Every finding on record at Three Springs SR Living & Rhab

Based on observation, interview, and record review the facility failed to ensure food was prepared in a manner which prevents potential food born illness for 7 of 7 (R1, R2, R3, R4, R5, R6, and R7) residents reviewed for food temperatures in the sample of 7.Findings include: On 7/10/2026 at 1:10 PM, V5 (Cook)stated, the gravy is used for mashed potatoes and pureed diets. On 7/10/2026 at 1:11 PM, the food temperatures were taken with a calibrated metal thermometer and the gravy registered on the calibrated thermometer at 120.0 Fahrenheit (F) and the pureed rolls dish registered at 120.5F. V14 compared the temperatures with V4 (Dietary Manager). V14 did not dispute the temperature. On 7/10/2026 at 1:12 PM, V4 (Dietary Manager) stated she would expect all food on the steam table to be at least 140 degrees or higher before serving to any resident. V4 stated she was not sure if the thermometer had been calibrated. On 7/10/2026 at 3:06 PM, V14 (Dietician) stated she expects all food that is being held on the steam table to be 140 degrees or higher and 120.0 F was too low, and it is important that food temperatures are at the right level to avoid foodborne illness, and the elderly population is older and more at risk. The Facility provided a list of residents on pureed diets and R1-R4 were documented as receiving pureed diets. R7's Minimum Data et (MDS) dated [DATE] document he is cognitively intact for decision making of activities of daily living. On 7/10/2026 at 4:04 PM, R7 stated there is not enough staff and hall trays are passed out late and the food is cold. R5's MDS dated [DATE] document R5 was cognitively intact for decision making of activities of daily living. On 7/10/2026 at 4:07 PM, R5 stated she likes to eat in her room, and her food is cold. It is more cold than warm, especially with the evening meal. R6's MDS dated [DATE] document he is cognitively intact for decision making of activities of daily living. On 7/10/2026 at 4:14 PM, R6 stated he likes to eat with his wife, and she has not been feeling well lately so they have been eating in their rooms, and the tray food is usually cold. The Food Policy with a 2016 edition documents, Staff will serve hot foods from the steam table. Dining Services staff will ensure proper holding temperatures and times for all food items. Hot foods will be held at > 135 F or per state specific regulations and cold foods will be held at < 41 F.

Based on observation, interview, and record review, the facility failed to ensure that residents had a clean and sanitary shower/restroom and paper towels in residents' rooms and shower/restrooms for 51 (R1-R5, R8-R12, R15-R37, R39-R55) of 55 residents reviewed for clean showers/restrooms and supplies in a sample of 55. The Findings Include:On 6/7/26 at 8:32 AM, V3 (Licensed Practical Nurse/LPN) stated that when supplies run low typically a staff member just runs up to the local grocery store to get what is needed to get by until the next delivery date. On 6/7/26 at 9:41 AM, V4 (Housekeeper) stated that they have been out of paper towels in the shower room on C Hall for the past couple days. V4 stated that they do occasionally have an issue of running out of items and someone will run up the local store to grab what they need. On 6/7/26 at 10:04 AM, V5 (Certified Nursing Assistant/CNA) stated that in the past when supplies are low/out the staff go on their own to the local stores to get what they need and do not always get paid back. V5 went on to state that no one had went to get more paper towels at this time. Instead, they have been just ripping off paper towels from resident bathrooms located in rooms to get by until they can refill the dispensers.On 6/7/26 at 10:30 AM, the women's and men's shower rooms on C Hall had no paper towels in the dispenser. Also, at this time the men's shower room had loose toilet paper thrown on the floor behind the toilet, the toilet bowel was dirty from a bowel movement, the shower stall had feces on the floor. In this same shower room, a rusted shampoo holder in the first shower stall was empty but had an orange/red dried trail under it going down the shower walls and floor leading to the drain.On 6/7/26 at 10:32 AM, R2 who is alert and oriented to person, place and time stated she doesn't have paper towels in her bathroom and has been out for a while, so she has been letting her hands air dry. R2 went on to state that the shower room is typically not cleaned up and sanitary when she goes in there. R2 stated that she is independent in showering herself and going to the bathroom and would like to see it nice and clean when she goes in for a shower. On 6/7/26 at 11:15 AM, V14 (CNA) stated that the hand towels have been out for a couple of days. This is not a common occurrence, but they have been trying to borrow paper towels from other dispensers to place in the areas that are out. V14 stated that there are times when supplies get low and they run to local stores to get the items and then provide receipts to get reimbursed. On 6/7/26 at 2:31 PM, V7 (CNA) stated they don't always have enough supplies so they buy them, and the facility says they will sometimes reimburse them. V7 went on to state that when asked why they run out, they say we don't tell them in time for them to order them. V7 stated that the residents who live on A, B and C Hall use the shower rooms/restrooms on C Hall. On 6/7/26 at 11:45 AM, V13 (Laundry/Housekeeping Manager) stated that they get their supplies ordered the first of the month. V13 stated that they are currently out of paper towels, and they hopefully will be delivered this week or next. V13 stated that this new company they order form takes a little bit longer on receiving the items. V13 stated that they do not have a policy on cleaning but 4 rooms a day are deep cleaned. This averages out to that each room is deep cleaned once a month. The bathroom/shower rooms should be cleaned daily including sweeping and mopping the floors, wiping down the walls, cleaning the toilets and fixtures like the sink. The shower rooms should be deep cleaned once a month. V13 stated that she prints a floor plan out at the beginning of the month and the staff circle the rooms that get deep cleaned and that is how they track what has been properly cleaned. V13 stated that she is working on a daily checklist of what should be done on each shift and the timeline it should happen. V13 stated that they have day and evening shifts but not overnight. On 6/7/26 at 2:20 PM, V1 (Administrator) stated that she orders food and nursing supplies weekly, and then monthly at the first of the month she orders chemicals, housekeeping/dietary cleaning products, paper products, and office supplies. V1 went on to state that the CNAs should clean and tidy the shower rooms when they are finished with residents or see it is needing attention, so it is always ready for the next resident who enters and appears clean. There is no par level they keep for products they base ordering on what they used the prior month, she is unsure what happened with the paper towels other than they were being used to clean up spills instead of cloth towels for that. The rooms are labeled men and women, but that is mainly for residents to not walk in on staff showering residents for privacy. V1 stated that A, B and C Halls use the shower/restrooms on C Hall. V1 stated that there is a stock of paper towels in the kitchen that she has used to fill the shower/bathrooms today, and she plans on running to the local store to get a roll of paper towels for R2's bathroom in her room. V1 stated that she does not have policies on ordering supplies or cleaning the shower/restrooms and those restrooms are the closest to the dining room. A resident census list was provided on 6/7/26 by V1 and documents that R1-R5, R8-R12, R15-R37, and R39-R55 all reside on A, B and C Hall.

Based on interview and record review the facility failed to ensure incontinence care was provided timely for 2 of 3 (R6 and R8) reviewed for activities of daily living (ADL) in the sample of 24.Findings Include: 1. R6's admission Record with a print date of 6/7/26 documents R6 was admitted to the facility on [DATE] with diagnoses that include heart failure, chronic kidney disease, weakness, edema, history of urinary tract infections, pain, and unsteadiness on feet.R6's Minimum Data Set (MDS) dated [DATE] documents R6 has a Brief Interview for Mental Status score of 12, indicating a moderate cognitive deficit. This MDS documents R6 requires partial/moderate assistance with toilet hygiene and toilet transfer.R6's current Care Plan includes a Focus area, (R6) is at risk for Self care deficit. Date Initiated: 12/06/2024. This Focus area includes the intervention of, Assist with toileting and showers/bath. Date Initiated: 12/06/2024. This Care Plan includes a Focus area of, The resident has a chronic Urinary Tract Infection. Date Initiated: 06/06/2024. This focus area includes the intervention of, Check at least every 2 hours for incontinence. Wash, rinse, and dry soiled areas. Date Initiated: 06/06/2024.On 6/7/26 at 11:32 AM, R6 stated sometimes they don't have enough staff to meet her needs timely. R6 stated she had incontinence episodes when she had to wait longer for care.2. R8's admission Record with a print date of 6/7/26 documents R8 was admitted to the facility on [DATE] with diagnoses that include acquired absence of right leg below the knee, peripheral vascular disease, obesity, pain, constipation, acute kidney failure, reduced mobility, muscle weakness, and need for assistance with personal care.R8's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview Mental Status score of 15, indicating R8 is cognitively intact. This MDS documents R8 requires substantial/maximal assistance for toilet hygiene and is frequently incontinent of bowel and bladder.R8's current Care Plan includes the Focus area of Self care deficit R/t (related to) unsteady gait, poor vision, depression, arthritis pain. Date Initiated: 11/05/2025. This Focus area includes the intervention of, Assist with toileting and showers/bath. Date Initiated: 11/05/2025. R8's current Care Plan does not include a Focus area or intervention related to the assistance needed related to toileting.On 6/7/26 at 10:28 AM, R8 stated they don't have enough staff to meet his needs timely. R8 stated he uses a bed pan for toileting and he had to wait up to 30 minutes recently to get on/off the bed pan. R8 stated it happened the day before yesterday (6/5/26), in the afternoon around shift change.On 6/7/26 at 10:04 AM, V5 (Certified Nursing Assistant/CNA) stated they are short staffed at times. V5 stated if they only have 3-4 CNAs in the facility call lights are probably not going to get answered timely but they answer them as quick as they can.On 6/7/26 at 2:08 PM, V6 (CNA) stated days they don't have a shower aid are very difficult with the number of residents they have that are fall risk, have behaviors, or require assist of two staff for care. V6 stated on those days call lights are not answered timely and incontinence care is delayed.On 6/7/26 at 2:31 PM, V7 (CNA) stated yesterday (6/6/26) there was only her and one other CNA on A and B halls and two on C and D halls. V7 stated call lights take longer to answer and it may be 15 minutes before they can if they are providing care to another resident.On 6/7/26 at 3:16 PM, V8 (CNA) stated they don't have enough staff to provide the type of care she likes to give. V8 stated some residents require a lot of care and when they are in with that resident there is no one to answer the other call lights.On 6/7/26 at 4:08 PM, V9 (Director of Nurses) stated they would like to have 6 CNAs on day shift, 5 on evening shift and 3 and a half on night shift. V9 stated they have a couple of residents staff have to set boundaries with because they want a lot of care and she doesn't think some CNAs can set the boundaries.On 6/7/26 at 4:45 PM, V1 (Administrator) stated they normally have three nurses from 6 am to 6 pm and two from 6 pm to 6 am and five CNAs on day shift, four on evening shift and three on night shift. V1 stated that is the minimum staffing. V1 denied any complaints/concerns related to incontinence care being provided timely.The facility undated Activities of Daily Living (ADLs), Supporting policy documents, Residents will provided (sic) with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.1.

Based on interview and record review the Facility failed to ensure medication errors did not occur for 1 of 3 residents (R6) reviewed for medication errors in the sample of 9. Findings include: R6's Physician Order Sheets (POS) for August 2025 documents a diagnosis of unspecified convulsions. The POS does not include a diagnosis of seizures or epilepsy. R6 has an order for carbamazepine ER (extended release) oral tablet 400 milligrams (mg) give 1 tablet by mouth two times a day for seizures, and phenytoin sodium extended capsule 100 mg, give 2 capsules by mouth two times a day for seizures, and 750 mg of methocarbamol, 1 tablet three times a day for muscle spasms. R6's Minimum Data Set (MDS) dated [DATE] document R6 was cognitively intact for decision making of activities of daily living and he was documented as having Seizure disorder or epilepsy. R6's Care Plan with a created date of 5/30/2025 documents R6 hasseizure activities. Interventions Give medications as ordered. Monitor/document for effectiveness and side effects. On 11/17/2025at 9:14 AM, R6 stated, I have been taking seizure medication almost all of my life. There were some issues with the nurse that day getting to the facility, and my seizure medication was 2 1/2 hours late, and it caused me to have a seizure, and the next day I got sent out to the hospital because I was having a seizure. It's important I do not get my medication late. On 11/17/2025 at 10:30 AM, R5 (Wife) and roommate of R6 stated (R6) has had seizures his whole life. As long as he takes his medication on time, we don't have any issues. Way back in August when he went out to the hospital, the (facility) was short a nurse and when the nurse was coming from (different town) and she was helping out, but she did not really work here. Once she got here, she was late giving him his seizure medication by almost two and half hours. I talked with (V1) about it, and we talked about how (R6) should always get his seizure medications on time. R6's August MAR document on 8/27/2025 methocarbamol was scheduled to be given at 8:00 AM but was not given until 10:25 AM. R6's carbamazepine was scheduled to be given at 8:00 AM but was not given until 10:24 AM, and the phenytoin sodium was scheduled to be given at 8:00 AM and was not given until 10:25 AM. R6's three medications related to muscle spasms and seizures were given late. R6's Health Status Note dated 8/28/2025 at 9:00AM, Note Text: Resident noted to have small seizure activity. A&O (alert and orientated) in between activity. Resident requested to go to ER (emergency room) for evaluation. This nurse placed called to (V19 Medical Doctor) and received order to send to (hospital) for evaluation. EMS (emergency medical services) called. The Author of this note was V9 (Licensed Practical Nurse/LPN). R6's ED (Emergency Department) Notes dated 8/28/2025 at 9:46 AM, Chief complaint from Nursing triage note: Chief complaint from (Facility) sent due to seizures lasting less than 10 seconds. EMS reports meds were given late. Hx (history of) seizures. R6's Health Status Note dated 8/28/2025 at 12:02 PM, Note Text: Received call from ER department reporting labs came back normal. CT done and came back normal. No seizure activity noted. 1000 mg Keppra given. Resident being discharged back to facility. R6's discharge papers dated 8/28/2025 Seizure disorder.R6's Grievance form dated 10/25/2024, Hates he has seizures if his medication is even a minute late and is concerned that he is not getting meds at exactly at 8 AM and 8 PM. On 11/17/2025 at 12:32 PM, V19 (Medical Doctor) stated (R6) has had the seizure/epilepsy diagnosis for years. It is important that his orders are being followed, and if (R6) did not receive his medication on time or as ordered it could cause (R6) to have seizures/harm and would not be good to miss or have delayed medications. On 11/18/2025 at 9:57 AM, V22 (Pharmacist) stated normally as long as they have a prescription for the medicine and for (R6) convulsion would fit the bill for a diagnosis for those medications. They do not have a diagnosis for seizures and or epilepsy for (R6). Taking medications late for seizures may or could contribute to a seizure. It would depend on if a seizure occurred as to whether it would be a significant medication error. If a seizure occurred, then yes. On 11/18/2025 at 10:07 AM, V18 (LPN) stated, I know that day I got a call from the (Facility) because they were down a nurse. It was about an hour a drive to the facility by the time I got there and started passing out medications the medications were late. Unfortunately, I did not notify the physician and let him know my medications were late. A lot of the medications were late being passed out that day I did the best I could do under the circumstances. On 11/18/2025 at 12:45 PM, V9 (LPN) stated I know (R6's) wife told me that he had been having some seizure activities and the day before he had gotten his seizure medication late. They are very particular about his seizure medication. When I saw (R6) he was experiencing small twitches movements, so I sent him out. The Facility Medical Policy with a revision date of 2012 documents, Medications shall be administered in a safe and timely manner, and as prescribed. 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 space provided for that drug and dose.

