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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the licensed nurse provided care and services to the 32 residents residing on the 3rd floor, when V4 (Licensed Practical Nurse) was found sleeping during her shift from approximately 9:15 pm on [DATE] to 5:00 am on [DATE]. V5 and V10 (Certified Nursing Assistants) observed V4 sleeping throughout the night and were unable to wake her. V5 and V10 failed to report to Administrative Staff that V4 had been sleeping, until 4:40 am on [DATE], despite having a resident (R3) actively dying on Hospice, a resident (R2) requesting pain medication and another resident (R1) on Hospice that was experiencing a decline in her health. V4 failed to administer R1's nighttime dose of insulin and staff failed to monitor and assess R1 every two hours during the night. This resulted in V12 (R1's Family) finding R1 at 5:45 am on [DATE], with her head hanging over the side of the bed, verbally non-responsive and experiencing a hyperglycemic episode. Video surveillance confirms that staff did not go into R1's room between 9:09 pm on [DATE], when V4 obtained R1's blood glucose level, and 5:45 am on [DATE]. These failures resulted in an Immediate Jeopardy and had the potential to affect all 32 residents residing on the 3rd floor. The Immediate Jeopardy began on [DATE] when V4 failed to provide nursing care to residents of the 3rd floor of the facility, including two residents on Hospice (R1, R3) and in the end stages of life, because she was sleeping for approximately eight hours of her shift. V1 (Acting Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 11:00 am. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 as the facility continues to investigate the events of [DATE]-[DATE] to determine if any other residents were affected by the events on those days, in-service staff regarding identifying potential neglect and proper procedures and timeframes for reporting it. Findings include: The facility Abuse and Neglect Policy (revised [DATE]), documents Policy: It is the policy of Sunset Home to provide each resident with an environment free from abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of resident property, exploitation and physical or chemical restraint not required to treat the resident's symptoms, as defined below. Sunset Home shall follow the procedure for reporting and investigation of alleged resident abuse and neglect as outlined below, and in accordance with Skilled Nursing and Intermediate Care Facilities Code (77 Ill. Adm. Code 300.3240). Purpose and Scope: The purpose and scope of this policy and procedure is to inform all individuals of the proper protocol for preventing, reporting and investigating allegations of abuse and neglect as specified in the corporate policy above. The facility policy documents, 'Neglect refers to the failure to provide goods and/or services necessary to avoid physical harm, mental anguish, or mental illness. The Staff Nurse Job Description (Revised [DATE]) documents, The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such Supervision must be in accordance with the current Federal, State, and local standards, guidelines and regulations that govern our facilities, and as may be required by the Director of Nursing or Charge Nurse to ensure that the highest degree of quality care is maintained at all times. The Job Description includes, under Major Duties and Responsibilities: Direct the day to day function of the nursing assistants in accordance with current rules, regulations and guidelines that govern the long-term care facility. Ensure that the nursing procedures manual is followed rendering nursing care. The policy advises that the licenses nurse is to, Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the residents' response to the care. Give/receive the nursing report upon beginning and ending shift duty hours. Provide leadership to nursing personnel assigned to your unit/shift. Under Nursing Care Functions, it documents that the Staff Nurse is to Make periodic checks to assure that prescribed treatments are being properly administered by nursing assistants and to evaluate the resident's physical and emotional status. Administer professional services such as: catheterization, tube feeding, suction, applying and changing dressings/bandages, packs, colostomy care, range of motion exercises, care of the dead/dying, etc., as required, within the Nurse Practice Act for the State of