Every finding on record at Woodlake Healthcare and Rehabilitation Center

Based on interview and document review, the facility failed to notify the Ombudsman of transfers and discharge for 1 of 4 residents (R17) reviewed for hospitalizations. Findings include:R17's admission Minimum Data Set (MDS) dated [DATE], indicated R17 was cognitively intact. R17 MDS indicated diagnosis of cancer, heart failure, renal insufficiency, and diabetes mellitus. R17's medical record identified the following MDS assessments:1) 7/8/25 discharge with return anticipated, with 7/17/25 entry record2) 8/1/25 discharge with return anticipated, with 8/4/25 entry record3) 8/17/25 discharge with return anticipated, with 8/25/25 entry record4) 9/29/25 discharge with return anticipated, with 10/5/25 entry record5) 10/23/25 discharge with return anticipated, with 10/29/25 entry recordA review of the facility information sent to the Ombudsman dated July 2025 through November 2025, lacked evidence of R17's name being included on the list of hospitalized residents. An interview on 12/18/25 at 11:24 a.m., director of social service (DSS) stated when residents were discharged to the hospital, a bed hold was offered and notice of voluntary discharge. DSS indicated he pulled a report monthly and sent it to the Ombudsman. DSS did not recall if R17 was on any of the reports.An interview on 12/18/25 at 1:23 p.m., the administrator stated the Director of Social Services ran a report from point click care monthly for the entire facility. The administrator stated the report was then emailed to the Ombudsman.The facility policy Ombudsman Notification of Transfer and discharge date d 11/24, revealed the facility would provide the Long-Term Care (LTC) Ombudsman's office with timely notice of discharges and transfers. The Director of Social Services/designee will provide the LTC ombudsman's office with a report of all facility-initiated transfers and discharges.

Based on interview and document review, the facility failed to ensure timely follow up for recommendations from in-house provider for 1 of 1 (R161) resident reviewed for eye drops.Findings include: R161's quarterly minimum data set (MDS) dated [DATE], included R161 was cognitively intact. R161 had diagnoses of arthritis, anxiety and depression. During interview on 12/15/25 at 4:53 p.m., R161 stated she had an eye doctor appointment about a week ago had not received the eye drops that had been ordered. R161's HealthDrive Eye Care Group after visit summary (AVS) dated 12/2/25, included R161 reported itchy eyes. Under the AVS section plan, the following was listed:- Discontinue Medication Order(s) effective 12/02/2025: Artificial tears ophthalmic Solution (eye drops to treat dry eyes)- New Medication Order: olopatadine (eye drop for dry, itchy eyes) 0.2%, apply 1 drop, Both eyes, every morning for 90 days R161's order summary sheet dated 12/18/25, included artificial Tears Ophthalmic Solution 1.4 % (Polyvinyl Alcohol) Instill 1 drop in both eyes as needed for Dry eyes. Order summary failed to include olopatadine eye drops. During interview on 12/16/25 at 2:18 p.m., health unit coordinator (HUC)-A stated R161 signed a consent to see the in-house eye doctor on 11/6/25. HUC-A was not able to find any documentation in R161's medical record about an eye doctor visit. Later on 12/16/25, HUC-A was able to locate the eye doctor provider note and had it uploaded to R161's chart. During interview on 12/17/25 at 9:11 a.m., health information management manager (HIM)-B stated the process for in house eye doctor appointments was for the provider to give a summary with all the residents seen with any recommendations or changes made. The summary would be sent to the care coordinators to then follow up with the resident's primary care provider (PCP) to write an order to be sent to pharmacy. The after-visit summary was also sent to the care coordinators but could take a little longer before that was sent out and uploaded. During interview on 12/17/25 at 11:39 a.m., licensed practical nurse care coordinator (LPNCC) -A confirmed she typically received a summary with the residents who were seen by an inhouse provider along with any follow up appointments and order recommendations. LPNCC-A stated she would then follow up with the resident's PCP to get an order for any medications recommended because the in-house eye doctor did not write orders. During interview on 12/18/25 at 11:39 a.m., director of nursing (DON) stated she was new to the facility but had reviewed the eye drop concern with R161. DON stated the summary was not an order because it was not signed by the eye doctor. The process was for the HUC to provide the care coordinators with a summary and they would follow up with the PCP. The DON was unsure when the after-visit summary for R161 was received. The DON stated it would be her expectation that going forward the eye doctor would send any medication orders directly to the pharmacy because it was within their scope to write an order. During interview on 12/18/25 at 11:52 a.m., with in-house eye doctor, HealthDrive, [NAME] President (VP)-F confirmed their provider visits the facility. VP-F stated their providers were recommending providers because they see residents infrequently. They place their recommendations on the summary provided and after visit summary and it was up to the facility to follow up with the PCP to obtain an order. VP-F stated the summary gets emailed to 5 facility employees and after visit summary gets emailed to 5 facility employees the day following the eye doctor closing the visit.Facility policy for medication orders dated August 2022, failed to address timeliness or processing of inhouse provider orders.

Based on observation, and interview the facility failed to ensure all medications and biologicals were locked in compartments which only allowed authorized personnel to have access. This had the potential to affect all residents, staff, and visitors.Findings include:During constant observation on 12/16/25 from 1:27 p.m. through 1:40 p.m., an insulin pen was observed laying on top of a locked treatment cart. The treatment cart was passed by a resident and multiple staff; none noted the insulin pen or interacted with it.On 12/16/25 at 1:40 p.m., the licensed practical nurse (LPN)-B was stopped at the cart and stated they had no idea where the pen was from or how it got there. LPN-B stated they were expected to keep the insulin pens in the medications cart, went to their cart, and pulled out a currently opened pen for the same resident. LPN-B then stated they would report the incident to their nursing supervisor and remove the pen from circulation.On 12/16/25 at 1:55 p.m., the registered nurse manager (RN)-A stated they had recently changed their processes, and the staff nurses were expected to keep the open insulin pens in the medication carts, and the unopened in the locked medication refrigerator on the unit. RN-A stated they will remove the above insulin pen from circulation as they were unsure of how long it had been out of the refrigerator or medication cart. RN-A stated the importance of storing medications correctly and safely to prevent other residents from having access to medications they were not prescribed to as it could harm them if they took it and did not need it.On 12/18/25 at 10:32 a.m., the regional director of nursing (O)-G stated they expected open insulin pens to be stored in the medication carts, and unopened pens in the locked medication refrigerator on the unit.The Medication Storage Policy dated May 2025, indicated all medications will be stored in locked compartments under proper temperature control, only authorized personnel will have access to the keys to the locked compartments, and during medication pass, the medication must be under the observation of a licensed nurse or trained medication aide or locked in the medication storage area/cart.

Based on observation, interview and document review the facility failed to maintain an environment that was clean and free from odors for 3 of 3 residents (R1, R2, R3) reviewed for environmental concerns. Findings include:During observation of the two-east unit on 9/11/25 at 10:50 a.m., a musty odor was observed outside room [ROOM NUMBER]. During observation on the east unit on 9/12/25 at 8:23 a.m., the hallway outside of room [ROOM NUMBER] smelled of urine. No trash or linen carts were in the vicinity.R1's admission Record indicated he admitted to the facility on [DATE]. Diagnosis included Surgery of digestive system, chronic pain, and weakness. During interview on 9/11/25 at 10:39 a.m., family member (FM)-A stated it smelled like death in his dad bathroom when he was at the facility even after they had cleaned it. R2's admission Record indicated she admitted to the facility 9/3/25 and resided on the two- east unit of the facility. Diagnosis included muscle weakness, DMII, hypertension and history of falls. R2's Brief interview for mental status (BIMS) dated 9/4/25, indicated her short and long terms memory was intact.During interview on 9/11/25 at 11:47 a.m., R2 stated she had been at the facility for about two weeks. R2 stated the facility has had the same carpet for 10 years and said, they dumped me in this shit hole. R2 said the carpet is stained and musty and said the housekeepers did not vacuum, just swept the carpet. R2 pulled out a bottle labeled fungicide she had ordered and said the carpet smelled better since she started using it and said she planned to spray the recliner they brought up from the basement because it stunk.R3's admission Record indicated she resided on the two- east unit of the facility. Diagnosis included fractures of left fibula and tibia (the two bones of the lower leg), pain in left wrist and left leg, fracture of left radius (one of two bones in your forearm), unsteadiness and dependence on other enabling machines and devices.During interview on 9/11/25 at 3:12 p.m., family member (FM)-B stated when R3 got to the facility, the first thing he smelled when they got to her unit was urine. FM-B said R3 had a catheter and the first night a staff member came to empty it and did not place the cap on it and the catheter was leaking urine all over the floor. FM-B said the second time the staff member emptied the catheter bag, she spilled urine on the floor then rubbed the urine into the carpet with a brown paper towel.A facility grievance form dated 8/4/25, filed by FM-C, indicated Residents room is a mess, not enough garbage cans, floor dirty.During interview on 9/12/25 at 10:01 a.m., social service designee (SSD)-A said she was aware of the concerns reported by R3. SSD- A said the concerns included the urine on the carpet, no recliner in the room and some other things. SSD-A said because of the scenarios, R3 did not think the facility was welcoming or clean.During interview on 9/12/25 at 10:52 a.m. the environmental services director (ESD) said typically if she was made aware of a concern and spoke with the resident and/or family and said if training was needed, they would do that. The ESD stated the facility currently did not have a floor technician and said she would like to have the hallways cleaned at least once per week but said they were currently stretched thin.

Based on interview and document review the facility failed to ensure reasonable accommodation of resident needs and preferences upon admission to the facility for 2 of 3 residents (R1, R3) reviewed who reported concerns related to accommodation of needs upon admission to the facility.Findings include: R3's admission Record indicated admitted to the facility on [DATE] at 12:45 p.m. Diagnosis included fractures of left fibula and tibia (the two bones of the lower leg), pain in left wrist and left leg, fracture of left radius (one of two bones in your forearm), unsteadiness and dependence on other enabling machines and devices.R3's Interagency Transfer Orders dated 9/4/25, included oxyCodone 5 milligrams (mg). Give 5-10 mg every four hours as needed for pain. The orders indicated R3 had restricted weight bearing and indicated non-weight bearing on left leg and left arm, okayed for a platform walker at the left elbow.R3's Medication Administration Record (MAR) dated 9/1/25 through 9/30/25, indicated the following order: oxyCODONE HCl (hydrochloride) Oral Tablet 5 MG. Give two tablets by mouth every four hours as needed for pain rated 6-10 out of 10. The MAR indicated R3 received her first dose of oxyCodone at 7:45 p.m. on 9/7/25, for pain rated 10 out of 10, seven hours after she admitted to the facility.R3's admission assessment dated [DATE], indicated she admitted from the hospital via medical transport. The assessment indicated R3's lower left extremity was in a cast, ACE wrap. Left lower arm in cast, ACE wrap. Foley catheter in use. The assessment indicated R3 was chairfast with ability to walk severely limited or non-existent. Could not bear own weight and/or must be assisted into chair or wheelchair. Able to make frequent though slight changes in body or extremity position independently. The assessment identified frequent severe pain in the last five days that interfered with day-to-day activities. R3's care plan dated 9/7/25, identified the use of an indwelling catheter and indicated pain. The care plan directed staff to monitor for non-verbal pain indicators or change in behavior related to pain such as grimacing, change in ability to perform activities of daily living (ADL)'s and directed staff to offer nonpharmacologic interventions such as heat/cold, massage and distraction. The care plan further identified and ADL and mobility deficit and indicated she transferred using a platform walker. R3's Progress Notes indicated the following:-9/7/25 at 3:38 p.m., R3 arrived on the unit at 12:45 p.m. R3 was alert and oriented and able to make needs known. R3 was oriented to room, call lights and questions were answered as best as writer could. -9/8/25 at 5:55 a.m., R3 reported severe pain in left arm and leg, as needed oxyCodone was given around the clock to manage pain. R3 had approximately three hours of sleep the previous night. -9/9/25, Social services met with R3 and family member (FM)-B and discussed options for transitional care unit transfer as well as going to the hospital. R3 decided to go to the hospital. 9/9/25, R3 left the facility via ambulance. FM-B spoke with writer and nurse manager, verbalized wanting to go to the emergency department and not come back to the facility. During interview on 9/11/25 at 3:12 p.m., family member (FM)-B stated R3 went through 48 hours of hell, when R3 admitted to the facility on Sunday at noon and had not received pain medication prior to discharge from the hospital, got to her new room at the facility where she was transferred into bed by the Medivan driver, himself and a staff person. FM-B said there were no mobility devices in the room and staff said someone from physical therapy would be performing an assessment on Monday but until then, R3 would have to remain in bed. FM-B said a commode was brought into her room but there was no way to get R3 onto to it because there were no devices. FM-B added he stayed for several hours and left for a couple hours and R3 called and asked him to come back. He stated they learned she was not going to get any pain medication because the pharmacy only delivered once a day on the weekends. He said R3 was at max pain, had not received pain medication since the morning and finally received pain medication again at 8:00 p.m. and said all they had offered prior was Tylenol. FM-B said R3 had been beside herself in pain. FM-B said the next morning he talked to social services and reported what had happened. He said a therapy assessment was not completed until 4:00 p.m. on Monday and therapy had at least brought a recliner, walker and a grab bar. FM-B said the second night was no better than the first and said R3 asked for a suppository and was assisted onto the commode and because the suppository was not effective a staff member forcibly put an adult diaper on R3 and put her back to bed. Then, around 10:00 p.m., two staff came into the room and turned on the light talking about how they were looking for something which woke R3 up. FM-B added, We had to get her out of there. FM-A said they told the social worker they were going to leave and were not coming back. During interview on 9/12/55 at 8:13 a.m., licensed practical nurse (LPN)-A stated therapy worked on the weekends sometimes but said most of the time she did not see them. LPN-A stated technically when they had a new admission, until therapy assessed them, she could not give them a walker. LPN-A said sometimes people were a little upset when they come in and said it could be that someone could not get out of bed until therapy came. LPN-A stated if a resident came and needed a pain medication they could get it from the emergency kit.During interview on 9/12/25 at 8:35 a.m., the therapy director stated the weekend coverage was 50/50. The therapy director said if equipment was needed on a weekend nursing was supposed to ensure it was available.During interview on 9/12/25 at 8:42 a.m., nursing assistant (NA)- A stated when someone admitted to the facility the admission orders directed diet, transfer status, etcetera. NA-A said sometimes they could ask the paramedics how someone transferred when they arrived. NA-A said therapy had to do an assessment and said if a resident needed equipment therapy had to tell them that, for instance if they had a special walker, we don't have that. NA-A said they tell residents they had to stay in bed until therapy assessed them, and they would use a bed pan until the needed equipment arrived. NA-A stated, if someone came on a weekend they had to stay in bed until therapy could evaluate. During interview on 9/12/25 at approximately 9:00 a.m., social service designee (SSD)-B stated there was a grievance filed and said R3 had waited a while to get pain medications and also had an incident in which a nursing assistant (NA) had spilled a catheter. SSD-B said the medications was a big one. During interview on 9/12/25 at 11:22 a.m., the director of nursing (DON) stated R3 came in with pain on a Sunday and said the nurse had an order for pain medication and faxed it to the pharmacy. The DON said by evening, staff called the pharmacy and got the okay to get a dose from the emergency kit. The DON said the nurses could call the pharmacy anytime to request a medication from the emergency kit. The DON said R3's main concern was pain medication and said she talked about not having a grab bar for the bed. The DON said they preferred to wait for therapy to do an assessment before providing devices. During interview on 9/12/25 at 10:16 a.m., R3 stated she never wanted to go back to one of those places, referring to the facility. R3 said when she got to the facility, she had no ability to put weight on her left arm or leg and said once she got into the bed she had no way to shift her weight or get any leverage and said she felt very trapped. R3 said when she asked about a walker she was told physical therapy would bring one but not until the next day. R3 said she did not think the facility was equipped to care for her when she admitted , had no wheelchair she could get into and no pain medications until 7:45 p.m., even though she had asked for them. She said the nurse told her they would not have medications until later in the day and the pain just kept getting worse and worse. R3 said there was a lack of preparation and said the staff had no knowledge of how to get her out of bed. She said she could not get staff to help and could not do it herself. R3 said the overnight staff were not helpful R1's admission Record indicated he admitted to the facility on [DATE]. Diagnosis included surgery of digestive system, chronic pain, and weakness. R1's admission assessment dated [DATE], indicated he admitted to the facility on [DATE]. The assessment indicated R1 was alert and oriented, had a colostomy and was continent of bladder. The assessment indicated R1 walked occasionally but for very short distances and spent the majority of each shift in bed or chair.R1's care plan dated 8/21/25, identified intact cognition and indicated R1 had a new colostomy and directed staff to check device each shift, and ass needed for appropriate fit, leakage and need for emptying. The care plan identified a self-care deficit and indicated he required assistance from staff for grooming, toileting, ambulation and wheelchair mobility.During interview on 9/11/25 at 12:25 p.m., FM-A stated R1 had been at the facility in the past and had received great care but since his current admission had not received good care. FM-A said he spent approximately eight hours a day at the facility during R1's stay. FM-A stated the first night R1 was at the facility, he (FM)-A got to the facility after 7:00 p.m. and the door was locked and no one would answer the phone to let him in. When he finally got in, R1's call light was on, and he was lying in a puddle of urine and waited an hour for someone to help him. FM-A said, it was so bad, and said he couldn't find anyone to help R1. FM-A said one of the nights, he waited two hours for someone to come and change R1's colostomy bag so he started to do it himself. FM-A said when a nurse finally came in, she asked how to change the bag.

