Based on observation, staff and resident interviews, record reviews, and a review of the policy titled Abuse Prohibition Policy and Procedures, the facility failed to protect the resident's right to be free from physical abuse by Certified Nursing Assistant (CNA) FF for one of 11 residents (R) (R3), from a total sample. Actual harm was identified to have occurred on 12/17/2024, (CNA FF) grabbed R3's hand tight and took her call light out of her hand resulting in bruises and discoloration on the first three fingers on the right hand of R3. Findings include: The facility had an Abuse Prohibition Policy and Procedures, dated January 2017. The policy's statement documented that it was the intent of the facility to actively preserve each resident's right to be free from mistreatment, neglect, abuse or misappropriation of resident property. The policy included definitions of abuse and physical abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. Physical abuse was defined as including hitting, slapping, pinching, and kicking. It also included controlling behavior through corporal punishment. Review of R3's clinical record revealed a diagnosis that included, but were not limited to, Parkinson's disease, polyneuropathy, adjustment disorder with mixed anxiety and depression, and dementia. Review of the 11/12/2024 Quarterly Minimum Data Set (MDS) assessment revealed that R3 was assessed as needing assistance from staff for Activities of Daily Living (ADL) care. Review of the 1/11/2025 Brief Interview for Mental Status (BIMS) form revealed that R3 was assessed as being cognitively intact with a score of 15 out of 15. A review of facility reported incidents revealed a Facility Incident Report Form, dated 12/18/2024, that documented an allegation of staff to resident abuse that had occurred on 12/17/2024 around 1:00 am. The form included that R3 reported to Registered Nurse (RN) LL on 12/18/2024 at 12:30 pm that she had bruises on her right hand because the CNA from the previous night (CNA FF) grabbed her hand tight and took her call light out of her hand. The form included that R3 had bruises on the first three fingers on the right hand. Further review of the form revealed that CNA FF had been removed from the schedule until an investigation was complete. The physician, responsible party, and ombudsman were notified. Review of the accompanying investigation information that included clinical record information, personnel file information, an assessment of the injury, and a follow-up summary revealed evidence that the allegation had occurred. The investigation revealed that CNA FF grabbed R3's hand on 12/17/2024 while in her room. CNA FF was terminated from employment. Review of CNA documentation on R3, dated 12/18/2024, revealed a new discoloration to the right hand was noted. Review of an incident report for R3, dated 12/18/2024, revealed that bruises were noted to the right hand, three middle fingers, towards the base of each finger. The bruises were dark purple and blue in color. Review of the facility's follow-up summary revealed that R3 was interviewed by different staff members, three separate times, on 12/18/2024 by RN Supervisor LL, the Assistant Director of Nursing (ADON), and the Social Services Director and again on 12/19/2024 by the Social Services Director. R3's statements remained consistent. R3 reported during the interviews that CNA FF had come into her room to answer the call light, grabbed her right hand and squeezed it tight, and took her call light, telling her she did not need the call light. R3 was asking for water, which she did not receive. Review of CNA FF's written statement, dated 12/18/2024, revealed she did not recall seeing any bruising and denied squeezing R3's hand. During an observation and interview on 1/13/2024 at 2:48 pm, when R3 was asked about bruising to her hand, she responded by pointing (with her left hand) to the base of the first three fingers on her right hand (to indicate where the bruises had been). During an interview on 1/14/2025 at 2:00 pm, the Director of Nursing (DON) confirmed that CNA FF was taken off the schedule during the investigation and then terminated. Review of the Employee Consultation form, dated 12/23/2024, and the Payroll Change Form, dated 12/23/2024, revealed that CNA FF was terminated on 12/23/2024. The Employee Consultation form included the nature of the incident as mistreating/abuse/neglect of a resident. The Payroll Change form included CNA FF, which was terminated for resident neglect. Following the incident, in-service education on abuse was provided to facility staff on 12/20/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record reviews, and review of the policy titled Abuse Prohibition Policy and Procedures, the facility failed to ensure that an allegation of abuse was reported to law enforcement for one of 11 residents (R) (R3), from a total sampled. Findings include: The facility had an Abuse Prohibition Policy and Procedures, dated January 2017. The policy included a section titled Reporting. The reporting section included that regarding reasonable suspicion of a crime, it would be reported to the State Agency and one or more law enforcement entities