**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interviews, clinical record review, facility investigation, police report, and facility policy, the facility failed to provide a safe environment free from physical, verbal, and psychosocial abuse for 2 of 2 residents reviewed (Residents #47 and #316). 1. Despite Resident #47 reported alleged physical abuse on 3/20/24, the alleged abuser continued to work until the Director of Nursing (DON) learned of the allegations and started an investigation on 3/26/24. The facility allowed the alleged abuser to return to work on 4/3/24 and he continued to work at the facility. Resident #47 reported the alleged staff member on multiple occasions entered and stayed in her room alone. Resident #47's Care Plan updated on 3/28/24 instructed the alleged staff member to not enter her room alone. Interviews with CNAs revealed the alleged staff member often came in and out of Resident #47's room throughout the day. Observations revealed the alleged staff member entering and exiting Resident #47's room alone. Resident #47 reported while crying about being afraid of the alleged staff member and being afraid to tell anyone about the situation. 2. A witnessed event on 6/16/24 around 11:30 PM of verbal abuse towards Resident #316 didn't get reported to the DON until 6/20/24 around 3:30 PM. The alleged abuser continued to work with vulnerable residents until the DON learned of the allegations on 6/20/24 around 3:40 PM. The facility's lack of action for multiple days, allowing the alleged perpetrators to continue to work with vulnerable residents resulted in an immediate jeopardy situation to the residents. The Department notified the facility of the immediate jeopardy (IJ) on 10/16/24 of the IJ that began on 3/20/24. The facility removed the immediacy on 10/16/24 after implementing the following: a. The facility educated all staff on 10/16/24 regarding the abuse policy and reporting of alleged abuse to their supervisor immediately. The facility would notify the as needed (PRN) staff prior to them working their next shift. b. The facility terminated the employment of the 2 alleged perpetrators. The facility lowered the scope and severity from a level K to a G prior to the survey exit after ensuring the facility implemented their removal plan. The facility reported a census of 61 residents. Findings include: 1. Resident #47's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 12, indicating moderately impaired cognition. The assessment reflected a Resident Mood Interview (PHQ 9) score of 6, indicating mild depression. The MDS reflected Resident #47 didn't have evidence of acute changes in mental status, indicators of psychosis including hallucinations or delusions, no behaviors such as physical, verbal, wandering or rejection of cares. The MDS included diagnoses of heart failure, diabetes mellitus, and depression. Resident #47 received Hospice services during the lookback period. The Care Plan Focus dated 3/28/24 indicated Resident #47 had a potential problem with her psychosocial well being problem related to an incident with a staff member. The Intervention dated 6/4/24 directed Staff B, Dietary, not to enter Resident #47's room alone. The Care Plan lacked documentation of delusions, hallucinations, or making false statements. Review of the facility's investigation reflected Staff C, CNA, completed their employee statement by phone on 3/26/24 at 6:00 PM. Staff C stated she went into Resident #47's room on 3/20/24 with an agency CNA, to put her to bed. While they provided her care, Resident #47 asked them if she told them something, could they promise not to tell anyone? Resident #47 then told them Staff B from dietary brought her meal to her room, visited with her for a little bit, and when he went to leave he kissed her on the neck prior to leaving the room. He also told her his wife didn't understand his sense of humor. Staff C reported she told Resident #47 she needed to tell someone. The facility immediately reeducated Staff C on timely reporting of allegations of abuse and they voiced understanding. Interview on 10/16/24 at 11:50 AM, Staff C explained Resident #47 told her Staff B would bring her meals and always tell her it was nice to have her to talk to because his wife didn't understand. On that day after saying that Staff B, bent down and kissed her before leaving the room. Review of facility's investigation, statement taken by the Director of Nursing (DON), for Resident #47 dated 3/26/24 at 7:00 PM stated The DON asked Resident #47 if she had any problems with her care or treatment by the staff. Resident #47 paused for approximately 30 seconds and then asked if she meant Staff B from the kitchen? The DON asked her if she could tell her what happened. Resident #47 replied, it's no big deal, she didn't want anyone to get in trouble. The DON reassured her that she just needed Resident #47 to tell her what occurred to ensure she is safe and cared for. Resident #47 responded, Oh she is definitely safe and she isn't afraid of anyone there. Resident #47 then stated, one-night last week they brought her the wrong drinks. Staff B brought her the correct one. He visited with her for a few minutes and kissed her on the cheek when he left. Again, adding it wasn't a big deal. Resident #47 remarked she felt perfectly safe with everyone there and not scared of anyone. Review of the facility's investigation statement by Staff B on 3/27/24 reflected he didn't recall the incident with Resident #47. He added he always been nice to her as she reminds him of his grandma. She jokingly called him her boyfriend in front of other staff members a few times that he could recall, while delivering trays. He reported he worked in healthcare for 7 years and never had an accusation such as that. Staff B explained he never kissed a resident even on the cheek and knew it would be inappropriate. He added he tried his best to be nice with all of the residents and go out of his way to help them. Review of the Police Department Report dated 3/26/24 at 8:59 PM, indicated Resident #47 appeared of sound mind. The police officers conducted an interview of the suspect. The interview of Staff B, concluded he was simply trying to be nice, he had no sexual intent or intent to harm. Interview on 10/15/24 at 4:33 PM, Resident #47 revealed she did not want to discuss the incident much. If she knew it would have blown up so much she wouldn't have told the girls (Staff C, CNA). Resident #47 reported the police came there, making it a whole big thing. Resident #47 stated after the incident, Staff B, talked to her but not like before, he just said hi. That lasted for a couple weeks, then Staff B came into her room and checking on her often. It started as Staff B, being nice and pushing her in the wheelchair to the dining room. Resident #47 stated Staff B, now came in her room and sits in her recliner uninvited. He came to Resident #47's room [ROOM NUMBER] 8 times a day and it made her uncomfortable. Resident #47 explained a time in the dining room, Staff B sat by her. He started rubbing her arm and back, Resident #47 asked Staff B to stop. Resident #47, repeatedly stated how uncomfortable Staff B made her when he came in her room so often. Resident #47 explained she made up excuses for him to leave, earlier that day (10/15/24) after lunch Staff B, came and sat in her recliner. When Resident #47 told him she was going to nap, Staff B responded with did that mean he had to leave? Resident #47 became tearful and said she couldn't directly tell Staff B that he made her uncomfortable or to tell him to stop coming to her room. Resident #47 hadn't told him the reason she wanted him to leave and just continued to make excuses. While tearful, Resident #47 stated she denied being afraid or uncomfortable with Staff B to the staff for fear of what would happen. Since the last time she had told Staff C what happened and the police showed up. Resident #47 expressed she had fear of the staff and Administration finding out what she said in the interview. The Hospice Residential Communication Form completed by the Hospice Social Worker on 6/18/24 indicated Resident #47 reported increased feelings of depression. The Hospice Nurse on 6/24/24 left a note that order sent to the primarcy care provider (PCP) to increase/add an antidepressant. The Hospice Physician Orders dated 6/25/24 reflected Resident #47 reported an increase in depression. The Provider replied if history of seizures, begin Wellbutrin XL (antidepressant) 150 MG by mouth everyday for 2 weeks then 300 MG everyday by mouth. On 10/16/24 at 8:28 AM, observed Staff B push a cart from the kitchen to Resident #47's room with a room tray. Staff B entered Resident #47's room delivering a breakfast tray. Interview on 10/16/24 at 11:30 AM, Staff J, Dietary, reported she often saw Staff B go into Resident #47's room. Staff J stated Staff B is part of the kitchen staff and didn't understand why he needed to go in there so often. Interview on 10/16/24 at 11:40 AM, Staff K, CNA, revealed she often saw Staff B go in and out of Resident #47's room. Interview on 10/16/24 at 11:58 AM, Staff L, CNA, revealed Staff B went in Resident #47's room a lot. Staff L explained at times, they had to ask Staff B to leave Resident #47's room to provide cares. Staff L, CNA, stated they didn't know Staff B couldn't be in Resident #47's room alone. Interview on 10/16/24 at 11:12 AM, Staff I, Human Resources (HR), stated she didn't know of Resident #47 making any allegations towards other residents or staff, other than the investigated incident on 3/26/24. Staff I, also denied any knowledge of Resident #47 having any negative feeling towards Staff B that may have led to a false accusation. Interview on 10/16/24 at 11:15 AM, Staff M, Social Services, stated other than the investigated incident with Resident #47 and Staff B, she didn't know of any other accusations towards staff or residents made by her. Staff M, denied knowing of any ill feelings Resident #47 may have towards Staff B that may have led to a false accusation. Staff M, met with Resident #47 routinely after the incident, Resident #47 didn't communicate to Staff M that she felt uncomfortable around Staff B. In an interview on 10/16/24 at 1:55 PM, the DON and Facility Administrator acknowledged the intervention that Staff B was not to enter Resident #47's room alone, on her Care Plan. They stated Resident #47's Care Plan shouldn't have that and they put it there as a precaution. In an interview on 10/17/24 at 1:07 PM, Facility Administrator acknowledged they expected residents' Care Plans get updated appropriately, timely, and followed as indicated. Review of Comprehensive Person Centered Care Planning Policy revised date December 2023 directed the interdisciplinary team (IDT) shall develop a comprehensive person centered Care Plan for each resident that included measurable objective and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. 