Based on interview and record review, it was determined that the facility failed to ensure that residents were free from abuse and neglect for 3 of 6 allegations of abuse reviewed (Resident identifiers are #2, 3, and 4). Findings include: Resident #3 Review on 1/5/23 at approximately 11:30 a.m. of facility's grievance report for Resident #3 revealed that on 12/28/22 at 8:15 a.m. a grievance report was filed by Staff G (Licensed Nursing Assistant (LNA)) for Resident #3 and given to Staff C (Nurse Unit Manager). Further review of grievance report revealed the following: Nature of Concern: Resident asked for help with ostomy at 1:00 a.m., aide told resident I am the only one here and I have something going on I will come back and never returned. Action Taken: 7-3 LNA assisted Resident #3 with ostomy and A.M. care. Follow Up: Resident #3 is satisfied with resolution. Signed by Staff D (Licensed Practical Nurse (LPN)), Staff A (Director of Nursing (DON)) and Staff B (Administrator) and dated 12/28/22. Interview on 1/5/23 at approximately 11:45 a.m. with Resident #3 revealed that on the night of the incident they had rang for help around 1:00 a.m., as they could not fix their ostomy and it was leaking. The LNA came in and said they were alone and had to help someone else and would be back. Resident #3 stated that they laid in bed and fell back to sleep waiting for the LNA to come back. Around 7:00 a.m. Resident #3 woke back up and rang again and that is when the day LNA came in and helped them. Resident #3 stated that they had feces in their bed and on their abdomen from the ostomy leaking. Interview on 1/5/23 at approximately 2:30 p.m. with Staff A revealed that Resident #3 was satisfied with the day staff assisting him/her with ostomy and no further investigation was warranted. Staff A stated that they did not question the LNA that was on the night of 12/27/22. Resident #2 Interview on 1/3/23 at approximately 11:00 a.m. with Anonymous #2 revealed that at the end of last week, Resident #2 was observed to have large dark purple area to left elbow with swelling, dark purple bruise to right upper arm with swelling, large purple area across the rib cage in alignment with the breast. Anonymous #2 stated that the DON was aware about these bruises. Interview on 1/4/23 at approximately 1:00 p.m. with Anonymous #1 revealed that Resident #2 had big dark purple bruises on their right upper arm, left upper arm, left elbow, left lateral side of chest underneath the left breast that was found approximately the fourth week of December 2022 (Anonymous #1 did not know exactly when bruises were initially found). Anonymous #1 stated that it was alleged by staff that Staff F (LNA) was rough with residents and that the DON was aware and did not suspend or investigate allegations of rough handling by Staff F. Review on 1/5/23 of Resident #2's nurse's note revealed the following: -12/27/22 at 10:19 p.m. and 10:52 p.m. an LNA reported that Resident #2 had decreased arm strength to right arm and that during care LNA noted bruising to left elbow and right upper arm. Right upper arm had a 9 [length] x [by] 6 [width] cm [centimeter] ecchymotic [bruise] area and firm center. Left elbow had 7x5 cm ecchymotic area. MD [Doctor of Medicine] on call was notified. -12/28/22 at 10:32 a.m. nurse's note revealed that the DPOAH [Durable Power of Attorney for Health] was updated regarding Resident #2's bruising. -12/28/22 at 10:43 a.m. nurse's notes revealed that upon investigation into bruising, .bruises were found a couple of days ago when resident [Resident #2] was slumped over in the chair. Upon inspection of [pronoun omitted] chair, [pronoun omitted] has a positioning device in the side of the chair that lines up perfectly with the bruise to [pronoun omitted] left side. and [pronoun omitted] elbow was resting on the side of chair lining up with the bruise on [pronoun omitted] elbow. Intervention is PT [Physical Therapy] referral for positioning in wheelchair . -1/1/23 at 9:46 p.m. nurse's note revealed resident [Resident #2] is presenting with a 10 / [out of] 10 pain aeb [as evidence by] facial grimacing, contraction of upper extremities, and increase respirations with holding of breath. bruises on right upper arm, left elbow, and left rib cage seems to have worsen aeb measuring 15+ [plus] x [by] 30+, black and purple in color, and increase in pain. Notified DON [Director of Nursing]. gave resident [Resident #2] Tylenol. -1/2/23 at 7:12 a.m. nurse's notes revealed that Large fluid filled pockets noted on bilateral upper arms near bruises areas. Resident [Resident #2] continues to display signs of pain when arms are touched or moved. PRN [as needed] Tylenol