type of Warning: Termination. Failure to follow procedures in transferring residents multiple times. You (E6) have been told several times how to transfer residents in a safe manner. You (E6) did not leave a call light with the resident when you left the room. This fall results in a fracture of the elbow to the resident. This is a category two offense with a failure to follow departmental rules. On 8-2-16 at 10:30 a.m., R19 stated, I got a fracture not too long ago, because a CNA left me standing without a call light. I could not get help and needed to 'pee' real bad. I don't want that staff to work with me anymore. On 8-3-16 at 8:45 a.m., E2 (Director Of Nursing/DON) stated, On 5-5-16 at 8:45 a.m., a staff member (E6) sat (R19) on her wheeled walker and went to the hallway to get other staff. When (E6) returned to (R19's) room, (R19) was on the floor. (E6) did not give (R19) her call light when she was sitting on the roller walker. (R19) was left without a communication device to call for help, got up without help, and fell . (R19) is alert and orientated, so it (the call light) would have helped prevent the fall and fracture (E6) was termed because according to our policy and procedure, residents are to have call lights within reach at all times. 2. The Facility's Gait Belt /Safe Handling Policy (undated) documents, The policy of this facility is assure the safety of residents and employees during transfer and repositioning tasks. It is mandatory in this facility to use gait belts for the safety of residents and staff, therefore all licensed and certified nursing staff are to use gait belts while transferring residents. Disciplinary action will be taken with anyone not using a gait belt during a resident transfer. R19's Fall Investigation Report dated 6-22-16 and signed by E2 (DON) documents, On the evening of 6-21-16 at 10:00 p.m., (R19) was returning from the bathroom to the bed, ambulating with a wheeled walker and staff (E4/CNA). (E4) leaned forward to take (R19's) blankets down when (R19) fell on (R19's) buttocks to the floor. (R19) complained of right lower back pain (R19) was sent to the hospital for evaluation .CT (Computed Tomography) report received states (R19) has a L 4 burst (Lumbar Back Burst) fracture with further height loss and a L1 vertebral body fracture. R19's CT of the Lumbar Spine dated 6-22-16, documents R19 has L1 and L4 vertebral fractures (Lumbar Back Fractures). E4's (CNA) Investigation Report dated 6-22-16 and signed by E2 (DON) documents, On the evening of 6-21-16 at approximately 10:00 p.m., (E4) transferred a resident (R19) without using a gait belt (E4) has been given a three day suspension .' The facility's Gait Belt Agreement dated 12-31-14 and signed by E4 on 6-8-16, documents E4 understands that a gait belt is required to be used for all resident transfers to promote safety. E4's Employee Warning Report dated 6-22-16 and signed by E2 (DON) and E4, documents E4 received a final warning three day suspension for transferring a resident (R19) without using a gait belt and not following the company fall and transfer policy. On 8-3-16 at 8:45 a.m., E2 (DON) stated, Staff (E4/CNA) walked (R19) back from the bathroom to (R19's) bed with a roller walker. (E4) let go of (R19) to pull (R19's) bed covers down. When (E4) let go of (R19), (R19) fell to the floor. (E4) was not using a gait belt. (E4) had to be educated on asking for help by using the call light instead of letting go of the resident. (E4) should have kept hold of (R19) while pulling down the covers on the bed. This fall resulted in fractures to (R19's) back because (E4) let go of the gait belt. B. 1. A Falls Management Program dated 7/8/13, documents the Incident Committee Team will discuss the falls on a regular basis and confirm about potential preventative fall measures and measures to minimize injuries from falls .The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. A Policy and Procedure for Safe Use of Bedrails (date unknown), documents, The aim of the introduction of this policy is to help prevent death, asphyxiation, entrapment, and serious injuries from the inappropriate use of bed rails. A Minimum Data Set (MDS) assessment dated [DATE], documents R10 was originally admitted on [DATE] with the [DIAGNOSES REDACTED]. The MDS dated [DATE] also documents that R10 has severely impaired cognitive skills, requires extensive assistance of two staff for bed mobility, is unable to ambulate, and uses a trunk restraint on a daily basis. A Side Rail assessment dated [DATE], documents R10 uses bilateral half side rails when in bed. A Resident Incident Report dated 6/21/16 at 3:30 p.m., documents (R10's) bed alarm was sounding. (R10) found lying face down on bed with (R10's) legs hanging off and right arm beneath the side rail. A Physician Notification dated 6/21/16, documents (R10) rolled to prone position while in bed. (R10) got her arm pinned beneath a side rail. Large dark purple bruise to right forearm near elbow .Bruise is 4.5 by 7.5 (centimeters). R10's medical record does not document a root cause analysis for R10's fall and arm entrapment from 6/21/16. A Care Plan intervention dated 6/21/16, documents adding a sensor pad to be placed while in bed for safety. Staff