Illinois. Provide and/or assist other staff with nursing care including performing the duties listed in the Certified Nursing Assistant job description as necessary. Monitor seriously ill residents. On [DATE] at 4:47 pm, V2 (Director of Nursing) provided a Resident Bedsheet to reflect the midnight census on [DATE], which was 32 residents (R1-R32). A Resident Bed Sheet, dated [DATE], was provided by V2 (Director of Nursing) on [DATE] at 4:47 pm. V2 confirmed that was the accurate midnight census of [DATE] and it identifies 32 residents 1. R1's electronic medical record documents R1 was admitted to the facility on [DATE] and has the current diagnoses of Chronic Pain, Type II Diabetes Mellitus with Hyperglycemia, History of Diabetic Ketoacidosis, Acute Ischemic Heart Disease, Muscle Weakness, Muscle Wasting and Atrophy, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease and was placed on Hospice on [DATE]. R1's current Plan of Care documents R1 has chronic back pain with instructions for staff to monitor for signs/symptoms of pain and administer Percocet (Narcotic) four times a day. R1's current Plan of Care also documents, I am high risk for falls (related to) gait/balance problems and instructs staff to provide a working and reachable call light, the bed in low position at night; personal items within reach, and Be sure my call light is within reach and encourage me to use it for assistance when needed. A Minimum Data Set assessment dated [DATE] documents R1 had a BIMS (Brief Interview of Mental Status) of 14, which indicates no cognitive impairment. However, Hospice admission documentation, dated [DATE], indicates R1 was placed on Hospice Services due to a physical decline related to malnutrition and cites R1 has experienced increased confusion over the last six months. R1's Hospice Plan of Care, dated [DATE], documents under Mobility/Safety that R1/Caregivers will demonstrate safe, effective use of equipment. Interventions: Instruct Patient/Caregiver on fall prevention and safety precautions. (R1) requires assistance of two for transfer but has not been out of bed for 2 days prior to Hospice enrollment. Patient is (a) fall risk. Education to keep bed in low position and call light within reach. R1's Nursing Progress Notes document no Nursing Assessments/Notes from [DATE] through [DATE] by the facility's licensed nursing staff. The next documented Nursing Note is on [DATE] at 6:15 am and reads (R1) is not opening eyes or responding to staff at this time. Upon checking the blood sugar, it is reading high. (V14/Medical Director) called and order received to give 20 (Units) Humalog now. After this, blood sugar came down 495, hospice called again. At this time the hospice nurse informed me she has heard from the daughters, and they are planning on taking (R1) out of here (as soon as possible) today. Discharge paperwork gathered, medications gathered, and (medical supply company) will be delivering her bed at noon today, ambulance to be scheduled once bed is delivered. Nursing documentation indicates R1 left the faciity on [DATE] at 12:43 pm with her family in the care of Hospice services. On [DATE] at 3:04 pm, V12 (Family/Healthcare Power of Attorney) stated that R1 has a video camera in her room that is triggered to record with motion or movement. According to V12, on [DATE] at 5:25 am, she could see Mom (R1) dangling over the side of the bed. I tried calling there (facility) to notify the staff and no one answered, it rang and rang. I only live 10 minutes away, so I just drove over there. When I got to Mom's floor, it was a ghost town. There were no staff to be seen. I went into her room, and she was still hanging over the side of the bed and her call light was on the floor. So, I went running down the hall looking for someone to help. The Aides came into her room and set her upright. Mom is not waking up and is lethargic. The Aides left and I tried to get (R1) to drink some water. Around 6:00 am, I started thinking that maybe (R1's) blood sugar was off, she's a Diabetic, so I went to find a nurse. The nurse tried to get a reading of her blood sugar, but it just registered high. The nurse called the doctor, and she got some fast acting insulin in (R1), but she still wasn't responsive. The nurse said they could send to (R1) the hospital, but she would have to come off of Hospice if they did. I looked at the video footage and saw that no one had been in (R1's) room since 9:09 pm ([DATE]). The nurse came in then to check her