given with no effect. Noted in MD [Doctor of Medicine] communication book, oncoming nurse aware. -1/2/23 at 9:56 a.m. nurse's note revealed Writer spoke with On Call Provider [provider name omitted] regarding increase in pain. MD sent order to [pharmacy name omitted] for 2.5 mg [milligram] Oxycodone po [by mouth] q3h [every 3 hours] PRN, MD stated if 2.5 [mg] was not effective in 30 minutes to call back and [pronoun omitted] would increase dose to 5 mg po prn q3h. Orders entered. Writer spoke with POA [Power of Attorney] who agreed to have resident try the Oxycodone to keep [pronoun omitted] comfortable. Resident resting in bed, anytime writer or other staff attempt to reposition resident [pronoun omitted] [sic] expresses 10/10 pain in right arm. -1/2/23 at 11:22 a.m. nurse's note [late entry, created date of 1/5/23 at 11:24 a.m.] revealed that .It was noted by nurse that resident existing bruising had become larger and was causing more pain to the resident. Nurse gave prn Tylenol with good results. Resident is at end of life and is starting the mottling process. Bruising has spread die to poor circulation. MD and family notified. Will continue to monitor. Further review of the nurse's note revealed no other documentation regarding Resident #2's bruises. Interview on 1/5/23 at 2:30 p.m. with Staff A revealed that he/she was notified on 12/28/22 that Resident #2 had bruises on both arms and left lateral side of chest. Staff A stated that staff had mention to him/her that since agency staff worked they have noticed increase bruising to residents. Staff A also stated that as there were no staff names and it was hearsay they did not investigate this allegation. Further interview with Staff A revealed that he/she was not aware of any allegations of rough handling by Staff F prior to this week. Staff A also stated that the cause of the right arm bruising was inappropriate repositioning and that Staff F did not utilize a draw sheet for repositioning and education was provided. Staff A was unable to provide documentation of education to staff for proper repositioning. Interview on 1/6/23 at approximately 10:10 a.m. with Staff R (LPN) revealed that he/she heard of rough handling by Staff F. Staff R stated that he/she brought this to management and was told by the DON that they are young. Staff R also stated that he/she had mentioned rough handling by Staff F to Staff C about 1 month ago and that Staff C was going to handle it. Staff R was not aware of any outcome of that reporting. Interview on 1/6/23 at 10:10 a.m. with Staff U (Advanced Practical Registered Nurse (APRN)) revealed that Staff U evaluated Resident #2 on 1/3/23 and Staff U stated that he/she did not have a discussion with the DON nor Nurse Unit Manager about the cause of Resident #2's bruises. Interview on 1/6/23 at 11:00 a.m. with Staff M (LNA) revealed that he/she had observed Staff F being rough during a transfer. Staff M stated that Staff F was hoyering Resident #2 with another staff out of bed and that the hoyer pad was not placed correctly. Staff M also stated that Staff F pulled the hoyer pad out under Resident #2 where Resident #2 hit the railing. Staff M also stated that this incident happened approximately 2 & 1/2 months ago and that he/she reported this to the nurse. Interview on 1/9/22 at approximately 10:00 a.m. with Resident #2's DPOA revealed that he/she was notified that Resident #2 had bruising in the arms the fourth week of December 2022 and also last week when Resident #2 had increase pain and bruising. Resident #2's DPOA stated that he/she was not aware of the extent of Resident #2's bruises and that he/she was told the Resident #2 has some bruises. Resident #2's DPOA also stated that if he/she was aware of the extent of Resident #2's bruises, he/she would have wanted to know what had happened. Interview with the Medical Examiner on 1/20/23 at aproximatley 1:30 p.m. revealed that an autopsy was performed and Resident #2 had unexplained injuries (a fracture and dislocation to the right shoulder and a dislocation to the left shoulder) that contributed to their death. Resident #4 Interview on 1/5/23 at approximately 2:30 p.m. with Staff A revealed there had been a report of alleged abuse by Staff F and that Staff F was suspended pending investigation. Review on 1/6/23 of email threads revealed that an anonymous email was sent to Human Resources (HR) on 1/4/23 5:56 p.m Further review of the anonymous email dated 1/4/23 revealed .I am concerned with [Staff F name omitted]. [pronoun omitted] is extremely unprofessional and abusive to the residents. I heard about the incident with [Resident #1's name omitted], and I was told about an incident with [Resident #4's name omitted] .This incident was witnessed by 3 other employees .The nurses [Staff Q [LPN] name omitted] and [Staff R [LPN] name omitted] were both in the room with [Staff F name omitted] .slap [Resident #4's name omitted] right across the stomach .