**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews with staff and family, review of facility investigative information and review of the facility policies titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, and Abuse, Neglect, Exploitation and Misappropriation Prevention Program the facility failed to ensure all residents were free from incidents of resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for actual physical and psychosocial harm beginning on 03/26/24 at approximately 3:00 P.M. when Resident #61 (a female resident), who was severely cognitively impaired was found naked in the facility spa room with Resident #4 (a male resident), who was dressed. On 03/26/24 at approximately 8:00 P.M. State Tested Nursing Assistant (STNA) #505 again found Resident #61 in the spa room with Resident #4. Resident #4 was observed with his pants down holding on to Resident #61's hip from behind as the resident was bent over. Resident #4 was observed making a pumping motion with an erect penis indicative of sexual activity. There was no evidence Resident #61 had consented or was able to consent to the sexual interaction with Resident #4. The facility failed to implement effective and individualized interventions to prevent these incidents of sexual abuse from occurring, to protect Resident #61 and other residents from Resident #4 and to address the safety and/or supervisory needs of the residents. On 04/09/24 Resident #51 was observed being sexually abused by Resident #4, when Resident #4 was observed grabbing the resident's breast without her consent. This affected two residents (#61 and #51) of five residents reviewed for abuse. The facility census was 60. On 05/23/24 at 1:10 P.M., the Administrator and Regional Director of Operations (RDO) #510 were notified Immediate Jeopardy began on 03/26/24 at approximately 3:00 P.M. when the facility failed to prevent and identify an incident of potential sexual abuse involving Resident #61. No interventions were implemented by the facility following this incident. On 03/26/24 STNA #505 observed Resident #61 being sexually assaulted/abused by Resident #4. The facility failed to ensure adequate and effective interventions were in place to prevent this incident or to ensure additional incidents of sexual abuse did not occur. On 04/09/24 Resident #51 was identified to be sexually abused by Resident #4 in a common area in the facility. Resident #4's care plan had not been updated to include his sexual behaviors until 04/10/24 and an intervention to redirect (the resident) with an activity was not initiated until 04/16/24. The Immediate Jeopardy was removed on 05/23/24 when the facility implemented the following corrective actions. • On 03/26/24 at 8:00 P.M. Resident #4 and Resident #61 were immediately separated. Resident #4 and Resident #61 were placed on 1:1 supervision. • On 04/09/24 at 2:48 P.M. Resident #4 and Resident #51 were immediately separated, and Resident #4 was placed back on 1:1 supervision with staff. • On 05/23/24 from 8:00 A.M. to 8:30 A.M. Regional Quality Assurance Registered Nurse (RQARN) #800 reviewed the progress notes of Resident #4 since his admission to the facility to ensure there were no other documented occurrences of like behaviors. • On 05/23/24 from 9:45 A.M. to 11:00 A.M. Facility Assistant Administrator (FAA) #801 completed interviews with 28 of 28 alert and oriented residents with Brief Interview of Mental Status (BIMS) scores of 12 and higher. All 28 residents denied any like concerns and denied abuse and mistreatment by staff and/or other residents. • On 05/23/24 from 9:50 A.M. to 2:30 P.M. Unit Manager Licensed Practical Nurses (UMLPN) #802 and #803 performed skin sweeps on 33 of 33 residents with BIMS scores less than 12. No new or unidentified skin impairments, psychosocial distress or signs of abuse or mistreatment were noted for these 33 residents. • On 05/23/24 from 11:00 A.M. to 11:30 A.M. Regional Director of Operations (RDO) #501 educated 18 of 18 administrative staff including the Administrator, FAA #801, the Director of Nursing (DON), Assistant Director of Nursing (ADON) #403, UMLPN #802, UMLPN #803, Food Service Director (FSD) #400, Director of Rehabilitation (DOR) #804, Administrative Assistant (AA) #805, Medical Records Clerk (MRC) #806, Maintenance Director (MD) #807 , Activities Director (AD) #808, Social Services Designee (SSD) #809, Business Office Manager (BOM) #810, Admissions Director #811, Housekeeping Supervisor (HS) #812, Administrative Assistant #814 and Scheduler #815 on the facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, the Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy and re-educated on 1:1 supervision requirements including but not limited to remaining with the resident at all times during the assignment. 18 of 18 staff confirmed understanding of the provided education. • On 05/23/24 from 11:30 A.M. to 7:49 P.M. the Administrator, FAA #801, the DON, ADON #403, UMLPN #802 and #803, FSD #400, DOR #804, AA #805, MRC #806, MD #807, AD #808, SSD #809, BOM #810 Admissions Director #811, HS #812, AA #814 and Scheduler #815 re-educated 98 of 99 facility staff on the facility Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating policy, the Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy and re-educated on 1:1 supervision requirements including but not limited to remaining with the resident at all times during the assignment. 