blood sugar and I can see Mom's call light on the floor then. The nurse says (R1's) blood sugar is over 200 and she needs insulin. The nurse never came back in (R1's) room. I could see at 1:13 am (on [DATE]), Mom raises the head of her bed up with the button on the bed rail and her call light is still on the floor. I couldn't tell what (R1) was trying to do then. Nobody comes in her room at all after 9:09 pm ([DATE]). I was so upset, I just had them discharge her to my house on Hospice. This was not something we planned, but I could not leave her there. Mom died two days later. I heard the nurse working was escorted out of the building for not checking on residents that night. On [DATE] at 7:40 am, V12 stated, Not sure how you put a price on time with a loved one, but I sure wish there was a way to quantify that, as we should have had more time with our mom (R1). I personally moved to [NAME] on [DATE]st to spend more time with her, though I got an amazing 2 months with her, I definitely thought I would have more, we all did. Video surveillance of R1's room, submitted by V12, from [DATE] and [DATE] was reviewed. The videos from R1's room are in segments, due to the surveillance camera being utilized only records when motion is detected in the room. The video surveillance recorded the following: On [DATE] at 9:09 pm, V4 (Licensed Practical Nurse) is at R1's bedside with her back to the camera. R1 is lying in bed and the call light is hanging from the wall, over the nightstand and on the floor. V4 states, Your accucheck is 291. I'm going to grab your insulin. I'll be back. V4 turns off the light as she leaves the room. Motion is not detected in R1's room again until [DATE] at 1:13 am. At that time, R1 is positioned on her right side in bed, facing the right bed rail. R1's call light remains on the floor in the same spot. R1 raises the head of the bed with the button on the bed rail to approximately a 70-degree angle. At 5:25 am, (Which was when V12 woke up and checked on R1 through the video camera. This allowed V12 to save the footage she had just viewed even though there was no motion at that time.) R1's head of the bed is in the same upright position, two pillows are on top of R1's lower to mid back, and R1's head is over the right side of the bed towards the ground. R1's upper body is partially against the bed rail. R1 is motionless and R1's call light is still on the floor in the same position. Between 5:26 am and 5:45 am, R1 remained in the same position over the right side of the bed. R1's left arm can be seen moving on two occasions and muffled, inaudible noises are coming from R1. At 5:46 am, V12, V5 (Certified Nursing Assistant) and V10(Agency Certified Nursing Assistant) enter R1's room, R1 is in the same position over the right side of the bed. V5 lowers the head of R1's bed and V10 assists V5 to get R1 positioned back to the center of the bed on her back. V12 is crying and states, Why has nobody been in here? V5 responds, I have been. I walked by all night checking on her. I promise. V12 replies, She's been like this since one in the morning. It's on camera. By 6:25 am, a licensed nurse has yet to be in R1's room to assess her and V12 remained at R1's bedside. R1 remains unresponsive. V12 states to R1 that she is going to go get a nurse to check R1's blood sugar. At 6:26 am, V7 (Licensed Practical Nurse) enters R1's room to obtain R1's blood sugar. V12 clearly tells V7 that staff have not been in R1's room since 9:00 pm (on [DATE]). V7 responds, Yeah, that's horrible. The Director of Nursing will be down to talk to you. V7 then tells V12 that R1's blood sugar reading was high, so off the charts. At 6:29 am, V12 can be seen showing V7 video surveillance of R1 from the night before and V7 questions V12 if she observed R1 in any distress. At 6:44 am, V3 (Assistant Director of Nursing) enters R1's room as V12 remains at R1's bedside to administer R1's insulin. V12 states to V3, She (R1) hasn't been responsive since I've been here. That was about five something, but no one has been in here since 9:00 (pm). I got up after 5:00 (am). I'll show you the picture of the snapshot of the camera of how (R1) was and I called up here and no one answered, and I came over here. V12 then showed V3 video footage of R1 on her phone. At 6:45 am, V3 states to V12, The nurse down here was escorted out of the building last night. V12 replies, Because of this, or because of something else? V3 then stated, Just kind of in general. She's been