Based on interview and document review, the facility failed to ensure assistance, to resident triggered call light needs, was provided timely to promote dignity and reduce the risk of potential complications (i.e., incontinence, skin impairments, falls, changes in condition, etc.) for 8 of 8 residents (R1, R2, R3, R4, R5, R6, R7, R8) who expressed concerns related to extended call light response times and associated potential risk factors to their health.R8:R8's quarterly Minimum Data Set (MDS), dated [DATE], identified R8 lacked communication impairments and required some form of physical assist with most of his ADLs and mobility. R8 was frequently incontinent of bowel and bladder, at risk for pressure ulcers, and was diagnosed with diabetes, Parkinson's disease, and muscle weakness. R8's medical record identified his most recent brief interview for mental status (BIMS) was 15 (cognitively intact). R8's admission Record, printed [DATE], identified he desired CPR if his heart were to stop beating. R8's comprehensive care plan, reviewed [DATE], indicated R8 experienced pain related to a prior right femur fracture, was at risk for falls and needed assist to anticipate needs, required a soft touch call light, history of skin impairments, and was additionally diagnosed with obesity and chronic respiratory failure with hypoxia. Alerts List reports, dated [DATE], through [DATE], identified the following R8 call light activation dates, activation/de-activation timeframes:-[DATE]: 3:01:20 p.m. to 3:32:22 p.m. (31 min and 2 secs).-[DATE]: 2:54:25 p.m. to 3:28:50 p.m., (34 min and 25 secs). R10:R10'a quarterly MDS, dated [DATE], identified R10 was cognitively intact and required some form of physical assist with most of his ADLs and mobility. R10 was occasionally incontinence of bladder and always incontinent of bowel, was at risk for pressure ulcers, and was diagnosed with, but not limited to, heart failure, diabetes, depression, diarrhea, and chronic renal disease that required dialysis management. R10's admission Record, printed [DATE], identified he desired CPR if his heart were to stop beating. R10's comprehensive care plan, reviewed [DATE], indicated R10 was at risk for falls and experienced pain/potential for pain. Alerts List reports, dated [DATE], through [DATE], identified the following R10 call light activation dates, activation/de-activation timeframes:-[DATE]: 9:45:25 a.m. to 10:16:15 a.m. (30 min and 50 secs). R4:R4's annual MDS, dated [DATE], identified R4 was cognitively intact and required physical assistance of staff for ADLs and mobility. He was always incontinent of bowel and bladder, and diagnoses included, but not limited to, diabetes, seizure disorder, schizophrenia (bipolar type), morbid (severe) obesity, and obstructive sleep apnea. R4 fell once in the past quarter and was at risk for pressure ulcers. R4's comprehensive care plan, reviewed [DATE], identified R4's cognition was impaired which impacted his memory and decision-making ability. Additionally, R4 had potential for pain related to his diagnoses and decreased mobility, and his behavioral expressions were mania and hallucinations/delusions. Alerts List reports, dated [DATE], through [DATE], identified the following R4 call light activation dates, activation/de-activation timeframes:-[DATE]: 4:02:16 p.m. to 4:41:06 p.m. (38 min and 50 secs), 4:41:54 p.m. to 5:05 p.m. (23 min and 50 secs), 8:49:23 p.m. to 9:13:11 p.m. (23 min and 48 secs), 9:50:18 p.m. to 10:17:25 p.m. (27 min and 7 secs). R5:R5's quarterly MDS, dated [DATE], identified R5 was cognitively intact and required extensive physical assist to dependence on staff for ADLs and mobility. R5 was frequently incontinent of bowel and bladder, was at risk for pressure ulcers, and was diagnosed with anxiety disorder, depression, morbid (severe) obesity, and benign neoplasm of the meninges (layers that covers the brain and spinal cord). R5's comprehensive care plan, reviewed [DATE], identified R5 experienced pain/potential for pain, and was at risk for falls related to decreased mobility with history of falls and associated fractures. Additionally, she was at risk for abuse with an intervention to assist and support her in an emergency. Alerts List reports, dated [DATE], through [DATE], identified the following R5 call light activation dates, activation/de-activation timeframes:-[DATE]: 2:14:45 p.m. to 3:04:23 p.m. (49 min and 38 secs).-[DATE]: 5:27:15 p.m. to 6:23:26 p.m. (56 min and 31 secs). R2:R2's quarterly MDS, dated [DATE], identified R2 was cognitively intact and overall independent with activities of daily living (ADLs). R2 was occasionally incontinent of bladder. Diagnoses included, but not limited to, anxiety disorder, bipolar disorder, post-traumatic stress disorder (PTSD), panic disorder, and a history of falling. At times, R2 experienced shortness of breath (SOB) with activity and a fall in the past quarter. R2 utilized oxygen and was at risk for pressure ulcers. R2's comprehensive care plan, reviewed [DATE], identified R2 had altered respiratory status with difficulty breathing related to acute respiratory failure with hypoxia and asthma and that her cognition/decision making skills may be affected by diagnosis of dementia with periods of delirium in relation to malignant brain cancer. Additionally, she was at risk for falls due to impaired mobility and balance, along with many other diagnoses. Staff were to encourage R2 to call for help to bring, or pick up, her laundry and when she wished her radiator adjusted. Staff were also directed to check on R2 frequently to anticipate her needs and there was to be a sign in her room to call for help when assistance was needed to minimize spontaneous impulsive self-transfers. Staff were also to watch her for orientation changes, increased restlessness, anxiety, and air hunger. The Alerts List identified R2 did not engage her call light between [DATE], and [DATE]. R6:R6's quarterly MDS, dated [DATE], identified R6 was cognitively intact and was overall dependent on staff for ADLs. R6 utilized a Foley catheter for bladder management but was always incontinent of bowel. R6 was at risk for pressure ulcers and diagnoses included, but not limited to, non-Alzheimer's dementia, MS, depression, and chronic pain syndrome. R6's comprehensive care plan, reviewed [DATE], identified R6 had cognitive impairments, but he was a reliable reporter. R6 experienced pain/potential for pain and was at risk for falls. Alerts List reports, dated [DATE], through [DATE], identified the following R6 call light activation dates, activation/de-activation timeframes:-[DATE]: 12:24:07 p.m. to 12:59:36 p.m. (35 min and 29 secs), 5:15:02 p.m. to 5:44:32 p.m. (29 min and 30 secs). R7:R7's quarterly MDS, dated [DATE], identified R7's primary language was not English, and she was severely cognitively impaired. R7 required substantial/maximal physical assist with ADLs and mobility, was always incontinent of bowel and bladder, and was at risk for pressure ulcers. Diagnoses included, but not limited to, heart failure, diabetes, non-Alzheimer's dementia, anxiety disorder, depression, dependence on supplemental oxygen, and morbid obesity with alveolar hypoventilation (failure to breath rapidly or deeply enough resulting in low oxygen levels and high blood carbon dioxide levels). R7's admission Record, printed [DATE], identified she desired CPR if her heart were to stop beating. R7's comprehensive care plan, reviewed [DATE], indicated R7 had an English language deficit, experienced chronic pain, was at risk for falls, needed staff to assist with anticipation of needs, was at risk for complications associated with high or low blood sugars, and had difficulty breathing. Alerts List reports, dated [DATE] and [DATE], through [DATE], identified the following R7 call light activation dates, activation/de-activation timeframes: -[DATE]: 4:02 p.m. to 6:13:26 p.m. (2 hours, 11 min, and 18 secs). -[DATE]: 5:58:48 a.m. to 6:37:10 a.m. (38 min and 22 secs), 8:18:39 p.m. to 8:43:12 p.m., (24 min and 33 secs), 10:29:18 a.m. to 11:15:54 a.m. (46 min and 36 secs), 10:41:21 p.m. to 11:09:28 p.m. (28 min and 7 secs).-[DATE]: 4:32:30 p.m. to 4:57:55 p.m. (25 min and 25 secs), 5:03:34 p.m. to 5:48:35 p.m. (45 min and 1 sec).-[DATE]: 10:27:31 a.m. to 10:56 a.m. (29 min and 27 secs), 6:33:31 p.m. to 6:59:29 p.m., (25 min and 58 secs). R1:R1 quarterly Minimum Dat Set (MDS), dated [DATE], identified R1 was cognitively intact and required substantial/maximal staff assistance for transfers and toileting. Additionally, R1 was frequently incontinence to bowel and bladder, was assessed to have moisture associated skin damage (MASD), and was at risk for developing pressure ulcers. Diagnoses included, but not limited to, diabetes and multiple sclerosis (MS). R1's comprehensive care plan, reviewed [DATE], identified R1 grieved his loss of independence related to MS and was triggered by call light wait times. Interventions indicated R1 wanted to be acknowledged by staff if his needs were unable to be met immediately when he activated his call light. Staff were directed to update him when they expected they would return to assist him and were to return to him at that time. Additionally, staff were to support R1 by providing him with a safe and welcoming environment. The care plan identified additional diagnoses of history of pressure ulcer to both left and right buttocks, morbid (severe) obesity, diarrhea, and borderline personality disorder. Additionally, R1 was able to use the standing lift with one staff when not behavioral, and when the nurse manager was in the building. At other times, he required two staff for standing lift transfers. A Grievance form, dated [DATE], identified R1 was concerned that he pushed his call light at 1:50 p.m. and it remained on until approximately 2:35 p.m. to 2:40 p.m. Staff informed him they would grab someone and be right back. The grievance form lacked evidence which day his concern pertained to; however, an Alerts list (call light activation and response times) report identified a log dated [DATE], and identified the following call light activation and de-activation timeframes:-8:41:58 p.m. to 9:11:24 p.m. (29 min and 26 seconds (secs).-3:40:31 p.m. t0 4:00:09 p.m. (19 min and 38 secs).-An attached staff's (unreadable signature) statement, dated [DATE], indicated they spoke to R1 and R1 indicated staff answered the light within 20 minutes to communicate that another staff needed to be present, and left to find another staff to assist. The note identified this was in accordance with R1's care plan. The facility follow-up lacked a call light log from [DATE], or any other days, or how long it took the staff to return. Alerts List (call light activation and response times) reports, dated [DATE], and [DATE], through [DATE], identified the following R1 call light activation dates, activation/de-activation timeframes: -[DATE]: 6:32:59 a.m. to 7:05:18 a.m. (32 min and 19 secs), 10:28:13 a.m. to 11:02:59 a.m. (34 min and 46 secs).-[DATE]: 10:22:42 a.m. to 11:05:04 a.m. (42 min and 22 secs), 8:20 p.m. to 8:46 p.m. (26 min and 27 secs).-[DATE]: 12:03:25 p.m. to 12:28:44 p.m., (25 min and 19 secs), 4:12:24, p.m. to 4:37:32 p.m. (25 min and 8 secs), 8:22:40 p.m. to 8:51:10 p.m. (28 min and 30 secs).-[DATE]: 5:44 p.m. to 6:12:13 p.m. (28 min and 3 secs), 9:26:24 p.m. to 9:50 p.m. (24 min and 32 secs).-[DATE]: 10:27:55 a.m. to 10:52:45 p.m. (24 min and 50 secs). R3:R3's medical record identified she admitted on [DATE] and a BIMS, dated [DATE], identified she was cognitively intact. Additionally, R3 desired full resuscitation (CPR) if her heart were to stop beating. R3s comprehensive care plan, reviewed [DATE], identified R3 required extensive physical assist of staff for ADLs and mobility, and was at risk for falls and skin breakdown due to incontinence-associated dermatitis. Identified diagnoses included but not limited to aftercare for knee replacement and morbid obesity. Alerts List reports, dated [DATE], through [DATE], identified the following R3 call light activation dates, activation/de-activation timeframes: -[DATE]: 7:36 p.m. to 8:07:18 p.m. (31 min and 6 secs).-[DATE]: 6:12:23 a.m. to 6:33:47 a.m. (21 min and 24 secs), 10:37:27 a.m. to 10:59:30 a.m. (22 min and 3 secs). Facility wide Alerts List reports, dated [DATE], through [DATE], identified the following additional call light information:-1st Floor (35 rooms activated at least once in the 4 days and 11 rooms in total with call light response times 20 min or greater on one or more instances.-[DATE]: 6 (call light activations 20 min or greater).-[DATE]: 6-[DATE]: 3-[DATE]: 3-18 total call light activations 20 min or greater.-20 to 29:59 min: 11 (number of call lights).-30 to 39:59 min: 2-40 to 49:59 min: 4-50 to 59:59 min: 0-60 to 119:59 min: 1 -2nd Floor (45 rooms activated at least once in the 4 days and 15 rooms in total with call light response times 20 min or greater on one or more instances.-[DATE]: 12 (call light activations 20 min or greater). -[DATE]: 5-[DATE]: 5-[DATE]: 4-26 total call light activations 20 min or greater.-20 to 29:59 min: 18 (number of call lights).-30 to 39:59 min: 3-40 to 49:59 min: 3-50 to 59:59 min: 2 -3rd Floor (44 rooms activated at least once in the 4 days and 25 rooms in total with call light response times 20 min or greater on one or more instances.-[DATE]: 25 (call light activations 20 min or greater).-[DATE]: 27-[DATE]: 16-[DATE]: 10-78 total call light activations 20 min or greater.-20 to 29:59 min: 33 (number of call lights).-30 to 39:59 min: 22-40 to 49:59 min: 9-50 to 59:59 min: 3-60 to 119:59 min: 9120 to 180 min: 2 Call light audits were requested, along with any information to support the higher trending of extended call light times was acted upon prior to the survey; however, none was provided. A post-survey email from the administrator, dated [DATE], provided additional details related to grievances, and identified the following respective information: (month, number of grievances related to Wait Times, percentage of wait times based on their census, and average call light response times): -January: 6; 3.64%; 7 min and 54 secs.-February: 3; 2.04%; 7 min and 29 secs.-March: 5; 3.4%; 7 min 48 secs.-April: 5; 3.5%; 7 min 36 secs.-May: 3; 2.0%; 7 min 28 secs.-June: 6; 3.68%; 8 min 9 secs.-July: 1 as of [DATE]; 0.63%; 7 min 29 secs. A post-survey email from the administrator, dated [DATE], provided additional details related to grievances follow-up and identified on [DATE], a staff meeting was held, and staff were educated on reasonable accommodation for needs/preferences, and call lights being a repeated grievance, along with customer service education, resident rights, dignity, and the importance of these items. An image of the education was attached which identified that on [DATE], multiple call lights were ringing on the second floor for greater than six minutes, and on [DATE], during the morning med pass, room [ROOM NUMBER] rang for 5.5 minutes before the nursing assistant stopped her tray delivery and answered the call light. While 5 minutes is GREAT, what was identified is that staff were passing the room while the call light was on and not acknowledging the resident. Another image identified F585 - Grievances, and Call lights are a repeat grievance month after month in the binder. The education provided lacked any additional information. During an interview on [DATE], at 11:22 a.m., R8 stated overall he had no concerns with his stay; however, call light response times bothered him. He expected the call light to be answered within five to 10 mins but, at times, which occurred at least weekly, the time was extended at times up to 30 minutes. He denied any negative outcomes related to this; however, he was concerned that he may have increased pain, incontinence, or that he may go hungry, if staff did not answer it timely. During an interview, and video reviews, on [DATE], at 11:31 a.m., R1 expressed multiple concerns related to his stay; however, he was most concerned with extended call light response times. Most of his requests centered around his bathroom needs, where extended wait times caused increased incontinence that led to increased skin concerns, such as chafing, especially in the setting of past skin breakdown. He explained, when he has to go, he has to go now. He indicated wait times were as long as 58 min and expressed, If I had a heart attack, I would be dead, and blamed a current urinary tract infection (UTI) on these wait times and having to sit in incontinent stool. He did not feel this was the fault of staff, but blamed management as they required him to have two staff for transfers [which was required when R1 became behavioral.] R1 showed the surveyor three videos. One video, dated [DATE], at 6:54 a.m., identified R1 yelled out for help for a few mins, and no one responded before he ended the video. A follow up video, dated [DATE], at 7:10 a.m., showed two staff in R1's room. R1 was agitated with elevated vocal tones with rushed speech, and argumentative with the staff. He stated to staff that he had to wait more than 20 mins and then more than 40 mins before staff assisted him. A third video, dated [DATE], at 10:45 a.m., showed R4 sat in a w/c in his room. He stated he pushed his call light button at 10:23 a.m., and staff had informed him they had to wait for someone as he needed two staff which he thought was bullshit as he could basically stand on his own. Additionally, he commented, I cannot handle this anymore, and that he was, Sitting here in my own piss with a chafed bottom. When interviewed on [DATE], at 12:11 p.m., R4 stated he was overall satisfied with his care; however, call light times could be better. Typically, staff answered his call light within 15 min, which was acceptable to him; however, there were times when it took 20 to 30 min, which was not acceptable. He indicated this elevated response time occurred maybe once a week, and had occurred in the past few days. He explained these instances were often when he felt he needed his incontinence product changed. This concerned R4 as he wished to be free of bed sores or other skin issues. Additionally, if there is something major and they would not respond quickly, that could be a problem. During an interview on [DATE], at 12:19 p.m., R5, when asked if there were any concerns with her call light, immediately stated she was sick and tired of sitting in [her] poop. She explained that 15 min was acceptable, but anything over that was not. Call light response times were often over the 15 min expectation, and she recently was made to wait over an hour for an incontinence brief change after she experienced an episode of diarrhea. This concerned her as she stayed in bed most of the time and already had skin breakdown. Additionally, as she was at the very end of the hallway, if something serious was to happen, she would not get timely help. She indicated she had many issues, with anxiety being among them, and just thinking about them not getting to her timely increased her anxiety. R5 stated increased response times were worse prior to and after meals, but today they seemed better. She expressed this was due to the surveyor's presence in the building, and thanked the surveyor for the visit as it saves [her]a call. During an interview on [DATE], at 10:58 a.m., licensed practical nurse (LPN)-A identified herself as the first-floor clinical coordinator. She stated staffing was based on census and not acuity, which concerned her, as her floor experienced higher acuity residents. Recently, in response to this concern, she redistributed assignments to assist with workflow; however, had yet to see improvements. She was unaware of any adverse outcomes related to their current staffing patterns; however, she had noticed an increase in grievances related to extended call light response times. LPN-A identified the facility had a grievance committee which met once a week; however, no official notes were taken. Despite this meeting, follow up on the grievance concerns basically was non-existent so far, other than the redistribution of assignments and instructions to staff that all staff were to answer call lights, but she stated staff already knew this expectation. LPN-A stated that initially facility expected call light times was between seven and 14 min, but when they received new administration, this increased to 20 mins. She expressed an expectation for her staff of 10 mins. LPN-A reported that around early 2022 or 2023, call light audit reports were run and any response over 13 mins was followed up on; however, this was no longer performed. Currently, call light times were only reviewed with the grievance process. LPN-A explained she felt call light grievances were increased due to admit after admit of complex people and her unit being heavy. She continued with staff just did not have the time to promptly answer call lights and due to this she focused on ensuring residents were updated about expected response time frames: This is how we manage, but it is not the greatest system. When interviewed on [DATE], at 1:00 p.m., R3 indicated that her call light was answered normally within five to 10 minutes, which she expected; however, there were times when this was elevated. She verbalized, at least once, it took over 30 minutes for assistance to go to the bathroom. This significantly concerned her as she was fearful of bladder accidents if her call light was not answered in her expected timeframes. In response, she attempted to plan and put her call light on before she had to void as you never know when they will show up. R3 stated she had filed a grievance related to call light use; however, this was in response to a staff member who brought her back to her room and just pushed her in and left her without ensuring she had her call light. She attempted to get staff's attention, as she was not well versed in operating the wheelchair (w/c) at that time, but staff did not respond until approximately 30 minutes later. This frustrated her and she continued to be concerned it may happen again, but she followed up she was better an w/c management. She had yet to hear back from the facility on any follow up to the grievance. During an interview on [DATE], at 1:07 p.m., R2 stated she was the resident council president. She denied any personal call light response time concerns over the past few days; however, explained that she was overall independent and did not need staff assistance that often. She identified, when she did use her call light, she often waited typically 15 min or so and had waited up to 30 min. This was unacceptable to her, as she felt if she engaged her call light, staff should be more concerned as this was not typical for her. Her expectation was 7 min or less based on a timeframe management told her approximately two years ago. She was unsure of the current management's expectations. R2 explained she observed residents who routinely engaged their call lights all day, especially at times when aides are not going to be available, such as mealtimes. This was going to then increase the time they had to wait. R2 stated she had heard residents who complained of call light issues recently and felt this needed to again be addressed at the next meeting. R2 denied management had approached her for conversations related to potential call light concerns. When interviewed on [DATE], at 1:24 p.m , NA-C stated she was expected to answer the call light as soon as it was noted to be on. Often the call lights were on for five to 10 mins, but at times longer. She was unable to state for sure how long call lights were on, as if she were in a room, she may not know the light was on until she finished working with that resident. NA-C verbalized 20 mins was too long for a call light to go unanswered as maybe someone was on the floor or someone needed help. She stated facility management had recently instructed staff they were required to answer the call light right away, but they have not involved her in any discussions related to extended call light response times. During an interview on [DATE], at 1:28 p.m., registered nurse (RN)-A stated facility expectations for answering the call light were five to eight mins, but she was not one hundred percent sure. Her own personal expectation for five to 10 mins; however, she expected staff to try as soon as possible. RN-A expressed increased call light wait times are mainly during morning cares and around mealtimes. She struggles with the extended wait times as residents need assistance for such things as bathroom processes and/or they may not feel well. In such cases, she wanted residents to be attended to sooner than later for fall prevention. If a resident was made to wait for extended periods of time, they were more apt to do things themselves. RN-A identified call light concerns were brought to management; however, she had yet to see action to decrease her concerns. When interviewed on [DATE], at 1:34 p.m., LPN-B stated facility call light response expectations were not more than 20 mins. If a call light was on, and staff answered it, but the resident needed additional staff assist [two-person transfer], the call light was kept on until both staff returned to the room. LPN-B was unaware of any extended call lights past the expected 20 mins. She explained if a call light was on for longer than this expectation, a resident was at risk for such things as falls and the importance of answering a call light timely was to know resident needs and to ensure resident safety. LPN-B denied any involvement in call light discussions; however, management had come around and informed staff that they expected all staff to answer the call lights. She was unsure as to when this instruction was provided. When interviewed on [DATE], at 1:56 p.m., R6 visited with a best friend (BF-A). BF-A stated she was here five days a week. Both R6 and BF-A expressed call light response concerns which often occurred a few days a week. At times, the wait times extended to an hour and a half and depended on who worked. Such an incident occurred last week when staff just did not show up. Often, the extended wait times occurred when R6 requested to lay down, as he required a mechanical lift for transfers, and/or he soiled his pants. Both R6 and BF-A were concerned for R6's skin status, which currently lacked breakdown, but which he was at great risk for, and for his safety. During an interview on [DATE], at 2:04 p.m., R7 visited with her family member (FM)-A. FM-A translated the conversation. R7 stated most of the time her call light was not answered timely, or staff entered her room, shut off the light, and walked back out of her room without helping her. She expected it to be answered right away. FM-A stated he also expected the call light to be answered right away, or at least timely, to at least inquire as to R7's needs and that a wait time above seven or eight minutes was too long. FM-A stated he was aware of call light response concerns as R7 complained to him when he visited, along with observed extended wait times when he visited. Her complaints and his observations did not occur daily but occurred enough for him to discuss concerns with staff. However, staff just gave him reasons such as they did not know what R7 wanted. R6 explained there were times she was scared, especially when she experienced SOB and wanted staff to check her oxygen levels, but staff did not respond to her call light which thus increased her anxiety. FM-A was also concerned that if staff failed to response to R7's call light, R7 may experience increased pain, hunger, and/or respiratory impairments, and, if staff continued to not answer her call light timely, R7 may give up calling, and then something serious may happen. When interviewed on [DATE], at 2:15 p.m., NA-A stated she was expected to answer the call lights as soon as possible. She expressed concerns related to longer response times which overall occurred during morning cares and around mealtimes. NA-A stated residents were at risk for falls related to this as often they needed help to the bathroom and if were made to wait, the resident may attempt to go by themselves. She had not seen an increase in falls, but she expressed an increased potential for them. NA-A stated management only talked about call light times when a grievance came up, otherwise, they just told her to answer the call light, even it if was not hers. During an interview on [DATE], at 2:24 p.m., social worker (SW)-A stated back in [DATE], there were many complaints related to call light response times, but since then, it had decreased. She was unaware of any recent increases. SW-A explained when a grievance was reported to her, she wrote it up or gave the already completed sheet to the grievance director. They then discussed the grievance and determined any corrective action if warranted. She indicated she participated in the grievance committee and felt that over the last month grievances for call lights had improved; however, she stated two care conferences (R1 and R6) this week brought up call light concerns. SW-A stated the expectation was for call lights to be answered within 20 mins. She was unsure who made that decision and verbalized 20 mins was a long time to wait, especially when the bathroom was required. She was concerned about this expectation and/or extended all call times as residents may attempt to get up independently and risk falling or soil themselves and feel embarrassed or angry. She had not heard of resident accidents related to this concern, but she was aware of upset residents. When interviewed on [DATE], at 2:45 p.m., the social services director (SSD) stated when a grievance came into his office, the team worked together to investigate and come up with an applicable plan if necessary. He denied he kept minutes during the meetings as the meetings were basically just a review of the grievances and what was done. When asked on any recent grievance trends, he stated call light wait times was one of them; however, he explained most of them were found unsubstantiated after review as the wait time the resident stated, was not their true wait time based on the call light logs. He identified seven grievances in [DATE], were more than a typical month but had yet to prepare his information for the [DATE], quality improvement meeting, so was unsure of any follow up on this higher trending. He expected call lights to be answered within 20 mins, which the previous director of nursing (DON) instructed. SSD identified wait times, at times, were over 20 minutes, but when he reviewed the logs after surveyor's request for them, he was impressed the average call light response times were under 10 mins. He verbalized call light times greater than the 20 mins were too long. When extended times were reported to him during the interview, he indicated those had not come to his attention prior to the survey and thus he was not aware of such extensive concerns, but he identified the facility performed call light education in the past with staff, along with previous audits. He was unaware of any recent follow-up. During an interview on [DATE], at 3:18 p.m., the interim director of nursing (DON) stated grievances were brought to the standup meetings and a noted trend was related to call light response times. Based on their grievance investigations, they determined staff often forgot to turn the call light off right when they entered the room. The DON indicated he continued to work with LPN-A on assignment adjustment to ease staff workload as the first floor was a heavier workload floor. No additional staff were yet added, however. He hoped the adjustments would help decrease extended call light response times. The DON stated, there is a general consensus around 20 minutes for staff to answer the call light; however, he indicated he wanted that lower, at an overall average of seven minutes, but he recognized things happen. He was unaware how 20 mins came to be the consensus. Call light concerns were brought up in staff meetings and he expected all staff to answer call lights as resident needs could be as simple as requests for a pen to being uncomfortable and/or needing the bathroom. They need our help, that is why they are here. When interviewed on [DATE], at 3:45 p.m., the administrator stated she was not super involved from a clinical s[T