[Staff F name omitted] calls the patient [sic] out their names [pronoun omitted] swears at them, [pronoun omitted] is extremely disrespectful . Review of the email threads revealed that the email dated 1/4/23 was forwarded to the Staff A on 1/5/23 at 8:09 a.m. and forwarded again on 1/5/23 at 10:30 a.m. to Staff C. Interview on 1/6/23 at 11:26 a.m. with Staff Q revealed that on 1/2/23, he/she was in Resident #4's room along with Staff F, Staff G, and Staff R to change Resident #4's catheter. Staff Q stated that he/she observed Staff F, with open hand, hit Resident #4's abdomen and Resident #4 responded by hitting Staff F. Staff Q stated that he/she felt uncomfortable about the situation. Staff Q also stated that he/she did not report this incident Interview on 1/6/23 at approximately 11:34 a.m. with Staff R revealed that on 1/2/23, he/she was assisting Staff Q with Resident #4's catheter change. Staff R stated that he/she was in Resident #4's room when he/she heard a loud smack and when he/she turned towards the noise Resident #4 was hitting Staff F. Staff R stated that he/she did not report this incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that alleged violations involving abuse were reported to the Administrator, State Survey Agency (SSA) and other officials for 5 out of 6 allegations of abuse reviewed (Resident identifiers are #1, #2, #3, #4, and #6). Findings include: Resident #1 Review on 1/5/23 at approximately 11:30 a.m. of facility investigation for Resident #1 alleged abuse dated 1/2/23, with a time stamp of 22:20 [10:20 p.m.], revealed the following: Resident #1 reported that they did not want the young [pronoun omitted] who took care of [pronoun omitted] today to take care of [pronoun omitted] again. Resident #1 reported that the Licensed Nursing Assistant (LNA) slapped [pronoun omitted] buttocks, smacked them with plastic bags, and laughed about it. Resident #1 described the LNA by approximate age and hair color. Resident #1 also stated that they had stated I wish to die if I am going to be beat, and the LNA responded by stating I wish you would die too. Further review of the facility investigation revealed that the Director of Nursing (DON) and the Nurse Unit Manager were notified at the time of filling out the report. Two staff statements were attached to the investigation. The statements were from Staff F (LNA) and Staff G (LNA). Interview on 1/5/23 at approximately 2:30 p.m. with Staff A (DON) revealed they were notified of 1/2/23 incident involving Resident #1 around 10:30 a.m. on 1/3/23. Staff A stated that Resident #1 denied allegations so no further investigation or reporting was necessary. Staff A confirmed that no education was provided after the conclusion of this incident as nothing was identified as a concern. Staff A confirmed that no report to the SSA was sent regarding this incident. Interview on 1/6/23 at approximately 8:42 a.m. with Staff D (Licensed Practical Nurse (LPN)) revealed that on 1/2/23 they had called and spoke to Staff A regarding incident with Resident #1 when they completed the investigation form. Resident #3 Review on 1/5/23 at approximately 11:30 a.m. of facility's grievance report for Resident #3 revealed that on 12/28/22 at 8:15 a.m. a grievance was filed by Staff G for Resident #3 and given to Staff C (Nurse Unit Manager). Further review of grievance report revealed the following: Nature of Concern: Resident asked for help with ostomy at 1:00 a.m., aide told resident I am the only one here and I have something going on I will come back and never returned. Action Taken: 7-3 LNA assisted Resident #3 with ostomy and A.M. care. Follow Up: Resident #3 is satisfied with resolution. Signed by Staff D, Staff A and Staff B (Administrator) and dated 12/28/22 Interview on 1/5/23 at approximately 1:00 p.m. with Staff C revealed that they had met with Resident #3 on the morning of 12/28/22 and resolved the situation by having the day LNA take care of [pronoun omitted]. Staff C stated that they did not initiate an investigation and did not identify the LNA in question but handed the grievance report off to the DON and was unaware of what occurred after that. Interview on 1/5/23 at approximately 2:00 p.m. with Staff B revealed they had no knowledge of any investigation for Resident #3's grievance as it was marked resolved on 12/28/22. Staff B confirmed that to their knowledge no report was made to the SSA regarding