here more than once. She's not one of our employees, but that doesn't mean anything, because she's not coming back. I apologize, also. I had not gotten report since she wasn't here, and I was not aware she went home. On [DATE] at 1:05 pm, V5 (Certified Nursing Assistant) stated the early morning of [DATE], she heard someone running and yelling down the hallway. V5 indicated she was in a resident room at the time, so she came out and saw V12 was who was yelling. V12 told her R1 had fallen. V5 stated she and V10 (Certified Nursing Assistant) immediately went into R1's room, where she saw R1 slumped over, the head of the bed was really high up, like at a 70-80 degree angle. Part of (R1) was leaning into the bed rail, but she was not on the floor. I didn't notice where her call light was, but she didn't use it all night. It should have been clipped to her or tied to the rail. We got (R1) upright into bed and she wasn't really awake but seemed ok. I told the girls in report what happened. (V12) was really upset and said nobody had been in to check on (R1) all night. (R1) was already in bed when I came on shift at 6:00 pm ([DATE]). Around 7:00 pm was the first time I saw her, and she was resting. They told me she had just went on Hospice. I went by her room again around 2:30 am ([DATE]) and she was lying flat in the bed, not with her head of the bed way up like we found her. I just peeked into her doorway; I didn't step into the room. We were really busy that night. The Nurse on the floor had been sleeping all night. From around 9:00 pm to 2:00 am, (V4/Licensed Practical Nurse) was sleeping at the nurses' station. Then (V4) got up, went into the common area and slept there from 2:15 am until 5:15 am ([DATE]). I tried to let her know when residents needed something, but she wouldn't wake up. V5 indicated the closer it got to 5:00 am and she could not get V4 to wake up, she knew she needed to notify someone. V5 stated, I had called (V6/Licensed Practical Nurse) just before 5:00 am, because (V6) was the House Supervisor, but she was working on another floor. I knew the 5:00 am meds were going to need to be passed and I could not get (V4) to wake up. (V6) came up and had to shake (V4) to get her to come around. V5 was questioned as to why she didn't notify management earlier that V4 had slept through the majority of her shift and V5 stated I didn't want to get anyone in trouble. On [DATE] at 5:50 pm, V10 (Agency Certified Nursing Assistant) stated she started her 12 hour shift on [DATE] at 6;00 pm. V10 stated V4 was late coming in to start the shift and as soon as V4 got there, she sat down at the nurses' station and ate her dinner. V10 stated, After that, (V5) left to get (V4) something from the gas station. (V4) passed her evening (medication) and after that she went to sleep. It was probably around 9:00 - 9:15 pm, she went to sleep at the nurses' station. (V5) and I split up the residents to do their check and change every two hours. I did help (V5) with (R3), just to reposition him. (R3) was in the process of dying that night, his breathing had changed, and he was making some sounds. (V5) and I did our last rounds around 4:00 am. (V4) was sleeping in another spot, in a chair then. I never saw (R4) go into a resident room after she did her 9:00 pm med (medication) pass. Near the end of the shift, (R1's) daughter was yelling in the hallway that (R1) was on the floor. (V5) and I went into (R1's) room right away. (R1) was hanging halfway off the bed with her head towards the floor. The head of the bed was way high up and the bed was in the highest position. I don't know how it go that way; I didn't go into to her room that night. (V5) and I got (R1) up in the bed, but she seemed asleep. I don't know (R1) well, so I wasn't sure if that was how she normally was. I've worked with (V4) before and she tends to sleep during her shift and not help, but CNAs (Certified Nursing Assistants) do their thing and Nurses do theirs. On [DATE] at 12:15 pm, V6 (Licensed Practical Nurse) stated on [DATE] at about 4:40 am, V5 called her and said the nurse on the 3rd floor was sleeping. V6 indicated she finished her tasks on her floor and got to the 3rd floor about 5:00 am. V6 stated, I found (V4) sleeping in the chair and out cold. I tried to wake her and shook her by her shoulders. She finally came around. I got her keys and asked her to leave the building. (V5) told me that (V4) had been sleeping all night. I was concerned because there were two