98 of 99 staff confirmed understanding of the provided education. One staff member could not be reached by call, text or at her home on this date. The facility implemented a plan for this employee to receive education on the facility Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating policy, the Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy and re-education on 1:1 supervision requirement including but not limited to always remaining with the resident during the assignment prior to her next shift worked. During this time frame 98 of 99 staff were also interviewed and all reported they were not aware of any other instances of abuse, neglect, or mistreatment of any resident. The one staff member who could not be reached at this time would be interviewed to ensure she was not aware of any other instances of abuse, neglect, or mistreatment of any resident. • On 05/23/24 at 1:14 P.M. RDO #510 visually confirmed Resident #4 to be on 1:1 supervision. Resident #4 would remain on 1:1 with staff indefinitely and would continue to be seen by psych services for behavior and medication management until such time the resident had a change of location to another facility or a change in physical capability/abilities. • On 05/23/24 from 1:25 P.M. to 1:50 P.M. RDO #510 educated the Administrator, Assistant Administrator #801, the DON, the ADON, and UMLPNs #802 and #803 on federal regulation F609: Reporting of Alleged Violations and F610: Response to Alleged Violations. Additionally, education was provided regarding ensuring proper interventions were in place, including timely psychiatric services, as appropriate, with notable changes in behavior. All confirmed their understanding of the federal regulation requirements. • On 05/23/24 at 1:59 P.M. the care plan of Resident #4 that was originally initiated on 02/01/2023 by LPN #816 was updated to include the 1:1 supervision. • On 05/23/24 at 2:25 P.M. RDO #510 notified the Medical Director via phone of the Immediate Jeopardy and abatement plan. • On 05/23/24 at 2:44 P.M. SSD #809 performed a psychosocial assessment on Resident #51 who showed no signs of psychosocial distress at this time. Resident #51 would continue to be followed by the facility's counseling services provider. • On 05/23/24 from 2:50 P.M. to 3:50 P.M. RQARN #800 reviewed progress notes for the last 90 days for all current facility residents for any related sexually inappropriate behaviors and the review showed no variances. • On 05/23/24 at 5:15 P.M. Stated Tested Nursing Assistant (STNA) #817, who was assigned to Resident #4's 1:1 supervision on 05/21/24, was terminated from employment at the facility by the Administrator due to her stating she chose to walk away to complete another task instead of maintaining the 1:1 supervision with Resident #4. • On 05/23/24 at 7:49 P.M. an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the facility Immediate Jeopardy and removal plan. Attendees included RDO #510, the Medical Director, FAA #801, the DON, the ADON, UMLPNs #802 and #803, DOR #804, MD #807, BOM #810, Admissions Director #811, MRC #806, FSD #400, AD #808, SSD #809, HS #812, AA #814, and Administrative Assistant #805. The removal plan was approved by the committee and ongoing compliance would be monitored as follows: • The DON or designee would verify 1:1 was in place (for Resident #4) and the staff person assigned to the 1:1 had full understanding of the requirement for providing 1:1, including but not limited to remaining with the resident at all times, each shift seven days a week for a period of one week and each shift five times a week for a period of three weeks thereafter. All variances would be corrected upon discovery and additional education and follow-up will be provided as deemed necessary. • The DON or designee would interview eight staff members five times weekly for a period of four weeks to ensure understanding of the 1:1 education provided and confirm their understanding that 1:1 entails always remaining with the resident during the assignment. All variances would be corrected upon discovery and additional education and follow-up will be provided as deemed necessary. • The DON or designee would review progress notes of current residents five times a week for a period of four weeks to ensure any notable changes in sexual behavior had an appropriate and timely intervention, including but not limited to psychiatric services, as appropriate, as well as to ensure care plans are updated appropriately to reflect changes as needed related to the noted behavior changes and interventions. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary. • The Administrator or designee would interview 10 residents weekly, for a period of four weeks regarding abuse and mistreatment to ensure residents remain free of abuse and/or mistreatment and feel comfortable reporting any concerns. Any variances would be corrected immediately upon discovery and additional follow-up and education would be provided as deemed necessary. • The DON or designee would assess 10 non-interviewable residents weekly for a period of four weeks to ensure residents remain free of signs of unknown skin impairment and abuse and/or mistreatment. Any variances would be corrected immediately upon discovery and additional follow-up and education will be provided as deemed necessary. • RDO #510 or designee would review all allegations of abuse three times a week, for a period of four weeks to ensure timely follow-up, completion of full investigation, documentation of allegation, reporting, and appropriate intervention implementation with review of resident progress notes, any self-reported incidents, and review of resident concern forms. All variances would be corrected immediately upon discovery and additional follow-up and education will be provided as deemed necessary. • The Administrator would audit 100% of new hires five times a week for four weeks for education on the facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating Policy, the Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy, as well as re-education on 1:1 supervision requirement including but not limited to remaining with the resident at all times during the assignment prior to her next shift worked. All variances would be corrected immediately upon discovery and additional follow-up and education will be provided as deemed necessary. • RDO #510 would review all audits weekly for a period of four weeks to ensure completion and compliance. All variances would be corrected immediately upon discovery and additional follow-up and education would be provided as deemed necessary. Results would be reported to the facility QAPI committee and additional ongoing compliance would be maintained through the facility quality assurance program, review of progress notes in the clinical operations meeting, and random audits as directed by the facility. Additional follow-up/education would be provided as directed by the committee. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings Include: 1. Review of Resident #61's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anemia, history of falling, hypertension, hearing loss, dysthymic disorder, protein-calorie malnutrition, dementia, Alzheimer's disease, depression, and anxiety. The resident was discharged to another facility on 04/05/24 at the request of her family. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #61 had severely impaired cognition. Review of the plan of care dated 03/05/24 revealed Resident #61 had alterations in mood and behaviors related to anxiety, depression and wandering. She had no documentation of sexually inappropriate behaviors or of behaviors that included disrobing. Review of the progress note dated 03/26/24 at 9:10 P.M and authored by the DON revealed Resident #61 was in the bathroom with another resident (#61), both residents were noted with their pants down. They were immediately separated and placed on one-on-one (1:1) supervision with staff. The note indicated Resident #61 was assessed with no signs of physical interaction, no new or unknown skin issues and no psychosocial distress. The note also indicated the responsible party was notified and was okay with and understands but prefers residents remain separated. Resident remains 1:1 with staff. The physician was notified. Review of Resident #61's medical record revealed there was no documentation related to an incident occurring between Resident #61 and Resident #4 earlier on this same date. Record review revealed Resident #61 was discharged from the facility on 04/05/24 per family request. Review of the medical record for Resident #4 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbances, psychotic disturbances and mood disturbances, Parkinson's disease, mild protein calorie malnutrition, hypertension, osteoarthritis, generalized anxiety disorder, essential tremor, depression, altered mental status, hearing loss, and cognitive communication deficit. Review of the progress note dated 03/26/24 at 9:10 P.M. and authored by the DON revealed Resident #4 was in the bathroom with another resident (#61), both residents were noted with their pants down. They were immediately separated and placed on one-on-one (1:1) supervision with staff. Resident #4 was assessed with no signs of physical interaction, no new or unknown skin issues and no psychosocial distress. The note indicated the responsible party was notified and was okay with and understands but prefers residents remain separated. Resident remains 1:1 with staff. The physician was notified. Review of Resident #4's medical record revealed there was no documentation related to an incident occurring between Resident #61 and Resident #4 earlier on this same date. Review of the progress note dated 03/28/24 at 5:09 P.M. revealed Resident #4 was no longer 1:1 with staff. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #4 had severely impaired cognition and physical behaviors directed towards others for at least one to three days in the seven-day review period. Review of the psychiatric note dated 04/09/24 revealed Resident #4 was being seen by the request of the facility for an initial psychiatric assessment related to the chief complaint of hypersexual behaviors related to dementia and generalized anxiety disorder. Staff reported he had grabbed a resident's breast today and was also found in the bathroom with his pants down with another resident. Throughout the assessment the resident had limited verbal engagement and would respond yeah to all questions. The note revealed staff placed him on 1:1 to protect other residents. Mental health nursing for ongoing symptom monitoring and management of anxiety and dementia was recommended. Review of the physician orders for March 2024 and April 2024 revealed Resident #4 had an order for Cimetidine 200 milligrams once daily for inappropriate sexual behavior dated 04/10/24. There were no orders for 1:1 supervision. Review of the plan of care, date revised 04/16/24, revealed Resident #4 had mood problems related to generalized anxiety disorder, inappropriate sexual behaviors (added 04/10/24), and depression. Interventions included administering medications as ordered, behavioral health consults as needed, monitor and record mood, report any change to the physician, and redirection offer activity and provide privacy (added 04/16/24). Review of a facility investigation dated 03/26/24 (no time noted) revealed Residents #4 and #61 were noted to be in the East Side Spa Room at the same time. Resident #4 had a Brief Interview for Mental Status (BIMS) score of one (severe cognitive impairment) out of 15 and Resident #61 was unable to complete the BIMS assessment (due to cognitive impairment). Both residents resided on the East side of the building and were known to use the spa room restroom regularly on their own. Resident #61 was noted to have her pants down attempting to use the commode and Resident #4 was zipping his pants up. The facility written investigation included there