are to ensure device is properly placed and working and keep bedroom door ajar to monitor (R10). A Care Plan intervention dated 10/7/15, indicates the same intervention for a sensor pad had already been implemented prior to the 6-21-16 fall. On 8/1/16 at 1:13 p.m., R10 was in the 2nd floor lounge alone without supervision. On 8/3/16 at 9:45 a.m., 12:10 p.m., and 1:28 p.m., R10 in her room with the door partly closed where R10 could not be visualized from the hallway as the 6-21-16 fall intervention indicates. On 8-2-16 at 10:00 a.m., R10's bed had half bilateral siderails. On 8/3/16 at 9:18 a.m., E2 (Director of Nursing) stated there was no further documentation on R10's 6/21/16 fall. E2 stated the entrapment of R10's arm had not been addressed and the side rails were not removed until the surveyor discussed this issue with E2 on 8/2/16. 2. A Resident Incident Report dated 11/28/15 at 9:00 p.m., documents (R10) was on floor with blood present around head. (R10) was moaning. Assessed more and noticed a small scrap to right middle knuckle and right knee. 1.5 inch gash to top of right side of (R10's) head. The Incident Report also documents in the Witnesses Description of Incident, that R10 was being showered by one staff member while the second staff member was getting a towel for R10 .R10 tried to stand from the shower chair and fell head first onto the floor. A Care Plan intervention dated 11/28/15, documents, When (R10) is getting a shower, one staff (Certified Nurse Aide) is to have hands on her at all times. A Minimum (MDS) data set [DATE], documents R10 requires two assist with bathing. On 8/4/16 at 9:18 a.m., E2 verified there was no further investigation into R10's fall on 11/28/15 to determine how R10 fell while two staff members were to be assisting with R10's shower. 3. A Resident Incident Report dated 10/4/15 at 4:00 p.m., documents (R10) fell from recliner onto the floor at the nurse's desk. The incident report also documents that the fall was heard but not witnessed by any staff members. A Care Plan intervention dated 10/4/15, documents Staff are to stay with the resident while she is in recliner. A Resident Incident Report dated 1/9/16 at 7:30 p.m., documents Not witnessed, (R10) found on floor. Bruise to (right) knee. The incident report also documents that R10 was in the resident dining room with no supervision and that R10's lap belt restraint was in place when last seen by staff. A Care Plan intervention dated 1/9/16, documents When (R10) is anxious, place (R10) at nurses desk with staff. R10's medical record does not document R10 was anxious on the evening of 1/9/16. On 8/4/16 at 9:18 a.m., E2 verified R10 fell on [DATE] and 1/9/16 while not being supervised.

Based on observation, record review and interview, the facility failed to safely operate the wheelchair lift on the facility transport van for one of five residents (R87) reviewed for falls in a sample of 14. This resulted in R87 falling out of the van onto the concrete parking lot. R87 incurred injuries of a swelling, hematoma, and lacerations to the back of the head, Whiplash to the neck, rib contusions and bruising to the bilateral shoulders. R87 complained of nausea, vomiting, and dizziness in the days following days the incident. Findings include: R87's admission face sheet dated [DATE] notes R87 to be [AGE] years of age and includes the following Diagnoses: [REDACTED]. The Resident Assessment and Care Screening for R87 dated [DATE] notes R87 requires extensive assist of two for transfer, dressing, and toileting. It documents R87 to be 6 foot 5 inches and 241 pounds. On [DATE] at 1:50 pm, R87 stated, "I know why you are here. It's about the fall from the van deal, isn't it? I thought I was dead. When (E4/CNA/Certified Nurse Aide/Transporter) went to take me off the van to go to my Doctor, (E4) unhooked the wheelchair, started to push me out the back of van onto the lift but the lift was on the ground. I went flying out the back and landed on my back, still in the wheelchair. (E4) fell out too. I hit my head. The back of my head had a bump with scratches. The scratches were bleeding and I am on Coumadin, so that scared me more. There was supposed to be two people transporting that day but there was only one. (E1/Administrator) finally talked to me on Friday, four days later. I asked (E1) why there weren't two staff on the van like there is supposed to be. There were always two before. (E1) told me they do not necessarily have to have two to assist in transport. I was going to see (Z8/Orthopedic Physician) that day for the fracture to my right arm and wrist. That is the reason I am in the nursing home, because I fell at home and broke them. After the van deal, I was scared to death. I was nauseated and dizzy for days after. My ribs still hurt real bad. I was told they are severely bruised. I couldn't believe (E4) was driving the van the very next day when they sent me to see my doctor (Z2/R87's Primary Care Physician). (E1) never did come ask me what happened. " Z6 (R87's friend) was also present during this conversation stated, "I rode in the front seat of the van. I saw it all happen. It looked like (E4) was pushing (R87) backward in the wheelchair when they both fell out the