Based on observation, interview, and record review, the facility failed to immediately, but no later than two hours, report to the state agency an allegation of abuse for one of three residents (R1) reviewed for employee to resident sexual abuse. Findings include: During an observation on 11/26/24 at 10:15 a.m. R1 was in his room calling out to nurse manager (NM)-A who was walking past R1's room. R1 was heard saying they said not to take the abuse allegations lightly, so I called 911 again and they told me to call the sergeant. NM-A asked R1 if the police officer came to talk to him and R1 stated no. R1 stated he wanted that woman arrested for abuse. NM-A stated, it was not abuse. R1 stated it was sexual abuse. NM-A stated to R1 it was not sexual abuse and walked out of R1's room. R1's Facesheet indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of gas gangrene. R1's additional diagnoses included pathological fracture on right radius, malignant neoplasm of prostate, paranoid schizophrenia, wedge compression fracture of third lumbar vertebra, wedge compression fracture of fourth lumbar vertebra, and wedge compression fracture of fifth lumbar vertebra. R1's Bladder and Bowel assessment dated [DATE] indicated R1 was continent of urine and incontinent of bowel. The assessment indicated R1 used a urinal to urinate. R1 wore incontinent briefs. R1's Functional Abilities and Goals assessment dated [DATE] indicated R1 required substantial/maximal assistance with toileting and partial/moderate assistance with personal hygiene and transfers. R1's minimum data set (MDS) dated [DATE] indicated R1 had a brief interview for mental stats (BIMS) score of fifteen, which indicated R1 was cognitively intact. R1 did not have hallucinations or delusions. R1's required substantial/maximal assistance with toileting hygiene, bathing, and dressing. R1 required partial/moderate assistance with personal hygiene. R1 was frequently incontinent of her bladder, and always incontinent of his bowel. R1 had schizophrenia and was not on antipsychotic medications. R1's BIMS assessment dated [DATE] indicated R1 had a score of fourteen which indicated R1 was cognitively intact. R1's progress note dated 11/17/24 indicated R1 stayed in bed during the duration of shift and staff has assisted R1 with activities of daily living. R1's care plan dated 11/22/24 indicated R1 had activities of daily living and mobility deficit related to gas gangrene of left foot, non-weight bearing on left leg, left lower extremity cellulitis, left and right foot wounds, weakness, peripheral vascular disease, anemia, malnutrition, paranoid schizophrenia, anxiety, malignant neoplasm of prostate, prediabetes, Charcot's joint in left food, planter callosity, pain, and lumbar wedge compression fractures. The intervention placed on 11/22/24 was cares in pairs. R1's care plan dated 11/25/24 indicated R1 had a history of behaviors. R1's behaviors are typically using the term abuse/hate crimes in relation to receive care such as being weighed, hair being washed/dried with hair dryer, and fixation on medical malpractice lawsuits from past hospital stays years ago. R1's behaviors are related to paranoid schizophrenia. The interventions indicated were two staff with R1 to provide cares cares in pairs, follow the hospital psychology services, staff would anticipate resident care needs prior to R1 becoming overly stressed and explain the cares in advanced. R1's progress note did not indicate R1's allegations of sexual abuse. During an interview on 11/26/24 at 9:13 a.m., R1 stated on 11/17/24 an nursing assistant (NA) was providing pericare when the NA grabbed on to his anus and pulled on it very hard about two to three times. R1 described the incident as a vicious and violent assault. R1 could not recall the name of the NA who assisted. R1 reported the incident to NM-A and thought NM-A had reprimanded or talked to the NA about it. R1 was unsure whether he obtained any injuries from the incident. R1 called 911 on 11/17/24 and described in detail what had happened. R1 stated the 911 operator told him to leave a message with the sergeant and the sergeant would call him back. R1 had left a message for the sergeant. R1 stated the receptionist brought R1 a note stating to call the sergeant back at the phone number provided. R1 provided the note. During an interview on 11/26/24 at 9:59 a.m., registered nurse (RN)-A stated she was told R1's care plan was updated with cares in pairs over the weekend because R1 stated he was not being cleaned up properly after an incontinent episode. During an interview on 11/26/24 at 10:25 a.m., NM-A stated she was told by R1 on 11/22/24 that an NA provided pericare after a bowel movement when the NA had wiped his anus too hard, and it was sexual assault. NM-A talked with social services director (SSD) and the director of nursing (DON) about the incident and did not report the incident to the state agency because. she does not make reports to the state agency. NM-A updated R1's care plan to assist R1 in cares in pairs to protect him and protect the facility. During an interview on 11/26/24 at 11:14 a.m., the SSD NM-A did not report an allegation of abuse to R1 or any concern of rough cares. SSD was not informed about R1's report of sexual abuse. During an interview on 11/26/24 at 11:28 a.m., the DON stated she did not get a report from NM-A regarding R1's abuse allegation. If she knew if someone reported an allegation of abuse, she would immediately report it to the state agency and complete an investigation. DON expected a NM to report to SSD, the administrator, executive director (ED), or herself about allegations of abuse. DON stated herself would report it to the state survey agency. If DON is not in the facility, she would expect any leadership to report the allegations to the state survey agency. During an interview on 11/26/24 at 12:31 p.m., The administrator stated he was unaware of an abuse allegation from R1 and just learning today that R1 made allegations about sexual abuse. The administrator stated he would have reported allegations of sexual abuse to the state survey agency. The administrator's expectation is that management staff does report abuse allegations to himself and then he would report the allegations to the state survey agency. The administrator stated if he is not in the facility, there is a reporting structure for notifying the state survey agency. During an interview on 11/26/24 at 1:05 p.m., the executive director (ED) stated all allegations of abuse should be reported to the state survey agency. If a leadership staff learned about the sexual abuse on 11/22/24, it should have been reported to the state survey agency on 11/22/24. During an interview on 11/26/24 at 1:57 p.m., NM-B stated if she were told about an allegation of abuse, she would tell the DON, ensure the resident is safe, place the employee of the allegation on suspension pending the investigation, educate the staff if applicable, and then interview other entities such as social services. NM-B would follow the directions of the DON. NM-B would report the allegations either within two hours or twenty-four hours depending on the allegation. During an interview on 11/26/24 at 2:02 a.m., DON stated she had reported the allegation to the state survey agency when she had found out about the allegations on the day of the survey, she reported the allegation to law enforcement and placed the aide on suspension pending the facility's investigation. The DON named NA-C as the aide who was involved in the incident based on R1's description. During an interview on 11/26/24 at 2:11 p.m., the police officer stated R1 told her he did tell NM-A about the sexual abuse allegations but could not recall when he told her. R1 told the police officer there was some sort of penetration feeling by sticking fingers into his anus. During an interview on 11/26/24 at 2:25 p.m., R1 stated he told NM-A about the sexual abuse because he thought she could help him. R1 only told NM-A about the incident because he was too embarrassed to notify anyone else. During an interview on 11/26/24 at 2:32 p.m., NA-C stated she did not recall events on 11/22/24 but recalls R1 never told her to stop providing pericare after an incontinent episode. NA-C told her he wanted to be cleaned better during pericares. NA-C stated she did not want to hurt R1 when providing pericares. The facility's Abuse, Neglect, and Exploitation policy and procedure dated January 2024 indicated all alleged violations would be reported to the administrator, state agency, adult protective services and to all other required agencies within specified timeframes immediately, but not later than two hours after the allegation of made, if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R423) reviewed. Findings include: R423's annual Minimum Data Set (MDS) dated [DATE], identified R423's cognition as moderately impaired and needed assistance with of one staff with activities of daily living (ADL's). During an observation on 10/24/24 at 7:45 a.m., R423 was laying in her bed with lights on. R423 had a tube of Asper Creme (treats muscle and joint pain), a container of petroleum jelly, and two bottles of Nystatin powder in the yellow bin next to the nightstand and unsecured. R423 stated the nursing assistant (NA) put that on for me. During medical record review on 10/24/24, the medical record lacked evidence of an assessment for self-administering medications (SAM) being completed. The medical record lacked evidence of a physician order for a SAM. During an interview on 10/24/24 at 9:33 a.m., NA-A stated R423 requested the contents of the yellow tube of creme on her shoulders for pain and I [NA-A] did on 10/18/24 around supper time. During a tour of R423 room on 10/24/24 at 1:26 p.m. nurse manager (NM)-A revealed a five-ounce Asper creme tube with 10% trolamine salicylate that expired 2/24. A 13-ounce petroleum jelly container and two bottles of nystatin topical powder 30 grams each which were low in content. One had expired 6/16/24 and the other 2/19/24. During an interview on 10/24/24 at 1:56 p.m., NM-A stated R423 did not have a SAM order and no assessment to SAM. NM-A stated R423 could not apply the creams and powder by themselves. NM-A stated R423 was not to have medications in her room without an order. NM-A stated she did not know the medications were in the room. NM-A stated the NAs were not trained to put on topical creams and powders. During an interview on 10/24/24 at 2:22 p.m., the director of nursing (DON) stated the NAs cannot put on creams and powders, only the nurses. The facility policy Self Administration of Medications dated 8/24, indicated a resident may only self-administer medications after the facility's has evaluated the resident and determined which medications may be self-administered safely. The nursing staff is responsible for proper rotation of bedside stock and removal of expired medications.

Based on observation, interview and record review, the facility failed to ensure assistance with dressing and grooming for 1 of 3 residents (R106) reviewed for activities of daily living (ADL) care provided for dependent residents. Finding include: R106's quarterly Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition, diagnosis of dementia (a group of symptoms affecting memory, thinking and social abilities) and required extensive assistance for dressing, grooming, bathing, oral cares and toileting. The MDS indicated R106 did not reject or refuse cares. R106's care plan dated 7/21/24, indicated R106 had an ADL deficit related to dementia and required extensive assist of 1 staff for dressing, grooming, bathing, and elimination. The care plan indicated R106 would receive the necessary assistance with all ADL's. The care plan also indicated R106 did not have any natural teeth and instructed staff to assist with denture placement every AM and removal every PM. The care plan instructed staff to encourage and assist R106 to perform proper hand hygiene on hands and nails before snacks and meals. The care plan did not indicate R106 preference to wear her own clothes or hospital type gowns. On 10/22/24 at 3:26 p.m., R106 was sitting in her room, in a wheelchair wearing a white with blue flowered hospital type gown. R106 did not have on any footwear. R106's hair was messy, uncombed with areas that were matted and others that stood up approximately 2 inches from her scalp. Certified nursing assistants (CNA)-A and D entered R106's room and transferred R106 from her wheelchair to bed using a ceiling lift. Upon completion of transfer CNA-A gave an opened package of chocolate frosted cookies to R106. R106 immediately began taking cookies out of the package and put them into her mouth. CNA-A did not assist R106 with hand hygiene. During interview on 10/22/24 at 3:31 p.m., CNA-A stated she was familiar with R106, her cares, and required assistance with dressing and toileting. CNA-A stated she knew how to care for R106 by looking at the care plan taped to the inside of the door of the closet. CNA-A pointed to the care plan and identified R106's cares were dressing, personal grooming, denture care and toileting. CNA-A stated R106 didn't have her dentures in at that time and confirmed she did not provide hand hygiene prior to giving R106 the opened package of cookies. On 10/25/24 at 10:11 a.m., R106 was lying in her bed wearing a white with blue flowers hospital type gown. R106's hair was messy, uncombed, and an opened package of chocolate frosted cookies was on the bed next to residents left hand. During interview on 10/25/24 at 11:01 a.m., CNA-C stated she was familiar with R106's care and frequently assisted her. CNA-C stated she had assisted R106 to get ready earlier that day. CNA-C stated R106 needed assistance getting dressed every day as well as help with her oral care and brushing her hair. CNA-C stated she did not know if R106 preferred her own clothes or a hospital gown, nor did she know where to find that information. CNA-C stated she had not assist R106 with hair care or denture/oral cares during morning cares. On 10/25/24 at 11:48 a.m., R106 was in her wheelchair being pushed towards the dining room by an unidentified staff member. R106 was wearing a white with blue flowered hospital gown and a pair of dark colored pants with yellow gripper socks. The hem on R106's pants was approximately 4 inches above her ankles. R106's hair was messy and uncombed. During interview on 10/25/24 at 1:11 p.m., family member (FM)-A stated R106 preferred to wear her own clothes every day and took great pride in her appearance. FM-A stated R106 always tried to look nice, and it would make her sad to not be dressed nice with her hair neat. During interview on 10/25/24 at 11:19 a.m., the director of nursing (DON) stated R106 required assistance with getting dressed, oral care, grooming and toileting. Staff should look at the care plan located inside the closet door to see preferences for R106. DON confirmed R106 did not prefer to wear hospital gowns. DON stated she expected staff to assist residents to wear clean, neat clothing and to comb their hair to help residents to feel good about their appearance. DON stated she expected staff to assist every resident with all necessary ADL's. DON stated assisting residents with ADL cares was beneficial to a residents physical and emotional health. Facility policy titled Activities of daily living (ADL's) dated January 2023 indicated the facility will provide care and services for activities of daily living to include, bathing, dressing, grooming and oral care. The policy further indicated any resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review the facility failed to provide and maintain dignity for 1 of 1 residents (R106) reviewed for dignity. Findings Include: R106's quarterly minimum data set (MDS) dated [DATE], indicated a severely impaired cognition, diagnosis of dementia (a group of symptoms affecting memory, thinking and social abilities) and required extensive assistance for dressing, grooming and toileting. R106's care plan dated 7/21/24, indicated R106 required extensive assist of 1 staff for dressing and grooming. The care plan did not indicate if R106 preferred to wear her own clothes or a hospital type gown. On 10/22/24 at 3:26 p.m., R106 was in her room, sitting in her wheelchair wearing a white with blue flowers hospital type gown. R106 did not have on any type of footwear. R106's hair was uncombed and had areas that appeared to be matted and other areas that stood up approximately 2 inches from her scalp. During observation and interview on 10/22/24 at 3:31 p.m. certified nursing assistant (CNA)-A assisted R106 to bed and stated she was familiar with R106 but didn't typically work with her during the day shift. CNA-A stated R106 was usually dressed in a gown but was unable to confirm if R106 preferred to be dressed in her own clothes. On 10/25/24 at 10:11 a.m. R106 was observed in bed wearing a white with blue flowered hospital type gown. On 10/25/24 at 11:48 a.m. R106 was observed in her wheelchair being pushed in the hallway in the direction of the dining room. R106 was wearing a white with blue flowered hospital gown and a pair of dark colored pant and yellow gripper socks. The hem on R106's pants was approximately 4 inches above her ankles. R106's hair was not combed. During interview on 10/25/24 at 10:41 a.m., CNA-B stated she was familiar with R106 and stated she liked to be dressed every day and frequently wore hospital gowns. CNA-B stated she knew how to take care of R106 as her cares were listed on a care sheet taped to the inside of the closet door. CNA-B was unable to indicate on the care sheet if R106 preferred to wear her own clothes or a hospital gown. During interview on 10/25/24 at 11:01 a.m., CNA-C stated she was familiar with R106 and had assisted her to get ready for the day that morning. CNA-C stated R106 required assistance to get dressed every day as well as help with her oral care and brushing her hair. CNA-C stated she did not know if R106 preferred her own clothes or a hospital gown, nor did she know where to find that information. During interview on 10/25/24 at 1:11 p.m., R106's family member (FM)-A stated R106 preferred to wear her own clothes every day and took great pride in her appearance. FM-A went on to say at a recent appointment R106 had been dressed in pants that were too short, was not wearing a bra under her shirt and her hair was messy. FM-A stated R106 would never have left her house looking like that. She continued to say R106 had many nice matching tops and bottoms but was rarely dressed in anything except a hospital gown. She stated her mom used to always try to look nice and it would make her sad to not be dressed nice with her hair neat. During interview on 10/25/24, at 11:19 a.m., the director of nursing (DON) stated R106 required assistance with getting dressed, oral care, grooming and toileting. She stated staff could look at R106's care plan located inside her closet door to see preferences for R106. DON stated she expected staff to assist residents to wear clean, neat clothing and to comb their hair to help residents to feel good about their appearance. DON stated it was important for residents to feel good about how they looked, and it was a matter of dignity for themselves. DON stated residents emotional well being could be negatively affected if they didn't feel good about their physical appearance. Facility policy titled Promoting/Maintaining resident dignity, dated October 2022 indicated the following: The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences. Groom and dress residents according to resident preferences.