was no skin-to-skin contact witnessed and neither resident appeared to be in distress. Resident #4 was assisted from the spa room and Resident #61 assisted with toileting and assisted from the spa room. One-on-one supervision was initiated to prevent reoccurrence of wandering in at the same time. Review of a signed witness statement from the DON dated 03/26/24 at 8:49 P.M. revealed RN #411 had notified her that there was an incident with Resident #4 and #61. She stated both residents were in the spa room and staff observed Resident #4 standing behind Resident #61 as she was pulling her pants up. Both the residents were re-directed out of the spa room, and they were immediately separated. Resident #4 was placed on 1:1 to prevent unintended wandering. Review of a statement from the DON dated 03/26/24 at 9:15 P.M. revealed the DON and Administrator spoke to STNA #505 and she re-iterated the pants of Resident #61 were down by her thighs, and she was in the spa room and Resident #4 was also present. Both residents were using the spa room for toileting. However, there was no written statement from STNA #505 who witnessed the incident in the facility investigation provided to the surveyor for review. Observation on 05/21/24 at 9:38 A.M. revealed Resident #4 was in bed sleeping and he did not have a staff member providing 1:1 supervision at this time. On 05/21/24 at 11:00 A.M. an interview with Licensed Practical Nurse (LPN) #472 revealed on 03/26/24 she had still been at the facility working over. She stated she was getting ready to leave around 8:00 P.M. when the nurse on duty stated Resident #4 had Resident #61 in the spa room and they both had their pants own and Resident #4 had his penis out. On 05/21/24 at 12:35 P.M. an interview with Family Member #700 (family of Resident #61) revealed she and her brother had been visiting the facility on 03/26/24 around 3:00 P.M. for a care plan meeting for the resident. She stated when they got there, they could not find Resident #61 anywhere and after about 15 minutes of searching, staff found her mother in the spa room with Resident #4. She stated she had not gone into the spa room however the Director (later identified as Director of Marketing #710) had gone in. She stated Director of Marketing #710 told her that her mother was completely naked in the spa room with Resident #4. She stated her clothes were in the spa room and she was told Resident #4 was attempting to help her mother. She stated later that evening around 10:00 P.M. she received a call stating they had found her mother and Resident #4 in the spa room again except this time Resident #4 had his pants down, his penis out and he was touching her mother inappropriately. She stated the facility decided to place both residents with an aide 24 hours a day until they could get her mother moved to another facility. She stated Resident #4 would seek her mother out and stared at her every time they were there. She stated it was creepy. On 05/21/24 at 1:20 P.M. an interview with STNA #503 revealed Resident #4 usually had an aide with him to provide 1:1 supervision, but he did not have anyone with him today. Observation on 05/21/24 at 1:25 P.M. revealed Resident #4 was sitting in the dining room. He did not have staff sitting with him 1:1; however, staff were walking around the dining room and nurse's station. On 05/21/24 at 4:45 P.M. an interview with the Administrator revealed the facility had not completed a Self-Reported Incident (SRI) related to the incidents between Resident #61 and Resident #4 (on 03/26/24) because the facility did not believe it was abuse, but rather just Resident #4 and Resident #61 trying to use the bathroom at the same time. The Administrator verified he had not completed any type of facility self-reported incident for any incidents involving Resident #4. On 05/22/24 at 9:45 A.M. an interview was attempted with Resident #4; however, he was not able to answer questions appropriately. The resident just kept saying yes and smiling. On 05/22/24 at 12:10 P.M. an interview with the DON revealed they had placed both Resident #4 and #61 on 1:1 supervision after the second time they were found wandering in the spa room together (on 03/26/24) and then Resident #61 was moved to another facility with a locked unit on 04/05/24. On 05/22/24 at 2:50 P.M. an interview with STNA #501 revealed he had just come on duty at 7:00 P.M. on 03/26/24. He stated he did not witness Resident #4 touch Resident #61 in the spa room; however, about 15 to 20 minutes after the incident had happened, he had to redirect Resident #4 from trying to take Resident #61 back into the spa room again. He stated the nurse was on the phone with the DON at the time Resident #4 tried to take Resident #61 back into the spa room. He stated he had not seen Resident #4 act like this before and had never seen him have sexual behaviors prior to that day. On 05/22/24 at 3:54 P.M. an interview with the Administrator revealed on 03/26/24 around 3:00 P.M. when Resident #61's family was in the building, they were looking for the resident and Director of Marketing #710 (who was no longer employed) found her in the spa room. The Administrator said he was told by Director of Marketing #710 Resident #61was getting up off the toilet with her pants down and Resident #4 was just standing in there. He stated Resident #4 did not have his pants down and he was not touching her. The Administrator indicated there was not an investigation completed related to this incident. On 05/22/24 at 4:33 P.M. an interview Director of Marketing #710 revealed she had only worked at the facility for about four months. She stated on 03/26/24 Resident #61's family was at the facility for a care conference, and they were trying to find Resident #61 but were unable to. She stated they started looking for