back of the van. I don't know if (E4) lost control, but I do know (E4) had already activated the lift to the ground. We were at the emergency room from 2:15 pm until 5:00pm. Neither (E1/Administrator) or the Director (E2/Director of Nursing), came to ask me what happened." The facility notification of R87's incident sent to the (state agency) dated [DATE], reports the following, "(R87) was on the van on [DATE] at 2:00 pm going to a doctor's appointment. The transportation driver was unloading (R87) at the (clinic) from the van in (R87's) wheelchair. (E4/CNA/Certified Nurse Aide/Transporter) started to push the wheelchair onto the electric lift, thinking (E4) had raised it up to the level of the van floor. (R87's) wheelchair fell to the ground and the van driver (E4) fell along with (R87) to the ground. (R87) bumped his head on the ground. Several nursing staff from the clinic came out to assist (R87). (R87) was immediately taken to the hospital emergency room for evaluation. The nurse practitioner has recommended an x-ray of (R87's) ribs be done tomorrow morning when (R87) goes to see (Z2/Primary Care Physician). Signed (E2/DON/Director of Nursing)." E8 (LPN/Licensed Practical Nurse) stated on [DATE] at 1:00 pm, "The x-ray was to be done at the Doctors office the next day. There is nothing in the chart that shows it was done." E4 (Z2's nurse) stated on [DATE] at 11:48 am, "We did not get any info requesting an x-ray from (Z7). The note we got does not mention that. We did not get an x-ray of the ribs on (R87). They did not report to us any bruising on (R87's) back." E4 (CNA/Transporter) stated on [DATE] at 2:45pm, "I was taking (R87) to the doctor by myself and the friend (Z6) was with us. I put the lift down on the ground as if I was picking someone up for transport but instead it should have been up even with the van for dropping off per transport. (R87) has two broken bones in the left arm. They had removed the right wheelchair arm as it irritated the sore arm. (R87) was facing the driver seat and I was facing the back exit. I could only push the left side arm of the chair and couldn't get good control of it. I didn't realize I left the lift down on the ground and we (E4) and (R87) went over the edge and onto the parking lot. I got out of the van, tuned on the lift from the back of the van and put the lift down to the ground. I then went around to the side and inside the van to unhook (R87). It was an error on my part. I landed on my feet." E4 was asked if there was supposed to be one or two staff on the van for transport. (E4) stated, "I believe that is the way it is supposed to be. There usually are two staff. They split the duties. One staff drives and the other staff does resident care. There is usually one on the ground and one in the van during loading/unloading. The aide that had been going with me, (E7/CNA/Transporter) quit the day before this happened, leaving just me to transfer. Now we have a second staff/helper. Ever since that happened to (R87), they have been really good to assure some one goes with me. I didn't have formal training. (E7) showed me how to do the job. I did not have any formal training. I did not see any manual on the lift on how to operate the lift. I just started transporting the end of September (2014). When I took the position, it was my understanding there would always be two people on the van for transport. I filled out two incident reports. One for (R87) and one in case I end up with injury on the job. There's no manual in a pouch on the van or anywhere on it. I was not give any training after the incident. No, I didn't get training after the fall either." On [DATE] at 12:00pm, E7 said, "I used to be the transporter. But I just made a job change. We normally ran with two staff on the van. I didn't have any formal training on operating the lift. I was shown how by the previous transporter. I have never seen any manual with instructions," E1 (Administrator) was asked to provide the manufacturers manual for operation of the van lift. At 2:00 pm on [DATE], E1 stated, "We didn't have the manual on the lift so we called the supplier and are now downloading the manual for the lift from the Internet." The Operator Manual front page notes, "Read manual before operating lift. Failure to do so may result in serious bodily injury. Keep manual in pouch." Page 26 states the lift operator's manual must be stored in the lift storage pouch at all times. Page 10 notes, "WARNING. Read manual and supplements before operating lift. Read and become familiar with all safety precautions, operation notes, details, operating instructions and manual operating instructions before operating the lift. Drivers and wheelchair lift attendants must read and become familiar with the contents of this manual before operation." Z2 (R87's) Primary Care Physician provided a clinical note regarding (R87's) incident of [DATE]. It includes the following physician note dated [DATE] at 11:10 am, "Clinically, (R87's) trauma resulted in rib contusions. In my mind, (R87) should mot have been in a position where (R87's) chair could move, i.e. brakes off and the chair not physically secured, until the lift is in proper position, if the door is open. Having two may have