Based on interview and record review, the Facility failed to store foods in a manner that prevents foodborne illness. This has the potential to affect all 66 residents living in the Facility.Findings include:On 9/9/25 at 11:30 AM, in the standing refrigerator in the main kitchen, there was a container labeled tartar sauce with the date 8/29. There was a container labeled banana pudding and a pitcher labeled CB (cranberry) juice that were both labeled 9/2. There were two containers, each with 28 individual cups of various colored liquids that were not labeled or dated. V12 (Dietary Aid) stated leftover food items should be thrown out after three days.On 9/12/25 at 2:30 PM, V1 (Administrator) stated she expects staff to follow dietary policies regarding labeling, dating and discarding items after 7 days.The Facility's Food Storage (Dry, Refrigerated, and Frozen) Policy dated 2016 documents, Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers.The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 9/9/25 documents there are 66 residents living in the Facility.

Based on interview and record review the facility failed to use the services of a registered professional nurse for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 66 residents residing in the facility. Findings Include: The facility schedule dated August 11, 2025 through September 11, 2025 was reviewed and on 8/9/25, 8/27/25, 8/29/25, 9/1/25, 9/3/25, 9/6/25, 9/7/25 and 9/8/25 the facility did not have an Registered Nurse providing resident care for 8 Consecutive hours. On 9/12/25 at 9:00 AM V3 (Infection Preventionist) stated she completed the working schedules for the facility, and she scheduled what staff was available. At the time the facility only had 1 Registered Nurse. On 9/12/25 at 9:15 AM V2 (Director of Nursing) stated she was new to the facility and understands that the facility has been unable to provide Registered nurse coverage in the past. However, she has been providing coverage on her off days when the facility has not been able to find Registered Nurse coverage. On 9/12/2025 at 10:00 AM V1 (Administrator) stated the facility has been unable to find Registered Nurses willing to travel to the area. The facility is doing the best that it can. Resident care has not suffered. The facility policy on Staffing undated documents RN coverage will be provided 8 hours per day, 7 days per week.

Based on observation and interview, the Facility failed to ensure adequate food was prepared for 5 of 5 residents (R10, R24, R51, R57, R63) reviewed for food and nutrition services in the sample of 60.Findings include:On 9/9/25 at 12:40 PM, V11 (Cook) was scraping the bottom of the pan of chili on the steam table. She asked, Do we think (R57) is going to eat this? V3 (Infection Preventionist/IP), stated, We will see when we take it down there to her (in her room). V11 continued to scrape the pan and was able to fill the bowl about half full. V3 stated, She wanted a grilled cheese yesterday, so maybe give her that and a little bit of chili. V11 stated sometimes we do run out of food and have to offer them something else.On 9/9/25 at 12:45 PM, meal service was complete. There was not enough remaining chili or peas to obtain temperatures.On 9/9/25 at 12:50 PM, V12 (Dietary Aid) stated sometimes the kitchen runs out of food because of the budget. The Facility is always removing items from our food order after we place it.On 9/11/2025 at 11:00 AM, during the Resident Council Group Meeting:R10 stated there is not enough food because the Facility company is not giving the kitchen enough money for their food budget. She stated her sister has to bring in snacks, so the Facility has something to give out during Bingo, and none of the residents here are getting enough calories each day.R10's Minimum Data Set (MDS) dated [DATE] documented R10 was cognitively intact.R24 stated the Facility does not provide enough food, and they are always out of sugar and pink sugar.R24's MDS dated [DATE] documented R24 was cognitively intact.R63 stated they ran out of chili last night, and she did not get any. The kitchen said they would put a tray back for her, but they did not do it. She got two pieces of ham instead and was mad about it.R63's MDS dated [DATE] documented R63 was cognitively intact.R51 stated he asks for more food at meals but does not get it.R51's MDS dated [DATE] documented R51 was cognitively intact.On 9/12/25 at 11:45 AM, V1 (Administrator) stated if there is ever a concern of not having enough food, dietary staff should go to the local store and buy it. She stated the Facility does not have a policy specific to dietary adequacy.

Based on interview, observation and record review the facility failed to ensure that Fentanyl patches were removed from 1 of 3 residents (R75) from a sample of 25 as ordered by the physician. Findings include:R75's Face sheet undated documents an admittance date of 9/8/25 with pertinent medical diagnoses of Unspecified Acquired Deformity of Right Lower Leg and Unspecified Osteoarthritis, unspecified site. R75's Physician Order Summary dated September 2025 documents pain medications as Fentanyl Transdermal Patch 72 hour 37.5 Micrograms/hour (Fentanyl), Celebrex Oral Capsule 200 Milligram Daily, Voltaren External Gel 1 % every 8 hours, as needed, Tramadol 50 Milligram every 6 hours and Tylenol oral tablet 325 Milligram x's 2 three times day. On 9/11/25 at 10:11 AM V13 (Granddaughter of R75) stated while her grandmother was in physical therapy, she discovered that her grandmother had three (3) Fentanyl patches on her back. Two (2) were on the right shoulder and the third patch was on her left shoulder. The Director of Nursing did remove two (2) patches from R75's left shoulder. On 9/11/25 at 11:30 AM V2 (Director of Nursing) stated she did remove 2 patches from R75's shoulder which should have been removed before the third patch was applied. V2 director of Nursing stated a Medication Error report is being compiled. On 9/11/25 at 3:02 PM V15 (Primary Medical Physician) stated he had been notified by the facility of the three (3) Fentanyl patches being on R75. V15 stated the hospital placed two (2) patches (a 25 Microgram and 12 Microgram) because they did not have the prescribed dosage of 37.5 Microgram. Since the two (2) patches had been applied more than 72 hours ago it was doubtful that it contained any medication that would harm R75. The facility had been encouraged to monitor R75 for any sedation, falls or drowsiness. V15 stated he did not view the additional patch as significant especially since R75 did not experience any negative outcomes. The facility staff have been ordered to continue to monitor resident for any side effects. R75's Electronic Medication Administration Record (eMAR) dated September 2025 documents the 8:00 PM scheduled Fentanyl Patch was placed on R75's shoulder at 9/11/25 at 00:38 AM.The facility policy Administering Topical Medications revised October 2010 documents remove old patch.

Based on observation and interview, the facility failed to provide 80 square feet of floor space per resident bed for 53 out of 53 residents (R1, R2, R3, R4, R5, R7, R8, R10, R11, R12, R14, R17, R18, R19, R20, R21, R23, R24, R25, R27, R28, R29, R30, R31, R32, R33, R34, R37, R38, R40, R41, R42, R43, R47, R48, R49, R50, R51, R52, R53, R54, R55, R56, R57, R59, R61, R62, R63, R64, R66, R67, R72, and R75) reviewed for room size in the sample of 61.Findings include:A Hall Rooms 1 - 12 are all Medicaid certified and provide 75 square feet per bed.B Hall Rooms 1 - 6 and 8 are all Medicaid certified and provide 75 square feet per Bed.C Hall Rooms 1 -8, 10 and 12 are all Medicaid certified and provide 75 square feet per bed.D Hall rooms [ROOM NUMBERS] are Medicaid certified and provide 77 square feet per bed.On 09/16/25 at 9:36 AM, V18 (Housekeeper) measured the rooms and verified that R1, R2, R3, R4, R5, R&, R8, R10, R11, R12, R14, R17, R18, R19, R20, R21, R23, R24, R25, R27, R28, R29, R30, R31, R32, R33, R34, R37, R38, R40, R41, R42, R43, R47, R48, R49, R50, R51, R52, R53, R54, R55, R56, R57, R59, R61, R62, R63, R64, R66, R67, R72, and R75 all reside in rooms that are waivered.Interviews were conducted throughout the survey from 09/09/25 through 09/12/25 demonstrate no concerns or complaints vocalized by residents in relation to the room size.On 09/11/2025 at 12:10 PM, V1 (Administrator) stated that there have been no changes to the room sizes.

Based on interview and record review the Facility failed ensure a safe discharge for 1 of 3 residents (R1) reviewed for proper discharge in the sample of 12. This failure resulted in R1 being discharged to her home on 7/19/25 without her physician's knowledge, order, or consent. Findings include: R1's Physician Order Sheets (POS) for July 2025 document a diagnosis of closed fracture with routine healing, unsteadiness on feet and other abnormality of gait and mobility, weakness, chronic kidney disease stage 3, encounter for other orthopedic aftercare. R1's POS also document R1 was admitted to the facility on [DATE]. R1's Hospital Discharge papers dated 6/23/2025 document R1 with a diagnosis of ORIF (open reduction internal fixation) of right ankle. R1 has an order for non-weight bearing. R1's Minimum Data Set (MDS) dated [DATE] documents R1 was cognitively intact for decision making of activities of daily living. R1 requires partial/moderate assistance to walk 10 feet, toilet transfer; command to step up on curb or 1 step not attempted due to medical condition. R1's Care Plan dated 6/24/25 documents at risk for falls r/t (related to) recent hospitalization. R1 is at risk for orthopedic complications. Dx (diagnosis of right ankle trimalleolar fx (fracture) s/p (status post) ORIF (open reduction internal fixation). R1's Care Plan does not address discharge. R1's Care Plan does not address R1 ever voicing that she did not want to remain in the facility and/or that she wanted to go home. R1's Progress Notes from 6/24/2025 to 7/16/2025 does not document that she ever voiced that she wanted to leave the facility and return home and no longer be in a nursing home. On 8/29/2025 at 10:39 AM, V4 (R1's daughter) stated, My mom had to go to the nursing home because she fractured her right ankle. She had to have surgery. They had to cut her ankle open and do surgery on it. She is still dealing with the wound from the incision. (R1) did not want to be in a nursing home but her home is very small and there were some steps she had to take to get into the home. In the beginning, (R1) could not do any steps or put weight on her foot and there was not enough room at her home to put in a ramp to assist her of getting up and down the steps. (R1) was not supposed to put any weight on that ankle. She needed some help when the accident occurred. She was not happy being at the nursing home, I doubt most people are happy when they first get there. However, she could not take care of herself when she got hurt. One day out of the blue my mom called me and told me the staff told her she could go home, and she was so excited but then a few hours later maybe around 3:30 PM, (R1) called me back and was upset because they said she could not go home because there was no doctor's order to release her. I did not think she was ready to go home. Then the next morning her friend (V10) was visiting her, and they told her the doctor had signed the order, and she could go home. (V10) then took her home because she had her car and then she stayed with her in her house and helped take care of her. (R1) is doing better, she got her boot off now and (V10) is still staying with her and she has a nurse that comes in once a week, in the beginning the nurse was coming in twice a week and (V10) takes her to her doctor's appointment. I was not there when they released her and did not see the discharge papers. I know my mom would not leave AMA (against medical advice) and would only leave the nursing home if they said it was safe for her to leave. She needed a lot of help back then but is healing and doing better now. On 8/29/2025 at 12:22 PM, R1 stated, I was in the nursing home for almost a month. One day a nurse told me I could go home. I don't know her name. I called (V13 R1's friend) to let her know because I needed a ride to get home. I was not supposed to put weight on my foot and was not supposed to do stairs. I have three stairs at my house, and I had to climb the stairs to get inside and go out. Then later that same night another nurse came back and told me no; the doctor had not signed off on the order so I could not be released and go home. Then the next morning another nurse said, yes, I could go home. I had an incision, so I was having dressings and stuff put on my ankle. My friend (V13) came the next day and then they said I could leave and (V13) took me home. But then (V13) had to stay with me and help me with my care. She also took me to my doctor's visit, helped me with the stairs, cooked and cleaned for me and helped with my bandages and dressing for my ankle. I would never leave without the doctor's permission. I just wanted to go home but again; I would not leave if the doctor thought I should stay. On 8/29/2025 at 12:32 V13 (R1's friend) stated, (R1) called me the night before and told me she was going to get to go home, and she needed me to drive her. Then later that same night she called me back and said it was a mix up and the doctor had not signed any orders, and she would not be going home. The next day I just went to check on her and see what was going on. We kept getting two or three different stories about when and/or if she could not go home. Finally, a nurse came in, I do not remember her name, and she said, 'I am the nurse and if I say she can go home she can go home.' They said the doctor signed the order, so I drove (R1) home that day and then I helped her up the stairs by putting a chair on the step and putting my arms around her so she would not fall. She could not have gotten in the house by herself. I then had to move in with her to help her that day because she could not at that point take care of herself and I wanted to help her get back on her feet again. I helped with cleaning her wound and putting the bandage on, assisting her and taking her to all her doctor appointments, cooking and cleaning and laundry, everyday things that at that time she could not do. She is doing better now, she has her cast off, but she still has 3 wounds on her leg that have not healed. We go to the wound doctor tomorrow. On 8/29/2025 at 1:29 PM, V10 (Social Service Director) stated, that Friday (R1) was saying she wanted to go home. That morning during morning meeting we discussed (R1) wanting to leave and I asked the nurse to get an order for her because we did not have an order for (R1) to discharge. (V14 Registered Nurse/RN) put in for an order, but she did not actually obtain an order from the doctor for (R1) to go home. At that time, I thought (R1) did have an order and I provided home health with PT (physical therapy), nursing and OT (occupational therapy) for her. The nurse never made contact with the doctor for (R1) to discharge. (R1) discharged on 7/19/2025. (R1) was discharged without a doctor's order. The nurse (V14) was brand new and had just graduated from nursing school. V10 stated she set up appointments for home health for (R1) and she followed up the next week but nothing after that. R1's Social Service Notes dated 7/19/2025 at 10:59 AM, Discharge recap of stay gone over with resident. Resident will be followed by (home health) with PT (physical therapy) and OT (occupation therapy). Resident voiced no concerns. R1's Health Status Note dated 7/19/2025 at 11:07 AM, Note Text: Resident discharged home with meds (medicine) per family vehicle. (R1 did not leave the facility in a family vehicle). R1's Occupational Therapy notes dated 6/24/-7/18/2025 documents recommend patient in the facility due to environmental limitations (steps to enter both front/back of home and unable to install ramp due to close proximity of front of home to main road and back due to fridge/cabinets blocking ability install ramp) and need for physical assistance to ascend/descend steps, although patient unexpectedly discharged home with friend intermittent assistance. Unsure extent of patient's friend's ability to provide physical lifting assistance. On 8/22/25 at 10:02 AM, V7 (Licensed Practical Nurse/LPN) stated a physician's order is needed to discharge a resident. V7 denied releasing a resident without a physician's order. On 8/22/25 at 10:15 AM, V8 (LPN) stated a physician's order is needed to discharge a resident. V8 denied releasing a resident without a physician's order. On 8/22/25 at 10:22 AM, V1 (Administrator) stated that V3 (Primary Care Physician) would not sign the release therefore V11 (Medical Director) signed the discharge release. The Director of Nursing made a mistake and clicked (V3's) name in the dropdown box instead of the Medical Director's name. On 8/25/25 at 3:04 PM V11 (Medical Director) stated being the medical director he gets calls all the time if the primary cannot be reached. However, he did not recall (R1) and would not release/discharge a resident if the primary was against it. V11 also stated he would not release/discharge a resident if physical therapy had recommended against it. On 9/1/2025 at 6:00 PM, V31 (Former Director of Nursing) during a phone interview stated, I did not take over as the Director of Nursing until 7/17/2025. I was told that the Social Service Director (SSD) told the floor nurse to see if she could get an order from the physician for (R1) to discharge home. I assume they got the order from the Medical Director, but I cannot say one way or the other. You will have to talk to the Social Service Director. I know I did not have anything to do with this and I did not click anything wrong on the drop-down box and/or clicked another doctor's name by mistake. On 9/1/2025 at 9:02 PM, V14 (RN) stated I was a brand-new RN that day straight out of school. I remember I was told to get a discharge order for (R1). I believe this was a few weeks ago. I also remember getting a call from (V1) later asking me if I got an order. I remember (R1's) daughter was here that day and picked her up. Am I in trouble? I am just trying to figure out what is going on. On 9/3/2025 at 1:39 PM, V3 (Primary Doctor) stated, I got a call from (the facility) and they asked me if I would discharge (R1) back home. I told them I did not feel like it was safe because (R1) was seeing ortho and they wanted her to have Physical therapy, and she was not done with her treatments. They wanted her to get stronger. At that time (R1) was not weight bearing and she had steps at her house. (Facility) did not know anything about how she would get home, if anyone would be helping her, and if she was going to be alone. I did not feel it was safe for (R1) to go home, and therapy was in the process of working with her because she had steps at home. I told them not to discharge (R1) because I was not sure about her support system. Then I find out later that they discharged her without my permission, and I am her doctor. (R1) went back home and they are lucky because she had a friend move in with her, but what if she would not have had a friend? I do not feel they should be able to release residents without my consent unless things are in place for the safety of the resident. This could have been very bad just releasing someone without support. The facility did not follow their protocols and again they did not know if (R1) was going to have 24/7 care at home like she would have at the nursing home. I did not feel it was safe, and home health does not provide 24/7 support so anything could have happened. Again, I never cleared (R1) because things were not in place and without knowing things are in place and protocols in place these could easily have impacted (R1) in a negative way. Thank goodness her friend moved in with her and was helping her out because this could have been bad. The Discharge Policy with a revision date of December 2016 documents, The purpose of this procedure is to provide guidelines for the discharge process. Why the discharge is necessary (i.e., closer to home, relatives, etc.,) (Note: If this information is not known, ask the supervisor about this information.) If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions.