2. Resident #316's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of neurocognitive disorder with Lewy bodies (disorder that affects memory), cognitive communication deficit (difficulty talking due to memory), anxiety disorder, abnormalities of gait and mobility, muscle weakness, and need for assistance with personal care. Resident #316 used antipsychotic medication, antianxiety medication, and antidepressant medication within the lookback period. The Care Plan Focus dated 6/21/24 indicated Resident #316 had a terminal prognosis related to Lewy body dementia. The Intervention instructed the staff to encourage him to express his feelings and listen with non judgmental acceptance and compassion. The Care Plan Focus dated 4/19/24 reflected Resident #16 had a risk for elopement and wandering related to disorientation to place. The Interventions directed the following: a. Identify patterns of wandering and intervene as appropriate. b. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. The Change of Condition Note dated 6/16/24 at 6:04 PM indicated Resident #316 received an order to increase his lorazepam (antianxiety medication) due to his increased restlessness and anxiety. The Condition Follow-Up Note dated 6/17/24 at 4:25 AM reflected Resident #316 didn't sleep that night, he moved his feet and legs constantly. He attempted to stand by himself, closes his eyes briefly then has an entire body jerk, waking himself. Resident #316 hallucinated and talked to himself. He occasionally answered questions correctly but frequently had word salad (confused nonsensical speech). He scratched his entire body but mostly his arms and legs. He had hydroxyzine without relief. Resident #316 required one-on-one (1:1) assistance for safety. Resident #316 had neurological checks within his normal limits. He received a recent increase in Aricept and Ativan the day before. Difficult to ascertain if restlessness and itching are medication related. Review of the facility's investigation, Staff I's, CNA, statement indicated on 6/16/24 they each watched Resident #316 for 30 minutes. Staff I sat with Resident #316 while Staff C sat at the other end of the table. When Staff I returned from break, she started answering call lights. Staff C started yelling and screaming at Staff I for not sitting with Resident #316. Staff I told the nurse that if she screamed at her like that again, she would go home. After that Staff C sat with Resident #316. Staff C talked very mean to Resident #316, and told him, he is going to sit his fucking ass down. Then she asked him where do you think you are going? You are not going anywhere. This went on until Staff I sat with Resident #316 again. The night nurse suggested Staff I take Resident #316 to the back desk and chart to keep things mellow for the night. Review of the facility's investigation dated 6/20/24, listed the corrective action as Staff C immediately suspended from working pending investigation. Review of time cards dated 6/16/24 to 6/20/24, Staff C continued to work the rest of her overnight shift on 6/16/24 6/17/24 and an overnight shift on 6/19/24 6/20/24. On 10/17/24 at 1:07 PM the Administrator stated he expected a staff who witnessed any form of abuse to separate the victim and alleged abuser. They need to make sure the victim is safe and immediately report the incident to the administration staff including himself and the DON. Review of facility provided policy Abuse Prevention and Prohibition revised September 2017 indicated that each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included but not limited to freedom from corporal punishment, involuntary seclusion, any physical or chemical restraints not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends or other individuals. The section labeled Prevention indicated all personnel, residents, visitors etc. are encouraged to report incidents and grievances without the fear of retribution. The facility will provide feedback regarding concerns. The facility employees will take action to protect, prevent abuse, and neglect from occurring within the facility by: Staff having knowledge of the individual residents' care needs. Supervision of staff to identify inappropriate behaviors (i.e. derogatory language, rough handling, ignoring residents while giving care etc.). Assess, Care Plan and monitor residents' rooms, self injurious behaviors, communication disorders, totally dependent on staff. Protection If a resident incident is reported, discovered or suspected, where the health, welfare or safety of the residents is involved, the facility will take the following steps to prevent further potential abuse while the investigation is in progress; if the suspected perpetrator is an employee: Remove employee immediately from the care of any resident; Suspend employee during the investigation. Reporting/Response All alleged violations will be reported via phone or in writing within 24 hours to the State Licensing Agency. The facility shall follow up to the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days. The Facility will report to the State Nurse Aide Registry or Licensing authorities any knowledge it has of any action by a court of law which would indicate an employee is unfit for service. The facility will analyze occurrences and determine what changes are needed, if any, to the policies and procedures to prevent further occurrences. The Administrator/Designee will inform the resident and his/her representative of the results of the investigation and corrective action taken.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinic record review, staff interviews, resident interview, Nurse Practitioner interview, and policy review, the facility failed to administer medications per physician orders for 2 out of 2 residents reviewed (Resident #25 and #2) for significant medication errors. 1. The facility failed to provide Resident #25 their ordered Revlimid (anticancer medication that slows the progression of multiple myeloma and various types of cancer) from 4/25/24 to 6/5/24. 2. Resident #2 received medications not prescribed to her. Resident #2 received her roommates' medications (Resident #10) instead of her own. The facility reported a census of 61 residents. The State Agency informed the facility of the Immediate Jeopardy on 10/16/24 at 2:47 PM that began on 4/25/24. The facility staff removed the Immediate Jeopardy on 10/16/24 through the following actions: a. The facility educated all nurses and certified medication aides (CMAs) on following the physician orders policy on 10/16/24. As needed (PRN) staff members will complete education prior to working the next shift. b. The DNS (Director Nursing Services)/designee will audit all missing/omitted MAR (Medication Administration Records) and TAR (Treatment Administration Record) entries daily for the next 4 weeks. They will educate nursing when needed on following physician orders, correct order entry, and the process for medication errors. c. Two nurses will double note all orders. This is a permanent systemic change. The DNS/designee will run missing entries report in the electronic medical record (EMR) daily for omissions on the MAR/TAR. The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented their removal plan. The facility identified a census of 61 residents. Findings include: 1. Resident #25's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 15, indicating intact cognition. Resident #25 required partial/moderate assistance with bed mobility, transfers, and toileting. The MDS included diagnoses of cancer, anemia (low blood iron), hypertension (high blood pressure), and renal (kidney) disease. The Care Plan Focus dated 2/5/24 reflected Resident #25 had an alteration in hematological (affecting the blood) status related to cancer. Resident #25 received treatments in [NAME] City. The Care Plan directed staff to administer medication as ordered, monitor for side effects, and effectiveness. A Physician order dated 3/27/24 directed staff to restart Revlimid (Lenalidomide) 5 milligrams (mg) by mouth on days 1-21 every 28 days. The Oncology Report dated 3/27/24 indicated Resident #25's care facility wasn't completely sure if he received his Revlimid or not. They believe he last received it February 24 through March 16, which put him due to restart on March 24, 2024. They reported they had a complete cycle worth of Revlimid for him in their facility. Orders placed to restart Revlimid 5 mg that day. A Physician order dated 4/10/24 directed staff to administer Revlimid (Lenalidomide) 5 mg by mouth on days 1-21 followed by 7 days off. The order directed to start the Revlimid on 4/25/24 to 5/15/24 with no dose from 5/16/24 to 5/22/24. The Advance Registered Nurse Practitioner (ARNP) signed the order and the facility faxed the order to the pharmacy on 5/8/24. The Oncology Report dated 4/10/24 indicated Resident #25's care facility wasn't completely sure if he received his Revlimid or not. They believe he last received it February 24 through March 16, which put him due to restart on March 24, 2024. They reported they had a complete cycle worth of Revlimid for him in their facility. Orders placed to restart Revlimid 5 mg on 3/27/24. Next cycle to start 4/25/24. A Physician order dated 6/5/24 directed staff to continue Revlimid 5 mg by mouth on days 1-21, followed by 7 days off. The order directed the staff to start the Revlimid on 6/5/24 to 6/25/24 with no dosing from 6/26/24 to 7/2/24. The order listed the Revlimid order as ongoing. The Oncology Report dated 6/5/24 reflcted Resident #25's care facility wasn't completely sure as to whether he received his Revlimid or not, but they