residents on Hospice that hadn't been checked on by a Nurse throughout the night. It was (R1) and a male resident (R3). V6 stated she called V3 (Assistant Director of Nursing) after V4 left the building and informed V3 she had to make a nurse leave for sleeping while on duty. V6 stated, (V5) called because the morning meds (medication) needed passed, but I was more concerned about checking the two residents dying (R1 and R3). V6 stated, around 5:45 am, I heard (R1's) daughter in the hall, very upset saying her Mom was on the floor or almost on the floor. I called (V3) again and told her (R1) daughter was upset. (V3) was walking into the building at that time and said she would check on (R1). There were some other residents on that floor I was concerned about, ones that need nursing attention during the night. (R1) is a very brittle diabetic and a fall risk, so she was one. (R4) needs a lot of attention at night, too. I had heard on occasion from day shift staff that (V4) would do her morning med pass late, like she would still be doing it when they came in at 6:00 am, but I didn't' witness that so I never reported it. On [DATE] at 2:06 pm, V3 (Assistant Director of Nursing) stated she was on call the weekend of [DATE]. V3 indicated she received a call on [DATE] at approximately 4:30 am from V6, who advised her there was an issue on the 3rd floor and she sent the nurse (V4) home for sleeping on duty. V3 stated, (V6) told me the Aides tried to wake (V4) and couldn't, so she went to the floor and had to physically shake (V4) to wake her up. I was coming in to work the floor at 6:00 am and I wasn't sure what (V4) had done or had not done the prior shift. I just knew another nurse was covering the morning med pass. When I got to the floor, (V7/Licensed Practical Nurse) said she had checked (R1's) blood sugar, which was just reading high. I called (V14/Medical Director) who ordered 20 (Units) of fast acting insulin. After giving it, (R1's) blood sugar was 495. I contacted the on call doctor and the Hospice staff, but the hospice staff informed me (R1's) family was taking her home that day. I know the daughter was upset with her mom's care during the night and said staff didn't monitor her as they should have. The aides should have been checking on R1 at least every two hours. We did apologize and advised (V4) would not be returning to work there. (V5) told me that (R1's) family thought (R1) had fallen on the floor, but she hadn't. (V5) told me she checked in on (R1) between 3:30 and 4:00 am ([DATE]). I did question (V6) why (V4) was left to sleep for so long. (V6) said the CNAs (Certified Nursing Assistants) were very frustrated with the fact that they couldn't get the nurse to function, but they reported it was essentially a normal night. I was told (V4) showed up late and had a pillow and blankets where she was sleeping. V3 was questioned if (V4) sleeping throughout the night on her shift could have led to a neglectful situation and V3 stated she did not consider resident neglect at that time, so it wasn't reported as such to the Administration. V3 concluded that if resident's didn't get medication or assessed properly during the night, it would be neglect. On [DATE] at 1:47 pm, V7 (Licensed Practical Nurse) stated she was on day shift [DATE]. V7 stated when she started the shift, I was asked to check (R1's) blood sugar because she was lethargic. When I saw (R1), she wasn't talking, but she was awake. (R1) had a blank stare and definitely was not as alert as usual. The Aides told me to let (V3) know, since she was her actual nurse for the day. (V3) told R1's daughter they could not send (R1) to the ER (Emergency Room) because she was on Hospice. I was told that (V4) had slept all night and didn't check on the residents. I heard the Aides tried to wake her that night and couldn't and (V6) had to actually shake (V4) to get her to wake up. I've worked as an Agency nurse with (V4) at other facilities. (V4's) been known to sleep on the job and has been caught using drugs in the bathroom while working other places. (V4) sleeps on shift all of the time and she's done it at numerous facilities. When she's on the schedule, she's a body and that's all. On [DATE] at 7:53 am, V16 (Nurse Practitioner) stated R1 had been progressing downhill medically. V16 stated, On [DATE]st (2023), (V12) expressed to me she was having issues with staff not toileting (R1) routinely. So, I told (V6/Licensed Practical Nurse) that I wanted someone checking on her (R1) every two hours. (R1) should have been on a every two hour check and change. (R1) was a brittle Diabetic and was not the most compliant, but (V4) not returning to give (R1) her insulin is a huge problem. Staff not checking on (R1) every two hours is a huge problem. Someone should have been in that room during the night. 