Based on observation, interview and record review the facility failed to supervise a moderately impaired resident with a history of stroke. R3 was left unattended outside and fell from the wheelchair for 1 of 3 residents (R3) reviewed for falls in the sample of 6. This failure resulted in R3 being sent to the hospital after sustaining a black eye and bruising to her forehead from the fall. Findings include: R3's Physician Order Sheet for August 2025 documents diagnosis of atherosclerotic heart disease, cerebral infarction due to thrombosis of left middle cerebral artery, unsteadiness on feet, weakness, need for assistance with personal care, lack of coordination, other abnormalities of gait and mobility, muscle weakness, hemiplegia and hemiparesis following cerebrovascular disease affecting unspecified side. R3's Minimum Data Set (MDS) dated [DATE] document she is moderately impaired for cognition for activities of daily living. She has impairment on one side on both her upper and lower extremities and uses a wheelchair. For transfers she requires a Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed -Helper does ALL the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. R3's Care Plan: dated 4/10/2025 documents, the resident has hemiplegia/hemiparesis. The Care Plan with a created date of 1/5/2025 documents, The Resident has impaired cognitive function/dementia or impaired thought processes, the resident is on anticoagulant therapy. The resident has an ADL (activities of daily living) Self Care Performance Deficit, start date 1/5/2024. For Falls with a created date of 7/17/2025, (R3) is at risk for falls related to history of stroke with hemiplegia and hemiparesis and weakness. The Care Plan with a start date of 4/10/2025 also documents the resident has impaired visual function. R3's Smoking assessment dated [DATE] documents, Resident is a supervised smoker. Resident has to be reminded to hand staff her cigarette to put it out. Resident only smokes occasionally and only a few drags off cigarette. R3's falls Risk assessment dated [DATE] documents R3 was at risk for falls. On 8/28/2025 at 12:18 PM, R3 was sitting near the entrance of the facility in her wheelchair. R3's wheelchair brakes were locked, and R3 was rocking back and forth, as an attempt to propel forward. R3 was moaning and was slumped in the chair. There was another resident outside as well but with her back to her and that resident (R4) was talking on the phone. There were no staff outside. The double doors were shut, and no staff were monitoring any resident. R3 was moaning repeatedly and rocking back and forth. Surveyor approached R3 and asked R3 if she needed anything, but she was not alert and was just moaning and then she leaned forward in her wheelchair, slipped out and hit her head on the concrete as fell out of the chair. R3 sustained abrasions on her knees and a large baseball size swelling on her forehead. Surveyor ran inside the building to alert staff (V1 Administrator) and to get assistance for R3. R3's Progress Notes dated 8/28/2025 at 12:20 PM, Note Text: This nurse was notified by staff that resident was found on the ground at the front entrance/patio area. Resident was found lying face down on the ground. Assisted resident to back and large bruise and swelling noted above right eye. Resident alert and able to answer questions appropriately. Resident c/o (complained of) pain to right hip area. This nurse contacted (Physician) and received order to send to (Hospital) for evaluation. EMS (emergency Medical Service) services contact and arrived shortly. Resident transferred to stretcher without incident and transported to hospital. R3's Hospital Records dated 8/28/2025 at 12:50 PM, documents, Patient sent from (Facility), reported she fell out of her wheelchair hitting her forehead. Large purple hematoma noted above right eyebrow. History of stroke with right side weakness aphasia. The patient spilled forward out of the wheelchair and struck her forehead, baseball size swelling and ecchymosis over the forehead. On 8/28/2025 at 2:33 PM, R3 was sitting outside and has an abrasion to the front of her head in the middle of her forehead approximately 6 millimeters in length and 4 millimeters in width , a black eye with a darken circle area is present on her entire left eye with a small blackish area under part of her eye on the right side, only 1/4 of the eye is covered in a black streak. On 8/28/2025 at 3:45 PM, V8 (Licensed Practical Nurse/LPN) stated (V15 Corporate) came and got me because (R3) is on my hall. She told me (R3) had fallen outside. (R3) is hard to understand and she does moan out loud, really loud when she needs something because she can't communicate very well. I think (V12 LPN) took her outside. I am not sure why she did not stay with her. (R3) likes to go outside and we have several residents that like to go outside but they are more alert than (R3). We are supposed to stay with (R3) when she is outside. I just got call from the hospital. I am not aware of her having any previous falls. She has never had behaviors and/or threw herself on the ground that I am aware of. On 8/28/2025 at 3:53 PM, V12 (LPN) stated, (R3) cannot walk on her own and she uses a wheelchair. You have to really pay attention to (R3) to know what she wants. (R3) moans a lot when she wants something. She had a stroke. She just recently lost her husband; they were roommates here together. (R3) was in the dining room today, and she was wanting her cigarettes, and she only had a small cigarette left so I took her outside. She likes to go outside. She only had a part of a cigarette and after she finished, (R3) did not want to come back in. (R3) has never thrown herself on the floor before, and I did not lock her wheelchair. I did not bring her back in because (R3) did not want to come back. I am not sure if she needed supervision or if she could stay outside unsupervised. I don't know. I know she does need supervision for the cigarettes, but I did not think about it for being outside because she loves to go outside. The Facility Fall Policy with a revision date of March 2018 documents, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to try to prevent the resident from falling and try to minimize complications from falling. The Facility Smoking Policy with a revision date of July 2017 documents, Any resident with restricted privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times when smoking.

Based on observation, interview, and record review the facility failed to ensure that residents who require assistance receive a shower or bath for 4 of 4 residents (R2, R8, R10, R11) reviewed for Activities of Daily Living assistance in the sample of 15. Findings Include: 1.R8's admission record, print date of 8/12/25, documented R8 has diagnoses including osteoarthritis, spinal stenosis, spondylosis of cervical region, depression, hypertension, bipolar disorder, schizophrenia, polyneuropathy, and intervertebral disc degeneration. R8's MDS (Minimum Data Set), dated 5/20/25, documented R8 is cognitively intact and requires partial to moderate assistance with bathing. R8's care plan, undated, documented R8 has an ADL (activities of daily living) self-care performance deficit impaired balance, requires assistance of 1 for transfers, and for bathing. On 8/11/25 at 9:40 AM R8 stated the facility does not have enough staff especially CNAs (Certified Nursing Assistants) and she has not been getting 2 showers a week because of it. R8 stated she had not received a shower for over a week until she finally got one yesterday. R8 stated her husband also resides at the facility and he has not been getting 2 showers a week. On 8/11/25 at 2:02 PM surveyor requested shower records for R2, R8, R10, and R11 for July and August of 2025. On 8/11/25 at 2:12 PM V1 (Administrator) stated R8 does not have any shower documentation for July. V1 provided R8's August shower records and they documented R8 only received 1 shower for the month of August on 8/10/25. 2. R2's admission record, print date of 8/7/25, documented R2 has diagnoses including heart failure, type 2 diabetes mellitus, atherosclerotic heart disease, hypothyroidism, bilateral primary osteoarthritis of knee, hyperlipidemia, orthostatic hypotension, hypertension, and gastro-esophageal reflux disease. R2's MDS, dated [DATE], documented R2 is cognitively intact and requires partial to moderate assistance with bathing and ADLS. On 8/11/25 at 11:17 AM R2 stated the facility is short staffed, it takes a long time to get her call light answered, and she has not had a shower for over a week. On 8/11/25 at 2:12 PM V1 (Administrator) stated she does not have any shower sheets for R2 for June nor July of this year. 3. R10's admission record, print date of 8/12/25, documented R10 has diagnoses including nontraumatic intracerebral hemorrhage, hemiplegia, cerebral infarction, muscle weakness, cognitive communication deficit, cerebral amyloid angiopathy, and a history of falls. R10's MDS, dated [DATE], documented R10 is moderately cognitively impaired and required substantial to maximal assistance with bathing. R10's care plan, undated, documented R10 has an ADL self-care performance deficit related to impaired balance due to stroke. This care plan documented R10 requires 2 staff with bathing/showering and toileting. On 8/11/25 at 8:32 AM as surveyor was entering the facility R10 stopped surveyor and stated, I still have not had a shower for over a week. Surveyor asked R10 how that makes her feel and R10 stated she feels dirty, and her hair feels greasy. R10 stated she used to get 2 showers a week but the last few months she has not been getting showers regularly because the facility does not have enough CNAS. On 8/11/25 at 12:10 PM R10 stated she has not had a shower for over a week. R10's hair appeared greasy.R10's shower records document R10 received showers on 7/4/25, 7/15/25, 7/18/25, 7/22/25, and 8/1/25. 4. R11's admission record, print date of 8/12/25, documented R11 was admitted to the facility on [DATE] and has diagnoses including cerebral infarction, intervertebral disc degeneration, sciatica, tremors, repeated falls, and retention of urine. R11's MDS, dated [DATE], documented R11 is moderately cognitively impaired and is dependent on staff for bathing. On 8/11/25 at 12:15 PM R11 stated to surveyor when do I get a shower? It's been a long time now. R11's hair appeared greasy and unkempt. On 8/11/25 at 2:12 PM V1 (Administrator) stated the facility does not have any documentation of R11 receiving a shower in July nor August. On 8/11/25 at 9:25 AM V11 (CNA) stated no administration staff help care for the residents when they are short staffed, and residents do not get showers on the days the facility does not have enough CNAs. On 8/11/25 at 9:48 AM V13 (CNA) stated the facility does not have enough CNAs, and showers don't get done like they are supposed to. On 8/11/25 at 2:02 PM surveyor requested shower records from V2 (Director of Nursing/DON). V2 stated she has no proof the showers were completed as there is missing documentation showing the showers were completed. V2 stated V1 started a QAPI (Quality Assurance Performance Improvement) on showers last week when she realized there was an issue. Surveyor asked V2 if the issue with showers not getting completed was due to lack of staff and V2 replied I don't know. On 8/11/25 at 2:12 PM V1 (Administrator) stated she started a QAPI on showers because last Friday one of the nurses called her and told her showers didn't get done. V1 stated she does not have any shower sheets for R2 nor R11 for June nor July. On 8/11/25 at 2:39 PM V2 (DON) stated it is the policy for residents to get at least 2 showers per week. On 8/12/25 at 11:32 AM V1 (Administrator) stated they do not have a policy on the frequency of resident showers although they are supposed to offer each resident 2 showers per week.