her. She stated she found Resident #61 in the spa room sitting on the toilet completely naked. She said Resident #4 had his hand on her arm attempting to get her to stand up. She stated she immediately asked Resident #4 to come out of the spa room with her, she went out, and told the nursing staff to go in the spa room and help Resident #61 get dressed. On 05/23/24 at 5:15 A.M. an interview with STNA #508 revealed Resident #4 was to have 1:1 supervision; however, they do not always have an extra aide working to sit with him. She stated staff would sit outside his room until it was time to do rounds or until someone needed help with something then they would leave his room to help and then they would go back to his room again. She stated this scenario happened three to four times a week. On 05/22/24 at 5:25 A.M. an interview with RN #411 revealed on 03/26/24 around 8:00 P.M. STNA #505 came to her, and stated Resident #4 was in the spa room with Resident #61 doing inappropriate things with her. She stated by the time she got into the spa room Resident #4 had his pants up and he was attempting to pull Resident #61's pants up. She stated Resident #4 seemed really embarrassed, he was fumbling around and quickly trying to pull Resident #61's pants up. She stated Resident #61 was clueless as to what was going on. On 05/22/24 at 5:51 P.M. an interview with STNA #505 revealed she had been working on 03/26/24. She stated around 8:00 P.M. she had gone into the spa room to get the Hoyer lift and when she walked in, she saw Resident #4 had Resident #61 bent over with both his hands on her hips making a pumping movement with his hips and both of the resident's pants were down. She stated she yelled at him that he could not be doing that to her, and she scared him, he jumped back, and let go of Resident #61. She stated Resident #4's penis was out and erect. She stated she ran out of the spa room to get Registered Nurse #411, who was at the nurse's station, about 15 feet away from the spa room. When they got back into the spa room Resident #4 had his pants pulled up and he was trying to help Resident #61 get her pants back up. She stated she wrote out a witness statement about what happened and made three copies of the statement. She stated she placed one copy under the doors of the office of Human Resources, provided a copy to the DON and also a copy to the Administrator. However, STNA #505 stated all of the copies of her written statements were now missing. She stated she purposefully made three copies because the last time she had filled out a report concerning an unrelated incident, that report also ended up being missing. She stated the administrative staff never asked her to complete another written witness statement. On 05/23/24 at 12:19 P.M. an interview with Psychiatric Nurse Practitioner #600 revealed the psychiatric service she worked for was called by the facility to do a telehealth visit for Resident #4 on 04/09/24 due to increase in inappropriate sexual behaviors. She stated she was told he grabbed the breast of a female resident and had previously been found with another resident, both having their pants down. On 05/28/24 at 2:40 P.M. an interview with the DON verified Resident #4 was taken off 1:1 supervision on 03/28/24 and then placed back on 1:1 supervision following an incident with Resident #51 on 04/09/24. On 05/29/24 at 8:50 A.M. an interview with the DON and Administrator revealed they denied having a written statement from STNA #505. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 04/2021, revealed residents have the right to be free from abuse. This included but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. The policy did not include a definition of sexual abuse nor any information on what constituted consent to sexual activity. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 09/22 revealed all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property were reported to the local, state, and federal agencies and thoroughly investigated by facility management. The policy did not include a definition of sexual abuse nor any information on what constituted consent to sexual activity. 2. Review of Resident #51's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, traumatic hemorrhage of the right cerebrum, insomnia, transient cerebral ischemic attack, schizoaffective disorder, epilepsy, chronic kidney disease, aphasia, panic disorder, anxiety disorder, polyneuropathy, left hemiplegia, dysphagia, ileus, fibromyalgia, and placement of cardiac defibrillator. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #51 had moderately impaired cognition. Review of the plan of care initiated 07/14/22 with a revision date of 02/16/24 revealed Resident #51 had alterations in mood and behavior related to anxiety, depression, insomnia, panic disorder, and schizoaffective disorder. She would at times manipulate staff. She had hallucinations and delusions at times. There was no indication she had any sexual behavior. Review of the progress notes from 04/01/24 through 04/10/24 revealed no documentation of any type of sexual abuse occurring. There was no note related to the resident being sexually abused by Resident #4 on 04/09/24, when Resident #4 grabbed the breast of Resident #51. Review of an undated witness statement authored by the Administrator revealed while doing daily rounds on the East side of the building he came up the 400 hall and Resident #4 and #51 were both in the TV lounge watching TV and they were seated on opposite sides of the room. He entered the spa room to check it and heard Resident #51 yell. He immediately came out of the spa room and saw Resident #4 walking away from Resident #51. He asked Resident #51 what was wrong, and she stated Resident #4 had tried to kiss and touch her. The Administrator asked