prevented the fall by giving more attention to both (R87) as well as the mechanical aspects of the van/lift. In my mind, this was gross negligence as (R87) should never have been in a state which allowed mobility until proper steps to ensure that the lift was in place of prevent this mishap. (R87) could very well have died or suffered serious, quality of life altering injuries as a result". R87's progress note dated [DATE] at 1:05 am includes the following: "(R87) complains of rib pain. Noted to have bruise on mid upper back." Progress note of [DATE] at 12:56am documents, "Skin warm and dry, faded greenish bruise to bilateral posterior shoulders." On [DATE] at 2:45pm, R87 was observed to have a bump to the back of the head with two scabbed areas approximately 2.5 cm (centimeters) in length within the bump. Also observed was a yellow/reddish bruise on the left shoulder which was approximately 6cm wide by 3cm long. The right shoulder had the same color bruise approximately 3cm wide by 3cm long. At 3:00 pm on [DATE] E2 (DON)was asked if the doctor had been notified of the bruising. E2 had no response. R87 stated on [DATE] at 11:00am, "That incident on the van, let me tell you I was scared to death. (E4/Transporter/CNA) was shook up at the time but didn't really say anything to me afterward, and didn't say anything the next day when (E4) took me (R87) to see my other Doctor (Z2/Primary Care Physician), not sorry or anything. Didn't really talk to me at all. That doesn't seem like the right thing to do. You would think someone from Administration would have come talk to me about what happened, but they didn't. The DON (E2) came in for less than five minutes not the day after, but the next day after that. I fell at home and broke my arm. They put a plastic cast on that but didn't x-ray my hand. When I came here for therapy they were turning my hand and wrist and it hurt bad. I told them it hurt right from the get go. When they finally did x-ray it, well they told me my wrist was definitely fractured."

Based on interview and record review, the facility failed to properly transfer a resident from the commode to bed for one of four residents (R7) reviewed for resident injury in the sample of 24. This failure resulted in R7 receiving a fractured left tibia. Findings include: A Minimum (MDS) data set [DATE], documents R7 requires extensive assistance from two staff for transfers. R7's Plan of Care dated 7/3/14, documents R7 requires "strong (two) assist." On 10/21/14 at 1:30 p.m., R7 stated "I broke my leg when (10/6/2014) I transferred from my commode to my bed." R7 stated "I usually need two people to transfer me but (E15, Certified Nurse Aide/CNA) did it by herself." R7 stated it hurt at the time but R7 did not report any problems until 10/7/14. R7 stated "I slept all night but it really started hurting when I was getting my bath the next day." On 10/22/14 at 12:20 p.m., E15 (CNA) stated on the evening of 10/6/14 R7 was on the commode and requested to be laid down because of pain in R7's left leg. E15 stated R7 has a healing left hip fracture (prior to admission) and experiences frequent pain. E15 stated "I put (R7) to bed myself." E15 stated "I used a gait belt and had (R7) put (R7's) arms around my shoulders." E15 stated R7 pivoted on (R7's) left leg and R7 stated "my leg bent, my leg bent." E15 stated R7 did not complain of any different type of leg pain at that time or after the transfer. E15 stated "I told the nurse that R7's leg was hurting and pain medication were given. (R7) did not have any complaints when the nurse came in to give (R7) pain medicine." E15 stated "I had no idea (R7) broke (R7's) leg or that (R7) had a new injury." E15 stated R7 went to sleep and had no further complaints to E15's knowledge. On 10/23/14 at 9:50 a.m., E11 (Registered Nurse/Unit Coordinator) stated R7 started complaining of left shin pain on 10/7/14 when receiving morning cares. E11 stated R7 requested E11 to come to R7's room. E11 stated R7 reported that R7 might have hurt (R7's) leg when transferred to bed on the evening of 10/6/14. E11 stated E11 assessed R7's left leg and found no obvious injury. E11 stated R7's left leg had no deformity, redness, or swelling. E11 stated R7's nurse administered pain medications. E11 stated R7's physician was notified and ordered to monitor R7's leg for changes. E11 stated R7's leg was monitored all day and E11 noticed "a little" swelling the afternoon of 10/7/14. E11 stated R7's physician was again notified and ordered an x-ray of R7's left leg. E11 stated "I believe (R7) should be a two person assist with transfers because (R7's) tolerance fluctuates throughout the day." On 10/22/14 at 10:55 a.m., E2 (Director of Nursing) stated R7 was improperly transferred by E15 (CNA) on 10/6/14. E2 stated "we know (R7) should have had two people transferring (R7)." E2 stated E15 was disciplined for improperly transferring R7. E2 stated as soon as R7 reported to E11 (RN, Unit Coordinator) that R7 potentially hurt (R7's) leg during a transfer, an investigation was initiated. E2 stated the investigation showed R7 did not report any change of condition until the morning of 10/7/14. An X-Ray report dated 10/7/14, documents R7 had a fractured mid tibia.