believe he last received it February 24 through March 16, which would have put him due to restart on March 24, 2024. Once again, Resident #25 didn't receive Revlimid since April 17th, 2024. The provider contacted the DON of Resident #25's care facility who advised the nurse believed they discontinued Resident #25's medication, so they didn't give Revlimid to the him. The provider provided information on Revlimid dosing and the importance of proper administration. The DON reported they had a complete cycle worth of Revlimid for him in the facility and could restart Revlimid that day. Review of the March and April 2024 MAR reflected Resident #25 received Revlimid 5 mg from 3/28/24 to 4/17/24. Review of the April, May, and June 2024 MAR lacked documentation of Resident #25 receiving Revlimid as ordered by the physician from 4/25/24 to 5/15/24. In addition, the forms lacked documentation Resident #25 restarted their Revlimid on 5/23/24 as order. A Physician Progress note dated 6/5/24 from the cancer center indicated they restarted Resident #25 on Revlimid 5 mg for 21 days every 28 days in the latter part of February 2024. The note identified Resident #25 didn't receive his Revlimid since 4/17/24. The ARNP contacted the Director of Nursing (DON) who advised the nurse believed they discontinued the medication, so they didn't give Resident #25 the Revlimid. The note documented the ARNP provided information on Revlimid dosing and the importance of proper administration. The note documented the facility reported they had a complete cycle worth of Revlimid for Resident #25 in the facility and would restart his Revlimid on 6/5/24. A Cancer Center note titled Missed Revlimid Cycles dated 6/5/24 documented the facility nurse and the DON reported Resident #25 didn't receive his Revlimid medication since 4/17/24. The note included Resident #25 brought a medication list with him that didn't have Revlimid listed. The note documented Resident #25 missed one complete cycle and a part of the following cycle of the Revlimid medication. The note documented the facility DON verbalized the facility had two cycles of the Revlimid medication on hand. The DON didn't provide an explanation on why Resident #25 didn't receive the Revlimid medication. The note documented written physician orders on 4/10/24 instructed the facility staff to start the next cycle of Revlimid on 4/25/24. The facility didn't administer the medication starting on 5/23/24. The facility received instructions to have Resident #25 start the Revlimid on 6/5/24 for 21 days then off for 7 days per the 28 day cycle and resume next cycle after the 7-day break. A graph labeled M Protein IgG Lambda (a type of paraprotein that is produced by myeloma cells) dated 4/1/24 to 10/28/24 documented elevated M Protein IgG Lambda levels in May 2024 when Resident #25 didn't receive their Revlimid medication. The graph documented the M Protein IgG Lambda levels consistently decreased since June 2024. Review of the clinical record lacked documentation of the facility notifying Resident #25's Primary Care Physician and/or family regarding Resident #25 not receiving the Revlimid medication per the Physician's order. The facility didn't complete an investigation and medication error form regarding the omission of the Revlimid. On 10/14/24 11:40 AM, Resident #25 reported he had his cancer medication screwed up at one time. He stated he thought it happened about a month ago or so. He stated the facility told him about it. When asked if he received the medication now, he reported he didn't know for sure. On 10/15/24 at 3:23 PM, The DON acknowledged she couldn't locate documentation that Resident #25 received the Revlimid medication from 4/25/24 to 5/15/24 and restarted the order on 5/23/24. The DON reported she was still looking into it. She thought maybe a nurse didn't know how to transcribe the medication onto the MAR with 21 days on and 7 days off. She stated the Revlimid came from an outside pharmacy set up by the cancer center. The DON stated the cancer center would contact her regarding medication concerns. On 10/15/24 at 10:10 AM, the Cancer Center Operation Manager, MSN (Master of Science in Nursing), reported the Cancer Center called the facility regarding concerns with the administration of the Revlimid medication. She stated the cancer center nurse talked to a facility nurse and the DON. She reported Revlimid as a medication used to help control Resident #25's multiple myeloma (cancer). She stated not receiving the medication could contribute to the progression of the multiple myeloma and could be potentially fatal. She stated Resident #25's had an elevation in his lab (M spike) (lab to measure the amount of M protein in the blood) in May. She reported the Cancer Center sent the physician orders for the Revlimid to the specialty pharmacy. She reported she didn't know of any issue with the facility receiving the medication. On 10/16/24 at 12:35 PM, the Cancer Center ARNP reported she had concerns with Resident #25 missing cycles of the Revlimid medication. The ARNP reported Resident #25 restarted the Revlimid in February 2024. She sent specific orders on when to dose the medication and when to stop it. She stated to give the Revlimid for 21 days and then stop for 7 days. She stated the treatment was ongoing. She had concerns for Resident #25's health as multiple myeloma could be a life-threatening illness. She reported the facility didn't have to refill his medication as they had so much on hand. The ARNP reported she called the DON on 6/5/24 as she was concerned Resident #25 could relapse and could die. She stated the DON blamed the problem on a new nurse. She stated the cancer center didn't typically call the facility ahead of time to get the resident's MAR but they did for Resident #25, as they wanted to check to see if he received his Revlimid. She reported they had a hard time getting information from the facility. She stated at the last appointment they requested the MAR ahead of time and didn't get the MAR until he came to the appointment. The ARNP stated not administering the Revlimid to Resident #25 consistently could lead to his demise and he could die. She stated if he didn't get the appropriate treatment it could lead to a relapse. She stated Resident #25 already had 2 stem-cell transplants in the past and she didn't want him to have to go through that again. She described Resident #25 as currently stable, with his lab counts improved. On 10/16/24 at 1:04 PM, the DON reported she received a call from a nurse at the Cancer Center at the beginning of the summer. She stated the nurse was checking to ensure Resident #25's Revlimid orders were put in the computer correctly. She stated the cancer center feared Resident #25 missed a cycle of his Revlimid. She stated the Cancer Center ordered to give the Revlimid for 21 days and then off for 7 days. She stated the nurse wanted to make sure they gave it correctly. The DON reported she didn't give the medication, her nurses did. On 10/17/24 at 9:15 AM, the Nurse Consultant reported she expected the staff to follow physician orders and the 6 rights of administering medications. A facility policy titled Physician Orders revised May 2019 instructed all drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. The policy further documented that the charge nurse or DON shall place the order for all prescribed medications. A facility policy titled Medication Errors and Adverse Reactions reviewed May 2023 directed the facility needed to report medication errors and adverse drug reactions the resident's attending physician. The policy directed to complete a medication error form and the nursing service would implement/follow any new physician's orders. The policy instructed to record the resident's condition and response to any ordered treatment. 2. Resident #2's MDS assessment dated [DATE] identified a BIMs score of 15, indicating intact cognition. Resident #2 required partial/moderate assistance with bed mobility, transfers, and toileting. The MDS included diagnoses of coronary artery disease (impaired blood circulation), hypertension (high blood pressure), hyperlipidemia (elevated cholesterol), thyroid disorder, anxiety disorder, depression, schizophrenia (mental health disorder that can cause hallucinations and delusions), and cognitive communication deficit. The clinical census report identified Resident #2 and Resident #10 resided in room [ROOM NUMBER]. An incident reported titled Medication Error dated 10/13/24 documented a CMA gave Resident #2 Resident #10's medications by accident. The incident report identified Resident #2 received the following unprescribed medications: Oxycodone (opioid) 5 mg (milligrams), Baclofen (muscle relaxer) 10 mg, Gabapentin (anticonvulsant) 100 mg, Lexapro (antidepressant) 10 mg, Melatonin (hormone to help with sleep) 6 mg and Topamax (anticonvulsant) 100 mg. The incident report documented immediate action taken included notifying the Physician, monitoring Resident #2 throughout the night, and reviewing the 6 rights of giving medications with the CMA. The incident report documented the facility notified Resident #10's family of the error. On 10/16/24 at 11:52 AM, Staff G, RN (Registered Nurse), verified she worked the evening of 10/13/24. Staff G reported Resident #10 called for a nurse. Staff G reported Resident #10 showed her a cup of pills and stated they weren't hers. Staff G looked at the cups of pills and verified they weren't Resident #10's medications. Staff G stated she took the cup of pills to Staff H, CMA, and asked her whose pills they were. Staff G stated Staff H reported she mixed up the pills and gave Resident #2's pills to Resident #10 and Resident #10 pills to Resident #2. Staff G reported she destroyed the cups of pills that Resident #10 gave her in the drug buster and dispensed the correct medications to Resident #10. Staff G stated she notified the doctor of Resident #2's medication error. She stated she checked on Resident #2 every hour throughout the night to make sure she was alert and would wake up. Staff G stated she educated Staff H on never taking two medication cups in the room at the same time, as she was asking for trouble. Staff G reported she educated Staff H regarding leaving medications in the room unattended. Staff G reported Staff H took both residents' medication cups in the same room at the same time and got them mixed up. On 10/17/24 at 9:15 AM, the Nurse Consultant reported she expected the staff to follow the 6 rights of administering medications. A facility policy titled Medication Administration reviewed May 2021 instructed to accurately prepare, administer, and document oral medications. The policy directed staff to identify the resident when administering medications by the photo on the MAR or by asking their name. The policy documented they must identify the resident before administering medications. The person administering the medication must remain with the resident until all they swallowed all of their medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records review, staff interview, facility investigation review, and policy review, the facility failed to notify the Department of Inspections, Appeals, and Licensing (DIAL) of 2 of 2 allegations of physical and verbal abuse within 24-hours of staff learning of the incidents. 