Based on observation, interview and document review, the facility failed to ensure care plan interventions were being utilized for 1 of 2 residents (R106) reviewed for safety. Findings include: R106's quarterly Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition, diagnosis of dementia (a group of symptoms affecting memory, thinking and social abilities) and required extensive assistance for dressing, grooming and toileting. R106's care plan revised on 9/15/24, indicated R106 was at risk for falls and had a history of falls. Interventions included staff assistance by placing the call light where the resident can reach it before exiting the room each time, and ensure all personal belongings are within reach for the resident. During continuous observation on 10/25/24 beginning at 10:11 a.m. through 11:06 a.m., R106 was lying in her bed. A white call light with a red button to push for assistance was noted to be lying on the floor under the bedside table approximately 2 feet away, outside of R106's reach. There was no clip to attach the call light noted on the call light cord. No other call light was noted in the room. During interview on 10/25/24 at 10:41 a.m., certified nursing assistant (CNA)-B stated R106 was functionally able to use the call light if she needed staff assistance. CNA-B stated R106 had both a soft touch call light and one with a button to push for assistance. CNA-B stated R106 would primarily use the white call light with the red button because she was most familiar with that type. CNA-B stated she would clip the call light to the blankets or the wheelchair to keep it within reach of R106. During interview on 10/25/24 at 11:01 a.m. CNA-C entered R106's room and confirmed R106's white call light was lying on the floor outside of R106's reach, and there was no other call light available within reach of R106. CNA-C stated R106 was functionally able to use her call light appropriately to summon for help if needed. CNA-C stated she had clipped the call light the blankets on the bed before her break and didn't know how it got on the floor. CNA-C stated without the call light R106 would have to yell out to get help. CNA-C stated she was unsure if staff in another room would be able to hear R106 if she was calling out. During interview on 10/25/24 at 11:19 a.m., the director of nursing (DON) stated all resident should have a call light or device within their reach to summon staff for assistance whenever staff left the room. DON stated she expected staff to either hand the call light directly to the resident or clip it the residents clothing or blankets. DON stated this was extremely important for residents' safety and for residents to be able to communicate their need of assistance to staff. Facility policy title Call lights: accessibility and timely response dated January 2023 indicated each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call light system. Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on observation, interview, and document review the facility failed to follow the person-centered care plan for 1 of 1 residents (R1) reviewed for activities of daily living (ADL). Findings included: R1's face sheet identified R1 had diagnoses which included COVID-19 and chronic diastolic (congestive) heart failure. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment. R1 required set up assist for eating and oral care. Personal hygiene is not completed. R1 required substantial/maximal assist of one person to transfer chair to bed. R1's care plan dated 6/24/22, identified R1 is at a safety risk and may fall due to history of stroke with right sided weakness. The care plan directed staff to check on R1 regularly to try to anticipate R1's needs. Keep call light and commonly used items within reach. R1's bowel and bladder care plan dated 6/26/22 directed staff to offer the bathroom when waking up, after breakfast, before and after lunch, before and after supper, night cares, night, and staff are to remind R1 before activities and as needed per R1's request. R1's care plan dated 12/26/23, identified R1 had ADL deficits and required assistance. The care plan directed staff to assist R1 with repositioning every two to three hours and as needed. During interview on 2/9/24 at 9:21 a.m., nursing assistant (NA)-A reported to be the primary nursing assistant for R1 on 2/5/24. Her shift started at 7:00 a.m. and R1 wanted to get up around 8:00 a.m. NA-A assisted R1 with morning cares. NA-A reported R1 went to the dining area following cares and was visualized in dining room around 8:00 a.m.- 9:00 a.m. From 9:00 a.m. to 11:15 a.m. NA-A was assisting other residents for the day and did not provide cares for R1. From 11:15 a.m. to 12:00 p.m. NA-A went on break. At 12:00 p.m. R1 was in the same location as she was last visualized at around 8:00 a.m. to 9:00 a.m. NA-A had not offered or assisted R1 to the bathroom or provide any further assistants. During interview on 2/12/24 at 10:23 a.m., NA-B indicated she worked the morning of 2/5/24. NA-B did not provide cares for R1 between breakfast and lunch. During interview on 2/9/24 at 10:31 a.m., NA-C indicated she worked the morning of 2/5/24. NA-C did not provide cares to R1 between breakfast and lunch. During interview on 2/12/24 at 9:48 a.m., registered nurse (RN)-A indicated her shift started at 6:00 a.m. and did not receive anything in report regarding R1. RN-A assisted R1 with breakfast and visualized R1 between 9:00 a.m. and 10:00 a.m. as another resident was talking with R1. RN-A assisted on another hallway between 10:15 a.m. to 10:30 a.m. Between 10:45 a.m. to 11:35 a.m. RN-A was passing medication to other residents. From 11:35 a.m. to 12:10 p.m. RN-A was on break . RN-A did not provide cares or interact with R1 during this time. During interview on 2/12/24 at 4:31 p.m., director of nursing (DON) and Administrator indicated R1's care plan was not followed and R1 went a prolonged period without being checked on. It was inappropriate for R1 to go two to three hours without being checked on and R1 should have been provided incontinence cares and offered to be turned/repositioned per R1's care plan. Policy and procedure titled comprehensive care plans dated august 2022 indicates it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on interview and document review, the facility failed to comprehensively assess and monitor after an acute change of condition related to increased weakness/fatigue was identified was identified for 1 of 3 residents (R1) reviewed for change of condition Findings include R1's face sheet identified R1 had diagnoses which included COVID-19 and chronic diastolic (congestive) heart failure. R1's provider orders for life-sustaining treatment (POLST) dated [DATE], identified cardiopulmonary resuscitation (CPR) should be attempted. Medical treatments indicated full treatment. Transfer to hospital and/or intensive care unit if indicated. R1's annual Minimum Data Set (MDS) dated [DATE], identified R1 was independent with eating and oral care. R1 required partial to moderate assistance with personal hygiene. R1's cognition was not identified. R1's care plan dated [DATE] identified R1 was at risk for exposure of Covid infection due to residing in congregate living facility, co-morbid conditions, advanced age and dependency on caregiver assistance, R1 tested positive for Covid [DATE].Staff are to monitor for presence or absence of symptoms: fever, cough, shortness of breath, sore throat, fatigue, muscle/body aches, headache, new loss of taste or smell, congestion or runny noise, nausea or vomiting, diarrhea. R1's nurse practitioner (NP) note dated [DATE] identified R1 was seen by NP due to testing positive for Covid during routine testing on this day. R1 reported to generally not feel well, with symptom onset when awaking in the morning. Symptoms included cough, nasal congestion, body aches, and fatigue. Review of symptoms indicates R1's report was limited due to history of dementia. Assessment and plan directs for nursing staff to notify provider with any change in patients condition. Progress note dated [DATE], indicated R1's temperature was 98.4 with oxygen saturation (02) of 95% on room air. R1 had body aches, runny nose and congestion, and fatigue. Progress note dated [DATE], indicated R1 had poor meal intake per usual and encourage fluids. Temp was 97.5 and 02 saturations were 96% on room air. R1 did not have symptoms of cough/runny nose/congestion and denied fatigue. Lung sounds were clear. R1's vital signs reviewed between [DATE] through [DATE] and identified vital signs were not consistently monitored and/or assessed during her Covid illness. The record identified the following: -Respiratory rate on [DATE] was 18 breaths per minute, on [DATE] respiratory rate was 16. No other entries were recorded. -Pulse on [DATE] was 67 beats per minute (bpm), on [DATE] pulse was 64 bmp. No other entries were recorded. -Blood pressures were recorded once daily between [DATE] through [DATE] and ranged between ,d+[DATE] (on [DATE]) to ,d+[DATE] ([DATE]). Readings were seemingly not outside of R1's baseline. R1's record did not have any recorded vital signs on [DATE], nor evident R1 had been provided toileting and/or repositioning after morning cares were completed. February medication administration record dated [DATE] indicated scheduled medication administration was documented as administered at 9:14 a.m. R1's late entry progress note dated [DATE] for 12:20 p.m., included [R1] who had elected full code status was noted by NARS [nursing assistants] sitting in her w/c [wheelchair] head slumped slightly down at the table. Per staff interview this is how resident often is waiting for her meals as she will nap while waiting for tray. Around 12:20 NAR went to give her the lunch tray and noted her to be unresponsive, blue, and cold to touch. Nurse was notified immediately by NAR. Nurse called NP, who was in building and immediately started chest compressions, the nurse on the floor to assigned to resident called 911. NP states that resident was blue, and [NAME] [sic] Mortis had started to set. She reported even though it was obvious she was deceased , she decided to complete 1 round of chest compressions. The note indicated R1 had died . Ambulance record dated [DATE], identified paramedics were dispatched at 12:25 p.m. due to a cardiac arrest/death. Assessment included R1 presenting to EMS lying supine (face up) in bed. R1 was pulseless, apneic (involuntarily not breathing), and unresponsive. R1 was moved to floor. When moving patient, neck and shoulder were stiff and did not move normally when patient was moved. When R1 was placed on the floor R1's neck and head to not rest on the ground due to rigor. Due to R1's presentation with obvious signs of death, EMS estimates patient had a prolonged downtime. Due to obvious signs of death no further resuscitation efforts were performed. During interview on [DATE] at 9:21 a.m., nursing assistant (NA)-A reported to be the primary nursing assistant for R1 on [DATE], her shift started at 7:00 a.m. R1 wanted to get up around 8:00 a.m. NA-A recalled R1 was weaker with tasks more then normal, was more difficult to transfer, and was leaning to one side more then the other. R1 required assist to wash her face, brush her teeth, and comb her hair, which was abnormal for R1. NA-A reported R1 was typically more combative with cares, however was not that morning. After she finished R1 cares, NA-A reported to registered nurse (RN)-A R1 was weaker than normal. NA-A indicated RN-A explained to her R1 was just getting over Covid and did not take R1's vital signs. After cares R1 was taken to the dining room for breakfast. NA-A recalled R1 required assist to eat breakfast around 8:00 a.m.- 9:00 a.m. by RN-A which was also abnormal. R1 usually fed herself. From 9:00 a.m. to 11:15 a.m. NA-A was assisting other residents for the day and did not provide cares for R1. From 11:15 a.m. to 12:00 p.m. NA-A went on break. At 12:00 p.m. NA-A returned to the floor and started to pass lunch trays. NA-A recalled R1 being in the same place from breakfast and R1's head was down. NA-A took R1's tray and brought it to R1 and noticed R1 was not responding. NA-A reported R1's hand was cold to touch and attempted to pick R1's hand up, but it dropped down. NA-A called for RN-A to look at R1. RN-A came over to assess R1 and told NA-A, R1 had passed away. NA-A then removed R1 from the dining room and took her back to her room. The nurse practitioner and emergency medical services were notified. During interview on [DATE] at 10:56 a.m., R2 recalled R1 being at the dining table on [DATE] between 8:30 a.m. and 9:00 a.m., R1 appeared to be sleeping. R1's head was down and eyes were closed. R1 had dark coloring under her eyes. R2 reported if residents seated at the table were sleeping, staff did not typically bother residents and let them sleep where they were. During interview on [DATE] at 12:44 p.m. family member (FM)-A indicated on [DATE], they were in the dining room at 11:15 a.m. FM-A remembered R1 sitting at the dining room table and appeared to be sleeping with her head down to her chest. FM-A left dining area and came back in dining area around noon when lunch was being served. R1 had not moved and R1's head was still down. FM-A recalled commotion when R1 received the meal tray and two staff members took R1 to her room. FM-A thought R1 had not moved from the position from the time of arrival to the facility to the time staff had removed R1 from the dining area. During interview on [DATE] at 11:05 a.m. R3 recalled being at R1's table on [DATE] for both breakfast and lunch meals. R3 reported R1 was not eating breakfast and RN-A was assisting R1, however she was not chewing food at breakfast and did not eat. R1 did not typically require assist to eat. R1 did not look very good and appeared to be out of it. R3 reported R1's head was down at the end of breakfast and appeared to be sleeping. When R3 arrived back at the dining table for lunch R1 was in the same position with head down. At around 12:30 p.m. a nursing assistant said R1 was dead. There was not initially a nurse present, but one joined and R1 was removed from the dining room. During interview on [DATE] at 10:08 a.m., recreational therapist (RT)-A recalled working in the area on [DATE]. RT-A was in posting activity signs around 9:30 a.m. to around 9:45 a.m. RT-A witnessed R1 sitting alone at the dining table where R1 typically ate meals. R1 was sitting with her head down and not moving. RT-A did not recall staff members around R1 at that time. During interview on [DATE] at 10:23 a.m., NA-B indicated she worked the morning of [DATE]. NA-B did not provide cares for R1 between breakfast and lunch. During interview on [DATE] at 10:31 a.m., NA-C indicated she worked the morning of [DATE]. NA-C did not provide cares to R1 between breakfast and lunch. During interview on [DATE] at 9:48 a.m., registered nurse (RN)-A indicated on [DATE] her shift started at 6:00 a.m. RN-A did not receive anything in report regarding R1. RN-A recalled feeding R1 at breakfast and R1 did not typically require help to eat. R1 was more sleepy and fatigued due to Covid. RN-A did not feel a need to assess R1's vitals due to this. R1's last known well time was between 9:00 a.m. and 10:00 a.m. Another resident was talking with R1, however did not hear the conversation. RN-A assisted on another hallway between 10:15 a.m. to 10:30 a.m. Between 10:45 a.m. to 11:35 a.m. RN-A was passing medication to other residents. From 11:35 a.m. to 12:10 p.m. RN-A was on break and recalled at 12:10 p.m. putting her lunch bag behind the nurses desk when staff started to call RN-A's name. RN-A was called to R1's lunch table; R1's lips were blue and she was getting stiff. RN-A directed NA-A and NA-B to bring R1 back to R1's room, paged NP-A who was in the building, and called emergency medical services (EMS). The NA's brought R1 back to her room. NP-A and EMS arrived, R1 was pronounced dead. During interview on [DATE] at 3:29 p.m., nurse manager (NM)-A indicated the expectation is for all residents who have Covid were assessed and monitored twice a day for ten days. The assessments were documented in an infection monitoring note which included temperature, respiratory status/oxygen, lung sounds, isolation precautions, chest X-ray/New Labs, headache/body aches/chills, sore throat/cough/congestion/runny nose/ other symptoms present and current or change of condition. NM-A expected nurses to document resident's symptoms and any change in condition. On the 11th day post Covid positive test, the nurses were expected to complete a post isolation review assessment and note. This certified the symptoms were improving and residents were safe to come out of their rooms. NM-A reported R1's 11th day of Covid was [DATE], and the note had not been completed. NM-A additionally identified R1's chart was missing Covid monitoring notes on both [DATE] and [DATE] . During interview on [DATE] at 11:54 a.m., nurse practitioner (NP)-A indicated not receiving any communications on [DATE] on R1's status until receiving a page at 12:20 p.m. and a return call to RN-A at 12:21 p.m. NP-A did not know how long R1 was down or unresponsive. NP-A entered R1's room and initiated and completed 30 rounds of compressions in bed. NP-A stopped CPR due to clinical signs of death. NP-A indicated it was pretty clear R1 had been expired for a while. R1 had modeling of skin, was cold to touch, head and neck were stiff and head was sticking straight out without any support. NP-A believed R1 was in full rigor. NP-A had anticipated R1 had expired for at least an hour before NP-A had arrived and potentially longer. NP-A reported there was a significant amount of time which was not accounted for. NP-A pronounced time of death at 12:25 p.m NP-A reported the expectation for any resident with a change of condition to be reported to the provider if there are any concerns including increased weakness or a resident's inability to do tasks they typically would be able to or anything outside of their normal. NP-A was unaware R1's vitals were not assessed on [DATE] and indicated it was concerning there was a lack of monitoring for a resident coming off Covid precautions. During secondary interview on [DATE] at 2:14 p.m. NP-A indicated vital signs are clinical data and without appropriate data it's difficult to make sound judgement on a change of condition. If vitals were appropriately assessed facility staff could have addressed and intervened on a change of condition appropriately. Ultimately it was unknown what led to R1's death. During interview on [DATE] at 12:54 a.m., director of nursing (DON) and administrator, DON reported the internal investigation started on [DATE] immediately. R1's last known well time was around 9:00 a.m. to 10:00 a.m. as RN-A reported seeing R1 with another resident. However the reported resident was noted to be near was a bad historian due to dementia and had unreliable/inconstant reporting and unable to interview. DON indicated RN-A should have completed an assessment including vital signs and monitored R1 after NA-A had reported concerns with weakness. DON indicated R1's care plan was not followed. R1 should have been provided care more frequently and it was not appropriate to go from breakfast to lunch without being checked on. Notification of changes policy dated [DATE], identifies the purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 1. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications. 2. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition. iii. Exacerbation of a chronic condition. 1. Residents incapable of making decisions: a. The representative would make any decisions that have to be made. b. The resident should still be told what is happening to him or her. 2. Death of a resident: The resident's physician is to be notified immediately in accordance with State law.