Based on record review and interview the facility failed to provide timely care, assess resident pain, and administer pain medications for one of fourteen residents (R3) reviewed for pain in the sample of 24. R3 complained of right shoulder pain, but did not receive an x-ray until eight days later. CT (computed tomography) scan results document R3 had a fractured right scapula. Findings include: A Resident Incident Report dated 6/22/13 at 5:20 a.m., documents R3 lost balance, fell backwards and hit the back of R3's head on the wall, then fell to the ground. Nurses Notes dated 6/22/13 at 5:20 a.m., document R3 sustained a laceration to the back of the head and a laceration to the right forearm. Nurses Notes dated 6/22/13 at 6:00 a.m., documents R3 was sent to the emergency room for an evaluation. Nurses Notes dated 6/22/13 at 9:20 a.m., documents R3 returned from the hospital with five staples to the back of the head and a treatment to the right forearm. A Nurses Note dated 6/23/13 at 2:15 a.m. and 8:15 p.m., documents R3 complained of right shoulder and side pain. A Nurses Note dated 6/24/13 at 9:30 a.m., documents R3 complained of right shoulder pain. Nurses Notes dated 6/24/13 at 1:30 p.m., documents Z1 (R3's Primary Physician) was notified of R3's complaints of right shoulder pain and ordered R3 be seen in urgent care or Z1's office for further orders. A Nurses Note dated 6/24/13 at 9:40 p.m., documents R3 complained of pain to right shoulder. A Nurses Note dated 6/25/13 at 4:45 p.m., documents R3 complained of right shoulder, arm, and wrist. A Nurses Note dated 6/25/13 at 7:00 p.m., documents Z2 (R3's Power of Attorney) telephone inquired about R3 needing an x-ray of right shoulder due to complaints of pain. A Nurses Note dated 6/25/13 at 7:00 p.m., documents Z2 stated "(Z2) will call Doctor's office tomorrow (morning) to stress the need." A Nurses Note dated 6/26/13 at 2:17 a.m., R3 complained of pain. Nurses Notes dated 6/27/13 to 7/1/13 do not document any monitoring of R3's condition or pain. A Nurses Note dated 7/1/13 at 2:30 p.m., document R3 returned from Z1's office after having the staples in the back of R3's head removed and had new orders to wear a sling on right arm and ice right shoulder twenty minutes four times per day for one week. An x-ray of R3's right scapula dated 7/1/13, documents fracture of scapula cannot be excluded. A Nurses Note dated 7/2/13 at 9:00 a.m., documents Z1 ordered a CT scan of right shoulder. A CT scan dated 7/8/13, documents R3 had a fractured right scapula. A physician's orders [REDACTED]. Nurses Notes dated 7/8/13 to 7/23/13, do not document any further monitoring of R3's shoulder pain or fractured scapula. R3's Physician orders [REDACTED]. R3's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Pain assessments dated 6/22/13 through 7/14/13, document R3 complained of mild to severe pain at least once a day, except for 6/25/13, 6/26/13, 6/29/13 and 7/5/13. R3's Physician order [REDACTED]. R3's Physician order [REDACTED]. A Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R3's Physician order [REDACTED]. A Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A Pain Management Policy (date unknown), documents all residents should be as free of pain as possible through a combination of medical intervention and functional therapy...pain management tracking will be implemented to track pain and response to medication and/or treatment on the Medication Administration Record...Residents will be monitored until pain is resolved or is under control... On 1/23/14 at 10:00 a.m., R3 stated R3 experienced a lot of pain after the fall on 6/22/13. R3 stated "it took a long time to go away." R3 stated R3 received therapy to help re-gain use of the right shoulder. R3 stated the shoulder pain "made it hard to move (R3's) arm." On 1/23/14 at 10:20 a.m., Z2 (R3's Power of Attorney) stated R3's right shoulder x-ray should have been done much sooner. Z2 stated Z2 reported R3's constant pain to staff. Z2 stated it took over a week for R3 to get an x-ray and then approximately another week to get a CT scan. On 1/23/14 at 11:53 a.m., Z1 (R3's Physician) stated he was notified of R3's shoulder pain on 6/24/13. Z1 stated he ordered R3 be seen by a Physician at Z1's office or "Urgent Care" before ordering an x-ray. Z1 stated after R3 was assessed the correct x-ray could be ordered. Z1 stated staff did not notify him of R3's pain after 6/24/13. Z1 stated R3 came to Z1's office on 7/1/13 and Z1 observed bruising and tenderness at the right shoulder. Z1 stated passive range of motion to R3's right arm produced pain. Z1 stated an x-ray was obtained on 7/1/13. Z1 stated R3's medications could have been adjusted as need to help control R3's pain. On 1/13/14 at 9:30 a.m., E4 (Assistant Director of Nursing) stated R3 should not have waited 8 days to get an x-ray. E4 stated when a resident is assessed to be in pain, the nurses need to document administration of medications and any type of alternative treatment.