this incident. Interview on 1/5/23 at approximately 2:30 p.m. with Staff A revealed that Resident #3 was satisfied with the day staff assisting him/her with ostomy and no further investigation was warranted. Staff A stated that they did not question the LNA that was on the night of 12/27/22. Staff A confirmed no report was made to the state survey agency regarding this incident. Surveyor: Wee Sit, [NAME] C. Resident #2 Interview on 1/4/23 at approximately 1:00 p.m. with Anonymous #1 revealed that Resident #2 had big dark purple bruises on their right upper arm, left upper arm, left elbow, left lateral side of chest underneath the left breast that was found approximately the fourth week of December 2022 (Anonymous #1 did not know exactly when bruises were initially found). Anonymous #1 stated that it was alleged by staff that Staff F was rough with residents and that the DON was aware and did not suspend or investigate allegations of rough handling by Staff F. Review on 1/5/23 of Resident #2's nurse's note revealed the following: -12/27/22 at 10:19 p.m. and 10:52 p.m. nurse's notes revealed that an LNA reported that that Resident #2 had decreased arm strength to right arm and that during care LNA noted bruising to left elbow and right upper arm. Right upper arm had a 9x6 [length x width] cm [centimeter] ecchymotic [bruise] area and firm center. Left elbow had 7x5 cm ecchymotic area. MD [Doctor of Medicine] on call was notified. -12/28/22 at 10:43 a.m. nurse's notes revealed that upon investigation into bruising, .bruises were found a couple of days ago when resident [Resident #2] was slumped over in their chair. Upon inspection of [pronoun omitted] chair, [pronoun omitted] has a positioning device in the side of their chair that lines up perfectly with the bruise to [pronoun omitted] left side. and [pronoun omitted] elbow was resting on the side of chair lining up with the bruise on [pronoun omitted] elbow. Intervention is PT [physical therapy] referral for positioning in wheelchair . -1/1/23 at 9:46 p.m. nurse's note revealed resident [Resident #2] is presenting with a 10/10 pain aeb [as evidence by] facial grimacing, contraction of upper extremities, and increase respirations with holding of breath. bruises on right upper arm, left elbow, and left rib cage seems to have worsen aeb measuring 15+ [plus] x [by] 30+, black and purple in color, and increase in pain. Notified DON [Director of Nursing], gave resident [Resident #2] tylenol. Interview on 1/5/23 at approximately 2:30 p.m. with Staff A revealed that he/she was notified about Resident #2's bruises, as mentioned above, the morning of 12/28/22. Further interview with Staff A also revealed that at that time, there were staff accusing agency staff and that there were no staff names mentioned and what was told to him/her was after agency staff started working more bruises were observed on residents and that they were hearsay. Staff A stated that there were no reports submitted to the SSA related to the bruising as it was related to the wheelchair positioning and the improper repositioning by staff. Staff A also stated that the accusation from staff related to the agency nursing staff was hearsay and there were no staff names mentioned and so this was not reported to the SSA. Staff A also stated that the staff should have reported to him/her that night that they initially observed the bruises on Resident #2. Resident #4 Review on 1/6/23 of an email thread revealed that an anonymous email was sent to Human Resources (HR) on 1/4/23 at 5:56 p.m Further review of the anonymous email dated 1/4/23 revealed .I am concerned with [Staff F [LNA] name omitted]. [pronoun omitted] is extremely unprofessional and abusing to the residents. I heard about the incident with [Resident #1's name omitted], and I was told about an incident with [Resident #4's name omitted] .This incident was witnessed by 3 other employees .The nurses [Staff Q [LPN] name omitted] and [Staff R [LPN] name omitted] were both in the room with [Staff F name omitted] .slap [Resident #4's name omitted] right across the stomach .