1. On 3/20/24 around 11:30 PM, Resident #47 notified a Certified Nursing Aide (CNA) of alleged physical abuse. On 3/26/24 around 5:50 AM a Dietary Aide learned of Resident #47's allegation of physical abuse by a second CNA. No one reported the allegation of abuse until the Dietary Aide reported it to the Director of Nursing (DON) on 3/26/24 around 6:00 PM. The facility began their investigation of the alleged abuse on 3/26/24 and reported the incident to that evening at 10:08 PM. 2. On 6/16/24 around 11:30 PM a CNA documented they witnessed alleged verbal abuse towards Resident #316. The CNA reported the alleged verbal abuse to the DON on 6/20/24 around 3:30 PM. The DON called the DIAL abuse hotline on 6/20/24 around 3:40 PM to report the alleged abuse. The facility failed to provide the completed investigation findings and results within 5 days to the DIAL. The Facility filed their Self-Report with the DIAL on 7/1/24 at 9:14 PM. The Department notified the facility of the immediate jeopardy (IJ) on 10/16/24 of the IJ that began on 3/20/24. The facility removed the immediacy on 10/16/24 after implementing the following: a. The facility educated all staff on 10/16/24 regarding the abuse policy and reporting of alleged abuse to their supervisor immediately. The facility would notify the as needed (PRN) staff prior to them working their next shift. b. The facility terminated the employment of the 2 alleged perpetrators. The facility lowered the scope and severity from a level K to an E prior to the survey exit. The facility reported a census of 61 residents. Findings include: 1. Resident #47's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 12, indicating moderately impaired cognition. The assessment reflected a Resident Mood Interview (PHQ 9) score of 6, indicating mild depression. The MDS reflected Resident #47 didn't have evidence of acute changes in mental status, indicators of psychosis including hallucinations or delusions, no behaviors such as physical, verbal, wandering or rejection of cares. The MDS included diagnoses of heart failure, diabetes mellitus, and depression. Resident #47 received Hospice services during the lookback period. The Care Plan Focus dated 3/28/24 indicated Resident #47 had a potential problem with her psychosocial well being problem related to an incident with a staff member. The Intervention dated 6/4/24 directed Staff B, Dietary, not to enter Resident #47's room alone. The Care Plan lacked documentation of delusions, hallucinations, or making false statements. The Nursing Note dated 3/26/24 at 6:40 PM identified Staff C, CNA, reported Resident #47 told her as she provided care of an incident on 3/20/24 at approximately 11:30 PM. Resident #47 reported that previous to 3/20/24, as Staff B, Dietary, brought a meal to her room, he visited with her for a while, and then kissed her on the neck prior to leaving her room. The Director of Nursing (DON) interviewed Resident #47 immediately, she reported Staff B kissed her on the cheek prior to leaving the room. She didn't remember exactly which day it occurred but stated she knew it happened prior to the day she said something to the girls. She denied feeling unsafe or afraid of Staff B and stated he's a nice man. The DON continued the investigation. Resident #47 had a BIMS score of 13, indicating intact cognition. Review of facility Self-Report indicated the incident approximately occurred on 3/20/24 at 11:30 PM. The facility submitted the report on 3/26/24 at 10:08 PM. Review of the facility's investigation reflected Staff C, CNA, completed their employee statement by phone on 3/26/24 at 6:00 PM. Staff C stated she went into Resident #47's room on 3/20/24 with an agency CNA, to put her to bed. While they provided her care, Resident #47 asked them if she told them something, could they promise not to tell anyone? Resident #47 then told them Staff B from dietary brought her meal to her room, visited with her for a little bit, and when he went to leave he kissed her on the neck prior to leaving the room. He also told her his wife didn't understand his sense of humor. Staff C reported she told Resident #47 she needed to tell someone. The facility immediately reeducated Staff C on timely reporting of allegations of abuse and they voiced understanding. Staff D's, Dietary Aide, statement on 3/26/24 at 6:00 PM, reflected Staff E, CNA, notified her around 5:50 AM that Staff C mentioned Resident #47 let her know when Staff B took her room tray, he set it down on the table, and then gave her a kiss on the neck. No one mention what day it happened. In an interview on 10/15/24 at 1:32 PM, Staff D reported on 3/26/24 at 5:50 AM, Staff E told her that Staff C told her about the incident with Resident #47 and Staff B. Staff D stated she reported it to the Administration at approximately 6:00 PM on 3/26/24. Review of the facility's investigation dated 3/26/24, listed the facility's corrective action as suspending Staff B pending the outcome of the investigation. The facility re-educated all staff on the current procedure for reporting any suspected adult abuse. 2. Resident #316's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of neurocognitive disorder with Lewy bodies (disorder that affects memory), cognitive communication deficit (difficulty talking due to memory), anxiety disorder, abnormalities of gait and mobility, muscle weakness, and need for assistance with personal care. Resident #316 used antipsychotic medication, antianxiety medication, and antidepressant medication within the lookback period. The Care Plan Focus dated 6/21/24 indicated Resident #316 had a terminal prognosis related to Lewy body dementia. The Intervention instructed the staff to encourage him to express his feelings and listen with non judgmental acceptance and compassion. The Care Plan Focus dated 4/19/24 reflected Resident #16 had a risk for elopement and wandering related to disorientation to place. The Interventions directed the following: a. Identify patterns of wandering and intervene as appropriate. b. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. The Change of Condition Note dated 6/16/24 at 6:04 PM indicated Resident #316 received an order to increase his lorazepam (antianxiety medication) due to his increased restlessness and anxiety. Review of the facility's Self-Report indicated an allegation of abuse occurred on 6/16/24 at 12:30 AM. The report listed the date knew as 6/20/24, with the Self-Report filed 7/1/14 at 9:14 PM. Review of facility's investigation, the DON's statement dated 6/20/24, reflected they received a phone call from Staff I, Human Resources (HR), reporting Staff F, CNA, told her Staff C, CNA, used profanity when caring for Resident #316. The event occurred on 6/16/24 during the graveyard shift and Staff F didn't report it until 6/20/24, her next scheduled day to work. Review of the facility's investigation, Staff I's, CNA, statement indicated on 6/16/24 they each watched Resident #316 for 30 minutes. Staff I sat with Resident #316 while Staff C sat at the other end of the table. When Staff I returned from break, she started answering call lights. Staff C started yelling and screaming at Staff I for not sitting with Resident #316. Staff I told the nurse that if she screamed at her like that again, she would go home. After that Staff C sat with Resident #316. Staff C talked very mean to Resident #316, and told him, he is going to sit his fucking ass down. Then she asked him where do you think you are going? You are not going anywhere. This went on until Staff I sat with Resident #316 again. The night nurse suggested Staff I take Resident #316 to the back desk and chart to keep things mellow for the night. Review of the facility's investigation dated 6/20/24, listed the corrective action as Staff C immediately suspended from working pending investigation. On 10/17/24 at 1:07 PM the Administrator stated they expected any staff who witness any form of abuse is to separate the victim and alleged abuser, making sure the victim is safe. Then immediately report the allegation to administration staff including the Administrator and the DON. Review of facility provided policy, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment revised 11/28/17 indicated in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of resident property, are reported immediately but not later than 2-hours after the allegation is made if the events that cause the allegation involve abuse or resulted in serious bodily injury. Not later than 24-hours if the events that cause the allegation didn't involve abuse and didn't result in serious bodily injury. Ensure all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, are reported to the Administrator of the facility, the State Survey Agency, and the Adult Protective Services (as appropriate). Ensure that after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident(s). Review of facility provided policy Abuse Prevention and Prohibition revised September 2017 instructed the following: a. Training Orientation program will include review of facility's policy on: i. What constitutes abuse, neglect, exploitation and misappropriation of resident property. ii. Care of the cognitively impaired/appropriate interventions to deal with aggressive and/or catastrophic reactions of resting; iii. Dementia Management and Resident Abuse Prevention; iv. How staff should report their knowledge related to allegations without fear of reprisal. v. How to recognize signs of burnout, frustration and stress that may lead to abuse. The Department of Justice information regarding Your Legal Duty . Reporting Elder and Dependent Adult Abuse. Elder Justice Act Reporting Reporting/Response All alleged violations will be reported via phone or in writing within 24 hours to the State Licensing Agency. The facility shall follow up to the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident's record review, staff interviews, facility investigation review, time card detail, employee files, and policy review, the facility failed to separate staff members accused of alleged physical and verbal abuse from dependent residents in a timely manner for 2 of 2 residents reviewed (Residents #47 and #316). 