Based on interview and document review the facility failed to notify the physician of change in condition for 1 of 3 (R1) reviewed for change of condition. Findings include R1's face sheet identified R1 had diagnoses which included COVID-19 and chronic diastolic (congestive) heart failure. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment. R1 required set up assist for eating and oral care. R1 required substantial/maximal assist of one person to transfer chair to bed. R1's care plan dated [DATE], identified R1 was at a safety risk and may fall due to history of stroke with right sided weakness. R1 had a diagnosis of thrombocytopenia, hypertension, chronic heart failure, and dementia. Staff were to check on R1 regularly to try to anticipate R1's needs. Keep call light and commonly used items within reach. R1's nurse practitioner (NP) note dated [DATE], identified R1 was seen by NP due to testing positive for COVID-19 during routine testing on this day. R1 reported to generally not feel well, with symptom onset when awaking in the morning. Symptoms included cough, nasal congestion, body aches, and fatigue. Review of symptoms indicates R1's report was limited due to history of dementia. Assessment and plan directed nursing staff to notify provider with any change in patients condition. R1's vital signs between [DATE] and [DATE], were reviewed. It was not evident R1's vital signs were obtained on [DATE] nor evident of any assessments completed related acute illness. During interview on [DATE] at 9:21 a.m., nursing assistant (NA)-A reported to be the primary nursing assistant for R1 on [DATE], her shift started at 7:00 a.m. and R1 wanted to get up around 8:00 a.m. NA-A recalled R1 to be weaker with tasks more than normal, required more assistance to transfer, and was leaning to one side more then the other. R1 required assist to wash her face, brush her teeth, and comb her hair and which was abnormal. NA-A reported R1 was typically more combative with cares, however was not that morning. After she finished R1 cares, NA-A reported to registered nurse (RN)-A R1 was weaker than normal. NA-A indicated RN-A explained to her R1 was just getting over Covid and did not take R1's vital signs. After cares R1 was taken to the dining room for breakfast. NA-A recalled R1 required assist to eat breakfast around 8:00 a.m.- 9:00 a.m. by RN-A which was also abnormal. R1 usually fed herself. During interview on [DATE] at 9:48 a.m., RN-A indicated her shift on [DATE], started at 6:00 a.m. and did not receive anything in report regarding R1. RN-A stated NA-A could have reported R1 was weaker than normal, however did not recall. RN-A recalled she assisted R1 with eating breakfast because she was tired and weak, but felt this was due to Covid symptoms. She did not feel there was any need to complete any further assessments, take vital signs, or notify the physician. RN-A returned from break at 12:10 p.m. and was immediately notified of concerns with R1. When RN-A saw R1 sitting at the table in the dining room, R1's lips were blue and appeared as though she had died . The first-time reporting concerns to nurse practitioner (NP)-A was a page at 12:20 p.m. NP-A called back right away, RN-A stated she told NP-A she was needed right away because R1 had died . During interview on [DATE] at 11:54 a.m., NP-A indicated not receiving any communications on [DATE] on R1's status until receiving a page at 12:20 p.m. and a return call to RN-A at 12:21 p.m. NP-A indicated the expectation would be for facility staff to report changes to the provider if there were any concerns. If nursing assistants were to report increased weakness or inability to do things they could typically be able to do NP-A would expect to be notified. During subsequent interview on [DATE] at 2:58 p.m. NP-A was not notified of any fatigue, change or abnormal vitals since R1 was diagnosed with Covid and placed on quarantine on [DATE]. Outside of R1's other co-morbidities R1 was rather stable from NP-A's knowledge. NP-A was not aware there were days R1's vitals and respiratory status was not assessed. NP-A would expect a report on any change of condition. Policy and procedure titled notification of changes dated [DATE]st, 2022, identifies the purpose of the policy is to endure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Significant change in the resident's physical, mental or psychosocial condition such a deterioration in health, mental or psychosocial status. Death of a resident: The resident's physician is to be notified immediately in accordance with state law.

Based on observation, interview, and record review, the facility failed to ensure food temperatures were taken in the kitchenettes to prevent foodborne illness. This had the potential to affect all 161 residents currently residing in the facility. Finding include: During an observation of temperature taking of the lunch meal on 1/26/24 at 10:30 a.m., with dining manager (DM) and the campus dining service and purchasing director (CDSPD) the cook documented the temperature of the meat on a Quality Checklist Sheet (QCS) dated 1/26/24. When asked to see the last month of temperature logs the DM produced completed lunch and dinner temperature logs. At 10:50 a.m. the DM stated she did not have any breakfast QCS logs. On 1/26/24 at 11:05 a.m. CDSPD produced three QCS logs dated 1/19/24, 1/23/24, and 1/25/24 that had temperatures for the breakfast meal. During an interview on 1/26/24 at 11:35 a.m., dining service aid (DSA)-A stated she had served the breakfast that morning and did not have time to take the temperatures. DSA-A stated the temperatures of all food should be taken before serving to the residents on the unit. During an interview on 1/26/24 at 11:05 a.m. CDSPD stated every meal needed to have the temperature taken prior to serving the food to the residents every day. CDSPD stated that temperature taking was discussed at the last staff meeting. The facility policy Food Safety Requirements dated 10/22, indicated when preparing food, staff shall take precautions in critical control point in the food preparation process to prevent, reduce, or eliminate potential hazards. d. Holding-staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained.

Based on observation, interview and document review, the facility failed to implement ongoing infection prevention and control program to prevent the spread of infection due to lack of appropriate use of personal protective equipment (PPE) for 1 of 1 resident (R6) on transmission-based precautions (TBP) for COVID-19. In addition, the facility failed to disinfect a multi-use mechanical lift used by COVID positive resident. This affected 2 of 2 residents (R2, R95), and had the potential to affect all 166 residents in the facility. Findings include: R6's quarterly MDS dated [DATE], indicated R6 had moderate cognitive impairment, traumatic brain injury, and bipolar disorder. R6's progress noted dated 1/22/24 at 1:57 p.m., indicated positive for COVID-19. R6 was placed on transmission-based droplet precautions, and would remain on isolation precautions until 1/27/24. R95's annual Minimum Data Set (MDS) dated [DATE], indicated short-term and long-term memory problems, and diagnoses included dementia, adult failure to thrive, and chronic congestive heart failure. R2's quarterly MDS dated [DATE], indicated cognitively intact, and diagnoses included paranoid schizophrenia, abnormal weight loss, breast cancer, and bone cancer. During observation on 1/25/24 at 9:44 a.m., nursing assistant (NA)-A and NA-B donned personal protective equipment (PPE) prior to entering R6's room. NA-A donned a surgical mask, gown, and gloves; however, NA-A failed to apply a N95 mask and failed to apply eye protection prior to entering R6's room. NA-B applied a N95 mask, gown, and gloves; however, NA-B failed to apply eye protection prior to entering R6's room. During observation on 1/25/24 at 9:57 a.m., NA-A exited R6's room still wearing a surgical mask. NA-A then walked from R6's room directly into R95's room. On 1/25/24 at 10:01 a.m. NA-A stated R6 was on precautions for COVID-19, a N95 mask should have been worn into R6's room and removed prior to exiting R6's room to prevent the spread of infection. On 1/25/24 at 10:07 a.m. NA-B exited R6's room, placed two bags of linens on the hallway floor directly outside of R6's room, rolled a hoyer lift out of R6's room in into the hallway, donned gloves, and entered a soiled utility room with the two bags of linens. However, NA-B failed to disinfect the hoyer lift after it was removed from R6's room. On 1/25/24 at 10:12 a.m., following continuous observation of the hoyer lift, NA-B took the unsanitized hoyer lift, with ungloved hands, from the hallway outside of R6's room, removed the battery and placed it into a standing lift, pushed the unsanitized hoyer lift to the end of the hallway, and took the standing lift, with the battery from the unsanitized lift, into R2's room and closed the door. On 1/25/24 at 10:23 a.m., infection preventionist (IP) stated measures were in place to prevent the further spread of infection, and staff were expected to look at the precautions signs posted on resident doors and don the required PPE indicated on the sign. For residents with COVID-19, IP expected staff to don a gown, gloves, N95 mask, and eye protection prior to entering the room. Staff were expected to remove their PPE and complete hand hygiene prior to exiting the room and after exiting the room, and staff were expected to keep bags with trash or soiled linens off the floor. Additionally, staff were expected to disinfect lifts used for a resident with COVID-19 with the purple top wipes right away and outside of the room. COVID(+) Residents in Last 4 Weeks document, undated, indicated 6 residents that resided on the 1st floor of the facility tested positive for COVID-19 from 1/17/24 to 1/24/24. COVID(+) Staff in Last 4 Weeks document, undated, indicated 5 staff tested positive for COVID-19 from 1/14/24 to 1/24/24. The facility's Coronavirus Prevention and Response policy dated October 2022, indicated the facility will respond promptly to identify, treat, and prevent the spread of the COVID-19 virus. Facility staff who enter the room of a resident with COVID-19 infection should adhere to standard precautions and use a N95, gown, gloves and eye protection. The facility's Cleaning and Disinfection of Resident-Care Equipment policy dated September 2023, indicated resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendation in order to break the chain of infection, and multiple-resident use equipment shall be cleaned and disinfected after each use.

Based on observation, interview and document review the facility failed to ensure 3 of 6 medication carts were kept locked or under direct observation of authorized staff in areas where residents, staff and guests could access medications. The deficient practice had the potential to affect all residents that resided on the first and second floors in the facility. Findings include: On 1/24/24 from 11:02 a.m. to 11:31 a.m., 1st floor medication cart (A) was unlocked and unattended. There were also approximately five to six residents within 10 feet of the open medication cart. On 1/24/24 from 11:42 a.m. to 11:51 a.m., 2nd floor medication cart (B) was observed unlocked and unattended. No residents were in the vicinity of the open medication cart. On 1/25/24 from 2:14 p.m. to 2:16 p.m., 2nd floor medication cart (C) was observed unlocked and unattended. No residents were in the vicinity of the open medication cart. On 1/24/24 at 9:31 a.m., registered nurse manager (RN)-B stated she expected all medication and treatment carts to be locked when unattended. On 1/24/24 at 4:00 p.m., licensed practical nurse (LPN)-B stated staff were trained to ensure medication carts were locked when not in use or out of eyesight. On 1/25/24 at 9:37 a.m., LPN-A confirmed that medication cart A had been left unlocked and unattended on 1/24/24 from 11:02 a.m. to 11:31 a.m., and should have been locked when unattended. On 1/25/24/ at 2:56p.m., director of nursing (DON) stated staff were expected to ensure all medication and treatment carts were locked when unattended for resident safety and security. Facility policy Medication Storage dated 4/1/2022, indicated all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) and only authorized staff will have access to the keys to the locked compartments.

Based on interview and document review, the facility failed to ensure a written notification of transfer was provided for 3 of 6 residents (R119, R126, R128) upon transfer to the hospital. In addition, the facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for 5 of 6 residents (R119, R128, R45, R50, R59), reviewed for hospitalization . This had the potential to affect all residents transferred to hospital. Findings include: R119's quarterly MDS dated [DATE], indicated R119's diagnoses included dementia with severe cognitive impairment. Progress notes indicated R119 was hospitalized from 10/20/23 through 10/24/23. R119's record lacked evidence a written notification of transfer was provided to the resident and/or resident representative. Additionally, R119's record lacked evidence the Ombudsman for LTC was notified of transfer to the hospital. R126's admission MDS dated [DATE], indicated R126's diagnoses included acute respiratory failure, and R126 was cognitively intact. Progress notes indicated R126 was hospitalized from 1/15/24 through 1/25/24. R126's record lacked evidence a written notification of transfer was provided to the resident and/or resident representative. R128's quarterly MDS dated [DATE], indicated R128 was cognitively intact and diagnoses included adult failure to thrive and neuropathy. Progress notes indicated R128 was hospitalized from 6/6/23 through 6/20/23. R128's record lacked evidence a written notification of transfer was provided to the resident and/or resident representative. Additionally, R128's record lacked evidence the Ombudsman for LTC was notified of transfer to the hospital. R45's admission record printed 1/26/2024, indicated R45's diagnoses included pneumonitis due to inhalation of food and vomit, vascular dementia, dysphagia (unable to speak or get words out), and wheezing. Progress notes dated 12/1/23, indicated on-call provider was updated after R45 reported labored breathing, cough, temperature of 99.6 degrees, respiratory rate of 32 and short shallow breaths. Progress notes further indicated the on-call physician wanted the resident sent into the hospital to be evaluated and was sent to North Memorial via ambulance, and that the facility had updated R45's family of his condition. R45's medical record lacked evidence of notification of the Ombudsman of R45's transfer to the hospital. R50's quarterly Minimum Data Set (MDS) dated [DATE], indicated R50's diagnoses included cerebral palsy, and R50 was cognitively intact. Progress notes indicated R50 was hospitalized from 11/28/23 through 11/30/23. R50's record lacked evidence the Ombudsman for LTC was notified of transfer to the hospital. R59's admission record printed 1/26/24, indicated R59 diagnoses included diarrhea, cholelithiasis without obstruction (gallstones), and postsurgical malabsorption. Progress notes dated 12/11/23, indicated on call provider was updated by facility when R59 reported right side abdominal pain which was not relieved with interventions. Progress notes indicated resident was transferred to emergency department via ambulance. Facility was updated that resident would be admitted for further evaluation. R59's medical record lacked evidence of notification of the Ombudsman of R59's transfer to the hospital. Voluntary discharge notice faxes sent to the Office of the Ombudsman for LTC, undated, included spreadsheets for 1/3/23 through 12/30/23. The spreadsheets included the names, dates, and location for all residents discharged to home or other LTC facilities. However, the spreadsheets did not include the names and dates of residents transferred to the hospital from 1/3/23 through 12/30/23. On 1/26/24 at 9:00 a.m. social services director (SSD) stated a Notice of Voluntary Transfer form was provided in the facility's hospital discharge packet, the notice should be filled out with the resident at the time of transfer, and a notice faxed to the ombudsman. SSD acknowledged the process needed improvement and was a work in progress. SSD stated the Ombudsman for LTC was notified of discharges to home or other facilities, but was not notified of transfers to hospital. SSD acknowledged the ombudsman should have been notified of all discharges, including residents transferred to the hospital. A facility policy regarding required notification for transfers/discharges was requested but not provided. 49035 49657 Resident #45 [NAME], [NAME] D. (46941)

Based on observation, interview, and document review, the facility failed to assess the resident and determine safety for 1 of 1 resident (R103) reviewed for self-administration of medications (SAM) . Findings include: R103's quarterly Minimum Data Set (MDS) dated [DATE], indicated R103 had moderate cognitive impairment. R103's Self Administration of Medication assessment dated [DATE], indicated assessment for the self-administration of nebulizer treatment, no other medications were included in the assessment. R103's order summary report dated 1/4/2024, indicated SAM orders for Ipratropium-Albuterol nebulizer, Ketotifen Fumarate eye drop, Loratadine, Synthroid, and Trolamine cream. However, no SAM orders for Colace, iron, metoprolol, and Prilosec. R103's care plan dated 1/25/24, identified SAM orders for some medications. However, Colace, iron, metoprolol, and Prilosec were not included. During observation on 1/24/24 at 4:00 p.m., the licensed practical nurse (LPN)-B prepared medications for R103 including; Colace 100 mg (2 capsules), iron 325mg, metoprolol 325mg and Prilosec 20 mg. LPN-B stated all R103's medications were self-administered with nurse set-up. LPN-B brought the medications to R103's room, set them on the table and left the room. On 1/25/2024 at 2:40 p.m., registered nurse manager (RN)-B stated residents could be assessed for SAM, if appropriate, on admission. If assessment indicated SAM was appropriate, an order from the physician would be requested. RN-B confirmed R103's orders and assessment did not include Colace, iron, metoprolol, and Prilosec. On 1/26/24 at 10:30 a.m., director of nursing (DON) confirmed R103's SAM assessment only listed nebulizer treatment. DON stated she expected SAM assessments and provider orders for all self-administered medications to ensure resident safety. The facility's Resident Self- Administration of Medications policy dated 4/1/2022, indicated each resident has the right to self-administer medication after being assessed and deemed appropriate. The assessment will be recorded in the medical record.

Based on interview and document review, the facility failed to provide a written notice of a bed hold upon transfer for hospitalization for 1 of 5 residents (R119) reviewed for hospitalization . Findings include: R119's quarterly Minimum Data Set (MDS) dated [DATE], indicated R119's diagnoses included dementia and severe cognitive impairment. A progress note dated 10/20/23 at 10:23 p.m., indicated R119 was sent to the hospital at 6:00 p.m., and was admitted to the Veteran's Administration (VA) hospital for sepsis via urinary source. R119's progress notes had no evidence a bed hold notice was provided to the resident and/or responsible party. A subsequent progress note dated 10/24/23 at 11:14 a.m., indicated R119 returned from the VA hospital on 10/24/23 at 10:57 a.m. On 1/25/24 at 9:00 a.m., director of social services (DSS) stated a notice of voluntary transfer form and written notice of bed hold should have been filled out with the resident, and the social worker should have acted as a backup to follow up on a bed hold. On 1/26/24 at 12:43 p.m., director of nursing (DON) stated a written notice of bed hold was not provided to R119 for the 10/20/23 to 10/24/23 hospitalization . The facility's Bed Hold Notice Upon Transfer dated August 2022, indicated at the time of transfer for hospitalization , the facility would provide to the resident and/or resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed.