[Staff F name omitted] calls the patient out their names [pronoun omitted] sweats at them, [pronoun omitted] is extremely disrespectful . Review of the email threads revealed than the email dated 1/4/23 was forwarded to the Staff A on 1/5/23 at 8:09 a.m. and forwarded again on 1/5/23 at 10:30 a.m. to Staff C. Review on 1/6/23 of initial report dated 1/5/23 for Resident #4 revealed that the initial report was sent to the State Survey Agency (SSA) on 1/5/23 at approximately 2:45 p.m. via fax, which is more than 2 hours from the reported alleged violation as mentioned on above email dated 1/4/23. Interview on 1/6/23 at 11:26 a.m. with Staff Q (LPN) revealed that last Monday (1/2/23) Resident #4 needed their foley catheter change which Staff R (LPN), Staff F, and Staff G, assisted Staff Q. Staff Q stated that he/she observed Staff F hit Resident #4's stomach with an open hand. Staff Q also stated that he/she felt uncomfortable after witnessing what Staff F did and thought that what Staff F did was inappropriate. Staff F also stated that he/she did not report this to the DON or the Administrator. Resident #6 Review on 1/5/23 of Resident #6's nurse's notes revealed that on 12/26/22 Resident #6 was found to have a purple burises above their right eye measuring about 6 cm [centimeter] [length] by 2 cm [width], and periwound was yellow. Further review of the nurse's note dated 12/2622 revealed that Risk Management was noted. Review on 1/5/23 of the facility's incident report on Resident #6's bruise to right eye dated 12/26/22 at 9:22 a.m. revealed that the bruise to right eye had an unknown cause. Review on 1/5/23 of Resident #6's nurse's note revealed that on 12/27/22 at 1:55 p.m. Resident #6 had a bruise on right eye that he/she may have bumped their head on the cross bar of the hoyer lift. Interview on 1/5/23 at approximately 2:30 p.m. with Staff A confirmed that the bruise to the right eye with the unknown cause when initially found should have been reported to him/her on 12/26/22. Staff A stated that he/she was not aware of Resident #6's bruise to right eye when initially found on 12/26/22 and that this bruise to right eye with an unknown cause was not reported to the SSA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that all alleged violations of abuse or neglect were thoroughly investigated for 3 out of 6 abuse allegation reviewed (Resident identifiers are #2, #3, and #6). Findings include: Resident #3 Review on 1/5/23 at approximately 11:30 a.m. of facility's grievance report for Resident #3 revealed that on 12/28/22 at 8:15 a.m. a grievance was filed by Staff G (Licensed Nursing Assistant (LNA)) for Resident #3 and given to Staff C (Nurse Unit Manager). Further review of grievance report revealed the following: Nature of Concern: Resident asked for help with ostomy at 1:00 a.m., aide told resident I am the only one here and I have something going on I will come back and never returned. Action Taken: 7-3 LNA assisted Resident #3 with ostomy and A.M. care. Follow Up: Resident #3 is satisfied with resolution. Signed by Staff D (License Practical Nurse (LPN)), Staff A (Director of Nursing (DON)) and Staff B (Administrator) and dated 12/28/22. Review on 1/5/23 at approximately 11:30 a.m. of facility nursing schedule for Dementia Unit for the night shift on 12/27/22 into 12/28/22 revealed one LNA on for the entire shift and one nurse. Interview on 1/5/23 at approximately 11:45 a.m. with Resident #3 revealed that on the night of the incident they had rang for help around 1:00 a.m., as they could not fix their ostomy and it was leaking. The LNA came in and said they were alone and had to help someone else and would be back. Resident #3 stated that he/she laid in bed and fell back to sleep waiting for the LNA to come back. Around 7:00 a.m. Resident #3 woke back up and rang again and that is when the day LNA came in and helped him/her. Resident #3 stated that they had feces in their bed and on their abdomen from the ostomy leaking. Interview on 1/5/23 at approximately 1:00 p.m. with Staff C revealed that they had met with Resident #3 on the morning of 12/28/22 and resolved the situation by have the day LNA take care of him/her. Staff C confirmed that they did not initiate an investigation and did not identify the LNA in question but handed the grievance report off to the DON and was unaware of what occurred after that. Interview on 1/5/23 at approximately 2:00 p.m. with Staff B revealed they had no knowledge of any investigation for Resident #3's grievance report as it was marked resolved on 12/28/22. Interview on 1/5/23 at approximately 2:30 p.m. with Staff A revealed that Resident #3 was satisfied with the day staff assisting him/her with ostomy and no further investigation was warranted. Staff A stated that they did not question the LNA that was on the night of 12/27/22.Resident #2 Interview on 1/3/23 at approximately 11:00 a.m. with Anonymous #2 revealed that at the end of last week, Resident #2 was observed to have large dark purple area to left elbow with swelling, dark purple bruise to right upper arm with swelling, large purple area across the rib cage in alignment with the breast. Anonymous #2 stated that the DON was aware about these bruises. Interview on 1/4/23 at approximately 1:00 p.m. with