Based on observation, interview, and record review the facility failed to provide enough nursing staff to adequately meet the needs for 4 of 4 (R2, R8, R10, and R11) residents reviewed for staffing in the sample of 15. These failures have the potential to affect all residents residing at the facility. Findings Include: 1. 1. R8's admission record, print date of 8/12/25, documented R8 has diagnoses including osteoarthritis, spinal stenosis, spondylosis of cervical region, depression, hypertension, bipolar disorder, schizophrenia, polyneuropathy, and intervertebral disc degeneration. R8's MDS (Minimum Data Set), dated 5/20/25, documented R8 is cognitively intact and requires partial to moderate assistance with bathing. R8's care plan, undated, documented R8 has an ADL (activities of daily living) self-care performance deficit impaired balance, requires assistance of 1 for transfers, and for bathing. On 8/11/25 at 9:40 AM R8 stated the facility does not have enough staff especially CNAs (Certified Nursing Assistants) and she has not been getting 2 showers a week because of it. R8 stated she had not received a shower for over a week until she finally got one yesterday. R8 stated her husband also resides at the facility and he has not been getting 2 showers a week. On 8/11/25 at 2:02 PM surveyor requested shower records for R2, R8, R10, and R11 for July and August of 2025. On 8/11/25 at 2:12 PM V1 (Administrator) stated R8 does not have any shower documentation for July. V1 provided R8's August shower records and they documented R8 only received 1 shower for the month of August on 8/10/25. 2. R2's admission record, print date of 8/7/25, documented R2 has diagnoses including heart failure, type 2 diabetes mellitus, atherosclerotic heart disease, hypothyroidism, bilateral primary osteoarthritis of knee, hyperlipidemia, orthostatic hypotension, hypertension, and gastro-esophageal reflux disease. R2's MDS, dated [DATE], documented R2 is cognitively intact and requires partial to moderate assistance with bathing and ADLS. On 8/11/25 at 11:17 AM R2 stated the facility is short staffed, it takes a long time to get her call light answered, and she has not had a shower for over a week. On 8/11/25 at 2:12 PM V1 (Administrator) stated she does not have any shower sheets for R2 for June nor July of this year. 3. R10's admission record, print date of 8/12/25, documented R10 has diagnoses including nontraumatic intracerebral hemorrhage, hemiplegia, cerebral infarction, muscle weakness, cognitive communication deficit, cerebral amyloid angiopathy, and a history of falls. R10's MDS, dated [DATE], documented R10 is moderately cognitively impaired and required substantial to maximal assistance with bathing. R10's care plan, undated, documented R10 has an ADL self-care performance deficit related to impaired balance due to stroke. This care plan documented R10 requires 2 staff with bathing/showering and toileting. On 8/11/25 at 8:32 AM as surveyor was entering the facility R10 stopped surveyor and stated, I still have not had a shower for over a week. Surveyor asked R10 how that makes her feel and R10 stated she feels dirty, and her hair feels greasy. R10 stated she used to get 2 showers a week but the last few months she has not been getting showers regularly because the facility does not have enough CNAs. On 8/11/25 at 12:10 PM R10 stated she has not had a shower for over a week. R10's hair appeared greasy. R10's shower records document R10 received showers on 7/4/25, 7/15/25, 7/18/25, 7/22/25, and 8/1/25. 4. R11's admission record, print date of 8/12/25, documented R11 was admitted to the facility on [DATE] and has diagnoses including cerebral infarction, intervertebral disc degeneration, sciatica, tremors, repeated falls, and retention of urine. R11's MDS, dated [DATE], documented R11 is moderately cognitively impaired and is dependent on staff for bathing. On 8/11/25 at 12:15 PM R11 stated to surveyor when do I get a shower? It's been a long time now. R11's hair appeared greasy and unkempt. On 8/11/25 at 2:12 PM V1 (Administrator) stated the facility does not have any documentation of R11 receiving a shower in July nor August. On 8/11/25 at 9:25 AM V11 (CNA) stated the facility has 6 CNAs today and that is enough however there have been multiple days when they only had 3 CNAs. V11 stated no administration staff help care for the residents when they are short staffed, residents do not get showers on the days the facility does not have enough CNAs, and there are times she and the other CNAs must complete mechanical lift transfers with just 1 CNAs due to the lack of staff. On 8/11/25 at 9:32 AM V12 (CNA) stated the facility frequently does not have enough CNAs on the days shift, that there are days when they just have 3 CNAs to care for all the residents, and that the night shift is short staffed too. V12 stated the Administrator said it is not her problem if people call off, the nurses don't help when they are short staffed, and that the CNAs have to transfer residents with mechanical lifts by themselves all the time due to being short staffed. V12 stated there is supposed to be a nurse or CNA on call but they refuse to come in and work when they are short staffed. On 8/11/25 at 9:48 AM V13 (CNA) stated the facility does not have enough CNAs, showers don't get done like they are supposed to, and evening shift is even more short staffed than day shift. On 8/11/25 at 2:02 PM surveyor requested shower records from V2 (Director of Nursing/DON). V2 stated she has no proof the showers were completed as there is missing documentation showing the showers were completed. V2 stated V1 started a QAPI (Quality Assurance Performance Improvement) on showers last week when she realized there was an issue. Surveyor asked V2 if the issue with showers not getting completed was due to lack of staff and V2 replied I don't know. On 8/11/25 at 2:12 PM V1 (Administrator) stated she started a QAPI on showers because last Friday one of the nurses called her and told her showers didn't get done. V1 stated she does not have any shower sheets for R2 nor R11 for June nor July. On 8/11/25 at 2:39 PM V2 (DON) stated it is the policy for residents to get at least 2 showers per week. On 8/11/25 at 2:51 PM V15 (CNA) stated the facility has been short staffed with CNAs recently. V15 stated they just do the best they can because no managers come in and work when the facility is short staffed. V15 stated the facility managers tell the CNAs they have to find their own replacement if they are unable to work. On 8/12/25 at 10:56 AM V17 (Licensed Practical Nurse/LPN) stated the facility was staffed with 1 nurse on the 6 PM to 6 AM shift and she feels that is not safe. On 8/12/25 at 11:07 AM V8 (Infection Prevention/Wound Care Nurse) stated the facility had been scheduling 1 nurse on the night shift and that 1 nurse is not sufficient. V8 stated the facility is not allowed to staff with agency nurses. V8 stated the CNAs have been working short. The facility's daily staffing pattern documents dated 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/25/25, 7/27/25, 7/28/25, 7/29/25, 7/31/25, 8/5/25, 8/6/25, 8/9/25, and 8/10/25 all documented the facility had 1 licensed nurse scheduled on the night shift from 6 PM to 6 AM for the entire facility. The facility's staffing policy, undated, documented our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. RN coverage will be provided 8 hours per day, 7 days per week. If RN coverage is not available for direct care staffing, LPN will cover with RN on call to assess and assist as needed. 2. Staffing numbers and the skill requirement of direct care staff are determined by the needs of the residents based on each resident's plan of care.The facility's daily census report, dated 8/13/25, documented there are 66 residents residing at the facility.

Based on observation, interview, and record review the facility failed implement fall interventions as care planned for 1 of 3 residents (R5) reviewed for falls in the sample of 15. Findings Include:R5's admission record, print date of 8/7/25, documented R5 has diagnoses including metabolic encephalopathy, orthostatic hypotension, chronic atrial fibrillation, atherosclerotic heart disease, hypothyroidism, hyperlipidemia, major depressive disorder, cognitive communication deficit, hypertension, urine retention, and a history of falling. R5's MDS (Minimum Data Set), dated 7/25/25, documented R5 is moderately cognitively impaired and requires supervision or touching assistance with transfers. R5's progress note, dated 8/3/25 at 4:20 PM, documented resident got herself up (and was) unattended in the dining room, her alarm sounded, and she was on the floor, fall witnessed, and no head involvement. R5's progress note, dated 8/8/25 at 3:49 PM, documented staff call this LPN (Licensed Practical Nurse) to DR (dining room), upon entering DR resident was noted sitting on her buttocks in front of her w/c (wheelchair), no injury noted. ROM (range of motion) WNL (within normal limits) for this resident. R5's care plan, undated, documented R5 is at risk for falls. R5's care plan interventions include non-skid socks and non-skid mat below and on top of wheelchair pad. On 8/11/25 at 10:53 AM R5 was observed sitting in her wheelchair in the dining room. R5 was wearing black and white socks that did not have non-skid material on the sole of the sock. On 8/12/25 at 1:52 PM surveyor observed R5's wheelchair along with V1 (Administrator) to see if R5 had a non-skid mat below and on top of her wheelchair pad. V1 stood R5 up from her wheelchair and raised the wheelchair cushion. No non-skid mat was observed below nor on top of R5's wheelchair pad. V1 confirmed R5's fall intervention of a non-skid mat was not in place per R5's care plan. On 8/12/25 at 2:53 PM V1 (Administrator) stated she expects resident fall interventions to be in place per their care plans.The facility's Falls and Fall Risk Managing policy, dated 3/2018, documented based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. It continues, Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 2. If a systematic evaluation of a resident's fall risk identified several possible interventions, the staff may choose to prioritize interventions. 3. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. 4. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling or indicate why those medications could not be tapered or stopped, even for a trial period. 5. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 7. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. 8. Position-change alarms will not be used as the primary or sole intervention to prevent falls but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.

Based on observation, interview, and record review the Facility failed to ensure staff were encouraging COVID-19 positive residents to wear masks and ensure staff don proper personal protective equipment (PPE) to prevent the spread of COVID-19. This has the potential to affect all 63 residents living in the facility. Findings include: 1. The COVID list documents R6 with an onset date of 12/2/2024. R6's Physician Order Sheet for 12/2024 documents a diagnosis of Other specified disorder of kidney and ureter, COVID 19 (12/2/2024), urinary tract infection, unspecified dementia. unspecified severity without behavior disturbances, psychotic disturbances, mood disturbances, GERD, Abnormal weight loss, hypoosmolality and hyponatremia, major depression, insomnia, hypothyroidism. depression, and essential hypertension. On 12/10/2024 at 8:44 AM, R6's Room has a tub of Personal Protective Equipment (PPE) outside of her door with a sign which documents, Droplet Precautions. The sign documents, Everyone must clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry or remove face protection before exit. R6's Minimum Data Set (MDS) dated [DATE] document R6 was severely impaired for cognition for decision making of activities of daily living. R6's Care Plan undated documents, (R6) is a wanderer/elopement risk related to dementia. (R6) has a behavior of pulling isolation sign off door while on isolation. On 12/10/2024 at 8:48 AM, R6 was lying in a bed (equipment surplus) that was on the B hallway. The bed was near the exit door. R6 was not wearing any mask. R6 was able to ambulate independently and exited the bed and then started walking down the hallway. No staff member approached R6 and or encouraged her to put on a mask. On 12/10/2024 at 4:01 PM, V1 (Administrator) stated the bed was surplus and they were in the process of removing the bed from the facility and it was not intended for any resident to lay on in the hallway. R6's Progress Notes dated 12/9/2024 at 3:26 PM, Note Text: Resident continues on isolation precautions r/t (related to) COVID+ status. No acute changes noted. No c/o (complaint of) cough/congestion noted. Resident restless at end of evening shift. Able to redirect without difficulty. Did upset residents across hall when resident was ambulating out into hallway due to resident being on isolation. On 12/11/2024 at 8:50 AM, upon entering the Facility, R6 was sitting in a chair next to Director of Nursing's office, close to the dining room and was not wearing a mask. Breakfast was being served in the dining room. On 12/11/2024 at 4:00 PM, V17 (Licensed Practical Nurse/LPN) identified R6 and R8 as being COVID positive and requiring them to be on contact isolation. On 12/11/2024 at 4:05 PM, V2 (Director of Nursing/DON) stated if a resident is COVID positive and if they were outside their room she would expect them to be wearing a mask and if they were confused, she would expect staff to redirect them if possible. On 12/12/2024 at 9:11 AM, V6 (LPN) stated, We started having positive cases of COVID, it started the Sunday before Thanksgiving, I remember because I was working. We first had staff members that were positive and so we tested residents, and that is when the outbreak started. I think we have five residents today that are still positive with COVID. (R6) is positive for COVID. 2. The COVID Line List documents R8 had symptoms of COVID-19 with onset date of 12/9/2024. R8's Physician Order Sheet for December 2024 documents diagnoses of Unspecified dementia, Alzheimer disease with late onset, osteoarthritis, COVID-19 (12/9/2024), weakness, need for assistance with personal care, chronic kidney disease, restlessness, and agitation. R2's undated Care Plan documents, COVID-19: I am at potential risk for alteration in my mood state/psychosocial well-being secondary to the changes and restrictions on visitation imposed by the CDC guidelines because of the COVID-19 virus and risk of exposure. I am concerned that I will not be able to see and interact with persons who are important to me. The care team has recognized that feelings of isolation, separation/seclusion may trigger long dormant memories for me of earlier times in my life. R8's MDS dated [DATE] documents R8 has some memory problems and has modified independence with some difficulty in new situations. On 12/12/2024 at 2:12 PM, R8's room had personal protective equipment, PPE, outside of her room with a sign on the door documenting, Droplet Precautions, everyone must clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry or remove face protection before exit. R8's Health Status Note dated 12/9/2024 at 9:02 AM, Note Text: tested positive for COVID, POA (Power of Attorney) notified. R8's Health Status Note dated 12/9/2024 at 3:30 PM, Note Text: MD (Medical Doctor) faxed regarding COVID positive. On 12/12/2024 at 2:14 PM, V8 (Certified Nursing Assistant/CNA) and V9 (CNA) were inside R8's room transferring R8 with a mechanical lift. V8 checked R8's adult brief to ensure R8 was not wet. Both V8 and V9 were only wearing surgical mask and were not wearing N95 mask, or the proper eyewear protection, or any gowns. On 12/12/2024 at 2:24 PM, V8 stated she should have been wearing a gown, different mask and shield when giving care to R8. V8 also stated she was working the D hall but helps on the other halls when they need it. On 12/12/2024 at 2:25 PM, V9 stated she did not look at the door or notice the PPE, but she should have seen that she was supposed to be wearing the proper PPE when giving care to R8, and she had just come back from vacation and did not realize R8 was positive for COVID. V9 stated I am working the D hall but help out on the other halls if they need me. On 12/12/2024 at 3:04 PM, V2 (DON) stated, I would expect staff when transferring and checking for incontinence for a COVID positive resident to be wearing full PPE. The Facility currently is on outbreak for COVID. The Facility COVID 10 Guidance (state surveying agency) Update Interim Guidance dated 5/25/2023 for Nursing Homes documents, Healthcare workers must use proper PPE when exposed to a resident with suspected or confirmed COVID-19 or other sources of SARS-CoV-2. If a resident is suspected or confirmed to have COVID-19, HCP (healthcare provider) must wear a N95 respirator, eye protections, gown, and gloves. Staff must wear full PPE (N95 respirator, gown, gloves and eye protection) when providing care. The Guidance documents Resident will be encouraged to wear source control when not in their room or eating but may be unable to follow that directive die to cognitive or clinical reasons. If cognitively or clinically unable to wear source control, this will be documented appropriately. The Centers for Disease Control and Prevention website, Infection Control Guidance: SARS-CoV-2, dated 6/24/24, documents, HCP (Healthcare Personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or face shield that covers the front and sides of the face. The Long-Term Care Facility Application for Medicare and Medicaid, CMS 671 Form dated 12/12/2024 documents there were 63 residents living in the facility.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was working in the facility for at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 66 residents living in the facility. Findings include: On 11/12/2024 at 9:04 AM, Staffing schedules were requested from the facility for the past 14 days. On 11/14/2024 at 9:33 AM, staffing schedules were reviewed and does not document any RN working on Wednesday 10/30/2024, Thursday 10/31/2024, Saturday November 2, 2024, Sunday November 3, 2024, and Monday 11/4/2024. Five of the 14 days reviewed does not documents any RN coverage. On 11/14/2024 at 2:45 PM, V1 (Administrator) stated, We have a census of 66 residents. I did not realize the RN coverage for the Director of Nursing only counted as half. We have another RN that works but she did not work this past weekend. V2 (Director of Nursing) did not work last weekend either. On 11/13/2024 at 2:55 PM, V2 (Director of Nursing) stated that currently the facility has two RN's me and V20 (RN). I know they are trying to hire more RN's. The Facility Assessment, dated 2024 documents, Licensed nurses providing care (Licensed Practical Nurse, Registered Nurse, staffing plan based on current Census, skilled census x 3.8, intermediate census x 2.5 total /45% days, 35% evenings, 20% nights. 25% of each shift= nurse hours. The Facility Staffing Policy dated 10/2017 documents, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. The Facility's Daily Census Sheets dated 11/12/2024 documents a total of 66 residents living in the facility.