1. Resident #47 reported an allegation of physical abuse on 3/20/24 to a Certified Nurse Aide (CNA). The CNA failed to report the allegation to Administration, which allowed the alleged abuser to work multiple days after the allegation. In addition, one dietary staff member learned of the allegation in the morning of 3/26/24, but failed to report the allegation until 5:00 PM that evening. This allowed the staff member to continue to work their entire shift on 3/26/24. 2. A CNA witnessed another CNA swear at a behavioral resident on 6/16/24. The CNA didn't report the incident to Administration until 6/20/24, their next scheduled day to work. Due to the lack of the CNA reporting the incident to Administration, the alleged abuser continued to work multiple days until 6/20/24. The Department notified the facility of the immediate jeopardy (IJ) on 10/16/24 of the IJ that began on 3/20/24. The facility removed the immediacy on 10/16/24 after implementing the following: a. The facility educated all staff on 10/16/24 regarding the abuse policy and reporting of alleged abuse to their supervisor immediately. The facility would notify the as needed (PRN) staff prior to them working their next shift. b. The facility terminated the employment of the 2 alleged perpetrators. The facility lowered the scope and severity from a level K to an E prior to the survey exit after ensuring the facility implemented their removal plan. The facility reported a census of 61 residents. Findings include: 1. Resident #47's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 12, indicating moderately impaired cognition. The assessment reflected a Resident Mood Interview (PHQ 9) score of 6, indicating mild depression. The MDS reflected Resident #47 didn't have evidence of acute changes in mental status, indicators of psychosis including hallucinations or delusions, no behaviors such as physical, verbal, wandering or rejection of cares. The MDS included diagnoses of heart failure, diabetes mellitus, and depression. Resident #47 received Hospice services during the lookback period. The Care Plan Focus dated 3/28/24 indicated Resident #47 had a potential problem with her psychosocial well being problem related to an incident with a staff member. The Intervention dated 6/4/24 directed Staff B, Dietary, not to enter Resident #47's room alone. The Care Plan lacked documentation of delusions, hallucinations, or making false statements. Review of the facility's investigation reflected Staff C, CNA, completed their employee statement by phone on 3/26/24 at 6:00 PM. Staff C stated she went into Resident #47's room on 3/20/24 with an agency CNA, to put her to bed. While they provided her care, Resident #47 asked them if she told them something, could they promise not to tell anyone? Resident #47 then told them Staff B from dietary brought her meal to her room, visited with her for a little bit, and when he went to leave he kissed her on the neck prior to leaving the room. He also told her his wife didn't understand his sense of humor. Staff C reported she told Resident #47 she needed to tell someone. The facility immediately reeducated Staff C on timely reporting of allegations of abuse and they voiced understanding. Review of the facility's investigation dated 3/26/24, listed the facility's corrective action as suspending Staff B pending the outcome of the investigation. The facility re-educated all staff on the current procedure for reporting any suspected adult abuse. Review of Staff B's time cards dated 3/20/24 to 4/10/24, reflected he continued to work on 3/20/24, 3/22/24, 3/23/24, 3/25/24, and 3/26/24 with access to vulnerable residents. The facility placed Staff B, on suspension during the investigation process and allowed him to return to work on 4/4/24. On 10/16/24 at 8:28 AM, observed Staff B push a cart from the kitchen to Resident #47's room with a room tray. Staff B entered Resident #47's room delivering a breakfast tray. Interview on 10/16/24 at 11:30 AM, Staff J, Dietary, reported she often saw Staff B go into Resident #47's room. Staff J stated Staff B is part of the kitchen staff and didn't understand why he needed to go in there so often. Interview on 10/16/24 at 11:40 AM, Staff K, CNA, revealed she often saw Staff B go in and out of Resident #47's room. Interview on 10/16/24 at 11:50 AM, Staff C explained Resident #47 told her Staff B would bring her meals and always tell her it was nice to have her to talk to because his wife didn't understand. On that day after saying that Staff B, bent down and kissed her before leaving the room. Interview on 10/16/24 at 11:58 AM, Staff L, CNA, revealed Staff B went in Resident #47's room a lot. Staff L explained at times, they had to ask Staff B to leave Resident #47's room to provide cares. Staff L, CNA, stated they didn't know Staff B couldn't be in Resident #47's room alone. 2. Resident #316's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of neurocognitive disorder with Lewy bodies (disorder that affects memory), cognitive communication deficit (difficulty talking due to memory), anxiety disorder, abnormalities of gait and mobility, muscle weakness, and need for assistance with personal care. Resident #316 used antipsychotic medication, antianxiety medication, and antidepressant medication within the lookback period. The Care Plan Focus dated 6/21/24 indicated Resident #316 had a terminal prognosis related to Lewy body dementia. The Intervention instructed the staff to encourage him to express his feelings and listen with non judgmental acceptance and compassion. Review of facility's investigation, the DON's statement dated 6/20/24, reflected they received a phone call from Staff I, Human Resources (HR), reporting Staff F, CNA, told her Staff C, CNA, used profanity when caring for Resident #316. The event occurred on 6/16/24 during the graveyard shift and Staff F didn't report it until 6/20/24, her next scheduled day to work. Review of the facility's investigation, Staff I's, CNA, statement indicated on 6/16/24 they each watched Resident #316 for 30 minutes. Staff I sat with Resident #316 while Staff C sat at the other end of the table. When Staff I returned from break, she started answering call lights. Staff C started yelling and screaming at Staff I for not sitting with Resident #316. Staff I told the nurse that if she screamed at her like that again, she would go home. After that Staff C sat with Resident #316. Staff C talked very mean to Resident #316, and told him, he is going to sit his fucking ass down. Then she asked him where do you think you are going? You are not going anywhere. This went on until Staff I sat with Resident #316 again. The night nurse suggested Staff I take Resident #316 to the back desk and chart to keep things mellow for the night. Review of the facility's investigation dated 6/20/24, listed the corrective action as Staff C immediately suspended from working pending investigation. Review of time cards dated 6/16/24 to 6/20/24, Staff C continued to work the rest of her overnight shift on 6/16/24 6/17/24 and an overnight shift on 6/19/24 6/20/24. Review of a disciplinary notice dated 7/2/24 for Staff C identified due to gross misconduct - suspicion of verbal or emotional abuse of a resident. On 6/20/24 a staff member reported that Staff C spoke to Resident #316 on 6/16/24 using profanity. The facility immediately placed Staff C on leave until 7/2/24. Following the completion and outcome of the investigation, the facility terminated Staff C's employment immediately. On 10/17/24 at 1:07 PM the Administrator stated they expected any staff who witness any form of abuse is to separate the victim and alleged abuser, making sure the victim is safe. Then immediately report the allegation to administration staff including the Administrator and the DON. Review of facility provided policy Abuse Prevention and Prohibition revised September 2017 indicated that each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included but not limited to freedom from corporal punishment, involuntary seclusion, any physical or chemical restraints not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends or other individuals. The section labeled Prevention indicated all personnel, residents, visitors etc. are encouraged to report incidents and grievances without the fear of retribution. The facility will provide feedback regarding concerns. The facility employees will take action to protect, prevent abuse, and neglect from occurring within the facility by: Staff having knowledge of the individual residents' care needs. Supervision of staff to identify inappropriate behaviors (i.e. derogatory language, rough handling, ignoring residents while giving care etc.). Assess, Care Plan and monitor residents' rooms, self injurious behaviors, communication disorders, totally dependent on staff. Protection If a resident incident is reported, discovered or suspected, where the health, welfare or safety of the residents is involved, the facility will take the following steps to prevent further potential abuse while the investigation is in progress; if the suspected perpetrator is an employee: Remove employee immediately from the care of any resident; suspend the employee during the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, policy review, and review of manufacturer recommendations, the facility failed to assess the risk of resident entrapment and/or obtain informed consent for the use of bed rails/grab bars for one (Resident #148) of two residents reviewed for entrapment from bed rails. In addition, the facility failed to conduct ongoing evaluations of risks and ongoing assessments to ensure a grab bar was meeting Resident #148's needs. Staff placed a grab bar (also known as an assistance handle, bed bar, and transfer aide) on Resident #148's bed on [DATE] without assessing the risks/benefits of the grab bar for the resident and without obtaining the resident/resident responsible party's consent. When Resident #148 began climbing out of bed, the facility failed to evaluate the risks of ongoing usage of the grab bar. On [DATE], Resident #148 was found with his/her upper body between the headboard and grab bar, hanging off the side of the bed. According to the Medical Examiner, Resident #148 died from positional asphyxiation (a form of asphyxia or deficient supply of oxygen to the body arising from abnormal breathing which occurred when someone's position prevented them from breathing adequately). This had the potential to affect 22 residents in the facility with bed rails. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, §483.25(n)(1)(2) Bedrails at a scope and severity of J. The IJ began on [DATE] when Resident #148 was found to be entrapped between the headboard and bed bar and died from positional asphyxiation. The Administrator and Staff V, MDS Resource, were notified of the IJ on [DATE] at 6:52 PM and were provided the IJ template at that time. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency (SSA) on [DATE] at 4:17 PM. The IJ was removed on [DATE] after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of isolated harm that was not immediate jeopardy for F700. Findings included: A review of the facility's policy titled, Bedrail Assessment, last revised 08/2017, indicated, If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails. 1. After the facility has attempted alternatives to bed rails and determined that these alternatives failed to meet the resident's assessed needs, the facility IDT [Interdisciplinary Team] will assess the resident for risks of entrapment and possible benefits of using bed rail. The risks and benefits of side rails will be considered for each resident. 2. If the use of bedrail is recommended by the IDT, the facility must obtain informed consent from the resident or if applicable, the resident representative for the use of bed rails prior to installation. Further review of the policy revealed 6. Assuring the correct use of an installed bed rail, and maintenance of bed rails is an essential component in reducing the risk of injury. After the installation of bed rails, it is expected that the facility will continue to provide necessary treatment and care, in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's record, and include the following components, but are not limited to: a.The type of specific direct monitoring and supervision provided during the use of the bed rails, including documentation of the monitoring; b.The identification of how needs will be met during use of the bed rails, such as for repositioning, hydration, meals, use of the bathroom and hygiene; c.Ongoing assessment to assure that the bed rail is used to meet the resident's needs; d.Ongoing evaluation of risks; e.The identification of who may determine when the bed rail will be discontinued; and f.The identification and interventions to address any residual effects of the bed rail (e.g., generalized weakness, skin breakdown). 7. If the side rail is associated with symptoms of distress, such as screaming or agitation, the resident's needs and use of side rails will be reassessed. A review of a User-Service Manual Joerns Deluxe Assist Handle [grab bar/bed bar/transfer aide] dated 2012, indicated Warning: An optimal bed system assessment should be conducted on each resident by a qualified clinician or medical provider to ensure maximum safety of the resident. The assessment should be conducted within the context of, and in compliance with, the state and federal guidelines related to the use of restraint and bed system entrapment guidance. Entrapment zones involve the relationship of components often directly assembled by the healthcare facility rather that the manufacturer. Therefore, compliance is the responsibility of the facility. While the guidelines apply to all healthcare settings, long term care facilities have particular exposure since serious entrapment events typically involve frail, elderly or dementia patients. A review of the facility's Bed Safety Evaluation dated [DATE] revealed the facility was required to measure the distance of the Headboard/footboard to mattress, horizontal measurement and the Rail to bed end (board), both ends. The evaluation indicated a. Place bed in flat position, elevate side rails b. With tape measure, measure the minimum and maximum distance between the side rail and bed end at the head and foot end of the bed. The Definition of Pass was if the Distance is less than 2-1/3 inches or greater than 12-1/2 inches. According to the evaluation, If measurement does not meet criteria, bed with side rails should not be used. There was no documented evidence the facility completed a Bed Safety Evaluation for Resident #148. A review of the admission Record indicated Resident #148 had diagnoses which included schizophrenia, bipolar disorder, and repeated falls. A review of Resident #148's 5-day Prospective Payment System (PPS) Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had no cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Per the MDS, the resident had behaviors of rejecting of care and wandering that occurred one to three days during the assessment period. The MDS noted the resident required extensive assistance of one person with bed mobility, transfers, dressing, toilet use, and bathing, limited assistance of one person for walking in the corridor and personal hygiene, and supervision with walking in their room, locomotion on and off the unit, and eating. The resident's height was noted to be 62 inches and weight was 226 pounds. According to the assessment, a bed rail was not being utilized as a restraint. A review of Resident #148's Care Plan, dated [DATE], indicated the resident had sustained falls and was at risk for further falls related to polypharmacy (multiple medications to treat a condition). The care plan's stated goal was for the resident not to sustain serious injury. Further review of the care plan revealed the facility developed interventions that included the following: - On [DATE], the facility revised Resident #148's Care Plan to include Resident has a history of placing self on the floor. Per the plan, if the resident wanted to sit on the floor, the resident should request assistance to sit on the floor and staff should stay with the resident to ensure safety and to ultimately assist the resident off the floor. - On [DATE], a floor mat was placed beside the resident's bed and the bed was lowered to its lowest position. - On [DATE], the facility revised the resident's care plan indicating Resident #148 had a tendency to rock to the side of bed and roll onto his/her hands/knees at the side of the bed. Staff were directed to provide the resident support and assist the resident to an upright position and to the safety of the bed, if allowed. The care plan revealed a floor mat was in place at the resident's bedside. - On [DATE], the facility developed an intervention to place Resident #148's bed to the right side of the door by a closet with a half rail/grab bar applied to both sides of the bed to establish boundaries. - On [DATE], the facility developed an intervention for a half rail/transfer aid (grab bar) applied to the outer edge of the bed to establish boundaries and to aid in transferring. - On [DATE], an intervention to place a mat/mattress between the wall and bed to help protect the resident from being on the floor was added to the care plan. A review of Resident #148's medical record revealed no documented evidence the facility's Interdisciplinary Team (IDT) assessed the resident for risk of entrapment or the risks and benefits of side rail/grab bar usage, as required by the facility's policy, prior to placing side rails on the resident's bed on [DATE]. In addition, there was no documented evidence the facility reviewed the risks and benefits of bed rails and obtained informed consent from the resident/resident's representative for the use of bed rails prior to their installation. Further, there was no documented evidence the facility ensured the bed's dimensions were appropriate for the resident or confirmed that the bed rails installed were appropriate for the size and weight of the resident. Further review of the Care Plan revealed the facility developed a care plan for Resident #148's psychosocial well-being related to a history of purposefully leaning or appearing as though the resident was fainting. The facility revised the care plan on [DATE] to include an intervention to conduct visual checks on the third shift every hour and converse with the resident to prevent behaviors. However, there was no documented evidence staff conducted visual checks of Resident #148 hourly on the third shift. A review of Resident #148's Progress Notes dated [DATE] at 5:30 AM, [DATE] at 5:30 AM, [DATE] at 5:30 AM, and [DATE] at 5:30 AM revealed the resident has a history of falls and falls are a behavior for this resident. Further review of Progress Notes dated [DATE] at 12:11 PM revealed Resident #148 was noted to have behaviors today with trying to roll onto the floor. During an interview on [DATE] at 10:52 AM, Staff G, Certified Nurse Aide (CNA), revealed the type of grab bar Resident #148 had on his/her bed was part of the bed and could be moved from side to side, but not up and down. Staff G stated Resident #148 used the grab bar sometimes to sit up on the side of the bed. Further interview revealed the resident would crawl into and out of bed (on all sides of the bed) onto his/her hands and knees. Staff G stated Resident #148 had a mattress behind the bed leaning against the wall to keep the resident from falling between the bed and the wall. During an interview on [DATE] at 8:43 AM, Staff