for the location in which the facility is located. Review of R3's clinical record revealed that she was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, Parkinson's disease, polyneuropathy, adjustment disorder with mixed anxiety and depression, and dementia. A review of facility reported incidents revealed a Facility Incident Report Form, dated 12/18/2024, that documented an allegation of staff to resident abuse that had occurred on 12/17/2024 around 1:00 am. The physician, responsible party, and ombudsman were notified. Review of an incident report for R3, dated 12/18/2024, revealed that bruises were noted to the right hand, three middle fingers, towards the base of each finger. The bruises were dark purple and blue in color. Although the facility's investigation information revealed that the physician, responsible party, and ombudsman were notified, there was no evidence that law enforcement was notified of the allegation of abuse with bruising. During an interview on 1/14/2025 at 2:40 pm, the Director of Nursing (DON) confirmed that law enforcement was not notified. During an interview on 1/24/2025 at 3:35 pm with the Administrator, when questioned why law enforcement was not notified, the Administrator responded that the situation was, and the police were not notified because the resident R3 did not sustain serious bodily injury. The Administrator also stated that the facility had reported allegations in the past but did not feel this incident warranted notifying the police. R3 said the CNA grabbed her hand, and the CNA denied it, and the resident did not sustain serious bodily injury. After surveyor inquiry, the facility contacted law enforcement. A review of the local police department's Incident/Investigation Report, dated 1/14/2025, revealed that the allegation of abuse of R3 by CNA FF was reported. The crime incident was listed as Abuse of Elderly. Cross reference to F600

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that Activities of Daily Living (ADL) care was provided by the appropriate number of staff as care planned for one resident (R1), and medications were administered as care planned and ordered for one resident (R2), from a total sample of 11 residents. Actual harm was identified to have occurred on 12/21/2024, when Certified Nursing Assistant (CNA) AA provided ADL care to R1 by herself, instead of with the required two-person assistance. R1 fell from the bed and sustained a laceration to the right side of the forehead. Actual harm was also identified to have occurred on 12/19/2024 when Licensed Practical Nurse (LPN) CC administered the wrong resident's medications to R2. R2 was sent to the hospital and admitted for monitoring for potential side effects. Findings include: 1. Review of the care plan revealed that R1 had impaired cognition, a self-care deficit, was at risk for falls, and received hospice services. The fall risk care plan problem included an intervention, dated 1/22/2024, for padded bolsters to bilateral sides of the bed to define the bed parameters and bring a sense of security related to fear of falling from the bed. The ADL self-care performance deficit care plan problem included an intervention, dated 1/25/2022, that documented R1 required total assistance from two staff persons to turn and reposition in bed. There was also an intervention, dated 1/25/2022, that indicated R1 was not toileted. She was incontinent of bowel and bladder, wore adult briefs, and was checked and changed. Review of progress notes revealed a 12/21/2024 6:28 am nurse's note entry that documented Licensed Practical Nurse (LPN) HH was notified by staff that R1 was observed on the floor. R1 was observed to be on the floor beside the bed with blood on the floor. R1 was responding normally to verbal and physical stimuli. The nurse's note documented that R1 had a cut above the right eyebrow and a scrape to the right knee with noticeable bleeding in both areas. Hospice services, R1's family, and the physician were notified, and R1 was sent to the hospital emergency room for evaluation. A review of the 12/21/2024 hospital emergency department physician documentation revealed that R1 sustained a 3-centimeter (cm) laceration to the right forehead and received three sutures to close the wound. A 12/21/2024 nurse's note at 2:47 pm documented that R1 had returned to the facility. The resident had three sutures to the right side of the forehead and a dressing wrapped around her head. A review of facility investigation information including a 12/21/2024 Facility Incident Report Form, staff written statements from 12/21/2024, and a 12/23/2024 conclusion summary revealed that R1 fell out of bed during the provision of ADL care by one staff person, CNA AA. During an interview on 1/6/2025 at 2:00 pm, the Director of Nursing (DON) confirmed that CNA AA did not follow R1's care plan. During the interview, a detailed view of R1's ADL self-care performance deficit care plan problem was reviewed. The care plan problem specified the interventions that were included on the [NAME], which was for the CNAs to reference for resident care needs. The interventions included that R1 required total assistance from two staff persons to turn