Based on interview and record review the Facility failed to ensure infection control surveillance was being followed for residents experiencing vomiting and/or diarrhea. This has the potential to affect all 66 residents living in the facility. Findings include: On 11/12/2024 at 9:35 AM, V1 (Administrator) stated, they had a few residents that were experiencing vomiting and diarrhea a few weeks ago but they were good now. On 11/13/2024 at 2:32 PM, V3 (Infection Control Specialist) stated, I started working here on 10/25/2024. I have not taken the course yet and do not have my certification. We have a census of 66 and we had 11 residents experience emesis and/or loose stools. Of those eleven residents three were sent out to the hospital. I reached out to Corporate, and they told me to test everyone for flu and COVID which I did, and everyone was negative. I was never instructed to put anyone on contact isolation and/or notify the health department. I did not do any surveillance and/or tracking my rooms. Staff members also got whatever it was, and I personally was really sick, but it only lasted 24 hours. I was not tracking staff members. Whatever it was, it seemed to go away as quickly as it came. We did have had a couple of call offs from staff for nausea and vomiting. On 11/14/2024 at 10:30 AM, a list of test results was requested for all of the residents tested for COVID and flu. On 11/14/2024 at 10:41 AM, active daily surveillance from 10/14/2024 to 11/14/2024 was requested. A system for preventing, identifying, and reporting and controlling infections for the outbreak was requested. On 11/14/2024 at 3:00 PM, The Facility provided a Sheet, undated (a floor plan), which does not identify each resident, it does not document any interventions that facility was implementing with the exception of the COVID and Flu vaccines. 4 of the rooms were documented as receiving the COVID/Flu vaccine, of the 11 residents displaying symptoms of diarrhea and/or vomiting. On 11/14/2024 at 3:02 PM, V3 stated, I do not have the test results for (R3) or (R11), I did not test them. On 11/14/2024 at 3:10 PM, V3 stated, I went through all of the call offs, and here is a list of staff members I think called off because of the stomach bug. On 11/19/2024 at 8:38 AM, V23 (Infection Control Specialist for Hospital) and V22 (Medical Director) stated, If two or more residents are experiencing symptoms then I would expect the facility to contact the Local Health Department and (V22) who in return would then notify me so we could start surveillance. (V22) and I were never notified of the outbreak in the facility. I would consider more than two people outbreak. Tracking staff is important as well to look at the call offs and if staff are experiencing the same symptoms and how it affects the facility. Surveillance is important in tracking trends and monitoring what is happening in the facility and the community. The Surveillance for Infections Policy with a revision date of September 2017 documents, The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. In addition to collecting data on the incidence of infections, the surveillance system is designed to capture certain epidemiologically important data that may influence how the overall surveillance data is interpreted; for example, focused surveillance data may be gathered for residents with a high risk for infection or those with a recent hospital stay. The Facility's Daily Census Sheets dated 11/12/2024 documents a total of 66 residents.

Based on interview and record review the Facility failed to ensure resident showers were being given for 4 of 5 residents (R2, R3, R6 and R12) reviewed for activities of daily living in the sample of 13. Findings include: 1) R2's Physician Order Sheet (POS) for November 2024 documents a diagnosis of atherosclerotic heart disease, obesity, hemiplegia, and hemiparesis following cerebral infection affecting left non-dominate side, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene. R2's MDS dated [DATE] documents R2 was cognitively intact for decision making of activities of daily living. R2 has no impairment on the upper and lower extremity and uses a wheelchair. R2's Care Plan documents R2 has bladder incontinence. R2 has an ADL (activities of daily living) self-care performance deficit and has limited physical mobility. On 11/12/2024 at 12:47 PM, R2 stated, I know I am supposed to get two showers a week and I only got one shower last week. I think they need more help because I did not get my shower. I am supposed to get my shower every Wednesday and Saturday and I did not get a shower on Saturday. On 11/13/2024 at 1:01 PM, R2 stated, I still have not gotten my shower and I would really appreciate it if you would talk to them because I feel so much better when I get a shower. 2) On 11/13/2024 at 10:30 AM, R6 stated she was president of the resident council and residents have been complaining about not getting their showers at the meeting. I personally, only got one shower last week. I know there were issues with showers for (R12) too. R6's MDS dated [DATE] documents she is cognitively intact and able to make her own decisions for activities of daily living. R6's Shower Sheets were reviewed for the past 14 days and only documents she received a shower once a week for the past 14 days. On 11/13/2024 at 1:50 PM, V2 (Director of Nursing/DON) stated, (R2) is supposed to get a shower every Wednesday and Saturday. I expect all residents to get a shower twice a week unless they refuse them or don't want them. 3) On 11/13/2024 at 12:33 PM, V14 (R3's Family Member) stated her and (R3's) other family member is unhappy with the inconsistent care (R3) received at the facility, which is why (R3) is being moved out of the facility today. V14 stated she would come to visit (R3) and (R3) would smell terrible and look like staff never bathe (R3) or brushed her hair and teeth. V14 stated she discussed the issues regarding (R3's) care with V2 (DON) and (V2) stated she would make sure (R3) would receive showers on Thursdays and Sunday. V14 stated she asked V2 for the shower sheets on (R3), and V2 could never produce the shower sheets. On 11/13/2024 at 10:02 AM, shower sheets were requested for R3 for the past 14 days and no shower sheet was available for 10/30/2024. Documenting R3 only received one shower for the last week in October. 4) R12's MDS dated [DATE] documents she was cognitively intact for decision making of activities of daily living. On 11/14/2024 at 1:32 PM, R12 stated there have been issues with not getting their showers, and they are supposed to be trying to fix it. They have talked about it at the resident council Meeting Minutes. R12's Shower Sheets were reviewed for the past 14 days and document she was only receiving one shower a week. Resident Council Meeting Minutes dated 11/14/2024 documents, Showers not timely manner. On 11/14/2024 at 1:13 PM, V2 (DON) stated they had some complaints related to residents not getting their showers and they were trying to fix the system. The Undated Bath. Shower Tub Policy documents: The date and time the shower/tub bath was performed. The name and title of the individual(s) who assisted the resident with the shower/tub bath. All assessment data (e.g., any reddened areas, sores, etc., on the resident ' s skin) obtained during the shower/tub bath. How the resident tolerated the shower/tub bath. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. The signature and title of the person recording the data. Reporting Notify. The Resident Right Policy with a revision date of 11/18 documents, Your facility must be safe, clean, comfortable and homelike.

Based on interview and record review, the Facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, 7 days a week. This has the potential to affect all 70 residents living in the Facility. Findings include: The Facility's Nurse's Schedule does not document a RN was scheduled for at least eight hours on 10/12/24, 10/13/24, 10/19/24, or 10/20/24. On 10/25/24 at 3:18 PM, V1 (Administrator) stated the Facility did not have a RN for at least eight hours on 10/12/24, 10/13/24, 10/19/24 or 10/20/24. On 10/25/24 at 9:25 AM, V2 (Director of Nursing), stated there can be problems with staffing due to call offs and the Facility is actively recruiting staff. On 10/25/24 at 9:50 AM, V1 stated the Facility is trying its best to recruit nurses, but it is difficult in a rural setting when the Facility does not use agency staffing. On 10/29/24 at 8:50 AM stated the Facility does not have a policy on RN staffing and follows the federal regulations. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 10/29/24 documents there are 70 residents living in the Facility.

Based on interview and record review, the Facility failed to respect end of life wishes for 1 of 3 residents (R2) reviewed for advanced directives in the sample of 4. Findings include: R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2, chronic kidney disease stage 3, liver cirrhosis, heart failure, and chronic venous hypertension. R2's Undated Care Plan documents R2 has chosen DNR (Do Not Resuscitate) as advanced directives for end-of-life plan. R2's Progress Note by V12 (Social Services Director/SSD) on [DATE] documented R2 wished to be a DNR with comfort focused care, and R2's IDPH Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form was completed with R2 and sent to physician for signature. R2's POLST Form signed by V13 (R2's Physician) on [DATE] documents, No CPR (Cardiopulmonary Resuscitation): Do Not Attempt Resuscitation (DNAR). R2's Physician Orders document [DATE] orders for both Full Code and DNR. R2's Progress Note by V10 (Licensed Practical Nurse/LPN) on [DATE] at 5:20 AM documents (R2) was found sitting in recliner without blood pressure or respirations. The Note documents (R2) was a full code and was assisted onto the floor where CPR was started, and an ambulance was called. R2's Progress Note by V10 (LPN) on [DATE] at 5:32 AM documents CPR was in progress with no improvement when the ambulance arrived, and paramedics called (R2's) time of death. On [DATE] at 9:25 AM, V10 stated she entered (R2's) room and found him unresponsive in the recliner. She stated she checked (R2's) Code Status which was listed as Full Code on his admission records and Face Sheet, then called out for other staff to help and initiated CPR which was done until the paramedics arrived and pronounced (R2) deceased . On [DATE] at 11:35 AM, during a confidential interview, V5 (Confidential Interview #2) stated she assisted with R2's CPR for about ten minutes until the ambulance arrived. She stated she felt R2's ribs crack on the first push down. On [DATE] at 1:15 PM, V1 (Administrator) stated R2 was a Full Code initially on admission, then his Code Status was clarified, and R2 was changed to a DNR. She stated R2's brother attempted to take him home, but R2 returned to the Facility the same day and all his orders were reinstated, including the orders for both Full Code and DNR. V10 (LPN) looked in R2's orders and saw Full Code and performed CPR not knowing he had a POLST Form for DNR. On [DATE] at 12:00 PM, V13 (R2's Physician) stated, Advances directives serve as guidelines so staff know what to do (in end of life situations). (R2)'s physical health was deteriorating, but his cognition was intact, and he was a DNR. He left the hospital as a DNR. He did not want to be in a nursing home. The Facility's Advanced Directives Policy revised ,d+[DATE] documents advance directives will be respected in accordance with state law and facility policy. The Policy documents Advanced Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provisions of health care when the individual is incapacitated. The Policy documents Do Not Resuscitate indicates that, in case of respiratory or cardiac failure, the resident legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used.

Based on interview and record review, the facility failed to ensure residents are free from verbal abuse for 1 of 4 residents (R10) reviewed for abuse in the sample of 60. The failure resulted in R10 becoming tearful making her feel terrible. Findings include: R10's Face Sheet, undated, documents R10 was admitted on [DATE] with diagnoses of Congestive Heart Failure, Cerebral Vascular Accident, Atrial Fibrillation, Diabetes, Hypertension. R10's Minimum Data Set (MDS) dated [DATE] documents R10 has no cognitive impairments. MDS documents R10 is independent with mobility and transfers with use of walker. R10's Care Plan updated 6/19/2023 does not document R10 is at risk for abuse. R10's Abuse Investigation dated 6/3/2023 documents At approximately 8:30PM on 6/3/2023, (V10 former Registered Nurse/Director of Nursing), received a telephone call from a staff member, indicating that (R10) stated that (V8 Licensed Practical Nurse/LPN) was rude with her last night, yelling at her about not being able to ambulate to the bathroom independently. Attempt was made to notify (V8) that she was barred from the facility pending investigation of allegation. (V8) was not immediately reachable. Responsible party, medical provider, local police department and Ombudsman were notified, Investigation was initiated immediately. A written interview of R10, conducted at 8:45PM on 6/3/2023 documented That one girl came in her to help me to the bathroom, and I couldn't stand so she went to get that nurse who wears the head band. The nurse started yelling at met telling me I can stand up by myself that I didn't need help. I tried telling her that I had been in bed the last 2 days, and I couldn't do it myself anymore. She told me I was being a lazy b****. I told her to forget it, I wasn't going to ask for help anymore, I will just pee in my chair. The other girl was real nice, she tried to help me. On 9/12/2023 at 1:45PM R10 stated I don't remember very well back in June. I might have had a stroke and couldn't walk. (V8) was mad that I was asking for help. She cussed me out. I heard she got fired. I'm sorry about that, but she was mean. It made me feel terrible. It wasn't my fault. V11 (Certified Nurse Assistant/CNA) written statement, dated 6/3/23, documented At approx. (approximately) 11:10 PM the resident, (R10's initials), call light came on. I walked into the room and ask what she needed help with to which she replied that she need to use the restroom and also stated it would take two people due to new doctor's orders following some recent health issues. The statement documented I headed to the nurse's station and saw the NOC (night) shift nurse (V8), and ask if she could help me take the resident (R10) to the bathroom. The nurse asked me why and I told her that there were changes to the resident transfer status and I needed help. The nurse said, 'she's just wanting attention, she gets like this you know, being a baby.' The statement documented We both then walked into the resident's room and the nurse stated, 'why can't you walk to the bathroom now (R10)?' The resident replied, 'the doctor said I need two people to help me now' and the nurse (V8) replied 'We don't have time for this you are being a d*** baby.' She then made the resident grasp her fingers which each hand to check the resident grip. I told the nurse that we needed to get her transferred to the wheelchair and to the bathroom. The nurse stated to the resident 'you need to stand up, there is no need we need to help you, you are being a baby.' (R10) told the nurse 'No, I'm not, the doctor stated I need two people to help me now just forget it, I won't even go to the bathroom' (at which time the resident became teary eyed). Me and the nurse helped the resident to stand, place her in her wheelchair, then once in the bathroom placed her on the toilet. By now the resident was in tears and the nurse said, 'I'm going to find out if she's a two assist, if not she can do it herself. The statement documented that V8 left the room and V11 attempted to comfort R10. The statement documented I told (V8) the nurse, that (R10) was crying, and she said, 'well she just wants attention, but she is a 2 assist now, I checked.' (V8) told (R10) to quit crying that she just wanted attention to which (R10) replied 'Just leave me alone. I'm not gonna ask for help again tonight.' The statement documented (R10) continued to cry, and I went back several times through the night to see if she wanted to use the restroom and she refused due to not wanting the nurse back in her room. On 9/12/2023 at 12:30 PM, V11 stated In June (R10) had been out of the facility for a couple of days. Before (R10) went to the hospital, she had been independent. (R10) used her call light and said she needed help to the restroom. When I went in (R10's) room she said she needed two staff to transfer her. I said 'Ok' and asked (V8) for help. (V8) said 'Why does (R10) need help?' When (V8) and I went in to (R10's) room, (V8) said 'Quit acting like a d*** baby.' As we were helping (R10) to the restroom (V8) said 'I don't know why you need help.' (R10) heard everything (V8) said. (R10) was very upset and said she wasn't going to ask for help the rest of the night. (R10) apologized for being a bother. (V8) needed to get out of that room. I was not going to ask (V8) to help with (R10) again. I would ask another staff member. (V8) worked the rest of her shift until 6:00AM. I told the (V10) the next day. I should've told her that night, but I didn't know if that was abuse or not. On 9/12/2023 (Local) Police Department was contacted regarding incident at facility on 6/3/2023. Police report documents (V10) at Facility advised one of her employees was accused of verbal abuse to (R10) last night during their night shift. She advised the new owners of the facility require them to make a report with the police to ensure the facility is investigating it on their end. (V10) advised nobody wanted to fill out a statement at this time. (V10) advised they will contact us if their investigation needs them to. The facility's Disciplinary Warning Notice and Action Taken Form, dated 6/7/23, documents Based on the investigation involving a resident complaint from the early morning of 6/3/23, employment of (V8) is terminated immediate based on facility policy in regard to Performance Management: Using language or conducting yourself a way that violated common decency. R10's Nurse's Notes, written by V8 (LPN), dated 6/2/2023 at 2:00AM documents Two assist to transfer to bathroom. Sleeps without difficulty when in recliner. (R10) is emotional at times. R10's Nurse's Notes dated 6/3/2023 at 2:00PM documents Alert with confusion. Up and about usual routine. Tearful in the AM. Accusing night shift of cussing her out. Spoke with night shift. Said this did not happen. On 9/12/2023 at 10:00AM V9 (CNA) stated I was here the morning the incident happened between (R10) and (V8). The incident happened a few hours before I got to work. (R10) was upset because (V8) talked rudely to her. (R10) told me (V8) yelled at her. (V8) has a loud voice and sounds rude, even if she doesn't mean to be. (V8) worked her whole shift, until 6am. V9 stated she didn't call V10 because they had already been notified. On 9/12/2023 at 10:00AM V1 (Administrator), stated I wasn't here in June, but it looks like (V8) was the only nurse here the night of 6/2/2023. Facility Abuse Policy dated 8/16/2022 This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment.