I, Licensed Practical Nurse (LPN), revealed Resident #148 barrel-rolled out of the side of the bed, then used the grab bar to pull him/herself up. She stated Resident #148 was able to get up from a kneeling position. During an interview on [DATE] at 10:00 AM, the MDS Coordinator revealed Resident #148 would roll or flop him/herself off the side of the bed. According to the MDS Coordinator, Resident #148 exhibited this behavior and others for attention. During an interview on [DATE] at 6:07 PM, Staff B, Registered Nurse (RN), stated Resident #148 had severe mental illness and had behaviors that included being combative and coming out of his/her room with no pants on. Staff B noted staff were also monitoring the resident for putting him/herself on the floor. A review of nursing Progress Notes dated [DATE] at 11:46 PM revealed Staff B documented, After repeated episodes of staff observing resident putting [him/herself] on the floor, a safety intervention has been put into place. Mattress lowered to the floor and metal bedframe removed from the room. DON [Director of Nursing] notified. Continued review of Resident #148's care plan revealed that, on [DATE], staff revised the care plan to include After repeated episodes of staff observing the resident putting [him/herself] on the floor intentionally, along with additional multiple behaviors noted, safety intervention of lowering mattress to the floor and removing the bedframe to prevent injury, has been put in place. An interview with the Director of Nursing (DON) on [DATE] at 2:31 PM revealed the intervention of putting Resident #148's mattress on the floor was never implemented and should have been removed from the care plan. She stated a night nurse initiated it and when the interdisciplinary team (IDT) reviewed it the following morning, they did not believe it was appropriate. The DON stated she had stated she was not going to put the mattress on the floor and make the resident sleep on the floor like a dog. There was no documented evidence provided by the facility denoting the facility assessed the safety of the resident's bed or implemented interventions to keep Resident #148 safe. There was no documented evidence the facility conducted an ongoing assessment to assure that the bed rail was meeting Resident #148's needs, conducted an ongoing evaluation of risks, or identified who could determine when the bed rail could be discontinued as required per the facility's Bedrail Assessment policy/procedure. A review of the facility's Logbook Documentation dated [DATE] revealed staff should Inspect Bed and Rails and Mattresses for damage and repair or replace as necessary. Further review of the log revealed no documented evidence Resident #148's bed/side rails were inspected for areas of possible entrapment or proper fit. During an interview on [DATE] at 11:48 AM with the Maintenance Supervisor, he stated he had been working at the facility for two months and had never worked in a long-term care facility before. He stated he had been given paperwork with instructions on how to check mattresses and bed rails but had only looked at a few beds. He also stated the computer system that the facility used to keep track of work orders issued a monthly reminder to do bed checks, but he had not been doing them. He stated he was scheduled to do his first checks on all the beds during the current month. He stated he had marked the task as being completed because he did quick visual checks on the beds to make sure they were safe but did not realize there was more to the inspection and paperwork to be completed. A review of a nurse's Progress Notes, authored by Staff B and dated [DATE] at 5:25 AM, indicated a CNA notified her that Resident #148 was on the floor. The note indicated that upon entering the room, Staff B observed the resident face down, hanging off the side of the bed between the bed and a dresser. The resident's lower body from the hips down was on the mattress with the resident's shins and feet suspended slightly above the surface of the bed. The note indicated the resident's torso was between the headboard and the grab bar. According to the note, Resident #148's head was tucked towards the chest and right shoulder, and the right side of the resident's head was resting on the floor. The note indicated the resident's right arm was tucked under the resident and the left arm was beside the resident bent at the elbow and wrist. Further review of the note revealed that, after moving the dresser, the resident's legs had to be lifted over the half side rail (grab bar) and rolled onto his/her back for assessment by the nurse. The note indicated the resident had lividity to his/her entire face (reddish to bluish-purple discoloration of the skin due to the settling and pooling of blood following death) and rigor mortis had started (rigor mortis was stiffening of the joints and muscles of a body a few hours after death). According to the note, Resident #148 had no pulse and no respirations. Cardiopulmonary resuscitation (CPR) was not performed related to lividity and rigor mortis. The note indicated the resident was last seen during rounds at 2:00 AM when the resident refused to be toileted but was given a chicken salad sandwich. The note indicated the bed was 16 inches from the floor and the nightstand was 18 inches from the bed. The distance between the headboard and the grab bar was not documented. According to the note, a medical examiner, physician, and Director of Nursing (DON) were notified and the DON and physician came to the facility. During an interview with the County Medical Examiner on [DATE] at 4:09 PM, he stated Resident #148 died from positional asphyxiation. A review of Resident #148's electronic medical record (EMR) revealed the last time staff documented any interaction with the resident was on [DATE] at 11:23 PM, when a CNA documented the resident was independent with walking in the room with no help or staff oversight at any time. During an interview on [DATE] at 6:07 PM with Staff B, the RN on duty at the time of the incident, revealed Staff C, CNA, came to her and warned Staff B to be prepared when she entered Resident #148's room. Staff B entered Resident #148's room and stated the resident's legs were on the bed and the rest of his/her body was hanging off the side of the bed. She stated the resident's legs were partially elevated off the bed from being stiff from rigor mortis. Staff B stated Resident #148's left shoulder and cheek were on the floor with their left arm out beside him/her, facing the wall. Staff B stated full lividity had set in and the resident's color was completely purple and black. Staff B stated it was a horrible sight. Staff B stated the bed was up approximately 18 inches off the floor, but she could not remember if the floor mat was down or not. She stated she had to have one of the CNAs move the nightstand and move the bottom part of the resident's body off the bed over the grab bar so she could assess the resident. Staff B stated Resident #148 was known to crawl around the bed and off the bed. She stated the resident broke his/her ankle several months prior and had started climbing out of bed and crawling on the floor and had continued to do it. She stated she felt the resident did it for attention. Staff B stated the resident used the positioning (grab) bar when in bed to assist him/her to sit up on the side of the bed. She said she had not thought of the positioning (grab) bar as a hazard since it was positioned far enough down that the resident's head could not get trapped, but the resident obviously got caught between the headboard and the grab bar. She stated she had completed bed rail assessments before because the facility had night shift staff complete them, but she could not recall if she had done a side rail assessment for Resident #148. Staff B stated she could not recall exactly the last time she saw the resident during the night in question but stated staff checked to make sure the resident was in their room and not trying to go out one of the facility doors. She stated the CNA saw Resident #148 during 2:00 AM rounds and gave the resident a chicken salad sandwich to eat. Staff B stated the CNAs found the resident when they were doing their final rounds that started at 4:00 AM. During a follow-up interview with Staff B on [DATE] at 8:20 AM, she stated she was not aware of the care plan intervention to check on the resident hourly and had not been monitoring the resident hourly. Staff B stated Resident #148 was independent in his/her room, and staff monitored when the resident came out of his/her room to make sure he/she was dressed and not going to other resident doors. During an interview on [DATE] at 8:48 AM, Staff C stated that on the night of the incident, she came into work at 2:00 AM. She stated if Resident #148 was asleep, she would usually not wake the resident, but on the night of the incident, during 4:00 AM rounds, for some reason she felt like she needed to wake Resident #148. She stated when she entered the room, she pulled the curtain back and the resident's legs were on the bed and his/her head was between the bed and the nightstand. Staff C stated she immediately went out of the room, told another CNA (Staff E), and went to get the nurse. She stated she walked back in the room when Staff E turned the resident over, and the resident was purple and black. Staff C stated she knew she could not go back in the room after that because she was close with the resident. Staff C stated she did not remember the grab bar or the floor mat and did not remember the height of the bed. She stated Resident #148 only needed assistance occasionally and had often put him/herself on the floor intentionally. During an interview on [DATE] at 9:53 AM with Staff E, she stated she was an agency CNA, and at the time of the incident she was working with Staff C. She stated when she started the shift at 6:00 PM the previous evening, she did a walk through with the CNA from the previous shift who told her that Resident #148 was independent and continent of urine. She stated she interpreted that to mean she should check on the resident but not wake them to check for incontinence. She stated she was down the hall answering a call light from approximately 3:45 AM to 4:00 AM and