and reposition in bed. The DON stated that the information on the [NAME] was generated directly from the care plan. During an interview on 1/7/2025 at 2:16 pm, CNA AA stated that on 12/21/2024, she was in R1's room providing care by herself. When questioned how she knows what to do for a resident and how to care for them, CNA AA stated she gets a report from the previous shift CNA and goes on the (electronic) chart system and clicks on the [NAME] to see what they need. She did not recall how many people were required to provide bed mobility for R1. Cross reference to F689 2. Review of clinical record for R2 revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction, aphasia, dysphagia, cerebral atherosclerosis, atherosclerotic heart disease, hypertension, hyperlipidemia, major depressive disorder, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, and vitamin D deficiency. A review of the care plan dated 10/30/2020 revealed that R2 had a communication problem related to aphasia following cerebral infarction. Further review of the care plan dated 1/16/2020 revealed interventions in place for licensed nursing staff to administer medications as ordered for cardiac prophylaxis, altered cardiovascular status, gastro-esophageal reflux disease, hyperlipidemia, depression, history of cerebral vascular accident and vitamin D deficiency. However, on 12/19/2024, Licensed Practical Nurse (LPN) CC failed to administer the correct medications to R2 as care planned and ordered. A review of facility investigation information including a 12/19/2024 Facility Incident Report Form, staff written statements, and a 12/23/2024 conclusion summary, revealed that R2 received oral medications that were ordered for R6 on 12/19/2024 around 9:03 am. R2 was subsequently admitted for observation due to polypharmacy and a syncopial episode. LPN CC documented in a written statement that on 12/19/2024, R2 was pushed (in his wheelchair) to the medication cart. LPN CC asked R2 if his name was R2 or R6's last name. R2 incorrectly stated R6's last name. LPN CC looked at the picture on the Medication Administration Record (MAR) (for R6), which she documented resembled R2. Her statement included that she administered R6's oral medications (to R2). During an interview on 1/9/2025 at 4:05 pm, which included RN Supervisor EE and the Director of Nursing (DON), RN Supervisor EE stated that she was coming out of a meeting (on 12/19/2024) when LPN CC told her about the medication error. RN EE went to put her paperwork down on her desk and said she was going to call the Nurse Practitioner and check on R2. As RN EE rounded the corner to go that way, the CNA called out about R2 being on the floor. When questioned why LPN CC asked R2 if his name was the last name of R2 or R6 (instead of just asking him what his name was), the DON stated that she did not know why LPN CC asked the question that way. The DON stated that R2 jokes and can be silly. RN Supervisor EE stated that R2 was probably joking when he told LPN CC his name was R6. Review of the 12/19/2024 hospital Emergency Department (ED) Physician Documentation revealed that it was determined that R2 had a vasovagal syncope (fainting) episode while having a bowel movement. Additional differential diagnoses included medication error, polypharmacy, and chronic obstructive pulmonary disease exacerbation. Poison control was contacted about the medication error and recommended baseline laboratory tests, an electrocardiogram (EKG), monitoring vital signs and 24-hour observation. R2 was subsequently admitted to the hospital. Cross reference to F760

Based on observation, interviews, record reviews, and a review of the policy titled Care Plans - Comprehensive, the facility failed to revise the care plan to include actual skin impairment (bruising) for one resident (R) (R3), from a total sample of 11 residents. Findings include: The facility had a policy titled Care Plans - Comprehensive. The policy documented that assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. Review of the care plan revealed that R3 was at risk for impairment to skin integrity. However, further review of the care plan revealed no evidence that the care plan had been revised to include actual skin impairment of bruising to the right hand, which was identified on 12/18/2024. A review of facility reported incidents revealed a Facility Incident Report Form, dated 12/18/2024, that documented an allegation of staff to resident abuse that had occurred on 12/17/2024 around 1:00 am. The form included that R3 had bruises to the first three fingers on the right hand. During an observation and interview on 1/13/2024 at 2:48 pm, when R3 was asked about bruising to her hand, she responded by pointing (with her left hand) to the base of the first three fingers on her right hand (to indicate where the bruises had been). During an interview on 1/9/2025 at 4:05 pm, when the MDS Coordinator was questioned if the bruising to R3 hand that was identified on 12/18/2024 would be information included on the care plan, she responded yes. The MDS Coordinator stated that the treatment nurse or RN supervisor would be responsible for adding the bruising information to the care plan. Cross reference to F600