Based on interview and record review the facility failed to prevent a fall by not using a gait belt during resident transfer and ambulation for one of eight residents (R3) reviewed for falls in the sample of 24. This failure resulted in R3 receiving a scalp laceration requiring five staples, and a laceration on the right forearm. CT (computed tomography) scan results document R3 had a fractured right scapula. Findings include: A Physician order [REDACTED]. A Minimum Data Set assessment dated [DATE], documents R3 scored fifteen out of fifteen on the brief interview for mental status, requires extensive assistance of two staff for transfers, and requires total assistance with showering. A Plan of Care initiated on 7/20/12 (revised on 1/17/14), documents R3 requires extensive assistance of two staff with transfers due to fair balance, history of falls, and Parkinson's Disease. A Resident Incident Report dated 6/22/13 at 5:20 a.m., documents R3 was in the shower room standing with a walker with assistance of E11 (Certified Nurse Aide). A Resident Incident Report dated 6/22/13 at 5:20 a.m., documents E11 turned away from R3 and R3 lost balance, fell backwards and R3 hit head on the corner of the wall. A Resident Incident Report dated 6/22/13 at 5:20 a.m., documents E11 reported E11 did not use a gait belt on R3 at the time of R3's fall. Nurses Notes dated 6/22/13 at 5:20 a.m., document R3 sustained a laceration to the back of the head and a laceration to the right forearm. Nurses Notes dated 6/22/13 at 6:00 a.m., documents R3 was sent the emergency room for an evaluation. Nurses Notes dated 6/22/13 at 9:20 a.m., documents R3 returned from the hospital with five staples to the back of the head and a treatment to the right forearm. Nurses Notes dated 6/24/13 at 1:30 p.m., documents Z1 (R3's Primary Physician) was notified of R3's complaints of right shoulder pain and ordered R3 been seen by Z1 for further orders. An x-ray of R3's right scapula dated 7/1/13, documents fracture of scapula cannot be excluded. On 7/2/13, Z1 ordered CT (Computed Tomography) Scan of R3's right scapula. A CT scan dated 7/8/13, documents R3 had a fractured right scapula. A Gait Belt Policy/Memo dated 2/13/13, documents "all licensed and certified nursing staff are to use gait belts while transferring residents....Disciplinary action will be taken with anyone not using a gait belt and to those who do not properly control transfer a resident as stated in his or her Care Plan. On 1/22/14 at 10:45 a.m., E4 (Assistant Director of Nursing) stated staff are always to use a gait belt on a resident that needs assistance with transfers unless otherwise noted in the plan of care. On 1/23/14 at 10:00 a.m., R3 stated R3 recalled the fall on 6/22/13 and E11 did not use a gaitbelt to keep R3 steady.

Based on observation, record review, and interview, the facility failed to ensure interventions to prevent injuries were developed for two of three residents (R1 and R3) reviewed for accidents/injuries in a sample of three. R1 experienced a fall and x-ray reports document a fractured hip. Findings include: 1) A Resident Incident Report dated 5/17/13 at 7:50 p.m. states R1 fell in (R1's) room next to the closet after transferring unassisted by staff. The report indicates R1 admitted to removing a personal alarm prior to falling. The report also states R1 was assessed for injury and no injury was noted at the time of the fall. The report states, "Interventions added: Place (personal alarm) where resident cannot reach." The report is signed by E4 (DON - Director of Nursing) but the section of the form titled "Additional Notes/Follow Up" is blank. A discharge record dated 5/18/13 shows R1 was transferred to a local hospital on [DATE]. A Transfer and Referral Record dated 5/18/13 states reason for transfer "Lethargic, (low blood pressure) 78/54 at 9:20 p.m., Seizure this morning, Resident had unattended fall evening of 5/17/13, seizure this morning, and had been lethargic, and recent drop in blood pressure...". A History and Physical from (a local hospital) dated 5/19/13 states, "...This patient's likely altered mental status is due to urinary tract infection...Troponin (Laboratory test that indicates heart damage) is significantly elevated. It is possible that (R1) might have had a (heart attack).... Due to the report that (R1) has fallen, will go ahead and check an x-ray of the pelvis and hip to see if there are any fractures..." An x-ray of R1's pelvis and both hips dated 5/19/13 shows a "confirmed subcapital fracture, left hip...". In a report to the state agency dated 5/21/13 E4 (DON - Director of Nursing) states, "... On 5/17/13 (R1) was found on floor in room...with no injury noted. On 5/18/13 (R1) was lowered to floor by staff for complaints of weakness and altered level of cognition...admitted to (a local hospital) on 5/18/13 with [DIAGNOSES REDACTED]. Hip x-ray done on 5/19/13 at (local hospital) due to transfer report from (facility) stating recent fall. X-ray reveals confirmed subcapital fracture, left hip...". A Resident Incident Report dated 6/10/13 at 4:25 p.m. indicates R1 was found "sitting in front of wheelchair on foot pedals no signs of injury denies pain". The report states, "Interventions added: (Personal alarm)." R1's nurses' notes dated 6/10/13 at 4:25 p.m., state, "Resident found in room sitting in front of wheelchair on foot rests. No sign of injury. Placed back in wheelchair. Denies pain. Evaluated left hip. No change in rotation of hip. Neuros started. WNL (Within Normal Limits) for patient." Nurses' notes state Z4 (R1's Attending Physician) and Z2 (R1's POA - Power of Attorney) were notified of R1's fall. On 6/18/13 at 11:45 a.m., regarding R1's fall on 5/17/13, E10 (LPN - Licensed Practical Nurse) stated, "... (R1) had a habit of disarming the alarm and that's what happened in that case. (Since R1 would disarm the alarm) We were to do frequent checks on (R1). The alarm didn't go off. (R1) disarmed it. (R1) was in the recliner and walked to the closet. (R1) was lying on the floor by the closet. We didn't move (R1) until fully assessed. I had the supervisor (E11 LPN) come in and assess (R1) with me. There was nothing out of the ordinary. (R1) could move all extremities with difficulty and did not complain of pain... I didn't add any interventions for (R1)... The unit coordinator makes recommendations regarding new interventions and puts them on the care plan....". On 6/18/13 at 11:55 a.m., E11 (LPN - Shift Supervisor) stated, "... Any time there's a fall in the building I'm notified. I ask if there's any injury. If there is or it's unusual for that resident I go and respond. I did respond that night (for R1 on 5/17/13) because I was actually on the floor when the CNA (Certified Nursing Assistant) found (R1) on the floor. (R1) seemed to be doing fine... Did ROM (Range of Motion) on (R1) and asked (R1) about pain. The only pain (R1) had was in one of (R1's) fingers. (R1) said (R1) was just embarrassed.... (R1) moved all extremities fine. (R1) was not feeling well, I believe it was the next night. The floor nurse noted a change in (R1's) level of consciousness... a little disorientated... (R1) said (R1) just didn't feel good and wasn't specific. At the time, I (E11) didn't feel like it was related to the fall (on 5/17/13). (R1) had a syncope episode that morning so we decided to send (R1) out and have (R1) evaluated...". On 6/18/13 at 10:30 a.m., regarding incident reports, E4 (DON) stated, "... The nurse does the initial investigation and adds an intervention then it comes to me to look at. I can't tell you how for sure it gets to the care plan. Falls have to go to the Fall Committee...". E4 (DON) verified R1 does not have a care plan intervention to address R1's tampering with the personal alarm after falling on 5/17/13. E4 (DON) acknowledged the personal alarm intervention on the 6/10/13 Resident Incident Report for R1 is not a new intervention and no new interventions have been added to R1's care plan. On 6/17/13 at 12:30 p.m., R1 was sitting in a wheelchair in (R1's) room asking to go to the bathroom. E6 (CNA) and E7 (CNA) propelled R1's wheelchair to the bathroom. E6 placed a gait belt around R1 and E6 and E7 assisted R1 to a standing position with R1 using a hand rail while a commode was placed for R1's use. R1 was cooperative and able to minimally assist staff with transfer and toileting. R1 was confused and a MDS (Minimum Data Set) dated 6/07/13 shows R1 has a BIMS (Brief Interview for Mental Status) score of 5 indicating R1 has severe cognitive deficits. An MDS dated [DATE] shows a previous BIMS score of 10 indicating R1 had moderate cognitive deficits at the time of that assessment. R1's care plan dated 1/09/12 states R1 is at high risk for falls and removes the personal alarm. A care plan intervention dated 2/06/13 states "(Personal Alarm) at all times". Resident Incident Reports dated 5/17/13 and 6/10/13 show R1 experienced falls and no new interventions were developed to address R1's safety. 