poked her head in Resident #148's room and the resident was lying in bed. She stated at approximately 4:30 AM, she and the other CNA started doing rounds and passing ice water. She stated Staff C went in to check on Resident #148 and came out of the room stating the resident had fallen. She stated when she went into the room, the resident's body was hanging off the side of the bed. Staff E stated she touched the resident, and the resident was cold. Staff E stated the nurse asked her to move the resident so the resident could be assessed. She stated the nurse moved the nightstand and she pulled the resident's legs over the bed rail. She stated the resident's face was completely purple, and the nurse stated the resident had passed. She stated she left the resident and finished rounds with Staff C. She stated she heard Staff B on the phone with the Director of Nursing (DON), and Staff B asked her and Staff C if the resident was in a low bed and if the bed was in a low position. Staff E stated she did not know Resident #148 was occasionally incontinent and would crawl out of bed. During an interview on [DATE] at 10:39 AM with Staff F, CNA, revealed she came in at 6:00 PM on [DATE] and worked until 2:00 AM on [DATE], noting she was not at the facility when the incident in question occurred. Staff F stated Resident #148 wandered and did what he/she wanted. She stated the resident asked her for a sandwich around midnight, though she was not sure of the stated time. Staff F stated Resident #148 was in bed lying down at 2:00 AM when she did rounds with Staff C at the shift change. She stated the resident's bed was at a normal height, but she did not remember a fall mat. Staff F stated the resident had a grab bar on one side of the bed. She stated she did not think the resident used the grab bar but may have used it to get up from a lying position. During an interview on [DATE] at 9:28 AM, Staff D, Physical Therapy Assistant (PTA), stated he had worked at the facility for ten years. He stated therapy staff should assess residents to see if side rails/grab bars were appropriate for the resident and make sure paperwork was in place. He stated if a grab bar/side rail needed to be replaced, he had been replacing them due to the facility not having a maintenance person for a couple of months. Staff D stated when he visited with Resident #148, he tried to make sure the resident was using the grab bar to get to the edge of the bed. He stated Resident #148 was a good-sized person and used to be able to get themself up once they were on the floor, but their ability had declined. Staff D stated he was not aware Resident #148 was crawling off the bed. Staff D stated if he had known Resident #148 was crawling off the bed, he would have recommended to have the grab bar removed and developed other interventions to keep the resident safe. During an interview on [DATE] at 2:53 PM, the Rehabilitation Director stated he had been at the facility for three to four years. He stated the facility tried not to use side rails, but when a resident was admitted to the facility for therapy and was assessed to have difficulty with bed mobility, then a positioning bar/grab bar would be appropriate. He stated therapy's involvement with side rails/bed rails was to work with residents on how to use them appropriately. He stated if therapy did not see a functional need for a side rail/bed bar, they would bring it to the team for discussion. He stated a resident crawling in and out of bed would need an individualized assessment to determine the risks and benefits of the grab bar device. However, the Rehabilitation Director then stated he was aware Resident #148 was putting themself on the floor and stated that, depending on the reason for the action, which was usually for attention, he felt that checking on the resident more frequently was an appropriate intervention to keep the resident safe. During an interview on [DATE] at 12:12 PM, the DON revealed when she was doing an investigation for Resident #148's incident, she realized the resident did not have a consent or an assessment for grab bar usage. She stated the facility did not use bed or side rails, only grab bars, which were used for positioning or identifying boundaries. The DON stated Resident #148 had a grab bar to identify boundaries because the resident would get too close to the edge of the mattress, and the bar let the resident know to scoot over. She stated the resident would also use the grab bar to push themself away from the edge of the bed. A follow-up interview with the DON on [DATE] at 2:31 PM revealed at the time of the incident, Resident #148 was independent and needed to be able to get out of bed; otherwise, the bed would have been considered a restraint for the resident. She stated it looked like the resident got up and was trying to crawl out the top of the bed between the headboard and bed/grab bar. The DON stated it looked like the resident put his/her hand on the nightstand, and either the resident's hand slipped, or the nightstand moved, and the resident fell to the floor. She stated it appeared that the resident tucked his/her head to roll but the nightstand kept the resident from going all the way over. The DON further stated the resident had small legs and a larger torso/upper body with extra skin under their chin, so when the resident fell forward, the resident was caught between the bed and the nightstand. The DON stated the resident crawled into bed like a child on his/her hands and knees onto the mattress and then laid flat on his/her stomach or rolled on his/her side. She stated the resident used the bed/grab bar to sit up on the side of the bed or to reposition. According to the DON, she did not believe the bed/grab bar was a danger because there was plenty of room between the headboard and the grab bar so that the resident's head would not get stuck. The DON stated she did not feel that the bed/grab bar impeded the resident from being able to move when the incident occurred. However, the DON was unable to answer how the facility was keeping the resident safe when they were crawling in and out of bed. She stated she believed if the resident had a roommate or if there had been a resident room on the other side of the wall where the resident was (there was a shower room next door), then someone might have heard the resident. She stated she could not remember if there was a mat beside or behind the bed against the wall. During an interview on [DATE] at 1:57 PM with the Administrator, he stated he was aware Resident #148 had fainting behaviors and put him/herself on the floor, noting he believed it was for attention. The Administrator stated he did not know what interventions were in place to keep the resident safe related to crawling in and out of bed. He stated the DON would know the safety interventions for Resident #148. According to the Administrator, the nurse should complete a side rail assessment and then have maintenance staff put the rail in place. He stated consents for the bed/grab bars should be obtained upon admission. Further interview with the Administrator revealed the facility's maintenance director left abruptly in April of 2022, and they were in the process of training a new maintenance director. In the meantime, he stated a maintenance person from one of the other facilities was supposed to be completing necessary bed/grab bar checks. Removal Plan: Removal of Immediacy Plan F700 Date/Time Presented to Surveyors: [DATE] at 9:30 AM Identified here are the steps and immediate action(s) the facility will take to address the reported non-compliance, keep residents safe and free from serious harm or death, and prevent serious harm from occurring or recurring. STEPS/IMMEDIATE ACTION: 1. Medical Director was notified on [DATE] of IJ. 2. On [DATE] all residents with grab bar/positioning enabling devices in use were evaluated by the Director of Nursing (DON)/designee for continued need utilizing the Point Click Care Electronic Medical Record Bed Rail Safety Evaluation UDA (user defined assessment) prior to implementation and at least quarterly for continued use. The Bed Rail Safety Evaluation is an Interdisciplinary Team (IDT) evaluation that assesses the residents physical and mental characteristics and abilities, the type and appropriateness of bed being utilized, documentation of resident/resident representative education of risk factors, education on use of equipment, and the risk factors involved in utilizing the equipment, as well as documentation of equipment safety via inspection by Maintenance Director/Designee prior to use. Nursing staff/designee assessed residents bed mobility to determine appropriate alternative devices needed for resident bed mobility. Nursing staff evaluated 100% of the beds with grab bar/positioning enabling devices and found no concerns. 3. Medical Director notified of resident requiring continued use of grab bars. 4. Recommendations reviewed with the resident/and or representative and implemented as ordered including revisions to care plans as indicated by Minimum Data Set/IDT nursing staff. Continued compliance will be audited as outlined below. 5. As of [DATE], all residents with grab bars have the appropriate consents in place as verified through electronic and hard copy medical record review. Consents must be in place prior to implementation of side rail use and will be a part of each residents nursing admission packet and implemented before any side rails are placed for a resident. Continued compliance will be audited as outlined below. 6. All staff will be in-serviced by the Director of Nursing/designee regarding the facility's process for evaluating side rail need and implementing side rails, including assessing the resident for risk of entrapment prior to installation, review of risk/benefits & obtaining consent prior to installation, and ensuring that the bed dimensions are appropriate for the resident's size and weight Staff education initiated [DATE] with all IDT staff recalled to the building to assist in completing this education. Individuals present on the evening and night shifts of [DATE] and the AM shift of [DATE] were educated by the DON/IDT. Policy sent to multiple staff members not present in the building with DON/IDT educating and receiving verbal verifica