Anonymous #1 revealed that Resident #2 had big dark purple bruises on their right upper arm, left upper arm, left elbow, left lateral side of chest underneath the left breast that was found approximately the fourth week of December 2022 (Anonymous #1 did not know exactly when bruises were initially found). Anonymous #1 stated that they were aware of occations that it was alleged by staff that Staff F (LNA) was rough with residents and that the DON was aware and did not suspend or investigate allegations of rough handling by Staff F. Interview on 1/5/23 at approximately 11:00 a.m. with Staff K (LNA) and Staff L (LNA) revealed that they were aware of Resident #2's bruising on the right arm, left elbow, and left lateral side of chest underneath the breast. Staff K and Staff L stated that they were not aware of any incidents that would cause the bruises and that they were told it was related to the wheelchair positioning. Staff K and Staff L also stated that Resident #2 was dependent with staff and that Resident #2 would not be able to self-reposition themselves in the wheelchair. Staff K and Staff L also stated that Resident #2 only had a positioning wedge in between their legs. Interview on 1/5/23 at approximately 1:19 p.m. with Staff N (Therapy Manager) revealed that there was a physical therapy referral for Resident #2 on 12/29/22 for wheelchair positioning. Staff N stated that the evaluation was not completed as Resident #2 was in bed and not able to get out of bed due to decline in condition and pain. Staff N also stated that there were no discussion with the nursing team regarding the possible correlation of the bruising, as mentioned above, with the wheelchair positioning. Interview on 1/5/23 at approximately 1:20 p.m. with Staff O (LPN) and Staff P (LPN) revealed that they were aware that last week (fourth week of December 2022) Resident #2 had bruising to right elbow, right upper arm, left lateral side of chest under the breast. Staff O and Staff P stated that Staff A and Staff C were aware. Staff O and Staff P also stated that the Staff A and Staff C had asked staff if anybody witnessed any incidents that would cause the bruising and that both Staff O and Staff P was unaware of any incidents which would have caused the bruising. Review on 1/5/23 of Resident #2's nurse's note revealed the following: -12/27/22 at 10:19 p.m. and 10:52 p.m. nurse's notes revealed that an LNA reported that that Resident #2 had decreased arm strength to right arm and that during care LNA noted bruising to left elbow and right upper arm. Right upper arm had a 9x6 (length x width) cm [centimeter] ecchymotic [bruise] area and firm center. Left elbow had 7x5 cm ecchymotic area. MD [Doctor of Medicine] on call was notified. -12/28/22 at 10:32 a.m. nurse's note revealed that the Durable Power of Attorney for Health (DPOAH) was updated regarding Resident #2's bruising. -12/28/22 at 10:43 a.m. nurse's notes revealed that upon investigation into bruising, .bruises were found a couple of days ago when resident [Resident #2] was slumped over in their chair. Upon inspection of [pronoun omitted] chair, [pronoun omitted] has a positioning device in the side of their chair that lines up perfectly with the bruise to [pronoun omitted] left side and [pronoun omitted] elbow was resting on the side of chair lining up with the bruise on [pronoun omitted] elbow. Intervention is PT [physical therapy] referral for positioning in wheelchair . -1/1/23 at 9:46 p.m. nurse's note revealed Resident [Resident #2] is presenting with a 10/10 pain aeb [as evidence by] facial grimacing, contraction of upper extremities, and increase respirations with holding of breath. bruises on right upper arm, left elbow, and left rib cage seems to have worsen aeb measuring 15+ [plus] x [by] 30+, black and purple in color, and increase in pain. Notified DON [Director of Nursing], gave resident [Resident #2] Tylenol. -1/2/23 at 7:12 a.m. nurse's notes revealed that Large fluid filled pockets noted on bilateral upper arms near bruises areas. Resident [Resident #2] continues to display signs of pain when arms are touched or moved. prn [as needed] Tylenol given with no effect. Noted in MD [Doctor of Medicine] communication book, oncoming nurse aware. -1/2/23 at 9:56 a.m. nurse's note revealed Writer spoke with On Call Provider [provider name omitted] regarding increase in pain. MD [Doctor of Medicine] sent order to [pharmacy name omitted] for 2.5 mg [milligram] Oxycodone po [by mouth] q3h [every 3 hours] prn, MD stated if 2.5 [mg] was not effective in 30 minutes to call back and [pronoun omitted] would increase dose to 5 mg po prn q3h. Orders entered. Writer spoke with POA [Power