Based on interview and document review, the facility failed to provide appropriate assistance to maintain non weight-bearing status during transfers for 1 of 2 residents (R1) who was non weight-bearing due to tibia and fibula (TIB/FIB) fracture. This resulted in actual harm as R1 sustained implant failure left distal fibula and syndesmosis (fibrous joint held together by ligaments), left distal fibula fracture, left syndesmosis injury, and subluxation of left joint (ligaments are often stretched or torn, and there may be a break in the bone.) This resulted in an immediate jeopardy (IJ) situation. The IJ began on 3/2/22, when R1 X-ray indicated R1 had a broken distal fibula plate with screws backing out. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 3/8/22 at 6:39 p.m. The immediate jeopardy was removed on 3/9/22, after the facility implemented corrective action but noncompliance remained at the lower scope and severity level of D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's hospital transfer orders dated 2/8/22, indicated admission to facility 2/8/22, with non-weight bearing (NWB) on left leg related to open reduction internal fixation (ORIF) of TIB/FIB fracture on 2/10/22. R1s hospital progress note (PN) dated 2/7/22, indicated R1 had sustained a fracture of her proximal fibula and distal tibia with a syndesmotic disruption (a disruption of the distal attachment of the tibia and fibula). As a result of this injury, R1 was non weight bearing to left lower extremity for six to eight weeks. R1's admission minimum data set (MDS) dated [DATE], indicated R1 had moderately impaired cognition with no behaviors or refusals, and history of a falls. R1 was an extensive assist of two staff for bed mobility, transfers, and toilet use. R1 used a wheelchair for mobility. R1's MDS further indicated impairment on one side and was not steady with moving on and off toilet or surface transfers without assistance. R1's initial care plan (CP) dated 2/8/22, indicated R1 had an ADL deficit and needed assistance with care. R1 required assistance to toilet, had weight bearing restrictions, and needed staff to provide weight bearing assist with the use of transfer belt and walker. R1's initial CP lacked direction of R1 needing non weight-bearing status on LLE (lower left extremity). R1's Kardex dated 2/8/22, indicated R1 was not able to ambulate, and required staff to provide weight bearing assist for transfers with the use of a sliding board and assist of 2 staff to maintain NWB to LLE, assistance with lifting legs in and out of bed, boost in bed, to get on and off the commode. R1's Kardex further indicated R1 had non-weight-bearing restrictions. R1's physical therapy (PT) evaluation dated 2/10/22, indicated R1 struggled maintaining non weight bearing precautions. R1's PT note dated 2/10/22, indicated R1 needed to use the slide board, two wheeled walker (2WW), and more education for transfers due to difficulty maintaining non-weight-bearing status. PT PN indicated R1 fully participated in therapy. R1's occupational therapy (OT) communication to nursing dated 2/10/22, recommended slide board transfer with assist a two staff. One staff to assist with holding left lower leg due to R1 inability to maintain non weight bearing on left leg. R1's nursing PN dated 2/11/22, indicated R1 was an assist of one with sliding board for transfers. R1's nursing assistant (NA) careguide undated, indicated R1 required an assist of one staff with slide board for transfer and R1's left leg was non-weight-bearing. R1's OT note dated 2/13/22, indicated R1 required OT intervention to maintain non-weight-bearing status. R1 progress note on 2/14/22, indicated R1 was nonambulatory based on direct observation, with staff and R1's interview. R1's lift mobility status form dated 2/14/22, indicated R1 was using a sliding board for transfers and was non-ambulatory. R1's nursing PN dated 2/15/22, indicated R1 tested positive for COVID-19, and was placed on isolation precautions. R1's nursing PN dated 2/15/22, 2/17/22, 2/18/22, indicated R1 was a assist of one. PN lacked use of slide board or non-weight-bearing status, even though this was PT and OT's recommendation. R1's physician PN dated 2/16/22, indicated R1 required a manual wheelchair, bilateral elevating footrests, and standard armrest. Further, R1 had mobility limitation due to falls, imbalance, and left TIB/FIB fracture status post ORIF and required assistance with transfers. PN indicated R1 had pain in left foot/ankle worse with elevation and used [MEDICATION(S)] (pain medication used to treat severe chronic pain) and [MEDICATION(S)] (medication used to treat muscle spasms). R1's care area assessment (CAA) dated 2/18/22, indicated R1 was able to understand others at all times, non-ambulatory and required an assist of two with transfers or use of sliding board to maintain non-weight-bearing. R1's CP revised on 2/18/22, to include extensive assist of two for toileting, with transfer device to commode to maintain NWB to L l/e or use of sliding board. Further, R1 had non-weight bearing restriction on left leg. R1's treatment administration record (TAR) dated 2/22, indicated R1 had restricted non-weight-bearing to left leg every shift. R1's nursing PN dated 2/23/22, 2/26/22, and 3/2/22, indicated R1 was assist of one with transfers and lacked the use of a slide board or that R1 was non-weight-bearing. R1's OT discharge summary dated 3/3/22, indicated R1 was discharged to the hospital. R1 was not maintaining non-weight-bearing and required surgery. Further, R1 required max assist for activities of daily living (ADL), non-weight-bearing status, and needed help to maintain non-weight-bearing status. R1's orthopedic PN dated 3/2/22, indicated R1 had been weight bearing at night to go to the restroom and left ankle had eversion (the action of turning a structure or organ outwards or inside out). R1's X-ray showed broken distal fibula plate with screws backing out. On 3/7/22, 11:43 p.m. R1's room, 273, was observed to have the bed positioned roughly 2 1/2 feet away from the wall. The exit side of the bed was located on the left side which was the same side R1 had the fracture. On 3/7/22, at 9:11 a.m. family member (FM)-A stated she had concerns regarding the facility not following physician's order for R1 to be non-weight-bearing. FM-A stated she had reported to nurse manager her concerns for R1, pivot transfers performed with one staff, not following physician orders, and care plan. On 3/7/22, at 6:00 p.m. during an interview, (FM)-B stated she had visited R1 from 2/14/22, to 2/19/22 and observed NA staff perform one-person pivot transfer most of the time. FM-B further stated R1 was able to get to the left side of the bed but once she swung her feet around, the left foot would hit the ground or contact the floor most of the time. FM-B stated R1 had been diagnosed with COVID-19 during this time and was weaker than normal. FM-B stated she reported to a nurse, social worker, aide, and physical therapist concerns that R1 was in pain during these transfers. On 3/7/22, at 9:46 a.m. during an interview, insurance care coordinator (CC) stated she had received a call from R1's family member who reported concerns regarding R1 requiring a second surgery caused by R1 not maintaining non [NAME] bearing status. On 3/7/22, at 11:43 a.m. during an interview, registered nurse (RN)-A stated R1's family had voiced concerns on 2/17/22 related to R1 was being transferred with one staff and not maintaining non-weight-bearing status. RN-A further stated upon admission R1 was a two-person transfer based on recommendation from the hospital. RN-A stated R1 swung her legs to the left side of bed and would bear weight during transfers. RN-A stated staff had been educated on transfers for R1. On 3/7/22, at 12:00 p.m. during an interview, occupational therapist (OT)-A stated R1 was non-weight-bearing due to the fracture in left lower extremity which required an ORIF. R1 required extensive cueing to ensure non-weight-bearing. Therapy recommended assist of two staff with slide board to transfer to wheelchair or bed. Staff were not to complete pivot transfer with R1 because of the need for extensive cueing. OT-A stated the therapy departments were working with resident on pivot transfers, but it was not safe for staff to complete this. OT-A further stated the bed should have been moved away from the window to allow for transfers out of bed on nonsurgical leg to touch the ground first. On 3/7/22, at 2:01 p.m. during an interview, licensed practical nurse (LPN)-A stated R1 was admitted from the hospital. During assessment, R1 was a heavy assist of two staff for transfers to maintain her non-weight-bearing status. LPN-A further stated R1 would transfer out of bed on her left side and staff needed to provide reminders not to put weight on her foot. LPN-A stated R1 would follow directions as given by staff and required assistance from staff to hold her left leg during transfers. On 3/7/22, at 2:15 p.m. during an interview, NA-C stated he had completed pivot transfers with R1 by himself. NA-C stated he did not use the slide board and R1 had difficulties holding her leg off the floor during the pivot transfers. On 3/7/22, at 3:13 p.m. during an interview, NA-B stated she completed pivot transfers to the commode for R1 and did not use the slide board. NA-B further stated R1 put weight on her foot and touched the floor when scooting to the side of bed, or when transferred. NA-B did not report this to the nurse. Further, NA-B stated the unit did not always have two staff available to help transfer R1. On 3/7/22, at 3:26 p.m. during an interview, NA-E stated R1 was a one-person transfer most of the time and did not use a slide board. NA-E further stated R1 positioned to the left side of the bed and often forget she was non-weight-bearing as she set her foot down when getting out of bed. NA-E stated R1's family member had concerns about transfers and not maintaining non-weight-bearing. R1's care guide was updated to direct staff to provide assist of two for transfers. On 3/7/22, at 4:00 p.m. during an interview, NA-A stated R1 was COVID positive on 2/14/22, and during that time one NA was used to pivot transfer and noticed R1 would bear weight on the left leg with transfers to the commode or wheelchair. NA-A stated they had tried the sliding board and were not successful. However, she did not communicate this to therapy. On 3/7/22, at 4:04 p.m. during an interview, NA-G stated R1 required to use a slide board. However, it was difficult to use and transfers did not go well. R1 could not keep left foot off the floor and would stand up to pivot transfer with her left leg bearing weight unless you gave R1, one step directions. NA-G stated she reported her concerns to the nurse supervisor about the transfers, slide board being difficult to use, and R1 resting her foot on the ground during pivot transfers. On 3/7/22, at 3:46 p.m. during an interview, RN-B stated R1 was non-weight-bearing, and would have one person assist for a pivot transfer performed. Further, RN-B stated the NA's did not report concerns about R1 attempting to self-transfer, difficulties with using slide board, or bearing weight. RN-B stated R1 missed her intial follow up visit with the orthopedic surgeon but required to be reschedule to 3/2/22, due to R1 testing positive for COVID-19. On 3/8/22, at 10:42 a.m. during an interview, RN-A stated R1's family first reported a concern about transferring on 2/17/22, and not again until 3/2/22, and then they started education for the TCU nursing staff on transfers for R1. RN-A further stated social services were aware of the concern about the transfer. On 3/8/22, at 11:00 a.m. during an interview, social worker (SW)-A stated R1 family member contacted the facility about concerns regarding R1's transfers during cares and asked if staff were assisting R1 with transfers. SW-A further stated she was told by FM-A that R1 required a second surgery to repair her left leg. R1's physician PN dated 3/2/22, indicated R1 believed she put weight on her foot during transfers to the bathroom only on night shift due to insufficient assistance from the nursing assistant staff. R1's post operative report dated 3/3/22, indicated R1 had a postoperative diagnosis of implant failure left distal fibula and syndesmosis (fibrous joint held together by ligaments), left distal fibula fracture, left syndesmosis injury, and subluxation of left joint (ligaments are often stretched or torn, and there may be a break in the bone.) Removal of deep implant left fibula, revision of ORIF left distal fibular shaft and syndesmosis. R1 was admitted to the hospital on 3/3/22, for surgical repair and revision of her first surgery related to injury sustained due to not maintaining non-weight-bearing status. On 3/8/22, at 1:24 p.m. during interview, orthopedic surgeon (MD)-A stated R1 required a second surgery because of injury where R1 foot was 40 degrees off from original placement after first surgery. MD-A stated this only could have occurred if R1 had beared weight on her foot during pivot transfers, resting on the ground, or if the foot hit the ground. MD-A stated R1 required to have a second ORIF with all of the plate and screws removed, repositioned the foot and replace the plate and screws. MD-A stated R1 should not have had any weight on the floor or surface. R1 was non-weight-bearing after her first surgery for at least six to eight weeks. On 3/7/22, 3:50 p.m. during interview, the director of nursing (DON) stated she was not aware of concerns regarding R1's care including transfers or weight bearing during transfers. DON stated her expectation would be for staff to follow physicians orders and ensure care plans were appropriate based on physician orders. Facility policy titled activities of daily living (ADL's) revised date 3/18, indicated appropriate care will be provided for residents who are unable to carry out ADL's independently in accordance to the plan of care, including appropriate support and assistance with transfers. The IJ which began on 3/2/22, was removed on 3/9/22 at 4:41 p.m. when the facility successfully implemented a removal plan which was verified that included: Review of the policies for accidents and incidents, Residents' charts were reviewed for weight bearing status, and the potential for being affected due to non-weight-bearing status, care plans, and assignment sheets were updated, in place and accurate. The facility provided education to nursing staff on safe transfers, following doctor's orders, documentation of resident compliance to include education on risk and benefits. The facility had a plan in place and check off system to assure all staff would be educated prior to working their next shift. On 3/9/22, between 4:00 p.m. to 4:41 p.m. interviews with director of nursing, nursing staff, nursing assistant staff, and management verified training on safe transfers, following doctor's orders, documentation of resident compliance to include education on risk and benefits. Residents' charts were reviewed for weight bearing status, and the potential for being affected due to non weight bearing status. Residents care plans, and assignment sheets were updated, in place and accurate.

Based on interview, and document review, the facility failed to ensure [MEDICATION(S)] (a narcotic medication) was administered as prescribed for 1 of 3 residents (R1) reviewed for medication errors. This deficient practice resulted in an immediate jeopardy (IJ) situation for R1 who received a [MEDICATION(S)] dose 20 times greater than what was prescribed and required [MEDICATION(S)] (used to treat a narcotic overdose) administration. The IJ began on [DATE], at approximately 8:32 a.m. when R1 was administered a dose of [MEDICATION(S)] which was twenty times greater than what was prescribed by the physician. R1 subsequently became unresponsive, was hypoxic (low oxygen level), and [MEDICATION(S)] was administered to reverse a narcotic overdose. The administrator and director of nursing (DON) were notified of IJ on [DATE], at 1:40 p.m. The facility had implemented corrective actions on [DATE], therefore the deficient practice was issued as past noncompliance. Findings include: R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 received hospice services. In addition, the MDS indicated it was, Very Important for family or a close friend to be involved in discussions about her care. A facility reported incident to the state agency (SA) dated submitted on [DATE], indicated at approximately 1:10 p.m. the facility house supervisor was notified R1 received an incorrect dose of [MEDICATION(S)]. The house supervisor contacted hospice and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was administered [MEDICATION(S)] at 3:38 p.m. and showed minimal response after two minutes. At 3:40 p.m. a second dose was administered and was effective as R1, began taking deeper and more frequent breaths. R1 had a large emesis and showed signs of lethargy at approximately 3:50 p.m. R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were to administer 2.6 mg (0.13 mL) by mouth three times daily and 2.6 mg every hour as needed. R1's Individual Narcotic Record indicated licensed practical nurse (LPN)-A documented 2.6 mL (52 mg) of [MEDICATION(S)] was removed at 8:32 a.m. and 1:59 p.m. on [DATE]. A Medication Error Report Form dated [DATE], indicated R1 received 104 mg of [MEDICATION(S)] rather than 5.2 mg. R1's nursing incident note dated [DATE], at 2:00 p.m. indicated while doing the narcotic count with the morning nurse it was noted an incorrect dosage of liquid [MEDICATION(S)] was left in the bottle. The amount remaining was 23.295 mL, however, the amount should had been 28.235. The note further indicated R1 received 52 mg of [MEDICATION(S)] at 8:00 a.m. and again at 2:00 p.m. It was noted R1 was unable to respond, her mouth was wide open, and R1's eyes were rolled up with eye lids slightly open. R1 was administered two doses of [MEDICATION(S)]. After the second dose, R1 became responsive and was talking to the nurse. Emergency Medical Services (EMS) was activated, however, R1 was not sent to the hospital per family wishes. Orders were given for staff to monitor R1 at the facility. During interview on [DATE], at 11:31 a.m. the director of nursing (DON) stated she was informed LPN-A, an agency nurse, made a medication error. The DON stated LPN-A made two medication errors on [DATE], when [MEDICATION(S)] was administered incorrectly to R1 at 8:00 a.m. and again at 2:00 p.m. The DON stated the medication error was discovered by registered nurse (RN)-A, who worked evening shift, during the narcotic count. [MEDICATION(S)] had been given to R1 per the hospice physician to stabilize her [R1]. Family chose to keep R1 at the facility and R1 died on [DATE]. The DON stated following the medication error, LPN-A was provided education before being taken off the schedule. In addition, LPN-A's agency was made aware of the medication error and it was recommended additional training and competency training be provided. The facility implemented training on [DATE], for all nurses and trained medication aides (TMA's) on the seven rights of medication administration (right medication, patient, dose, time, resident, route, reason, and documentation). The facility also held a Quality Assurance and Performance Improvement (QAPI) meeting to discuss the medication error and a report was filed to the board of nursing related to LPN-A's medication error. R1's liquid medications which included [MEDICATION(S)] (antianxiety) was audited and found to be correct. Additionally, other residents' liquid medications were audited to ensure accuracy of administration. The DON confirmed a signification medication error occurred and she expected nurses and TMAs to follow the seven rights and to give medications as ordered. The DON stated although R1 was terminal and declining R1 was noted to be alert prior to this (medication error incident). During interview on [DATE], at 11:59 a.m. R1's primary physician (MD)-A stated due to R1's fragile [CONDITION(S)] (narrowing of the arteries) and heart failure, R1 was enrolled to hospice on [DATE]. MD-A stated he expected the staff agency of the facility to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on [DATE], at 2:07 p.m. the facility consultant pharmacist stated R1's medication error had been discussed at the QAPI meeting on [DATE], and R1 had stabilized and responded after receiving [MEDICATION(S)]. During interview on [DATE], at 1:34 p.m. LPN-A stated R1, had an order to give 2.6 mg [[MEDICATION(S)]] three times a day and I did not click for the rest of the [order] description. I did it and I did not catch it right away [medication error]. She had administered [MEDICATION(S)] twice during her shift at 8:00 a.m. and again at 2:00 p.m. The medication error was not caught until staff performed the end of shift narcotic count. After the medication error was identified RN-A and herself went to R1's room and LPN-A stated R1 appeared like she was asleep. Hospice was contacted and an order was received to give R1 [MEDICATION(S)]. LPN-A stated she obtained vital signs on R1, however, did not document the results and thought she gave the vital signs to RN-A. She had been to R1's room a total of four times during the shift and R1 was noted to be, sleepy and did not arouse. [MEDICATION(S)] was given twice to R1, and after the second dose R1 was responsive and RN-A asked R1 to take deep breaths. During interview on [DATE], at 3:01 p.m. RN-A stated during the narcotic count at shift change she identified a medication error had occurred as there was more medication missing from R1's [MEDICATION(S)] bottle than what was reconciled. RN-A went to R1's room after identifying the medication error and noticed R1 was not speaking, was non-responsive to voice or touch, her eyes were rolled to the back of her head and her mouth was wide open. Hospice then gave an order to administer [MEDICATION(S)]. After the first dose R1 started breathing through her nose and R1 was instructed to take deep breaths. A second dose was given after two minutes and R1, popped her head, she was alert, and saying hi like nothing had happened. Prior to [MEDICATION(S)] administration R1's oxygen saturation was 70 percent (normal was 95 to 100 percent) on three liters of oxygen. RN-B had taken R1's vital signs and RN-A thought RN-B documented the results. After R1 was administered [MEDICATION(S)], R1 got sick and vomited. R1's oxygen saturations continued to range from the high 70's to low 80's on three liters of oxygen. When EMS arrived, R1's oxygen was increased to six liters and R1's oxygen saturation increased above 90 percent. During interview on [DATE], at 4:01 p.m. house supervisor, RN-B stated she was informed of a medication error involving R1 from LPN-A on [DATE]. When she went to check R1, she [R1] did not look great. She reached out to the primary provider but was unable to get through. Hospice was then called, and the hospice medical director gave an order to administer [MEDICATION(S)]. RN-B stated before the first dose of [MEDICATION(S)] was administered R1's respirations were under 10 (normal was 12 to 20 breaths per minute while resting). With the first dose of [MEDICATION(S)], R1 had minimally responsive respirations which were shallow and slow. When the second dose of [MEDICATION(S)] was administered R1 had deep respirations and was alert, came back around, and was verbalizing and following instructions. R1 then started to cough and vomit and police had arrived. RN-B confirmed she had not documented R1's respirations in the medication record because she thought RN-A completed the documentation. During interview on [DATE], at 4:14 p.m. hospice RN, RN-C stated she was made aware a medication error involving R1 occurred on [DATE]. RN-C stated it was a significant medication error because R1's naive (non-tolerance) to the amount of [MEDICATION(S)] given due to being fragile and R1 was not a long-term opioid patient. Family shared they felt R1's death was hastened by the medication error because they visited R1 the previous evening ([DATE]) and R1 was alert and holding normal conversations. During interview on [DATE], at 5:50 p.m. family member (FM)-A stated several family members were at the facility the day before the medication error ([DATE]) and R1 was alert and conversing appropriately at that time. FM-A stated she was at the facility on [DATE], at 12:00 p.m. and a nursing assistant was in the room tapping R1's cheek and trying to wake R1 up and R1 only rolled her eyes. FM-A stated she left the facility at approximately this time and later returned after the medication error was identified. FM-A stated she was informed an agency nurse had made the medication error. FM-A stated following the medication error and after a conversation with EMS it was decided to keep R1 at the facility instead of transferring her to the hospital. Nurses at the facility were supposed to monitor R1 as RN-A was busy with other residents and did not get assistance. FM-A also stated the facility did not want to take responsibility for the medication error, blamed the agency nurse, and stated R1 was declining. The facility Medication Administration -General Guidelines dated [DATE], directed the licensed nursing and authorized personnel who prepared and administered medications to follow the five medication rights during medication preparation and the staff was to compare the medication label against the medication administration record (MAR), when removing the dose from the container to verify against the label and MAR and staff was to complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 rights. The past noncompliance IJ which began on [DATE], was removed as of [DATE], when the facility implemented corrective action which was verified through observation, interview, and document review. The plan included: - All scheduled staff who administered medications were reeducated on medication administration, including dosing on [DATE], and was ongoing. - Staff who had not received education were notified education on medication administration must be completed prior to their next scheduled shift on [DATE]. - The facility conducted audits of R1, and other residents who received liquid controlled medications, to ensure medication labels matched orders and the quantity of medication remaining was appropriate on [DATE]. - During observation on [DATE], and [DATE], five licensed nurses were observed to prepare and administer 25 medications to different residents which included narcotic suspensions, topical, eye drops, and oral medications. No errors were observed. Interviews: During interview on [DATE], at 10:30 a.m. RN-C stated following the medication error the facility had started staff training on the seven rights of medication administration on [DATE], and all staff were trained before their shift from the nurse manager at her unit. The same information was posted on the unit education clip board for staff to review. RN-C further stated after the training was ongoing until all staff received it. During interview on [DATE], at 10:40 a.m. RN-D stated she received training on the seven rights of medication administration and all the staff passing medications were to double check and make sure the dosage conversation for liquid medications was correct. RN-D further stated the training was being provided by the nurse manager and was ongoing. During interview on [DATE], at 10:44 a.m. RN-E stated he received training regarding checking the seven medication rights. RN-E also stated for the liquid medications the nurses were supposed to make sure the dosage was converted and staff were supposed to read the instructions in the order by clicking on it for more details. During interview on [DATE], at 11:06 a.m. LPN-B stated had received training on the seven medication rights. LPN-B also showed the surveyor a education clip board with which had several staff signatures on the same training. During interview on [DATE], at 11:11 a.m. LPN-C stated she received training on the seven rights of medication administration. During interview on [DATE], at 11:24 a.m. RN-F stated following the medication error, education was provided on the seven medication rights. RN-F also stated during medication administration staff were to triple check, and if in doubt, they were to ask another nurse and supposed to read the instructions on the orders when giving the medications.