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that bed bolsters were secured, and that Activities of Daily Living (ADL) care was provided by the appropriate number of staff, to prevent accidents for one of 11 residents (R) (R1) sampled for ADL care. Actual harm was identified to have occurred on 12/21/2024, when a Certified Nursing Assistant (CNA) AA provided ADL care to R1 by herself, instead of with the required two-person assistance. R1 fell from the bed and sustained a laceration to the right side of the forehead. Findings include: Review of the clinical record for R1 revealed that she was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, Alzheimer's disease, fibromyalgia, dementia, and adult failure to thrive. Review of the 10/11/2024 Quarterly Minimum Data Set (MDS) assessment revealed that R1 was cognitively impaired and dependent on staff for ADL, including bed mobility. Review of physician's orders revealed a corresponding physician's order, dated 1/22/2024, for padded bolsters to bilateral sides of the bed to define the bed parameters and bring a sense of security related to fear of falling from the bed. The ADL self-care performance deficit care plan problem included an intervention, dated 1/25/2022, that documented R1 required total assistance from two staff to turn and reposition in bed. There was also an intervention, dated 1/25/2022, that indicated R1 was not toileted. She was incontinent of bowel and bladder, wore adult briefs, and was checked and changed. Review of the Fall Risk Evaluation form, dated 10/9/2024, revealed that R1 was assessed as being at moderate risk for falls. Review of progress notes revealed a 12/21/2024 6:28 am nurse's note entry that documented Licensed Practical Nurse (LPN) HH was notified by staff that R1 was observed on the floor. R1 was observed to be on the floor beside the bed with blood on the floor. R1 was responding normally to verbal and physical stimuli. The nurse's note documented that R1 had a cut above the right eyebrow and a scrape to the right knee with noticeable bleeding in both areas. Hospice services, R1's family, and the physician were notified, and R1 was sent to the hospital emergency room for evaluation. Review of the 12/21/2024 hospital emergency department physician documentation revealed that R1 sustained a 3-centimeter (cm) laceration to the right forehead and received three sutures to close the wound. A 12/21/2024 nurse's note at 2:47 pm documented that R1 had returned to the facility. The resident had three sutures to the right side of the forehead and a dressing wrapped around her head. A review of facility investigation information, including a 12/21/2024 Facility Incident Report Form, staff written statements from 12/21/2024, and a 12/23/2024 conclusion summary, revealed that R1 fell out of bed during the provision of ADL care by one staff person, CNA AA. CNA AA documented in a 12/21/2024 statement that she went to R1's room on her rounds to perform care. As she had the resident turned on her right side (in bed) to get changed, the sheet and the bolster started sliding off, causing the resident to fall off the bed. During an interview on 1/6/2025 at 2:00 pm, the Director of Nursing (DON) stated that from what she determined, the bolsters were not secured to the bed, and R1 rolled off onto the floor. The DON also confirmed that CNA AA did not follow R1's care plan. During an interview on 1/7/2025 at 2:16 pm, CNA AA stated that on 12/21/2024, she had positioned R1 on her side (in the bed) to change her because she had a bowel movement. CNA AA stated that the bolster slid off really fast, and R1 fell (on the floor) and hurt herself. CNA AA confirmed that she was alone in R1's room providing care. After R1's fall out of bed with head injury sustained on 12/21/2024, in-service education was provided to nursing staff on following the care plan and [NAME] and checking bolsters on the bed on 12/21/2024. CNA AA was also removed from the schedule and then terminated on 12/23/2024. Review of the Payroll Change Form, dated 12/23/2024, revealed that CNA AA was terminated. In addition, a 30 Day Resolution plan was developed on 12/23/2024 to address the CNA's failure to follow the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure staff followed care plan interventions to ensure that a two-person assist was provided for one resident (R) (R#1) during a bed bath which resulted in actual harm when the resident fell out of the bed and sustained a fracture of the right femur. The sample size was six residents. Findings include: R#1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: Alzheimer's disease, low back pain, age related osteoporosis and vitamin D deficiency. Review of the 9/1/22 admission Minimum Data Set revealed the resident was assessed as requiring a two-person physical assist with bed mobility and bathing. The resident had a care plan since 9/14/22 for activities of daily living self-care performance deficit related to impaired balance with the following interventions: resident is totally dependent on two staff to provide a shower three times a week and totally dependent on two staff for repositioning and turning in