of Attorney] who agreed to have resident try the Oxycodone to keep [pronoun omitted] comfortable. Resident resting in bed, anytime writer or other staff attempt to reposition resident [pronoun omitted] [sic] expresses 10/10 pain in right arm. -1/2/23 at 11:22 a.m. nurse's note [late entry, created date of 1/5/23 at 11:24 a.m.] revealed that .It was noted by nurse that resident existing bruising had become larger and was causing more pain to the resident. Nurse gave prn Tylenol with good results. Resident is at end of life and is starting the mottling process. Bruising has spread die to poor circulation. MD and family notified. Will continue to monitor. Further review of the nurse's note revealed no other documentation regarding Resident #2's bruises. Review on 1/5/23 of Resident #2's incident report dated 12/27/22 10:00 p.m. revealed that the LNA reported bruising noted to the left elbow and right upper arm, which Resident #2 was unable to provide description. Further review of the incident report revealed predisposing physiological factors were impaired memory, confusion, and incontinent. Review on 1/5/23 of Resident #2's incident report dated 1/1/23 at 9:57 p.m. revealed that Resident #2 had increase pain and bruising. Resident #2 was unable to provide description, DON was notified and prn [as needed] Tylenol was given. Pain assessment revealed that resident had occasional labored breathing, short period of hyperventilation, occasional moaning or groaning, facial grimacing, rigid fist clenched, knees pulled up, and distracted or reassured by voice or touch. Review on 1/5/23 of Resident #2's paper chart revealed a therapy form with dated 5/26/21 that stated Patient has been evaluated by therapy and is being provided with the following posture/position in wheelchair .Implement the following: .ensure foot [NAME] in place to separate feet .when positioning patient, ensure butt positioned all the way back on wheelchair .check by placing hand underneath, behind back rest to see where coccyx located .Other Recommendations: .Ensure Velcro on bottom of cushion to reduce sliding .Alert maintenance to put Velcro for foot [NAME] and/or cushion when needed . Interview on 1/5/23 at approximately 2:30 p.m. with Staff A revealed that he/she was notified about Resident #2's bruises, as mentioned above, the morning of 12/28/22. Staff A stated that he/she started an investigation on 12/28/22, observed the bruises and saw that the bruising aligned with Resident #2's wheelchair positioning as there was a statement from a staff that the weekend prior to 12/28/22, approximately 12/24/22 to 12/25/22, staff noted Resident #2 slump over the left side while in the wheelchair. Staff A also stated that the bruising to right arm was a result of not using a draw sheet for repositioning in bed by Staff F and Staff G and that education was provided. Staff A was unable to provide documentation of staff re-education on safe repositioning practices. Further interview with Staff A also revealed that at that time, 12/28/22, there was staff accusing agency staff and that there were no staff names mentioned and what was told to him/her was after agency staff started working more bruises were observed on residents and that they were hearsay. Staff A stated that there were no reports submitted to the State Survey Agency (SSA) and that there was no formal investigation on the accusations made by staff related to agency staff. Staff A also stated that the investigation related to the bruises was not reported to the SSA as the bruises were found to be related to wheelchair positioning. Interview on 1/6/23 at 10:10 a.m. with Staff U (Advanced Practical Registered Nurse (APRN)) revealed that Staff U evaluated Resident #2 on 1/3/23 and at that time Resident #2 was actively dying and that he/she did not evaluate Resident #2's bruising. Staff U stated that the focus was comfort for Resident #2. Staff U stated that he/she did not have a discussion with the DON nor Nurse Unit Manager about the cause of Resident #2's bruises. Interview on 1/6/23 at 11:00 a.m. with Staff M (LNA) revealed that he/she had observed Staff F being rough during a transfer. Staff M stated that Staff F was hoyering Resident #2 with another staff out of bed and that the hoyer pad was not placed correctly. Staff M also stated that Staff F pulled the hoyer pad out under Resident #2 where Resident #2 hit the railing. Staff M also stated that this incident happened approximately 2 & 1/2 months ago and that he/she reported this to the nurse. Interview on 1/6/23 at 11:45 a.m. with Staff R (LPN) revealed that he/she called Resident #2's on call provider about Resident #2 having increase pain to right