Based on interview and record review, the facility failed to properly prepare sufficient discharge information, and provide orientation to a resident as well as receiving hospital staff regarding resident's daily patterns, in order to minimize the potential for unnecessary/avoidable anxiety or depression for 1 (R2) of 5 residents reviewed for discharge planning in the sample of 11. A reasonable person would react to being removed from their home and taken to an unfamiliar location with unfamiliar people with feelings of fear, agitation, anxiety and frustration. Findings include: R2's Admission Record dated 4/13/17 documents R2's original admitted to the facility as 4/12/16 and his discharge date to a hospital emergency room as 4/24/17. R2's Admission Record further documents [DIAGNOSES REDACTED]. R2's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents form dated 3/24/17 documents in part, The reason for this proposed discharge is: the safety of individuals in this facility is endangered. The Emergency Transfer or Discharge box is neither marked yes or no. R2's Transfer and Referral Record, dated 4/24/17, fails to document Diagnosis, Reason for Transfer or Resident/Patient to Return to. On 5/4/17 at 1:00 PM, E9, CNA stated that she and E8, CNA took R2 to the emergency room (ER) at an out of state hospital on [DATE] around 10:30 AM. E9 said E15 (Former Director of Nursing) had told them that they did not have to stay. E9 said E8 drove the vehicle around the block several times waiting for E9 to come out of the ER. E9 said R2 was good and did not have any behaviors during the ride to the ER or while being checked in to the ER. E9 said they had a manila envelope containing R2's records and a paper towel with some information on it when they checked R2 in at the ER. E9 said she gave Z7 (ER nurse) the facility's phone number. E9 said Z7 spoke to E15 on the phone and then Z7 told E9 that she could go. E9 said when she was leaving the ER, the ER was trying to get R2 to sign papers and he wouldn't sign. On 5/4/17 at 2:10 PM, E8, CNA stated that she drove the facility vehicle to take R2 to the out of state hospital on [DATE]. E8 said Z1 asked her about a week before if she would take R2 to the out of state hospital. E8 stated that she was told to take R2 to the emergency room . E8 stated that there was a packet of papers the facility had given them to take in with R2. On 5/9/17 at 2:40 PM, Z6 (hospital Social Worker) stated when R2 arrived to the ER at the out of state hospital, they were given a packet of medical information along with a napkin that stated the following, Involuntarily discharged due to being a danger to staff and residents. Needs further psychiatric evaluation and possible admission. Z6 stated there was no name or date on the napkin. Z6 stated R2 was accompanied by 2 aides who tried to leave him once he was in the lobby, but out of state hospital staff insisted that they needed to stay. Z6 stated she called E15 to find out what was going on, in which E15 stated he was no longer their responsibility. Z6 then stated that E15 reported that R2 was medically stable and had no new behaviors in the past 30 days. Z6 stated R2 was then admitted due to the fact he was not able to go back to the facility, essentially making him homeless. Z6 further stated that R2 was admitted to a regular medical room and not admitted into the psychiatric unit. Z6 stated that the facility did not forward any upcoming appointments or follow-ups needed for R2. Z6 stated that contact with Z2, R2's POA could not be made until 4/26/17 so they had no information on R2. On 5/4/17 at 2:30 PM, Z7 (hospital Social Worker) stated R2 was dropped off at theER on [DATE]. Z7 then stated when E15 was questioned regarding his need to be there, she stated that R2 had had no new behaviors in the past 30 days but stated it was day 31 from when the facility had provided R2 with an involuntary discharge notice and he was no longer their responsibility. Z7 stated that upon R2's arrival to the hospital Z2, R2's POA could not be reached. Z7 stated that upon initial evaluation a full assessment of R2 could not be completed due to R2's cognition impairment. On 5/12/17 at 9:25 AM, E2, Social Services Director stated that she did not counsel R2 prior to discharge. On 5/5/17 at 3:00 PM, E15, Former Director of Nursing stated that she sent a normal transfer packet with R2 when she had E8 and E9 take him to the hospital ER. E15 stated she did not make any copies of what she had sent, but was called by the emergency department for additional information. On 5/4/17 at 11:58 AM, Z3 (Ombudsman) stated that she received a phone call from Z6, (Social Worker from out of state hospital) saying that R2 was dumped at the emergency room (ER) with some discharge information written on a napkin. Z3 said Z6 told her that normally they have to wait in the ER and not just drop them off. Z3 also stated that Z6 said because R2 had no behaviors while he was in the ER, the hospital couldn't put in for a psychiatric evaluation; there was nothing to evaluate. Z3 stated that Z6 said R2 did not have the correct discharge paper work; R2 just had his medical record. On 5/17/17 at 2:05 PM, E1, Administrator stated that the facility boxed up R2's personal belongings and assumes his family picked them up. E1 then stated, Although I can't say for sure. R2's Nurses Notes, dated 4/24/17 at 12:30 PM by E15 document, Spoke with (Z6) concerning PMH (Patient Medical History), and reason for resident transfer to ER. R2's Progress Notes from the hospital dated 4/24/17 document, (Z6, Social Worker) spoke with (E15) at The Facility regarding (R2) being brought to The Hospital and to attempt to obtain further information. Per (E15) (R2) has not had any change in behaviors and no new issues reported in the past 30 days. (E15) reported that no emergent condition was noted for (R2) but (R2) was given a 30 day notice and that today was day 31 and that after attempting to locate a new facility (approx 30 days) without success, they dropped him off at the hospital on day 31 and he is no longer our responsibility. R2's Progress Notes further documents, Of note (Z6) requested official letter to be faxed, as letter that was brought with (R2) was written on a napkin. (Z6) inquired as to reason for bringing (R2) to The Hospital as facility previously stated no new changes, behaviors, or issues and per (E15) no other hospital would just let us drop him off in the ED (Emergency Department). Notes further document, At present time (R2) is not able to complete assessment due to cognitive impairment. Full assessment deferred until (Z6) is able to speak further with Z2 to complete assessment. R2's Hospital Inpatient Consultation Report dated 4/24/17 at 8:09 PM documents in part, Oriented to person only. Poor historian. Unable to state why he is here. Unable to answer most questions. Could not tell me where he had been living. Item recall 0/3. Did state he is not guilty and he has been falsely accused but could not elaborate on this. (R2) reported feeling down at times but could not elaborate on this. R2's Clinical Records were thoroughly reviewed and documentation could not be found that R2 was given any counseling or sufficient preparation on where he was being discharged to and why he was leaving his home. Documentation was also not found on what happened to R2's personal belongings after he was discharged or that R2 was sent to the hosptial with any of his personal belongings. R2's Minimum Data Set ((MDS) dated [DATE], documents R2 has a BIMS (Brief Interview for Mental Status) score of 7 which indicates R2 is severely cognitively impaired. An interview was not attempted with R2 due to the cognitive status and R2 residing in an out of state hospital. However, a reasonable person would react to being removed from their home and taken to an unfamiliar location with unfamiliar people with feelings of fear, agitation, anxiety, frustration. A Facility Daily Census sheet provided by the facility on 5/4/17, documents both R8 and R10 as interviewable residents. On 5/4/17 at 10:50 AM, R10 stated that, If the facility took me to the hospital and told me I couldn't come back I'd be disappointed. On 5/9/17 at 11:10 AM, R8 stated, If the facility took me to the hospital and wouldn't let me come back, I'd be pissed! On 5/19/17 at 11:20 AM, E2 (Social Worker) was asked how it would make her feel if she lived in a nursing home and was dropped off at a hospital and wasn't allowed to come back. E2 stated, It wouldn't make me feel very good, especially if I didn't know why. I'd be disappointed.

A. Based on observation, record review and interview, the facility failed to implement safety measures and progressive interventions to prevent falls, and provide safe transfer techniques for 5 of seven residents (R1, R3, R4, R5, R10) reviewed for falls in the sample of 15. This resulted in staff failing to transfer R3 safely and R3 sustained a fractured femur. Findings include: 1. The physician's orders [REDACTED]." The Minimum Data Set ((MDS) dated [DATE], documents R4 is moderately impaired with cognition, has unsteady sitting and standing balance, with limited range of motion to the lower extremities, and requires extensive assistance for transfers. On 12/09/2014, at 10:01 AM, R4 was in bed on her right side. A fall mat was on the floor next to R4's bed and the bed was in low position. A soft foam lap top cushion was next to the bed. At that time, E2, Director of Nursing (DON) stated, "(R4) leans really bad." On 12/09/2014 at 12:05 PM, R4 was in the wheelchair with a soft foam lap cushion attached to the wheelchair, and a personal body alarm (PBA) with a long string attached by a clip to R4's shirt. On 12/09/2014 at 12:13 PM, E10 and E18, Certified Nurses Aides (CNA) applied a gait belt to R4 after removing the soft foam lap cushion. Without locking R4's wheelchair, E10 and E18 attempted to transfer R4 to the bed. R4 was holding onto the arms of the wheelchair to steady herself and the wheelchair began to roll backward. R4 immediately began to sit back down, nearly missing the seat of the wheelchair. Both E10 and E18 left R4 in the wheelchair, left the room without placing the soft foam lap cushion back onto R4's wheelchair. R4 began to propel herself into the hall, leaning over forward. R4 was out in the hall for several minutes, when E10 noticed and reapplied the lap cushion. On 12/09/2014, at 3:35 PM, E11 and E12 toileted R4 and placed her in bed. E12, CNA attached the clip of the personal body alarm to R4's blouse and placed the base of the alarm next to the pillow, with no attachment to anything. E12 washed her hands and left R4's room. On 12/10/2014 at 9:20 AM and 10:05 AM, R4 was laying in bed with the base of the personal body alarm not attached to anything, enabling the alarm to sound if R4 begins to leave the bed. On 12/10/2014 at 12:45 PM, R4 was in the wheelchair by the nurses station leaning forward, with her head resting on the lap cushion. R4 was asleep. The string attached to the PBA and blouse was 22 and 1/2 inches long. The Incident Detail Report, dated 8/10/2014, at 5:40 AM documents, in part, "(R4) rolled out of bed onto floor. No injury noted at this time, but later on noted bruise to right thumb. Bed was in low position. Comments: Position resident in center of bed to prevent rolling out of bed." The Nurse's Note, dated 8/10/2014 at 5:30 AM, documents R4 was "found lying on the floor on the right side on mat beside bed, alarm not sounding." The Safety Risk Data Collection for R4, dated 5/11/2014, documents, in part, "Is at risk for falls due to confusion, poor balance, poor safety awareness, leans forward in wheelchair, unsteady gait, leans back. Pressure alarm in bed, PBA (personal body alarm) in wheelchair, lap (cushion) when in wheelchair." Quarterly Review for R4 dated, 11/04/2014, documents in part, "Pressure alarm and PBA at all times." R4's Care Plan, revised 11/12/2014, documents, in part, "Is a high risk for falls. Interventions-Apply lap (cushion) when up in wheelchair due to leaning forward, inability to right self consistently. Monitor for proper placement. Keep in high traffic area. Do not leave in bathroom unattended. Remind her not to get up without assist." 2. The POS for 12/2014 documents [DIAGNOSES REDACTED]." The MDS dated [DATE], documents R10 is moderately impaired with cognition, has poor sitting and standing balance, and requires extensive assistance from staff for transfers, with limited range of motion to the lower extremities. On 12/09/2014 at 12:37 PM, R10 was sitting at the dining room table, leaning forward, with her chin resting on the table. A long, knotted string was attached with a clip to R10's blouse and to a PBA attached to the wheelchair. E23, CNA instructed R10 to sit up straight. On 12/10/2014 at 11:00 AM R10 was in a low bed. The base of the PBA was laying next to the pillow by R10's head. The base was not attached to anything. The long string was attached to R10's blouse. On 12/10/2014 at 11:30 AM R10 was in a wheelchair in her room, leaning far over the bedside table. The string to the PBA was attached to her blouse but was not taut enough to sound. An activity tray to the right of R10's wheelchair was positioned downward. At 11:48 AM, R10 was still in her room in the same position. The string attached to the alarm measured 19 and 1/2 inches in length. On 12/10/2014 at 1:45 PM, R10 was seated in the wheelchair in her room, leaning forward. Her body was wedged between the left arm rest of the wheelchair and the raised activity tray. Her head was laying on the bed, with the string pulled taut, but not sounding. R10 was awake. On 12/10/2014, at 2:40 PM, R10 was in bed. The PBA was attached to the wheelchair which was across the room. The Safety Risk Data Collection for R10, dated 7/05/2014, documents, in part, "At risk for falls due to poor balance, poor posture, leans forward in wheelchair, poor weight bearing, confusion, previous falls. PBA in place when up in wheelchair. half lap tray in place for improved posture. Last fall 6/12/2014." R10's Care Plan, revised 9/30/2014, documents, in part, "Is high risk for falls related to unaware of safety needs. Interventions-Apply PBA PRN when in bed at night due to increased confusion. Encourage her to sit up when leaning forward, Lay down between meals to prevent leaning forward as often, remind to use call light for assist to transfer and not attempt per self, 1/2 lap tray in place when up in wheelchair for proper positioning. Able to reposition 1/2 tray as she wishes." On 12/11/2014, at 3:00 PM, E3 Assistant Director of Nursing (ADON) reported the facility has no policy related to the use of the PBA with a clip, or how long the string must be to be effective to alert staff or assist in preventing falls, or where the base of the alarm should be attached to be effective when a resident is in bed. 3. R1's 11/17/14 Incident Report documents "Description: staff was transferring resident (R1) from wheelchair to toilet and resident (R1) tried to sit down before turning, so staff lowered her to the floor. Comments: staff to use gait belt for all transfers." R1's Care Plan, revised 11/9/14, documents the new interventions as may use mechanical lift, transfer with 2 assist and gait belt on and off toilet or may offer bedpan. On 12/11/14 at 1:55 PM, E3 stated, regarding R1 incident 11/17/14, "I would assume from the intervention that they didn't use a gait belt." 4. R5's MDS for 6/30/14, 8/29/14, and 11/29/14 document R5 requires extensive assist of one person for transfers. R5's 6/30/14 MDS documents R5's balance is unsteady and can only stabilize with assistance, and has severe cognitive impairment. R5's 8/29/14 MDS documents R5's balance is unsteady, but he can stabilize himself, and has severe cognitive impairment. R5's 11/29/14 MDS documents R5's balance is unsteady for transfers and can only stabilize with assistance, and is cognitively intact. R5's Incident Reports, dated 7/13/14, 9/2/14, 9/3/14, and 11/23/14, document R5 fell in his room while trying attempting to transfer himself and had no significant injuries. The above Incident Reports continue to document for interventions the comments of remind/encourage resident to use call light to ask for assistance with transfers. On 12/11/14 at 1:55 PM, E3 also stated, regarding R5's falls, "There weren't really progressive interventions. I would have tried to identify why he (R5) was trying to get up." The Facility's Fall Protocol, revised 3/2011, documents, "1. On admission and readmission, a Fall Risk Assessment will be completed within 24 hours. 2. Preventative measures will then be implemented for those residents assessed as moderate to high risk. When a fall occurs: 7. Depending on the nature of the fall, preventative measures will be implemented accordingly. 8. Care plans will be updated as appropriate within 3 days of a fall occurrence." 5. On 12/9/2014 at 10:15AM R3 was lying in bed with eyes closed. E13, Treatment Nurse stated R3 has an immobilizer on the left leg from a fracture. E13 stated the injury happened from a fall in-house. Nurse's Notes on 3/28/2014 at 3:30PM document, "(R3) was lowered to the floor by a CNA due to wheel chair rolled backwards during a transfer...." Nurse's Notes on 3/30/2014 at 9:00AM document, "This nurse notified POA (Power of Attorney) that after speaking to several staff members it was discovered that Friday evening while staff was transferring resident (R3) to wheelchair, the wheelchair moved and staff had to lower resident to the floor....." . This entry was signed by E2, Director of Nursing (DON). The x-ray report on 3/29/2014 documents, "A comminuted fracture is noted involving the distal third of the femur. Posterior displacement of the distal fracture is noted...." A comparative x-ray report on 6/19/2014 documents, "Marked displaced healing fracture distal shaft of the femur with approximately 6.9 centimeter (cm) over-riding of the fracture fragments...". A comparative x-ray report on 8/28/2014 documents, "Subacute supracondylar fracture of the femur with moderate displacement and angulation.....There is no significant interval of change." On 12/22/2014, E3 Assistant Director of Nursing (ADON) stated, "(R3) was a transfer with 2 assist at the time of the fall on 3/28/2014. I am not sure why the CNA transferred (R3) by herself. We tell them (CNAs) to read the residents' Care Plans. That CNA knew (R3) was a 2 person transfer." B. Based on observation and record review, the facility failed to ensure that chemicals are stored in areas which are inaccessible to cognitively impaired, mobile residents for two of two residents (R2 and R6) reviewed as mobile and cognitively impaired in the sample of 15 and one resident (R20) in the supplemental sample. Findings include: 1. On 12/10/2014, at 11:34 AM, in the Women's Bath across from Room D6, there was one aerosol can of foam disinfectant cleaner in an unlocked cabinet on the wall. In a plastic bin on top of this cabinet were six four ounce tubes of protective barrier cream. The warning labels on the back of these tubes documented if the cream is swallowed to seek medical help and contact Poison Control. 2. On 12/10/2014, at 11:40 AM, in an unlocked cabinet under the sink in the D-hall kitchenette, there was one aerosol can of foam disinfectant cleaner. 3. On 12/10/2014, at 11:56 AM, in an unlocked cabinet on the wall in the C-Hall Women's Shower/Bath Room, there were two spray bottles of liquid bleach cleaner and one four ounce tube of antifungal cream. The Warning Label on the back of the antifungal cream documented if the cream is swallowed to seek medical help and contact Poison Control. 4. On 12/10/2014, the Material Safety Data Sheet (MSDS) for the aerosol foam disinfectant cleaner was reviewed and documented " Eye Contact: Flush with water for 15 minutes. If irritated, seek medical attention. Skin Contact: Wash with soap and water. If irritated, seek medical attention. Inhalation: Remove to fresh air. Resuscitate if necessary. Get medical attention. Ingestion: DO NOT INDUCE VOMITING. Drink two large glasses of water. Get immediate medical attention." The MSDS for the liquid bleach cleaner documented "Eye Contact: In case of contact, immediately flush eyes with plenty of water. Remove contact lenses and flush again. Get medical attention if irritation persists. Skin Contact: Rinse with water for a few minutes. Inhalation: If inhaled, remove to fresh air. Get medical attention if irritation persists. Ingestion: Get medical attention if symptoms occur." 5. On 12/11/2014, the facility provided a list of residents who are independently mobile and cognitively impaired which included R2, R6 and R20.