Based on observation, interviews and record review, the facility failed to ensure a system was in place to reduce accident hazards that resulted in second degree burn to the right shin of one of one resident (R1) reviewed when R1's bed was placed next to a baseboard heater. The failure for the facility to identify the hazards for burn due to residents' beds being placed next to a baseboard heater had the potential to affect four of the 47 residents (R2, R3, R4, and R5), whose beds were found next to heaters at risk for immediate jeopardy (IJ). The IJ began on (MONTH) 31, (YEAR) when the facility did not reassess all memory care residents who had their beds next to the heater baseboards and was identified on (MONTH) 10, (YEAR). The director of nursing and assistant director of nursing were notified of the IJ on (MONTH) 10, (YEAR) at 2:35 p.m. The IJ was removed on (MONTH) 11, (YEAR) at 6:25 p.m. but noncompliance remained at the lower scope and severity level of G, isolated pattern for potential of harm, which is not immediate jeopardy. Findings include: R1's medical record was reviewed. R1 admitted to the facility on (MONTH) 14, (YEAR) with [DIAGNOSES REDACTED]. R1's care plan indicated R1 is able to move in bed independently, at risk of impaired decision-making and communication, unable to use call light consistently, and required staff to anticipate R1's needs, and monitor closely for behaviors. R1's progress note dated (MONTH) 30, (YEAR) indicated R1 had redness at the left hip with no other skin impairment noted. Facility's incident report dated (MONTH) 31, (YEAR) indicated staff found R1 with both legs hanging over left side of the edge of her bed with right shin resting against the edge of the baseboard heater cover. The report indicated the staff repositioned R1, noted skin impairments to the legs, and notified the nurse. The report indicated the staff repositioned R1's bed away the heater and provided treatment to R1's impaired skin. The incident report indicated R1 had history of laying in bed improperly with lower extremities hanging off the edge of the bed. R1's progress note dated (MONTH) 31, (YEAR) indicated night staffs found R1 in bed, during rounding, with legs hanging over the edge of the bed, and on the side with a heater running along the wall. The progress note indicated staff assessed R1 and found reddened area that was thought to be a burn from the heater next to R1's bed. The progress note indicated the staff intervened by repositioning R1's bed away from the wall with heater to prevent further burn. The progress note indicated the facility notified R1's physician and family representative. R1's hospice progress note dated (MONTH) 6, (YEAR) indicated the facility's nurse reported R1 had a burn to the right leg when she put her legs out of the side of the bed and onto the baseboard heater cover. The progress note indicated R1 had right shin burn, measuring 6 centimeters (cm) by 5 cm on the wound perimeter. The progress note indicated the wound had small amount of yellow drainage. The nurse practitioner telephone encounter note dated (MONTH) 9, (YEAR) indicated the facility reported R1 sustained a burn to the right shin a week ago when R1 rested her leg against a wall heater. The note indicated the facility requested the nurse practitioner's intervention as the treatment prescribed by hospice was not effective. Another note later the same day indicated the nurse practitioner discontinued the hospice order for [MEDICATION NAME] and ordered [MEDICATION NAME] 1% cream (used for the prevention and treatment of [REDACTED]. The nurse practitioner's progress note dated (MONTH) 10, (YEAR) indicated R1 had a burn injury and requested the facility to refer R1's burn wound to the facility's wound physician for further assessment and treatment. During an observation on (MONTH) 9, (YEAR) on the memory care unit, the facility had four residents' (R2, R3, R4, R5) beds against the wall with heater. R2 was observed to be in bed next to the wall with heater. During an observation on (MONTH) 10, (YEAR) on the memory care unit, R2, R3, R4, and R5's beds were still against the wall with heater and R2 was in bed. In an interview on (MONTH) 9, (YEAR) at 2:40 p.m., the mechanical specialist (MS)-A stated he became aware of the incident a week after it happened. MS-A had not checked the surface temperature of heaters in the past. MS-A stated he did check the surface temperatures of three rooms today and the temperatures were between 95 to 100 degrees Fahrenheit. MS-A stated he was not involved in safety assessment of heaters in regards to residents with cognitive impairments and did not do one after R1's burn incident. MS-A stated he had not checked temperature of heater and heater covers and was not aware of such process being in place at the facility. MS-A stated he would anticipate bed position changes to prevent this accident from happening in the future, but had not do so except for the bed in R1's room. The facility had no system in place to check and record surface temperature or determine the appropriate baseboard temperature. In an interview on (MONTH) 9, (YEAR) at 3:13 p.m., registered nurse (RN)-B stated since R1's burn incident, staff have repositioned all beds next to wall with heater. RN-B stated she was not aware of any process for monitoring residents' safety in rooms with regards to the baseboard heater. RN-B was not aware of additional resident beds that had not been moved to reduce the hazard [MEDICAL CONDITION] baseboard heaters at the memory care unit. In an interview on (MONTH) 9, (YEAR) at 3:50 p.m., the plant operations director (OD)-C stated his staff used heat gun to check resident room temperatures weekly, but temperatures were not documented. OD-C stated the staff responsible the memory care unit had removed all beds away from walls with heaters. OD-C stated he doubled and tripled checked with nursing department to ensure all beds were moved away from walls with heaters. In an interview on (MONTH) 9, (YEAR) at 4:38 p.m., the director of nursing stated stated staff have been educated to ensure beds were away for wall with heater campus-wide. The director stated no safety assessment was completed for residents with beds against wall with the baseboard heater on the memory care unit. The director of nursing was not aware of additional resident beds that had not been moved to reduce the hazard [MEDICAL CONDITION] baseboard heaters at the memory care unit. In interviews on (MONTH) 10, (YEAR), multiple staff stated they were educated on ensuring residents' bed were away from the walls with heater, but the positions of the four beds for R2, R3, R4, and R5 had not been repositioned or changed since the burn incident. In an interview dated (MONTH) 16, (YEAR) at 2:50 p.m., the facility's administrator stated, after R1's burn incident, the facility moved all beds away from heaters, but some of the beds were moved back to positions near heaters. The administrator stated the facility educated staff, updated care plans to address bed position changes with families during care conferences, and will continue to monitor staff to ensure residents are safe at the facility. The administrator was not aware of additional resident beds that had not been moved to reduce the hazard [MEDICAL CONDITION] baseboard heaters at the memory care unit. Facility's policy and procedure, Safety and Supervision of Residents, dated (MONTH) 2007 indicated the facility strives to make the environment as free from accident hazards as possible. The policy indicated the facility's accident prevention priorities for resident's safety, supervision, and assistance include facility-oriented approach to safety by addressing risks for groups of residents and identifying environmental hazards, developing strategies to mitigate or remove hazards to the extent possible, and training employees to try to prevent avoidable accidents. The policy indicated the facility's staff will use various sources to identify resident risk factors, implementing interventions to reduce accident risks and hazards, and monitoring the effectiveness of the interventions. The policy indicated resident-specific risks and environment hazards such as bed safety, falls, electrical safety, and water temperatures are addressed based on a resident's complexity. Facility's policy and procedure, Abuse Investigation and Reporting, dated (MONTH) (YEAR) indicated the facility is committed to providing an environment as safe as possible to each resident. The policy indicated the facility will have an overall proactive approach for the detection and prevention of abuse and neglect. The immediate jeopardy that began on (MONTH) 31, (YEAR) was removed on (MONTH) 11, (YEAR), when the facility reviewed and/or completed fall assessments, updated care plans, removed beds away from the baseboard heater, all room radiator temperatures checked and documented, nursing staff educated on risks related to safe beds positioning for residents, and maintenance staff educated on documenting resident room checklist, including the temperature of the heater and baseboards. The director of nursing and maintenance will be responsible for monitoring the nursing and maintenance tasks respectively.

Based on observation, interview, document review, and review of video surveillance tapes, the facility failed to ensure that residents were not subjected to abuse for 2 of 2 residents reviewed (R1 and R2), who were physically abused by 1West employees on multiple occasions. These employees had also worked with other residents residing on 1West as well as multiple shifts on the facility's other five units (1East, 2East, 2West, 3East, and 3West), potentially affecting all 244 of the facility's residents. This resulted in an immediate jeopardy to the safety of all residents. The immediate jeopardy began on 06/22/15 when facility leadership staff learned that eight different employees had either abused 2 of the facility's 244 residents or had witnessed the abuse and did not report it. The facility's Administrator and Interim Director of Nursing were notified of the immediate jeopardy on 6/26/15 at 12:45 p.m. The immediate jeopardy was removed on 7/1/15 at 4:05 p.m. after it was verified an acceptable removal plan was implemented to protect the health and safety of residents, but noncompliance remained at the lower scope and severity, no actual harm with a potential for more than minimal harm that is not immediate jeopardy at a widespread scope (F). Findings include: R1's medical record was reviewed. R1's care plan, dated 06/24/15, indicated that R1 has severe cognitive impairment. R1's ability to understand others is impaired as well as R1's ability to express his needs. R1 is unable to use a call light. R1 is totally dependent on staff for all care and requires the presence of two staff for care delivery. At times, R1 is resistive to care and can be verbally or physically aggressive with staff by striking out or kicking care givers. When R1 is uncooperative with care, staff are to leave R1 alone, reapproach him later, or have a different staff reapproach him. R2's medical record was reviewed. R2's care plan, dated 06/18/15, indicated that R2 is cognitively impaired and suffers from [MEDICAL CONDITION]. R2 is at high risk for falls, due to R2's functional strength impairment resulting from [MEDICAL CONDITION], decreased mobility, balance problems, and unsafe movements. R2 needs staff assistance to transfer safely. R2's primary means of mobility is a wheelchair. R2 has difficulty speaking and understanding others. R2 requires a calm, gentle approach for care and is able to perform some activities of daily living, with staff encouragement. R2 has episodes of weepiness and resistance to care. R2 can become combative and push staff away. When R2 is uncooperative with care, staff are to leave R2 alone, reapproach her later, or have a different staff reapproach her. Observations during the course of the investigation from 06/25/15 - 06/30/15 established that R1 and R2 reside in separate rooms on the same hallway on 1West. A Non-Fall Incident Report, dated 05/26/15 at 4:00 p.m., indicated that R1's family member reported to staff that R1 had an injury on his left upper lip. A nurse assessed the injury and observed that R1 had 0.3 cm scratch to the left lip that was scabbed over and a 0.3 cm bruise/mark to the inner side of the left upper lip. The nurse documented that the resident said no when asked if he or someone else bumped his lip or hurt him. Neither the source, date, nor time of R1's injury was known. R1's progress notes, dated 05/26/15 at 6:15 p.m., indicated that RN/(I) interviewed R1 about the lip injury and R1 stated he bit his lip. RN/(I) observed a scab on R1's outer lip and the roof of R1's mouth had a pinkish-purple discoloration. R1 denied pain. R1 denied that anyone had harmed him. R1 indicated that he felt safe. R1's family member informed RN/(I) that R1 sustained the lip injury last week on Thursday or Friday night (which was 05/21/15 or 05/22/15). Family member (FM)/kk was interviewed on 06/25/15 at 2:00 p.m. FM/kk stated she observed that R1 had an injury to his left upper lip when visiting on 05/22/15. FM/kk brought the injury to the staff's attention on 05/26/15. The clinical coordinator told FM/kk that the cause of R1's lip injury was from R1 biting his lip. FM/kk asked if this was accurate or if an investigation should occur. The clinical coordinator and unit social worker said an investigation was not necessary. FM/kk stated that she had been uncomfortable with a prior report from staff about an alleged fall R1 had in early April 2015 when R1 sustained a large bruise to the back of the head and scrapes to the back. A plastic wall plate had been broken which staff said had occurred when R1 jumped up from the bed swinging and then fell . Staffs' explanation concerned FM/kk because FM/kk did not think R1 could jump up, given R1's mobility deficits. Prior to R1's fall with injuries, FM/kk had also asked staff about several other unexplained bruises or abrasions R1 had on his body and was not provided any reasonable explanation about how the injuries occurred. FM/kk stated that she had installed a video surveillance camera in R1's room in mid-April 2015 because staff were never able to identify how R1 had sustained injuries and R1 cannot provide reliable information. Installation of the video camera was unknown to staff. FM/kk stated she first reviewed some of the surveillance videos after R1 sustained the lip injury in May 2015 and she continued to periodically review the video tapes after that. During FM/kk's visits with R2 around the same time, R2 told FM/kk that the staff were rough with her, and that you don't believe me. R2 was upset off and on, and was refusing to have baths. FM/kk installed a video surveillance camera in R2's room on 06/07/15. FM/kk reviewed one of video tapes recorded on 06/19/15 and became so concerned about what she saw on the video that she spent the night in the facility on 06/20/15 to ensure R1's safety. On the afternoon of 06/22/15, FM/kk provided copies of several video tapes to leadership staff, which depicted multiple incidents when R1 and R2 were abused by facility care givers from 05/22/15 to 06/21/19. Hidden video surveillance in R1's room captured staff-to-resident interactions on videotape. The videotapes were observed by investigators on 06/29/15. The identities of staff in the videotape were confirmed by Administrator/B on 06/29/15. The videotape dated 05/22/15 at 12:45 a.m. shows: R1 is in bed. Nursing Assistant (NA)/Q and NA/Z are in R1's room at R1's bedside, attempting to provide incontinence care to R1, which R1 is resisting. NA/Q jabs at R1 with his right arm but the point of contact to R1's body cannot be seen. R1 grabs at both staff and attempts to raise his head off the pillow. NA/Q strikes R1 in the face with a closed fist between the left upper lip and nose. R1 immediately covers his nose and mouth with both hands and turns his head away from NA/Q. NA/Q and NA/Z continue to provide care to R1. R1's pillow is removed from the bed. R1 continues to resist care and fights staff with his right arm. Staff change R1's shirt and stand him up at the bedside. R1 is then calm. NA/Z places soiled linen in a bag. NA/Q assists R1 to bed in a reclining position. Care is completed at 12:50 a.m. and staff turn the lights off in R1's room. NA/Z was interviewed on 06/25/15 at 6:30 a.m. prior to viewing the video surveillance of R1. NA/Z stated she normally works the night shift on 1West. NA/Z received training on care of residents with dementia and how to respond appropriately when residents exhibit resistive behavior. NA/Z has also received training on abuse prevention and what constitutes resident abuse. NA/Z stated she has never witnessed any employee abuse, mistreat, or hit a resident. NA/Z stated she had no concerns about the conduct of any co-workers. NA/Z stated if she ever observed anyone mistreat a resident, she would immediately report it to a nurse. There was no evidence that NA/Z reported the incident of 05/22/15 when NA/Q abused R1. At the time of the investigation on 06/25/15, NA/Q was suspended from duty, effective 06/22/15 (the date that facility leadership staff observed the video surveillance tapes given to them by FM/kk), but NA/Z remained on the current staff schedule for duty and continued to perform care of residents. Hidden video surveillance in R1's and R2's rooms captured additional staff-to-resident interactions. The videotapes dated 04/28/15 - 05/17/15 were observed by investigators on 07/08/15 and the identities of staff in the videotapes were confirmed by Administrator/B on 07/10/15. The videotapes dated 06/10/15 - 06/21/15 were observed by the investigators on 06/29/15 and the identities of staff in the videotapes were confirmed by Administrator/B on 06/29/15 and 06/30/15. The videotapes show: (1) On 04/28/15 at 4:46 a.m., NA/Q is providing incontinence care to R1 while R1 is in bed. NA/Q pushes roughly on R1's body, in attempt to turn R1 to the right side. After four minutes of providing care, NA/Q hits R1 with an open hand on R1's lower body. The video does not show the exact point of NA/Q's contact on R1's body but does show NA/Q raising his left hand and striking down at R1's lower body. (2) On 04/30/15 at 12:30 a.m., NA/Q is providing incontinence care to R1 while R1 is in bed. NA/Q pushes roughly on R1's body, in attempt to turn R1 to the right side. R1 is resistive and not cooperating with NA/Q's attempts to turn him. NA/Q then slaps R1 with an open hand on R1's shoulder. (3) On 04/30/15 at 4:50 a.m., NA/Q is providing incontinence care to R1 while R1 is in bed. NA/Q pushes roughly on R1's body, poking and jabbing at R1 with his arms and the weight of his body. R1 punches at NA/Q and tries to kick NA/Q. NA/Q then pokes R1 in the left cheek with his knuckles. (4) On 05/17/15 at 5:26 a.m., NA/Q is providing incontinence care to R1 while R1 is in bed. R1 is not exhibiting any resistance toward care but NA/Q punches R1 with a closed fist in the left hip. R1 rubs the area of his left hip with his hand where NA/Q struck R1. NA/Q begins to change R1's bedding. R1 is resistive and kicks at NA/Q. NA/Q punches R1 with a closed fist on R1's left upper thigh. R1 again kicks at NA/Q. NA/Q punches R1 a third time with a closed fist underneath R1's left upper thigh. R1 continues to be resistive as NA/Q attempts to apply a clean incontinent product. R1 is flat on his back in bed. NA/Q jabs at R1 with his arms and tries to hold R1 still with his body weight while the incontinent product is applied. R1 kicks at NA/Q again. NA/Q reaches across R1's body and punches R1 two times with a closed fist on R1's right upper thigh. (5) On 06/10/15 at 8:54 p.m., NA/U is in R2's room on her personal cell phone. R2 is sitting in a wheelchair. Five minutes later at 8:59 p.m., NA/U remains on the cell phone. No care has been provided to R2 during this time. R2 reaches for something from her bedside table and NA/U pushes R2's hand away, preventing R2 from obtaining the object from the bedside table. NA/U continues with the personal cell phone call. At 9:02 p.m., NA/U assists R2 from the wheelchair to a standing position. NA/U holds onto R2's pajama bottoms to maintain R2's balance rather than using a transfer belt to ensure R2's safety. At 9:05 p.m., R2 reaches for a glass of water from the bedside table and NA/U jerks the water glass out of R2's hand in an abrupt manner. R2 begins crying. (6) On 06/19/15 at 4:50 a.m., NA/Q and NA/P are providing incontinence care to R1 while R1 is in bed. Both staff are standing side by side, leaning over R1's bed. R1 is resisting care. NA/P jumps backward away from R1's bed and NA/Q forcefully yanks R1 by the arms upward in bed, toward the head of the bed. NA/Q then jabs at R1's chest with an open hand. R1 kicks at NA/Q and NA/Q punches R1 with a closed fist in the stomach. There was no evidence that NA/P reported the incident of 06/19/15 when NA/Q abused R1. (7) On 06/19/15 at 6:45 p.m., NA/V is in R1's room making R1's bed. R1 is sitting in a recliner. R1 independently gets in bed and lays down with his head at the foot of the bed. NA/V grabs R1 by both of his arms and quickly swings R1 around toward the head of the bed in a rough manner. R1 kicks at NA/V. NA/V makes a gesturing boxing motion at R1. R1 rubs both of his upper arms where NA/V grabbed him. (8) On 06/19/15 at 9:00 p.m., NA/S and NA/X are in R2's room, both on personal cell phones. R2 is sitting in a wheelchair. No care is provided to R2. At 9:12 p.m., R2 transfers herself from the wheelchair to bed, while both staff are sitting in R2's room, uninvolved with R2. R2 stumbles during the self-transfer and almost falls as she plops herself down on the bed and leans significantly to the side, which R2 self-corrects. At 9:14 p.m., both staff are still on cell phones and neither has assisted R2 with any care. At 9:16 p.m., NA/S stands in front of R2's wheelchair and shakes her index finger at R2 in a scolding manner. (9) On 06/21/15 at 11:23 a.m., NA/R is providing care to R2 in R2's room. R2 is nude in bed. NA/R throws a towel at R2, which hits R2 in the face and covers R2's face. R2 picks up the towel and throws it back at NA/R. NA/R then balls up the towel and throws it forcefully in R2's face. R2 tries to cover her exposed body with the towel. LPN/y enters the room and completes R2's care. NA/R and LPN/y then transfer R2 to a wheelchair. Neither employee used a transfer belt assisting R2 to the wheelchair. (10) On 06/21/15 at 11:24 a.m., NA/R and NA/S are providing personal care to R1 in his room. R1 is resistive and strikes out at the staff as they attempt to change his clothes. Several minutes later, care is completed. R1 is lying in bed on his back not exhibiting any resistive behavior. NA/S walks over to R1's bedside and tweaks or pulls the tip of R1's nose with her fingers. Administrator (ADM)/B and Interim Director of Nursing (DON)/C were interviewed on 06/25/15 at 7:30 a.m. They stated that FM/kk visits R1 and R2 on a consistent basis, usually in the afternoons and late evenings. On the afternoon of 06/22/15, FM/kk provided them with video surveillance tapes showing several occasions when staff mistreated R1 and R2 during provision of care in their rooms. ADM/B, DON/C, and FM/kk reviewed the video tapes together, which entailed resident misconduct by nine employees, including physical abuse of R1 and R2. Four of the nine employees were on duty working at the time the videos were reviewed on 06/22/15. The four employees were immediately removed from duty and suspended. The remaining five employees were called at home and placed on investigatory suspensions. A total of nine employees were suspended on 06/22/15. ADM/B and DON/C then notified local law enforcement of the matter. The police responded to the facility and attempted to interview R1 and R2, but were unsuccessful due to the cognitive limitations of both residents. The police took the video tapes for further review. On 06/22/15, ADM/B and DON/C re-educated all staff on the Resident Bill of Rights, abuse, and reporting. On 06/22/15, ADM/B and DON/C advised House supervisors, managers, and 1West nurses to increase supervision of nursing assistant care to residents. RN Clinical Coordinator (RNCC)/H was interviewed on 06/25/15 at 5:10 a.m. RNCC/H stated she was functioning as the House Supervisor for the night shift of 06/24/15 - 06/25/15. RNCC/H stated she had not been informed of the need to increase supervision of staff during care to residents. RNCC/H had not made any additional unit rounds during the shift. RNCC/H was aware there was an internal investigation taking place but RNCC/H didn't know what the investigation was about or if it pertained to resident care. RN Supervisor (RNS)/F was interviewed on 06/25/15 at 7:00 a.m. RNS/F, who was working as a unit nurse during the night shift of 06/24/15 - 06/25/15, stated she is the usual house supervisor during the night shift. RNS/F stated she usually rounds to each of the facility's six units three times or more during the night. She has worked in this capacity for many years and knows most of the staff who work the night shift. She has no concerns about the resident care provided by any of the night staff. NA/Z and NA/Q are both excellent nursing assistants. She has not been informed about any of the details related to the current internal investigation. On 06/22/15, she was told that only nurses could provide care to R1 and R2 but nursing assistants could resume the care of R1 and R2 on 06/24/15. She was not told of any need to increase supervision of staff during care to residents. LPN/z was interviewed on 06/25/15 at 6:40 a.m. LPN/z stated she normally works the evening shift on 1West but had worked the night shift of 06/24/15 - 06/25/15 on 1West. Typically there are two nurses on 1West during the evening shift but only one nurse during the night shift. She has never observed any of the staff mistreat a resident and she has no concerns about any of the employees who work on 1West. None of the staff have ever reported a concern to her about a co-worker's care of resident or conduct toward a resident. No one advised her of the need to increase supervision of staff during care to residents or to observe resident care. She heard that four nursing assistants were escorted out of the facility but she didn't know why or what the subject matter of the investigation entailed. The facility's staff education, dated 06/22/15 - 06/25/15, in response to the incidents involving R1 and R2 did not include re-education of RNCC/H, RNS/F, or LPN/z. The 1West unit assignment sheets indicated that the employees who had been suspended in connection with the mistreatment of [REDACTED]. The facility had not undertaken any measures to explore the extent of potential abuse to other residents residing on 1West who had received care by these employees. The facility's pay-roll records (undated) indicated that the employees who had been suspended in connection with the mistreatment of [REDACTED]. For example, NA/Q had worked 50 shifts on 1East in addition to the 73 shifts he worked on 1West. The facility had not undertaken any measures to explore the extent of potential abuse to other facility residents who resided on 1East, 2East, 2West, 3East, and 3West where these employees had also worked. At the time of the 06/25/15 investigation, NA/Z and NA/P remained on the current staff schedule for duty. Both employees had witnessed the physical abuse of R1 and failed to immediately report it to the Administrator and State agency. The facility suspended NA/Z from duty on 06/29/15. The facility suspended NA/P from duty on 07/01/15. Police Officer (PO)/D was interviewed on 07/01/15 at 8:05 a.m. PO/D interviewed NA/Q and showed NA/Q the videos from 05/22/15 and 06/19/15 involving R1. NA/Q identified himself in the videos and confessed that he had mistreated R1. PO/D forwarded the matter to the City Attorney to charge NA/Q with criminal abuse. PO/D interviewed NA/R and showed NA/R the video from 06/21/15 involving R1. NA/R identified herself in the video but denied that she did anything wrong. PO/D forwarded the matter to the City Attorney to charge NA/R with criminal abuse. The facility's policy Vulnerable Adult, Reporting of Maltreatment of [REDACTED]. All persons who interact with tenants are required to do so in a respectful manner. Any staff member who observes or suspects maltreatment of [REDACTED].Examples of physical abuse: intentional and non-therapeutic physical acts by staff which cause pain, suffering, injury, or hurt to a resident .any physical injury sustained by resident which is not explained by the resident's history of the injury .Examples of mental or emotional abuse: any derogatory, threatening, derisive, profane, obscene, or demeaning language, whether verbal or with gesture, directed towards a resident .persistent conduct by any person intended to produce mental or emotional distress in a resident .Measures to reduce risk: an overall atmosphere of respect is the standard set in the facility .all resident care is directly supervised by a registered nurse .most care conducted by teams of staff working together improves efficiency and decreases isolated times .frequent safety checks for vulnerable residents required .supervisors educated on signs/symptoms of stress and burnout in staff to avoid abuse/neglect to residents. The immediate jeopardy that began on 06/22/15 was removed on 07/01/15 when it was determined that the facility had operationalized their plan for removal in regards to a formalized process for assessing the safety status of each resident in the facility, increased nursing supervision of resident care by nursing assistants, education of staff on identification, investigation, and trending injuries of unknown origin, and education of all staff as they reported to work regarding the facility's policies related to abuse, neglect, resident mistreatment, and reporting prior to allowing staff to work with residents. In addition, monitoring systems had been developed and initiated to ensure compliance with facility protocols. However, non-compliance remained at isolated actual harm that is not immediate jeopardy.