her if he actually kissed or touched her, and she stated no. The statement noted out of an abundance of caution Resident #4 was placed on 1:1 with a referral made to the psychiatric group to address his behaviors. On 05/21/24 at 3:40 P.M. an interview with Resident #51 revealed (on 04/09/24) Resident #4 had grabbed her breast and tried to kiss her. Resident #51 stated she told him to get away from her. She

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, interviews with staff and family, review of a local Fire Department Patient Care Record, review of hospital records, review of facility investigation information, and review of facility policy and procedures, the facility failed to ensure all residents received adequate and timely care and treatment to meet their total care needs. This resulted in Immediate Jeopardy and subsequent actual harm/death beginning at 05/27/24 at approximately 4:30 A.M. when Resident #42, who was dependent on staff for transfers, incontinence care, management of insulin dependent diabetes and who was physically impaired due to Huntington's disease (an incurable neurological disorder that damages brain cells impacting movement, behavior and cognition) and a fall risk related to unstable medical condition, seizures, debility, weakness and tardive dyskinesia (a condition affecting the nervous system causing repetitive, involuntary movements) was found unresponsive in his room, absent of pulse, slumped over in his chair with blood on his face, clothing and on the floor. The resident had last been seen by staff (Licensed Practical Nurse (LPN) #433) on 05/26/24 at approximately 10:00 P.M. sitting in his wheelchair in his room. LPN #433 checked the resident's blood glucose level at that time which was 400 milligrams per deciliter (mg/dl) (elevated/hyperglycemic) and administered 40 units of scheduled Glargine insulin at that time. There was no evidence the nurse went back to reassess the resident's blood glucose level or monitor the resident after giving the routine insulin. Resident #42 remained in his wheelchair in his room throughout the night and was not checked again all night until State Tested Nursing Assistant #501 went into the resident's room at 4:30 A.M. and found the resident unresponsive. The resident required cardiopulmonary resuscitation and when the local fire department arrived to take over the code/care, Resident #42's blood glucose was 509 mg/dl. The resident was transported to the emergency room where his blood sugar was noted to be 607 mg/dl. The resident was admitted to the intensive care unit and subsequently passed away on 05/28/24. This affected one resident (#42) of six residents reviewed for change of condition. The facility census was 60. On 06/04/24 at 3:45 P.M. the Administrator, [NAME] President of Operations #81 and Regional Director of Operations #510 were notified Immediate Jeopardy occurred on 05/27/24 at 4:30 A.M. when Resident #42 was found unresponsive in his room. Prior to this time, the resident had not been checked or provided care by staff since 05/26/24 at 10:00 P.M. when LPN #433 checked the resident's blood sugar and administered routine insulin. Resident #42 was not checked or provided care by staff for approximately six and a half hours overnight until 4:30 A.M. despite having hyperglycemia (high blood sugar) of 400 identified by the facility nurse at 10:00 P.M., despite being at risk for falls and care planned to be in out in a common area when in his wheelchair and despite being care planned for every two-hour check/change for incontinence care. The resident was found unresponsive, required cardiopulmonary resuscitation (CPR) and was sent to the hospital where he subsequently passed away on 05/28/24. The Immediate Jeopardy was removed on 06/04/24 when the facility implemented the following corrective actions. • On 06/04/24 from 5:30 P.M. to 7:24 P.M. Regional Quality Assurance Registered Nurse (RQARN) #800 audited 12/12 residents with physician orders for blood sugar checks to ensure residents with physician orders for blood sugar checks had parameters that included when to notify the physician. Variances were corrected on discovery. • On 06/04/24 from 5:40 P.M. to 8:05 P.M. Assistant Director of Nursing (ADON) #403 audited 12/12 residents with physician orders for blood sugar checks for the last 24 hours to ensure the physician's order was followed, notifications were complete as needed, and appropriate follow up was completed as needed with appropriate interventions as necessary. No variances identified. • On 06/04/24 from 4:00 P.M. to 4:30 P.M. Regional Director of Operations (RDO) #510 educated the Administrator, Facility Assistant Administrator (FAA) #801, the Director of Nursing (DON), Assistant Director of Nursing (ADON) #403, Unit Manager Licensed Practical Nurse (UMLPN) #802, UMLPN #803, Food Service Director (FSD) #400, Director of Rehab (DOR) #804, Administrative Assistant (AA) #805, Medical Records Clerk (MRC) #806, Maintenance Director (MD) #807, Activities Director (AD) #808, Social Services Designee (SSD) #809, Business Office Manager (BOM) #810, Admissions Director #811, Administrative Assistant (AA) #814 and Scheduler #815 on following individualized care plans related to incontinence checks and resident monitoring. 17/17 staff educated confirm understanding. • On 06/04/24 from 4:30 P.M. to 5:00 P.M. RQARN #800 educated the DON, ADON #403, UMLPN #802 and #803 on the facility policy Nursing Care of the Resident with Diabetes Mellitus including obtaining follow up blood sugar checks if indicated. 