Based on record review and interview the facility failed to protect 2 (R3, R28) of 2 residents reviewed from abuse. This failure resulted in E5 throwing a shoe at R3 and hitting her in the chest. R3, with staff knowledge, remained in the facility and then abused R28 while staff was present. This abuse for R28 was not immediately investigated when it was reported the following day. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 12/28/10, the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the abuse policies and procedures and their system of communication. The findings include: 1. The written "Occurrence Report" dated 11/15/10 for R3 documented "(R17) - I was sitting here at the table and saw (E5, Certified Nurse Aide, (CNA) throw (R3's) shoe at her and hit her in the chest, while saying "Here's your shoe"." The report states "alleged abuser was sent home and is still off today while the investigation was going on." The report documented on 11/17/10 that E5 was terminated on that date. E7, Licensed Practical Nurse, LPN, stated on 12/21/10 that on 11/15/10, after supper around 6:30 PM to 6:45 PM, she was at the nurses station and R3 was at the long table in front of the nurses station. R17 began yelling at E5 that she (E5) threw a shoe at R3. E5 then went down the hall and E7 called E2, Director of Nursing. E7 stated that when she got off the phone she went down the hall to R28's room where E5 was assisting R28 and she told E5 to leave the premises. When E7 left R28's room, E5 was still in the room finishing up what she was doing before she clocked out. E5 didn't clock out until 7:13 PM. E7 stated she didn't stay with E5 and didn't know what she did prior to clocking out. Review of the time card confirmed that E5 clocked out at 7:13 PM. E8, CNA, stated on 12/22/10, by phone, that 11/15/10 was her first day to work and she was orienting with E5. E8 was in a room near the dining room and she could hear R3 screaming. E8 stated when E5 came down the hall, they went into R28's room. E8 asked E5 what had happened. E5 stated that R3 had thrown a shoe at her and she had thrown it back. E5 "cussed" at R28 and said the F word and "s...". E5 washed R28's arm pits and let her arm drop "flat down" on the wheelchair handle. R28 was crying. E5 threw a wash cloth at R28 and hit her in the chest with it. E5 told her to wash her face. R28 jumped when she threw the washcloth and R28 started crying again. E8 stated E7 came to the room and told E5 to leave. E5 left the room but E8 didn't see where she went. E8 thought it was about 7:00 PM. E8 stated that she did not tell anyone about the incidents with R28 until the next day. E7 had the other CNA's come to the nurses desk but didn't tell her to come so she didn't report it that night. The incident with R28 was not immediately reported to Administration or the Department on 11/15/10. E8 did not report the incident with R28 until 11/16/10. The original "Occurrence Report" for R3 that was sent to the Department on 11/16/10 and only identified the incident with R3. On 11/17/10 the Department was sent a follow up report that documented under "Injury Cause or Staff Comments" for E8 stated "(E5) told me that she threw the shoe at (R3) after (R3) had thrown it at (E5), (E5) said that she did not have to put up with that. (E5) was then seen throwing a wash cloth at another resident telling her to wash her own face. (E5) also was seen holding a residents arm up to wash underneath and just let it drop hitting the arm of her wheelchair. (E5's) attitude was terrible after (R17) had yelled at her." The report does not name R28 as the resident that E5 threw the washcloth at or let her arm drop. E2 confirmed on 12/21/10 that the incident report for R28 was not sent to the department. The " Occurrence Report" with "Type" of "Alleged Abuse" for R28 dated for 11/15/10 documented on 11/16/10 that E8 had come into work the next day, 11/16/10 at 4:30 PM, and reported that "she saw (E5) throw a washcloth at (R28) telling her to wash her face. (E8) also said that (E5) had lifted (R28's) left arm and let is (it) fall down onto the wheelchair. (she has no control of this arm due to [MEDICAL CONDITION]." The "Witness Statement" by E8 noted "(E5) came down the hall and said that she did throw the shoe at (R3) because (R3) had thrown it at her and that she did not have to put up with that. After that happened (E5's) attitude only got worse. She was cursing on the hall saying s*** and F***. She was rude with the residents. (R28) was crying and (E5) threw a wash cloth at her and told her to wash her face. (E5) then lifted R28's arm and let it fall onto the arm of the wheelchair". The incident report for R28 was not sent to the Department. E2 provided the report to the surveyor on 12/21/10. The report noted that the physician and power of attorney were not notified until 11/17/10. Other incidents of alleged abuse include: A. According to 2 confidential resident interviews, R3 was pushed into the main dining room on 11/15/10 by E5, Certified Nurse Aide (CNA). Both residents stated E5 was jumping at R3, saying "Boo" and scaring her. One interview stated other staff were in the dining room and laughed at E5 scaring R3. One confidential interview stated that E5 threw a shoe at R3 and hit her in the chest. E3 was present and saw the incident. One resident stated E5 had also "kneed" R3 in the back prior to this incident. The confidential interview stated that E5 and E3, CNA's were both "mean" and "rough" with some of the residents especially R3. The confidential interview stated they had heard slapping noises and screaming when E3 was in a room with R3. E2, Director of Nursing, confirmed on 12/22/10 that she was only aware of E5 throwing the shoe. B. E4, CNA, stated on 12/21/10 that E5 was "hateful and rude" and "rough" with the residents. E4 stated she had seen E5 scare R3 before and throw wash cloths at residents, especially R3. E4 had seen E5 grab R3's arm when R3 was swinging at her. E4 stated E5 liked to "torment" the residents. E4 stated she told E2, Director of Nursing (DON), about all the incidents she had seen after the incident on 11/15/10 when E5 threw the shoe at R3. E4 had worked at the facility approximately 1 and a half months when the 11/15/10 shoe incident occurred. There were no abuse investigations provided for any of the allegations except for the 11/15/10 incident. C. E6, CNA, stated on 12/22/10 that she had seen E3 throw one of R3's baby dolls over the nurses station. E6 stated R3 thinks the dolls are real and R3 was very upset and crying. E2, DON, confirmed on 12/22/10 that she was not aware of that incident. E6 also stated that R10 had said "that girl (pointing at E3) pinches me on my sides". This occurred approximately 4 weeks ago. The information was reported to E11, Assistant Director of Nursing. There were no abuse investigations provided for either incidents. D. E9, CNA, stated on 12/22/10 that she was working in the room across from R10. E3 was in the room with R10 with the door shut and she could hear them both screaming. E9 went over and knocked on the door to see if E3 needed assistance. E3 told her she didn't need any help and as she left E9 heard additional screaming. E9 stated she told E12, LPN, who told her to tell E2 in the morning. E2 did not recall any staff reporting the incident. E. E10, CNA, stated on 12/22/10 that recently R3 was hitting E7, Licensed Practical Nurse (LPN), with her doll she holds. They got the doll away from her, R3, and either E7 or E3 took the doll and threw it over the nurses station. R3 thinks her dolls are babies. R3 got irate and thought they were hurting her baby. E2, Director of Nursing, was not aware of the incident on 12/22/10. The Immediate Jeopardy was identified to have begun on 11/15/10 when staff identified a potential physical abuse by staff and failed to immediately remove the staff from resident care, protect other residents from further abuse, and report another incident of abuse to the Administrator as required by the facility policy and procedure. E2, Director of Nursing, was notified of the Immediate Jeopardy on 12/27/10 at 2:40 PM. The Facility took the following actions to remove the Immediacy: 12/17/10 E5 was terminated. 12/21/10 Licensed staff was in serviced regarding the policy on what to do when an employee is suspected of abuse. 12/22/10 All polices regarding resident abuse and reporting of suspected abuse was reviewed. E3 was suspended for 2 days while an investigation was initiated into allegations of abuse. The allegations were unfounded and she returned to work 12/24/10. 12/23/10 An all staff meeting was held to discuss: When, who and how to report alleged abuse. That allegations of abuse had to be reported immediately. The allegation must be documented and given to the administrator and DON The perpetrator must be removed from the facility immediately. staff needed to be careful with their interactions with residents, so not to offend/scare them and be sensitive to their needs. This included the tone of their voice. Abuse Policies have been reviewed. 12/28/10 Care plans of residents with behavioral problems have been updated to include at risk of abuse due to particular behaviors.