bed. The resident also had a [NAME] Report with interventions for assist x 2 during bed baths. Review of the 12/1/22 Nurse's Notes revealed at 9:40 p.m. the nurse was summoned to the resident's room and noted resident on the floor on the left side. The staff member stated that she was bathing the resident and as she turned the resident towards the door, she was coming around the side of the bed, heard a bang and resident fell on the floor. The resident was transferred to the emergency room (ER) for evaluation. Review of the 12/3/22 hospital History and Physical revealed the resident had an intra-articular, comminuted fracture extending from the distal femoral metadiaphysis into the femoral component of the knee arthroplasty. During an interview with the Director of Nursing and the Assistant Director of Nursing on 8/24/23 at 11:50 a.m., they confirmed the agency Certified Nursing Assistant (CNA AA) was providing care alone and should have had another staff person to assist her with the bed bath for R#1, as care planned. They stated the resident has always been a two person assist. Cross refer to F689.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide adequate supervision during a bed bath to prevent an avoidable fall for one of six sampled residents (R) (#1). Actual harm occurred on 12/1/22 when R#1 fell from her bed during care and sustained a right femur fracture. Findings include: Review of the policy titled, Fall Management dated 5/17/17 indicated it is the policy of this facility that the administration and staff provide a safe environment for all residents. The facility will assess residents for fall risk, will evaluate each resident individually and provide, to the best of the facility's ability, interventions to decrease the likelihood of falls. R#1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: Alzheimer's disease, low back pain, age related osteoporosis and vitamin D deficiency. Review of the 9/1/22 admission Minimum Data Set revealed the resident was assessed as requiring a two-person physical assist with bed mobility and bathing. Review of the 12/1/22 Nurse's Notes revealed at 9:40 p.m. the nurse was summoned to the resident's room and noted resident on the floor on the left side. The staff member stated that she was bathing the resident and as she turned the resident towards the door, she was coming around the side of the bed, heard a bang and resident fell on the floor. The resident was transferred to the emergency room (ER) for evaluation. On 12/2/22 at 5:04 a.m. the resident returned from the ER with no new orders. Review of the 12/2/22 Fall Follow Up Note indicated the resident's right knee was swollen with no pain. The writer was concerned about swelling in the knee and investigated if there were any diagnostic observations completed. X-Rays were completed at the ER, but the resident was discharged back to the facility before the results were read. The X-Ray results showed a right femur fracture. The physician ordered for the resident to be sent back to the ER. Review of the 12/3/22 hospital History and Physical revealed the resident had an intra-articular, comminuted fracture extending from the distal femoral metadiaphysis into the femoral component of the knee arthroplasty. The 12/6/22 hospital Discharge Summary indicated the resident was Status Post right open reduction internal fixation surgery to the right hip. In review of the facility's investigation and five-day follow-up report sent to the State Survey Agency on 12/7/22, indicated in the resident's care plan she was to be a two person assist to the shower three times a week, she was a Hoyer lift which also requires a two person assist. It also indicated she was totally dependent and was a two person assist with bed mobility as well. It further documented the CNA (CNA AA) was neglectful in providing care to the resident as evidenced by the fact that the CNA did not follow the resident's care plan and she caused harm to her. She was an agency CNA and will no longer be allowed to return to the facility and the agency has been made aware of this. Review of the staffing agency's Complaint Report that was completed by the facility revealed the CNA (CNA AA) was bathing the resident and when she completed the bath and was changing the linen, she rolled the resident to the right side away from her toward the door. The CNA made her way to the foot of the bed and the resident fell out of the bed to the floor. The resident was sent to the ER and had a contusion to her right knee, right femur fracture. The resident was care planned to have a shower, not a bed bath, she is also care planned as a two person assist for transfers, showers and bed mobility. The CNA did not have anyone assisting her with the bath or turning the resident. During an interview with the Director of Nursing and the Assistant Director of Nursing on 8/24/23 at 11:50 a.m., they confirmed the agency Certified Nursing Assistant (CNA AA) should have another staff person to assist her with the bed bath. They stated the resident has always been a two person assist. They stated that the staffing agency was notified of the incident and told the agency that CNA is not to return to the facility.