4/4 staff educated confirm understanding. • On 06/04/24 at 5:26 P.M. the facility Medical Director was notified of the Immediate Jeopardy related to quality of care and treatment. • On 06/04/24 from 5:30 P.M. to 8:24 P.M. Facility Administrator, FAA #801, the DON, ADON #403, UNLPN #802 and #803, FSD #400, DOR #804, AA #805, MRC #806, MD #807, AD #808, SSD #809, BOM #810, AD #811, Housekeeping Supervisor (HK) #817, AA #814 and Scheduler #815 educated all nursing staff on following individualized care plans related to incontinence checks and resident monitoring. 92/92 of staff educated confirm understanding. • On 06/04/24 from 5:30 P.M. to 8:12 P.M. RQARN #800, the DON, ADON #403 and UMLPNs #802 and 803 educated all licensed nursing staff on the facility policy Nursing Care of the Resident with Diabetes Mellitus including obtaining follow up blood sugar checks as appropriate. 15/15 of staff educated confirm understanding. • On 06/04/24 from 5:30 P.M. to 6:45 P.M. Clinical Resource Specialist LPN #816 audited all current resident care plans to ensure resident care plans for fall interventions reflect resident preferences and that refusals to follow care planned intervention to be in common areas when up in wheelchair are addressed in the care plan. Audit revealed 0/64 resident care plans reviewed had fall interventions for placement in common area when up in wheelchair. No variances identified. • On 06/4/24 from 6:45 P.M. to 8:15 P.M. Clinical Resource Specialist LPN #816, audited all current resident care plans to ensure residents with an incontinence care plan to check every two hours include resident preferences and refusals to follow care planned checks. Audit revealed 0/64 care plans reviewed had like intervention to check every two hours. No variances identified. • On 06/04/24 at 6:30 P.M. RDO #510 added facility education for Following individualized Care Plans related to incontinence checks and resident monitoring and the facility policy Nursing Care of the Resident with Diabetes Mellitus to facility General Orientation manual. • On 06/04/24 5:30 P.M. to 7:30 P.M. Clinical Operations Specialist RN #992 completed an audit of 90 days of progress notes for active residents with physician's orders for blood sugar checks to ensure any patterns of hyperglycemia or hypoglycemia were addressed appropriately with appropriate follow up and/or physician notification. No variances noted. • On 06/04/24 at 8:25 P.M. Ad hoc Quality Assurance Performance Improvement (QAPI) meeting held to discuss the plan of action. Attendees included: RDO #510, the facility Administrator, the Medical Director, FAA #801, the DON, ADON #403, UMLPNs #802 and #803, DOR #804, MD #807, BOM #810, AD #811, MRC #806, FSD #400, AD #808, SSD #809, and AAs #805 and #814. • The facility implemented a plan for the Regional Quality Assurance RN/Designee to review all residents with physician's orders for blood sugar checks five times a week, for a period of four weeks to ensure physician order was followed, notifications complete as needed, and follow up completed as needed with appropriate interventions as necessary. • The facility implemented a plan for the DON/designee to interview eight staff members five times weekly for a period of four weeks to ensure understanding of following individualized care plans related to incontinence checks and resident monitoring. • The facility implemented a plan for the DON/Designee to review progress notes of current residents with physician orders for blood sugar checks five times a week for a period of four weeks to ensure any patterns of hyperglycemia or hypoglycemia are addressed as appropriate with appropriate intervention and/or physician notification as appropriate. • The facility implemented a plan for the DON or Designee to audit 100% of new hires five times a week for four weeks to ensure new hire staff receive education on facility policy for Following Care Plans related to incontinence checks and resident monitoring and the facility policy Nursing Care of the Resident with Diabetes Mellitus including obtaining follow up blood sugar checks as appropriate. • The facility implemented a plan for the DON or designee to audit all residents with physician orders for blood sugar checks five times a week for four weeks to ensure all blood sugar check orders include parameters that include when to notify the physician. • The facility implemented a plan for the DON or designee to audit all residents with fall care plans five times a week for four weeks to ensure interventions are in place as appropriate, reflect resident preference and refusals, and are being followed by interdisciplinary care team with communication on care card as appropriate. • The facility implemented a plan for the DON or designee to audit all residents with incontinence care plans five times a week for four weeks to ensure check and changes follow standard of care, reflect resident preference and refusals, and are being followed by interdisciplinary care team with communication on care card as appropriate. • The facility implemented a plan for RDO #510 to review all audits weekly for a period of four weeks to ensure completion and compliance. The QA Committee will monitor the results of all audits and monitoring and follow-up as needed. Although the Immediate Jeopardy was removed on 06/04/24, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance Findings included: Review of the closed medical record for Resident #42 revealed the resident was admitted to the facility on [DATE] with diagnoses including respiratory failure, dysphagia, gastrostomy, peptic ulcer disease, Huntington's disease, diabetes, epilepsy, benign prostatic hyperplasia, dyskinesia, hypothyroidism, malignant neoplasm of the thyroid, hypertension, metabolic encephalopathy, severe protein calorie malnutrition, kidney failure, and cystitis with hematuria. Resident #42 was discharged to the hospital on [DATE] and subsequently passed away on 05/28/24. Review of the plan of care dated 12/14/23 and revised on 01/18/24 revealed Resident #42 was at