2. The Electronic Medical Record documents R3 was admitted to the facility on [DATE] for Hospice services related to Malignant Neoplasm of the Colon. A [DATE] Pain Evaluation documents R3 as experiencing daily moderate pain in his back related to metastatic cancer and he receives narcotics. R3's Hospice Care Plan, dated [DATE], documents R3 was experiencing a significant decline and identifies the following: Goal is for pain to be controlled with R1's desired comfort level, Initiate comfort medications for symptom management, Staff are to collaborate with the Primary Nurse regarding R1's condition and Ensure and coordinate provision of care and services meet R1's needs. On [DATE], Physician's Orders document Hospice changed R3's medication orders to the following: Lorazepam 0.5 mg every four hours for end stage restlessness, Atropine Sulfate 1% two drops orally every two hours for oral secretions, Morphine 20mg/ml 0.75 ml (milliliters) every four hours for pain and instructed staff to continue to assess and document R3's pain level twice per day on day shift and night shift. On [DATE] at 8:49 am, Nursing Progress Notes document, Sponge bath given in bed, area to hips cleaned with (normal saline) all even covering. (R3) actively dying, turned every couple hours, air mattress on bed, area on feet and shoulders pinkish in color not open at this time. There are no documented Nursing Progress Notes for R3 during the afternoon or night of [DATE] or the morning of [DATE]. On [DATE] at 5:50 pm, V10 (Agency Certified Nursing Assistant) stated (V4) passed her evening (medication) and after that she went to sleep. It was probably around 9:00 - 9:15 pm, she went to sleep at the nurses' station. (V5) and I split up the residents to do their check and change every two hours. I did help (V5) with (R3), just to reposition him. (R3) was in the process of dying that night, his breathing had changed, and he was making some sounds. (V5) and I did our last rounds around 4:00 am. On [DATE] at 12:50 pm, V5 (Certified Nursing Assistant) stated she was aware the evening of [DATE] that R3 was on Hospice and in the end stages of life. V5 stated, We did turn (R3) every two hours as much as we could. He had a wound that he needed to stay off of. (R3) was on Hospice and actively dying that night, so we focused on keeping him comfortable. He had a lot of stuff in and around his mouth, so we tried to clean that up. I never saw (V4) go into his room during the night. Like I said, she was sleeping the whole time. On [DATE] at 12:15 pm, V6 (Licensed Practical Nurse) stated on [DATE], at about 4:40 am, V5 called her and said the nurse on the 3rd floor was sleeping throughout the night. V5 indicated she was aware that there were Hospice patients on the 3rd floor, and she was concerned they hadn't been checked on by a Nurse throughout the night. V6 stated, (V5) called because the morning meds (medication) needed passed, but I was more concerned about checking the two residents dying (R1 and R3). I went to the gentleman's room first (R3). The gentleman passing (R3) was having extreme air hunger and lots of oral secretions. His eyes were fixed, and he seemed to be just hanging on. I wouldn't want to die like that. I immediately gave him Atropine, Morphine and Ativan. I had another nurse pass the morning meds. At that time, V6 was questioned regarding a documented Pain Assessment in R3's Medication Administration Record on the evening of [DATE], where V6 initialed R3's pain was at a 7 on a scale of 1-10. V6 confirmed at that time, she back dated that pain assessment on R3 to [DATE] and that was actually R3's level of pain when she arrived to his room on [DATE] at approximately 5:15 am. On [DATE] at 12:30 pm, V3 (day shift Nurse/Assistant Director of Nursing) stated V5 did report to her the morning of [DATE] that R3 had increased secretions throughout the night and V6 did not pass on any information regarding the condition she found R3 in that morning ([DATE]). Medication Administration Records document V4 charted she administered Lorazepam 0.5 mg and Morphine 0.75 ml to R3 at midnight on [DATE], when V5 and V10 had observed V4 to be sleeping