2. Resident Incident Reports for R3 from January 2013 through June 2013 show staff reported R3 had injuries from an unknown source on 1/06/13 at 12:00 a.m., 1/16/13 at 9:00 a.m., 3/21/13 at 2:30 p.m., and 3/27/13 at 10:10 a.m. An incident report dated 1/06/13 states during care staff noted purple bruising on R3's 5th toe on the right foot and on the top of R3's right foot. The incident report dated 1/16/13 states staff noted a "quarter size bruise" on R3's left shoulder. A report for 3/21/13 indicate Z3 (R3's Attending Physician) examined R3 and found a 0.5 cm (centimeter) by 0.5 cm circular skin tear on R3's right lower outer leg. An incident report dated 3/27/13 states staff, "Discovered 1.5 by 1 cm skin tear, circular, left upper arm...". The Resident Incident Reports for R3 state R3 was unaware of how injuries were received on 1/06/13, 1/16/13, 3/21/13, and 3/27/13. The Resident Incident Reports are signed by E3 (DON - Past Director of Nursing) but there is no further documentation to indicate an investigation was conducted to determine the a possible source of injury or the rule out potential resident abuse. R3's Resident Incident Reports dated 4/17/13 at 4:45 p.m., 4/28/13 at 6:00 p.m., and 6/11/13 at 12:35 p.m. show R3 received skin tears during care. R3's Resident Incident Report dated 4/17/13 states staff noted a skin tear on R3's left forearm after staff assisted R3 with dressing. R3's nurses' notes, treatment sheets, and Resident Incident Report dated 4/17/13 contain no description or measurement of R3's skin tear on that date. A Resident Incident Report dated 4/28/13 at 6:00 p.m. states R3 received a skin tear on the right elbow during staff transferring R3 to bed with a sit to stand lift. The 4/28/13 Resident Incident Report states, "Re-educate staff to make sure extremities are clear when transferring resident". Nurses' notes dated 4/28/13 at 6:00 p.m. indicate R3's skin tear to the right elbow measured 2.0 by 2.0 cm (centimeter) and steri strips were applied to the wound. A Resident Incident Report dated 6/01/13 at 12:35 p.m. states R3 received a skin tear to the left elbow while being transferred by staff with a sit to stand lift from the wheelchair to the bed. R3's nurses' notes, treatment sheets, and Resident Incident Report dated 6/01/13 contain no description or measurement of R3's skin tear on that date. R3's 6/01/13 nurses' notes state 3 steri strips were applied to R3's wound. R3's care plan dated 5/08/12 states R3 is transferred with a sit to stand lift but no new interventions have been developed to address injuries observed and reported on 1/06/13, 1/16/13, 3/21/13, 3/27/13, 4/17/13, 4/28/13, and 6/01/13. There is no documentation indicating R3's injuries on 1/06/13, 1/16/13, 3/21/13, 3/27/13, 4/17/13, 4/28/13, and 6/01/13 were evaluated or investigated. On 6/18/13 at 10:30 a.m., regarding R3's injuries, E4 (DON - Director of Nursing) stated, "... The only incident I've looked at was the last one (dated 6/01/13) The rest were done by the previous DON (E3 Past DON). The nurse does the initial investigation and adds an intervention. Then it comes to me to look at. I can't tell you how for sure it gets to the care plan .... I've looked in the office and there's no other files or any other documentation about an investigation (regarding R3's injuries of unknown origin.... I can tell you we will be doing things differently now....". On 6/18/13 at 12:30 p.m., E14 (CNA - Certified Nursing Assistant) and E15 (CNA) transferred R3 from the wheelchair to the bed with a sit to stand lift. R3 was able to follow staff's directions for participation during the transfer. R3 is aphasic and has great difficultly verbalizing. R3's BIMS (Brief Interview for Mental Status) score on 5/30/13 was 14 indicating R3's cognitive abilities are intact. R3 denies ever being injured by the mechanical lift or by staff. An undated policy titled Accidents and Incidents states, "...All accidents involving an employee, resident, visitor, or volunteer shall be investigated, and recorded on a Confidential Accident/Incident Report form....It is the responsibility of the Director of Nurses (DON) or designee to investigate and ensure appropriate completion, notification, and follow up on all Accidents and Incidents.... I. The charge nurse must conduct an immediate investigation of the accident/incident.... V. The DON/Designee will conduct an investigation of the accident/incident as well. Findings will be indicated on the Accident/Incident report form in the appropriate area. VI. The Care Plan Coordinator will be notified of the accident/incident so that appropriate changes may be made to the care plan as needed. VII. There will be follow-up assessment and accompanying documentation on the Accident/Incident form. IX. Once completed and all follow-up has been documented, the DON will forward the Accident/Incident Report to the Administrator for review and signature....".