Based on observation, interview, document review, and review of video surveillance tapes, the facility failed to immediately report to the Administrator and State agency incidents of abuse for 1 of 2 residents reviewed (R1), thoroughly investigate incidents of abuse for 2 of 2 residents reviewed (R1 and R2) who were physically abused by 1 West employees on multiple occasions, failed to prevent further potential abuse to all facility residents, and failed to thoroughly investigate injuries of unknown origin for 2 of 2 residents reviewed (R1 and R2). The employees who abused residents on 1 West or witnessed the abuse of residents on 1 West and did not immediately report it to the Administrator and State agency had also worked multiple shifts on the facility's other five units (1 East, 2 East, 2 West, 3 East, and 3 West) potentially affecting all 244 of the facility's residents. This resulted in an immediate jeopardy to the safety of all residents. The immediate jeopardy began on 06/22/15 when facility leadership staff learned that multiple employees who worked on 1 West had abused 2 of the facility's 244 residents or had witnessed the abuse and did not report it. The facility's Administrator and Interim Director of Nursing were notified of the immediate jeopardy on 6/26/15 at 12:45 p.m. The immediate jeopardy was removed on 7/1/15 at 4:05 p.m. when an acceptable removal plan was implemented to protect the safety of residents, but noncompliance remained at isolated actual harm that is not immediate jeopardy. Findings include: R1's medical record was reviewed. R1's care plan, dated 06/24/15, indicated that R1 has severe cognitive impairment. R1's ability to understand others is impaired as well as R1's ability to express his needs. R1 is unable to use a call light. R1 is totally dependent on staff for all care and requires the presence of two staff for care delivery. At times, R1 is resistive to care and can be verbally or physically aggressive with staff by striking out or kicking care givers. When R1 is uncooperative with care, staff are to leave R1 alone, reapproach him later, or have a different staff reapproach him. Hidden video surveillance in R1's and R2's rooms captured staff-to-resident interactions on videotape. The videotapes dated 04/28/15 - 05/17/15 were observed by investigators on 07/08/15 and the identities of staff in the videotapes were confirmed by Administrator/B on 07/10/15. The videotapes dated 05/22/15 - 06/21/15 were observed by the investigators on 06/29/15 and the identities of staff in the videotapes were confirmed by Administrator/B on 06/29/15 and 06/30/15. Investigators observed the video surveillance tapes, recorded in R1's room from 04/28/15 - 06/19/15. These video tapes show that R1 was abused seven times by NA/Q during bedside care from 04/28/15 - 05/17/15. The abuse included NA/Q slapping R1 with an open hand, poking R1 with his knuckles, and punching R1 with a closed fist. Investigators observed the video surveillance tape, recorded in R1's room on 05/22/15 at 12:45 a.m. The video tape shows NA/Q and NA/Z providing incontinence care to R1 at R1's bedside, during which time NA/Q punches R1 in the face with a closed fist between the left upper lip and nose. R1 sustained an injury to the left upper lip in connection with the incident. Although NA/Z was present at R1's bedside when NA/Q struck R1, NA/Z did not immediately report the abuse of R1 to the Administrator and State agency. Investigators observed the video surveillance tape recorded one month later in R1's room, on 06/19/15 at 4:50 a.m. The video tape shows that NA/Q and NA/P are providing incontinence care to R1 at R1's bedside, during which time NA/Q forcefully yanks R1 by the arms upward in bed, jabs at R1's chest with an open hand, and punches R1 with a closed fist in the stomach. Although NA/P was present at R1's bedside when NA/Q abused R1, NA/P did not immediately report the abuse of R1 to the Administrator and State agency. Administrator (ADM)/B and Interim Director of Nursing (DON)/C were interviewed on 06/25/15 at 7:30 a.m. They stated that on the afternoon of 06/22/15, FM/kk provided them with video surveillance tapes showing several occasions when staff mistreated R1 and R2 during provision of care in their rooms. ADM/B, DON/C, and FM/kk reviewed the video tapes together, which entailed resident misconduct by nine employees, including physical abuse of R1 and R2. Nine employees were suspended from duty on 06/22/15 in connection with incidents on the video tapes, but NA/Z and NA/P were not among the nine suspended employees. Staffing schedules reviewed on 06/25/15 showed that NA/Z and NA/P remained on the current staff schedule and continued to provide care for facility residents, despite their failure to immediately report witnessed physical abuse of R1 by another employee. ADM/B and DON/C were interviewed on 06/25/15 at 7:30 a.m. They stated that on the afternoon of 06/22/15, facility leadership had observed the video surveillance tapes from 05/22/15 to 06/19/15. Their focus was directed on the employees who mistreated residents and they failed to recognize that two employees, NA/P and NA/Z, had witnessed the abuse of R1 and did not immediately report the abuse. As a result, the facility did not safeguard residents from NA/P and NA/Z until after the OHFC investigation began. The facility did not suspend NA/Z from duty until 06/29/15 after investigators reviewed the video surveillance tapes with ADM/B and questioned the identities of staff (NA/P and NA/Z) in the videos. The facility did not suspend NA/P from duty until 07/01/15. The 1West unit assignment sheets indicated that the employees who had been suspended in connection with the mistreatment of [REDACTED]. ADM/B and DON/C were interviewed on 06/26/15 at 7:50 a.m. They acknowledged that the facility had not undertaken any measures to explore the extent of potential abuse to other residents residing on 1 West who had received care by these employees. With the exception of R1 and R2, the facility had not interviewed any of the 1 West residents or their families about the care or treatment they had received by 1 West employees. The facility had not conducted any physical or emotional assessments of the 1 West residents after learning that numerous staff had been physically and/or emotionally abusive to at least two residents on 1 West (R1 and R2), which were the only two rooms that had video surveillance capturing the mistreatment of [REDACTED]. The facility's pay-roll records (undated) indicated that the employees who had been suspended in connection with the mistreatment of [REDACTED]. For example, NA/Q had worked 50 shifts on 1 East in addition to the 73 shifts he worked on 1 West. ADM/B and DON/C were interviewed on 06/26/15 at 7:50 a.m. They acknowledged that the facility had not undertaken any measures to explore the extent of potential abuse to the facility's other residents who resided on these units. The facility had not initiated any measures to obtain feedback from residents/families regarding any concerns or problems with care experiences or fears about environmental safety or treatment by care givers. The facility had not initiated a means to physically or emotionally assess residents who did not have the ability to report potential abuse by care givers. The facility had not tracked or trended injuries of unknown origin, such as bruises, abrasions, and skin tears, to determine possible patterns of injuries that may represent abuse. R2's care plan reviewed and dated 06/16/15, indicated that R2 is cognitively impaired and suffers from [MEDICAL CONDITION]. R2 is at high risk for falls, due to R2's functional strength impairment resulting from [MEDICAL CONDITION], decreased mobility, balance problems, and unsafe movements. R2 needs staff assistance to transfer safely. R2's primary means of mobility is a wheelchair. R2 has difficulty speaking and understanding others. R2 requires a calm, gentle approach for care and is able to perform some activities of daily living, with staff encouragement. R2 has episodes of weepiness and resistance to care. R2 can become combative and push staff away. When R2 is uncooperative with care, staff are to leave R2 alone, reapproach her later, or have a different staff reapproach her. A Non-Fall Incident Report, dated 03/19/15 at 7:40 p.m., indicated R2 had a skin tear on right elbow and R2 stated they hit on me and beat on me, then R2 started crying. A nurse assessed the injury and documented that R2 had a skin tear measuring 1.0 cm with scant amount of fresh blood on right elbow. R2's progress notes, dated 03/19/15 at 10:42 p.m., indicated that R2 had sustained a skin tear on right elbow, had not been resistive or combative with cares. Causal factors unknown. The root cause analysis of R2's injury, dated 03/19/15 indicated perhaps skin tear occurred when staff dressing resident or possibly a ring of a staff member caught on resident's skin. The form noted one interview with a nursing assistant, no other data was noted on the incident form. There was no evidence that facility staff pursued any other avenues to determine when, where, and how R2 sustained the injury, the facility did not provide documentation of an investigation regarding R2's allegation of physical abuse. When interviewed on 06/30/15 at 1:00 p.m., RN Clinical Coordinator (RNCC)/G verified that she reviewed the incident injury of unknown origin dated 03/19/15. She stated that she is responsible for reviewing incident reports for her unit for reporting to state agency and any follow up that may be needed. RN-G stated that the evening housing supervisor RN/uu was informed of the injury of unknown origin on 03/19/15 and RN/uu conducted the investigation but cannot recall who was interviewed. RN-G verified that the incident was not reported to state agency and when asked if it should have been reported, stated yes absolutely. RN-G stated that RN/uu and oncall assistant director of nurses made decision not to report incident to the state agency. When asked who the oncall assistant director of nurses RN/uu contacted, RN-G stated that RN/uu stated cannot recall who was contacted. When interviewed on 06/30/15 at 1:50 p.m., Interim Director of Nursing (DON)/C verified that there was no documentation on the investigation that was done regarding R2's injury of unknown origin and R2's report of being hit, and the incident was not reported to the state agency and when asked if it should have been reported, stated yes. Review of the injuries of unknown origin for R2 from 3/1/15 to 6/25/15 also included a report of bruise on the left hand and forearm which the root cause was must have bumped self. Observations and attempts to interview R1 throughout the onsite investigation from 06/25/15 to 07/01/15 indicated that R1 cannot reliably recall or report information regarding his care or treatment by facility staff. R1 had an injury of unknown origin that was not thoroughly investigated, or reported to the state agency. A Non-Fall Incident Report, dated 05/26/15 at 4:00 p.m., indicated that R1's family member reported to staff that R1 had an injury on his left upper lip. RN/I assessed the injury and observed that R1 had 0.3 cm scratch to the left lip that was scabbed over and a 0.3 cm bruise/mark to the inner side of the left upper lip. RN/I documented that the resident said no when asked if he or someone else bumped his lip or hurt him. Neither the source, location, date, nor time of R1's injury was known. The incident was not reported to the state agency. R1's progress notes, dated 05/26/15 at 6:15 p.m., indicated that RN/(I) interviewed R1 about the lip injury and R1 stated he bit his lip. RN/(I) observed a scab on R1's outer lip and the roof of R1's mouth had a pinkish-purple discoloration. R1 denied pain. R1 denied that anyone had harmed him. R1 indicated that he felt safe. R1's family member informed RN/(I) that R1 sustained the lip injury last week on Thursday or Friday night (which was 05/21/15 or 05/22/15). The root cause analysis of R1's injury, dated 05/26/15, indicated that R1 may have bit his lip while eating or may have bumped his lip. Facility staff made this determination based solely on the interview of R1. There was no evidence that facility staff pursued any other avenues to determine when, where, and how R1 sustained the injury, such as interviewing the care givers who had provided care to R1 after 05/21/15, when FM/kk had first observed the injury. Family member (FM)/kk was interviewed on 06/25/15 at 2:00 p.m. FM/kk stated she observed that R1 had an injury to his left upper lip when visiting on 05/22/15, and asked the nursing assistant what had happened. FM/kk brought the injury to the staff's attention on 05/26/15. The clinical coordinator identified the cause as R1 biting his lip and FM/kk asked if this was accurate or if an investigation should occur. The clinical coordinator and unit social worker said an investigation was not necessary. Review of the facility's reports of injuries of unknown origin for R1 from 3/1/5- 6/25/15 indicated there had been 6 incidents of bruises, abrasion, and skin tears when a cause was not determined. Review of the facility wide reports of injuries of unknown origin for May and June 2015, and included 3 incidents on 3 East, 3 incidents on 1 East, and 12 incidents on 1 West unit. The Clinical Coordinator for 1 West RN/I was interviewed 6/26/15 at 11:40 a.m. and stated that the incident trends are not given to her and she was not aware of a higher rate of injuries of unknown origin on 1 West. Social Worker SW/ii was interviewed 6/30/15 at 9:30 a.m. and said all injuries of unknown origin were reviewed at Interdisciplinary Team, and would be discussed. The higher rate of incidents on 1 West had not been identified. The Assistant Director of Nursing (ADON) RN/L was interviewed on 7/1/15 at 8 a.m. and stated that she directed the Quality Assurance program at the facility. She stated there had not been a central tracking for patterns of injures of unknown origin. She noted that the investigations of injuries of unknown origin on 1 West included the resident's voice about what had happened. When asked what should happen if a resident reported being hit by a staff, she said an immediate report should go forward for investigation, and a report to the state agency. She did not know why this had not happened when R2 reported she was hit. The facility's policy Vulnerable Adult, Reporting of Maltreatment, dated 08/28/13, indicated Saint Therese is committed to providing as safe an environment as possible for each resident. All persons who interact with tenants are required to do so in a respectful manner. Any staff member who observes or suspects maltreatment of [REDACTED].The person taking the report immediately takes steps to protect the resident ., Examples of physical abuse: intentional and non-therapeutic physical acts by staff which cause pain, suffering, injury, or hurt to a resident .any physical injury sustained by resident which is not explained by the resident's history of the injury .Examples of mental or emotional abuse: any derogatory, threatening, derisive, profane, obscene, or demeaning language, whether verbal or with gesture, directed towards a resident .persistent conduct by any person intended to produce mental or emotional distress in a resident .Measures to reduce risk: an overall atmosphere of respect is the standard set in the facility .all resident care is directly supervised by a registered nurse .most care conducted by teams of staff working together improves efficiency and decreases isolated times .frequent safety checks for vulnerable residents required .supervisors educated on signs/symptoms of stress and burnout in staff to avoid abuse/neglect to residents. The immediate jeopardy that began on 06/22/15 was removed on 07/01/15 when it was determined that the facility had operationalized their plan for removal in regards to a formalized process for assessing the safety status of each resident in the facility, increased nursing supervision of resident care by nursing assistants, education of staff on identification, investigation, and trending injuries of unknown origin, and education of all staff as they reported to work regarding the facility's policies related to abuse, neglect, resident mistreatment, and reporting prior to allowing staff to work with residents. In addition, monitoring systems had been developed and initiated to ensure compliance with facility protocols. However, non-compliance remained at isolated actual harm that is not immediate jeopardy.