all night. On [DATE] at 7:53 am, V16 (Nurse Practitioner) stated a patient on Hospice and near the end of life should be assessed by the Licensed Nurse frequently, we want these people to be comfortable, oral care needs to be given, assessed for pain. The nurse (V4) not checking on (R3), making sure his medical needs are met in the dying stages is 100% neglect. The next Nursing Progress Note is on [DATE] at 5:26 pm, Family has been here with (R3) most of the day, Hospice nurse was just in and (saw) resident, she doesn't feel like he will transition over tonight, our goal is to keep him comfortable, he keeps his lips pierced together when giving morphine and Ativan, but this nurse was able to administer it, turned and repositioned often, fingers are cool to touch, his feet are mottling somewhat, will continue to monitor and note changes accordingly. Nursing Progress Notes document R3 expired on [DATE] at 9:33 am. 3. The Electronic Medical Record documents R2 has the current diagnoses of Low Back Pain, Pain in the Left Hip and Repeated Falls. R2's Current Plan of Care documents, I have chronic pain (related to) Low Back Pain. (Complaint of) pain even after scheduled pain meds, this occurs almost daily. The Plan of Care advises staff of the following: Nursing is to anticipate need for pain relief and respond immediately to any complaint of pain, (R1's) pain is alleviated/relieved by as needed Tylenol, Evaluate the effectiveness of pain interventions every shift, R2 is able to call for assistance when in pain, ask for medication, tell you how much pain is experienced, Nursing staff is to monitor/document for side effects of pain medication, monitor/record pain characteristics every shift and as needed, and monitor/record/report to Nurse R2's complaints of pain or requests for pain treatment. R2's current physician orders, dated [DATE] document R2 can received Tylenol 500 mg (milligrams) every 6-8 hours for breakthrough pain and instructs staff to assess R2's pain in the morning and at night. A Minimum Data Assessment, dated [DATE], documents R2 has a BIMS (Brief Interview of Mental Status) of 11, suggesting R2 has moderate cognitive impairment, but is able to make her needs known. On [DATE] at 1:05 pm, V5 (Certified Nursing Assistant) stated she recalled R2 asking for pain medication during the night of [DATE]. V5 stated she could not recall what kind of pain R2 was having, but she tried to notify V4 (Licensed Practical Nurse) of R2's request for pain medication; however, V4 would not wake up at that time. V5 stated I know (R2) didn't' get it (pain medication). On [DATE] at 10:52 am, R2 was questioned about her pain and if she had recently gone without pain medication after requesting it. Due to R2's cognition, she was unable to cite anything specific, but stated, There are times it gets missed. R2 stated she will often ask for additional pain medication during the night because she had pain in her hip. R2 stated, I get pain there (pointing to her hip) when I lay in bed, it's like an ache and the Tylenol will help me go back to sleep. The Electronic Medication Administration Record documents staff failed to assess R2's pain level on the night of [DATE] and R2 did not receive any PRN (as needed) Tylenol 500 mg on [DATE] or [DATE]. On [DATE] at 2:30 pm, V2 (Director of Nursing) stated V3 and V1 (Assistant Administrator) were in charge of the building that weekend, as she was off. V2 stated she didn't find out anything about what happened that weekend until Monday ([DATE]). V2 indicated she heard (R1's) Daughter was upset over her Mom's care and (V3) was handling it. I'm just now hearing the whole story. V2 stated she would have expected the Aides to let someone know well before 4:40 am that V4 had been sleeping on shift. V2 concluded, if residents were not getting proper care or receiving medication that night, she would consider that patient neglect. On [DATE] at 2:42 pm, V1 (Acting Administrator) stated the only thing she was notified of that weekend, was on the evening of [DATE]. V1 stated she was told a Hospice patient was going home with family and that very early in the morning staff had found an Agency Nurse sleeping and she was immediately sent home. V1 stated, I was told nothing more. On Monday, I contacted the Staffing Agency and told them (V4) was found sleeping and was difficult to arouse. I asked for (V4) to be put on a Do Not Return list for our facility. V1 was unaware if anyone in management had offi[TRUNCATED]