arm and increase bruising. Staff R stated that he/she asked the provider if x-rays were needed and that the provider told Staff R that it was not needed at that time. Staff R also stated that he/she had notified Resident #2's Durable Power of Attorney (DPOA) about Resident #2's pain and that bruises were larger, but did not go into detail of extent of the bruises. Staff R also stated that Resident #2's DPOA wanted to know what had happened to Resident #2's bruises and also wanted Resident #2 to be comfortable. Interview on 1/6/23 at approximately 1:00 p.m. with Staff S (LPN) that he/she got report from the prior shift nurses that Resident #2 had bruises to right arm and left elbow, let rib cage which was reported immediately to the DON. Staff S stated that the DON responded that he/she was aware of the bruising. Staff S also stated that a few nights ago the areas on arms had increased fluid pocketing, Resident #2 also had grimacing, whimpering and guarding with touch and movement of the arms. Review on 1/6/23 of Resident #2's provider note dated 1/2/23 that Staff T (Doctor of Medicine) had a telephone encounter. Resident #2's provider note dated 1/2/23 revealed .Developed bruises on both arms and chest under L [left] breast since last week, no clear cause. Now they are bigger and [pronoun omitted] has fluid filled pockets just distal to elbows. R [right] arm seems very weak-but this is where most pain is. Severe pain, respiratory rate 40's .GOC [goal of care] are comfort-focused. Will need to be evaluated in person for rashes and blisters . Interview on 1/6/23 at 1:28 p.m. with Staff T revealed that he/she received a call from the facility about Resident #2's bruising and that plan of care for Resident #2 was comfort focused and so interventions provided to the nurse was adjustment of pain regimen. Staff T stated that the bruising needs to be evaluated in person to determine cause and at that time Resident #2 was actively dying so the focus was comfort for Resident #2. Staff T also stated that there were no discussions about the cause of bruising. Interview on 1/9/22 at approximately 10:00 a.m. with Resident #2's DPOA revealed that he/she was notified that Resident #2 had bruising in the arms fourth week of December 2022 and also last week when Resident #2 had increase pain and bruising. Resident #2's DPOA stated that he/she was not aware of the extent of Resident #2's bruises and that he/she was told the Resident #2 has some bruises. Resident #2's DPOA also stated that if he/she was aware of the extent of Resident #2's bruises, he/she would have wanted to know what had happened. Interview with the Medical Examiner on 1/20/23 at aproximatley 1:30 p.m. revealed that an autopsy was performed and Resident #2 had unexplained injuries (a fracture and dislocation to the right shoulder and a dislocation to the left shoulder) that contributed to their death. Resident #6 Review on 1/5/23 of Resident #6's nurse's notes revealed that on 12/26/22 Resident #6 was found to have a purple buries above their right eye measuring about 6 cm [centimeter] [length] by 2 cm [width], and periwound was yellow. Further review of the nurse's note dated 12/2622 revealed that Risk Management was noted. Review on 1/5/23 of the facility's incident report on Resident #6's bruise to right eye dated 12/26/22 at 9:22 a.m. revealed that the bruise to right eye had an unknown cause. Interview on 1/5/23 at approximately 2:00 p.m. with Staff J (LPN) revealed that Resident #6's had a bruise on the right eye. Staff J stated that he/she wrote a note and an incident report. Staff J did not know the cause of the bruise initially and was told it was from being hit during a hoyer lift transfer. Staff J also stated the incident reports, once opened gets sent to the DON, and there were no follow up education regarding safe hoyer lift transfers. Review on 1/5/23 of Resident #6's nurse's note revealed that on 12/27/22 at 1:55 p.m. revealed that Resident #6 has a bruise on right eye that he/she may have bumped their head on the cross bar of the hoyer lift. Interview on 1/5/23 at approximately 2:30 p.m. with Staff A confirmed the above findings on Resident #6. Staff A was unable to provide any corrective actions in regards to re-educating staff on safe hoyer lift transfers. Observation on 1/6/23 at approximately 1:00 p.m. with Staff I (LNA) revealed that Resident #6 had a faded yellowish discoloration above the right eye near the eye brow. Staff I stated that he/she usually takes care of Resident #6 during the day and that Resident #6 was a hoyer lift for transfers. Staff I also stated that he/she has not had any follow up re-education on safe hoyer lift transfers.