Based on record review and interview the facility failed to implement abuse policies and procedures for reporting incidents of abuse immediately to the Administrator and the Department and prevent further abuse from occurring for 3 (R3, R28, R10) of 3 abuse reports reviewed. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 12/28/10, the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the abuse policies and procedures and their system of communication. The findings include: The facility policy and procedure titled "Resident Abuse Prevention Program" states "Any witness to abuse must be reported to the administrator immediately". It further states "Any incidences observed by staff or reported by resident will be reported to supervisor immediately and action to ensure residents safety will be initiated." The policy also states "When the incident or suspected incident of abuse is reported, the Administrator, or the party designated by the Administrator, will investigate the incident, and notify the (Department) within 24 hours of the initial report. Instances of staff failing to report abuse to the Administrator and failing to protect residents from further abuse includes: 1. E4, CNA, stated on 12/21/10 that E5 was "hateful and rude" and "rough" with the residents. E4 stated she had seen E5 scare R3 and throw wash cloths at residents, especially R3. E4 had seen E5 grab R3's arm when R3 was swinging at her. E4 stated E5 liked to "torment" the residents. E4 stated after the 11/15/10 incident of E5 throwing a shoe at R3, she had reported these instances to administration. E4 had worked at the facility approximately 1 and a half months when the shoe incident occurred. 2. E6, CNA, stated on 12/22/10 that she had seen E3 throw one of R3's baby dolls over the nurses station. E6 stated R3 thinks the dolls are real and R3 was very upset and crying. E2, DON, confirmed on 12/22/10 that she was not aware of that incident. E6 also stated that R10 had said "that girl (pointing at E3) pinches me on my sides". This occurred approximately 4 weeks ago. The information was reported to E11, Assistant Director of Nursing. There were no abuse investigations provided for either incidents. E10, CNA, stated on 12/22/10 that recently R3 was hitting E7, LPN, with her doll she holds. E7 or E3 took the doll and threw it over the nurses station. R3 thinks her dolls are babies. R3 got irate and thought they were hurting her baby. 3. E9, CNA, stated on 12/22/10 that she was working in the room across from R10. E3 was in the room with R10 with the door shut and she could hear them both screaming. E9 went over and knocked on the door to see if E3 needed assistance. E3 told her she didn't need any help and as she left E9 heard additional screaming. E9 stated she told E12, LPN, who told her to tell E2 in the morning. E2 did not recall any staff reporting the incident. 4. E8, CNA, stated on 12/22/10 by phone that that was her first day to work and was orienting with E5. E8 was in a room near the dining room and she could hear R3 screaming. E8 stated when E5 came down the hall and they went into R28's room. E8 asked E5 what had happened. E5 stated that R3 had thrown a shoe at her and she had thrown it back. E5 "cussed" at R28 and said the F word and "s...". E5 washed R28's arm pits and let her arm drop "flat down" on the wheelchair handle. R28 was crying. E5 threw a wash cloth at R28 and hit her in the chest with it. E5 told her to wash her face. R28 jumped when she threw it and started crying again. E8 stated E7 came to the room and told E5 to leave. E5 left the room but E8 didn't see where she went. E8 thought it was about 7:00 PM. E8 stated that she did not tell anyone about the incidents with R28 until the next day. E7 had the other CNA's come to the nurses desk but didn't tell her to come. The incident with R28 was not immediately reported to Administration or the Department on 11/15/10. E8 did not report the incident with R28 until 11/16/10. The original "Occurrence Report" for R3 that was sent to the Department on 11/16/10 and only identified the incident with R3. On 11/17/10 the Department was sent a follow up report that documented under "Injury Cause or Staff Comments" for E8 stated "(E5) told me that she threw the shoe at (R3) after (R3) had thrown it at (E5), (E5) said that she did not have to put up with that. (E5) was then seen throwing a wash cloth at another resident telling her to wash her own face. (E5) also was seen holding a residents arm up to wash underneath and just let it drop hitting the arm of her wheelchair. (E5's) attitude was terrible after (R17) had yelled at her." The report does not name R28 as the resident that E5 threw the washcloth at or let her arm drop. E2 confirmed on 12/21/10 that the incident report for R28 was not sent to the department. The " Occurrence Report" with "Type" of "Alleged Abuse" for R28 dated for 11/15/10 documented on 11/16/10 that E8 had come into work the next day, 11/16/10 at 4:30 PM, and reported that "she saw (E5) throw a washcloth at (R28) telling her to wash her face. (E8) also said that (E5) had lifted (R28's) left arm and let is (it) fall down onto the wheelchair. (she has no control of this arm due to [MEDICAL CONDITION]." The "Witness Statement" by E8 noted "(E5) came down the hall and said that she did throw the shoe at (R3) because (R3) had thrown it at her and that she did not have to put up with that. After that happened (E5's) attitude only got worse. She was cursing on the hall saying s*** and F***. She was rude with the residents. (R28) was crying and (E5) threw a wash cloth at her and told her to wash her face. (E5) then lifted R28's arm and let it fall onto the arm of the wheelchair". The incident report for R28 was not sent to the Department. E2 provided the report to the surveyor on 12/21/10. The report noted that the physician and power of attorney were not notified until 11/17/10. 5. E7, Licensed Practical Nurse (LPN), stated on 12/21/10 after supper around 6:30 PM to 6:45 PM she was at the nurses station and R3 was at the long table in front of the nurses station. E7 stated R17 began yelling at E5 that she threw a shoe at R3. E7 stated E5 went down the hall and she called E2, Director of Nursing. E7 stated that when she got off the phone she went down the hall to R28's room where E5 was assisting R28. E7 stated she told E5 to leave the premises. E7 stated when she left E5 was still in the room finishing up what she was doing before she clocked out. E5 didn't clock out until 7:13 PM. E7 stated she didn't stay with E5 and didn't know what she did prior to clocking out. Review of the time card confirmed that E5 clocked out at 7:13 PM. The Immediate Jeopardy was identified to have begun on 11/15/10 when staff identified a potential physical abuse by staff and failed to immediately remove the staff from resident care, protect other residents from further abuse, and report another incident of abuse to the Administrator as required by the facility policy and procedure. E2, Director of Nursing, was notified of the Immediate Jeopardy on 12/27/10 at 2:40 PM. The Facility took the following actions to remove the Immediacy: 12/17/10 E5 was terminated. 12/21/10 Licensed staff was in serviced regarding the policy on what to do when an employee is suspected of abuse. 12/22/10 All polices regarding resident abuse and reporting of suspected abuse was reviewed. E3 was suspended for 2 days while an investigation was initiated into allegations of abuse. The allegations were unfounded and she returned to work 12/24/10. 12/23/10 An all staff meeting was held to discuss: When, who and how to report alleged abuse. That allegations of abuse had to be reported immediately. The allegation must be documented and given to the administrator and DON The perpetrator must be removed from the facility immediately. staff needed to be careful with their interactions with residents, so not to offend/scare them and be sensitive to their needs. This included the tone of their voice. Abuse Policies have been reviewed. 12/28/10 Care plans of residents with behavioral problems have been updated to include at risk of abuse due to particular behaviors.

Based on interview and record review it was determined that the facility failed to ensure that all allegations of abuse are reported immediately to the Administrator, thoroughly investigated and reported immediately to the Department for 1 (R3) of 1 abuse investigations reviewed. The findings include: R3 was admitted to the facility on [DATE] with diagnoses, in part, of left [MEDICAL CONDITION], dementia, diabetes mellitus, and hypertension. The Minimum (MDS) data set [DATE] assessed R3 as moderately cognitively impaired. R3 was unable to answer questions. According to the written note dated 10/11/10 by E6, Licensed Nurse working 10:00 PM to 6:00 AM, R17 reported to her that she had witnessed E5, Certified Nurse Aide (CNA), "knee" R3 in the back while pushing her down the hall in her wheelchair. The note states "Says another staff member witnessed this but didn't say who". The note stated R17 said it had happened about 3 weeks ago. The Occurrence report noted that the Department was not notified of the incident until 10/13/10. The Occurrence report also states that the physician was not notified due to "event found to be false". The report also states the power of attorney was not notified because "accusation false". E2, Director of Nursing, confirmed on 11/1/10 that the physician and responsible party had not been notified of the incident. E2 stated that she had only interviewed E5, CNA, and one other staff regarding the incident. E2 also confirmed that she had not interviewed any other residents regarding the incident except for R3 and R17. E2 stated that she had received the written note when she arrived to work the next morning and had started the investigation then. E2 stated that E5 was not working at the time the note was written.

Based on record review and interview it was determined that the Facility failed to use a gait belt, assistive devices, and preventive measures for 2 (R13, R1) of 5 residents reviewed for falls. This failure resulted in R13 falling and sustaining subdural hematomas, hospitalization and death due to subdural hematoma. This failure also resulted in R1 falling out of bed and sustaining a fractured right ankle. The findings include: 1. R13 was admitted to the facility on [DATE] with diagnoses, in part, of atraumatic brain injury, right sided weakness, renal cell [DIAGNOSES REDACTED], Parkinsons disease, seizure disorder and non-malignant neo [DIAGNOSES REDACTED]. The "history and physical examination an excellent candidate for a comprehensive program, given the complexity of his current problems". The consultation record for "Admission to the Rehab Unit" noted R13 had a history of [REDACTED]. R13 received rehabilitation services at the hospital until his discharge to the facility on [DATE]. According to the hospital history and physical, R13 was admitted to the facility from the hospital for further physical and occupational therapy. The goal was to discharge R13 home. On admission to the facility R13 had orders for Physical and Occupational Therapy evaluation and treatment. The physician ordered R13 could be up with assist of 1 person. R13 was also receiving Coumadin. The Physical Therapy evaluation dated [DATE] noted the treatment [DIAGNOSES REDACTED]. The evaluation noted precautions included fall risk, decreased vision, decreased awareness of surroundings and coumadin. The evaluation noted R13 had fair standing balance and poor balance during movement. Short term goals were, in part, to ambulate with hands on assist of 1 person for 100 feet with a wheeled walker. The discharge plan was to discharge "to home when stronger". The "Immediate Need Care Plan At Risk For Accident/Injury" dated [DATE] noted R13 had occasional confusion and had gait/balance problems. The "Total Plan Of Patient Care" dated [DATE] noted R13 required assist of 1 person with a wheeled walker for ambulation. The Plan stated as "Privileges" that R13 could be "Up with Assist". The facility "Occurrence Report" sent to the department noted on [DATE] at 12:40 AM stated "Resident got up unassisted setting his alarm off, when staff responded to alarm found resident standing in the doorway of his room. Resident wanted to go to the bathroom, so CNA (Certified Nurse Aide) put her arm around the resident to hold him up and when they went to walk across hall resident abruptly turned and fell on to the floor. Staff noted a 6 cm (centimeter) raised hematoma to his rt (right) forehead, eyes fluttering and unresponsive. (Ambulance) was called and resident sent to (hospital) ER (emergency room ) were (where) it was found that resident had a 1.2 cm subdural hematoma in (the) temporal parietal area.. Resident was then transferred to (hospital) (where) he had just came to (facility) from on [DATE]. Resident has renal (cancer) with mets (metastasis) to the brain". The nurses notes by E6, Licensed Practical Nurse, dated [DATE] at 12:44 AM noted that R13 was found standing up in his room. The note states R13 wanted to sit at the nurses station and "CNA ambulating (with) res (resident) arm in arm towards NS (nurses station) Res abruptly turned around, away from CNA et (and) fell face down on the floor...". E6 documented R13 was unconscious but breathing with a large hematoma to the right brow line. The ambulance arrived at 12:52 Am and transported R13 to the local hospital emergency room . The nurses note at 8:00 AM noted R13 was transferred to another hospital from the emergency room . E6 stated on [DATE] that she had been in R13's room thirty minutes prior to the fall when his alarm sounded. E6 stated R13 was in bed and had set the alarm off. E6 stated thirty minutes later she was at the nurses station, the alarm sounded and E7, CNA, responded to the alarm. E6 stated E7 and R13 were walking towards the nurses station. E6 stated R13 and E7 "linked elbows" and E7 was 1 step ahead of him. E6 stated E7 did not have hold of R13's body. E6 stated R13 let go and turned around and "tipped over". E6 stated R13 did not try to catch himself and "fell straight on his head". E6 stated R13 was unconscious and she called 911. E6 stated that R13 had just been admitted at noon on the 13th and they were still adjusting to R13. E6 stated she thought R13 had a balance problem and that he was a 1 person assist to walk. E6 confirmed that E7 did not have a gait belt on R13 or wheeled walker when she was ambulating R13. E6 also confirmed that R13 had on regular socks. E6 stated E7 did not ask for help when ambulating R13. E7 stated on [DATE] that she was assisting another resident when the alarm for R13 sounded. E7 stated that it was "less than 5 minutes" for her response time to the alarm. E7 stated that by the time she got to R13 he was already up and standing in the doorway. E7 stated she didn't have time to get the gait belt or shoes for R13. E7 stated she did not have a gait belt with her and it was on her cart. E7 confirmed that R13 had on regular socks. E7 stated that R13 stated he needed to go to the restroom so she was taking him to the restroom which was on the way to the nurses station. E7 stated she had R13 around the waist and he pulled away from her. E7 confirmed that R13 required a gait belt. E7 stated that R13 had just come in to the facility. E7 stated that she came in at 10:00 PM on [DATE] and report was usually at 11:00 PM. E7 stated they didn't have time to go over R13 in report at the beginning of the shift but she knew R13 was a 1 assist for everything. E7 stated the CNA from the shift before her had told her. E3, Assistant Director of Nursing, confirmed on [DATE] that E7 did not use a gait belt to ambulate R13. E3 confirmed that R13 was 6'0" tall and weighed 157 pounds. The emergency room report dated [DATE] assessed R13 with "Subdural hematoma (with) midline shift (with) underlying [DIAGNOSES REDACTED] (and) renal cell CA (cancer) Compassionate care". The "Head CT (Computerized tomography) dated [DATE] stated "There is now a moderate sized left temporal-parietal subdural hematoma which is acute and measures up to 1.2 cm in width and there is a mild shift of the ventricles from left to right. There also appears to be a small subdural hematoma in both right and left frontal regions. There appears to be small areas of hemorrhage in anterior portion of the right temporal lobe possibly due to hemorrhagic contusion. Small areas of hemorrhage are also seen the superior anterior right and left frontal lobes." R13 was transferred to another hospital. The hospital "discharge summary" dated [DATE] stated R13 "had just been sent home from rehab on ,[DATE]. He fell that night at the nursing home in (city). Details were unknown. He was found to have a forehead laceration with a large subdural hematoma involving the left frontoparietal lobe. He was sent her from (city) hospital for a neurosurgical evaluation. While in the ER, per discussions with the patient and family, the ER doc (doctor), (physician), (physician) the patient was made compassionate care. I was asked to admit for that reason. He was sonorous, minimally responsive, with right hemiparesis on admission with an occasional muscle twitching to his left leg. He was provided morphine, ativan and atropine as needed. He died on ,[DATE] at 2:30 in the morning.". The discharge summary noted as "Cause of Death" "Subdural hematoma secondary to fall, while on anticoagulation for [DIAGNOSES REDACTED]with underlying mass, a probable metastasis". 2. A review of R1's physician's orders [REDACTED]. The most recent Minimum Data Set, MDS, dated [DATE] indicated R1 is Moderately Cognitively Impaired, and needs assistance of two staff for all mobility, and transfers. A review of the facility "Occurrence Report" dated [DATE] at 22:25 (10:25 PM) indicated: Fall, Bruise Left knee, left cheek, Right Ankle Swollen. "Resident yelling, chanting "help me O' Lord, help me I pray. Resident found lying on floor, on left arm, face down. Bed was in high position, Personal Body Alarm was not on resident. Resident complaining of right ankle pain, ankle/foot swollen. X-ray obtained in house with no acute fracture or dislocations noted. Resident is to have ace wrap to foot during day, ice for ,[DATE] hours. Staff has been inserviced on proper positioning of bed and resident. continue to monitor for any further complaints." Resident state of motion at time of fall: Turning over in bed. "Root Cause - Staff did not follow plan." A review of the X-ray report of [DATE] indicated, Right Ankle;" A lucent line is noted involving the medial malleolus and may represent a non-displaced fracture." The report also indicated "Question non-displaced fracture of the medial malleolus as detailed above. Clinical correlation and short interval follow up may be helpful. A review of R1's nursing notes from ,[DATE] through ,[DATE] indicated R1 did occasionally complain of continued right ankle pain. On [DATE] a comparative X-ray was taken and indicated: Right Ankle: A fracture of the medial malleolus is noted. Minimal displacement is identified. A review of the most recent care plan dated [DATE] indicated R1 was at risk for falls due to decreased balance, meds, and decreased strength of her lower extremities. Intervention's listed included; Personal Body Alarm on at night and as needed during day when in bed, position resident in middle of bed, place pillow or wedge behind back, keep bed in low position when not caring for resident. On [DATE] at 11:30 AM, E10 and E11 were observed to put R1 to bed using a mechanical lift. Once in bed and peri care completed, E10 and E11 turned R1 to her right side and put pillows behind her for comfort. No personal alarm was attached to R1 at this time. Throughout the afternoon of ,[DATE], R1 was intermittently observed, and remained in bed without the personal alarm attached to her. On [DATE] at 3:00 PM, E2, stated she had reviewed the R1's fall on [DATE]. E2 indicated R1 had a history of [REDACTED]. E2 indicated at the time of R1's fall, staff had left R1 in bed with the bed in the high position and no personal alarm attached to R1. E2 was not aware that on ,[DATE] staff had also not attached the personal alarm to R1 after putting her to bed.