risk for falls and potential injury related to unstable medical conditions, debilitation, weakness, seizures, Vitamin D deficiency, tardive dyskinesia and he attempted to be independent beyond ability. Interventions included placing Resident #42 in the common area when the resident was up in his wheelchair. Review of the plan of care dated 12/14/23 and revised on 02/07/24 revealed Resident #42 was incontinent of bowel which made him at risk for urinary tract infections and skin breakdown. Interventions included changing resident every two hours and as needed. Review of the plan of care dated 12/14/23 and revised on 02/08/24 revealed Resident #42 was at risk for hypo/hyperglycemic episodes related diabetes, requiring insulin. Interventions included to be alert to medication which cause a change in blood sugars, diet as orders, insulin as orders, monitor blood sugars as ordered, monitor for signs and symptoms of hyperglycemia: flushed, dry skin, nausea and vomiting, abdominal pain, decreased blood pressure, acetone breath and increased respirations, and sliding scale as ordered. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 had moderately impaired cognition. The assessment revealed the resident required moderate assistance for rolling in bed, sit to stand transfers and chair to bed transfers. Review of the physician medication orders revealed an order for Glargine insulin, dated 03/21/24 to administer 40 units twice daily. The medication was scheduled to be administered at 9:00 A.M. and 9:00 P.M. Review of the physician orders revealed an order for Lispro insulin, dated 03/22/24. The order revealed the medication was to be administered per sliding scale before meals: if blood sugar 180 to 200 give two units, if 201 to 250 give three units, if 251 to 300 give four units, if 301 to 350 give five units, if 351 to 400 give six units, if 401 to 450 give seven units and if above 450 call the physician. The hours of administration were listed as rise, lunch and after. Review of a telephone order dated 04/25/24 revealed Resident #42 had an order to discontinue Trulicity (a medication used to treat type 2 diabetes) and check blood sugars with meals and at bedtime. The order did not include any changes to the resident's Lispro or Glargine insulin orders. Review of the facility Transfer and Lift Data Form dated 05/16/24 revealed Resident #42 required assistance with transfers. The form identified the resident required at least one staff assist to transfer. Review of the facility document Resident Temporary Leave of Absence for Resident #42 revealed the resident's wife signed the resident out of the facility on 05/25/24. Review of the facility document Resident Temporary Leave of Absence for Resident #42 revealed the resident's wife brought the resident back on 05/26/24 at 4:00 P.M. Review of the May 2024 medication administration record (MAR) revealed on 05/26/24 staff documented a 1 (one) meaning the resident was away from home with medications and there was no blood glucose level recorded for the dinner meal even though the resident had returned to the facility at 4:00 P.M. on 05/26/24. Review of the nursing progress notes revealed an entry on 05/26/24 at 4:09 P.M. Resident returned from LOA with wife. In addition, review of the MAR for the 05/26/24 9:00 P.M. administration time revealed LPN #433 documented on the MAR that Resident #42 had a blood sugar of 400 mg/dl and was given 40 units of insulin Glargine. Record review revealed there was no follow up documentation regarding the blood sugar of 400 mg/dl in the resident's medical record after this entry. Review of facility documentation provided by RDO #510 and titled Insulin Glargine Subcutaneous Solution Pen-Injector 100 units per milliliter (u/ml) (Insulin Glargine) dated 05/27/24 revealed on 05/26/24 at 10:22 P.M. 40 units of Insulin Glargine was administered in Resident #42's right upper quadrant of the abdomen by LPN #433. The next narrative nursing progress note, dated 05/27/24 at 7:09 A.M. and authored by LPN #433 revealed at 4:35 A.M. the nursing assistant notified the nurse Resident #42 was unresponsive in his room. The nurse checked his code status and went into his room, as she was going to the room, she had the nursing assistant (STNA #506) go get the other nurses, crash cart and had the other nursing assistant, who was in the room with the resident when she entered, call 911. Upon entering, the nurse observed Resident #42 slumped over in his chair in front of his dresser and noted dark fluid coming from his nose, mouth and on the floor in front of him. The nurse called his name and gave him a sternal rub before checking for pulse. When the nurse did not feel a pulse and he did not respond, the nursing assistant (STNA #501) helped her get Resident #42 on the floor and on the back board before calling 911 while she started CPR. She switched back and forth with the other nurse (LPN #472) doing cardiopulmonary resuscitation (CPR) for 10 minutes until Emergency Medical Service (EMS) arrived at 4:42 A.M. and took over CPR. At 5:05 A.M. EMS stated they had obtained a pulse and left facility at 5:10 A.M. transporting Resident #42 to the hospital. The note indicated at approximately 10:00 P.M. on 05/26/24 this nurse gave Resident #42 his medications and he was alert, oriented and responsive. He took his medications and the nurse indicated she told the resident the nursing assistant would be in soon to lay him down. She notified STNA #542, the STNA on duty, that Resident #42 still needed to be laid down before she left shift at 11:00 P.M. STNA #501 had come to work early to help STNA #542 put the remaining residents in bed. STNA #542 failed to report to STNA #501 Resident #42 was still up in his chair. Review of the local Fire Department Patient Care Record, dated 05/27/24, revealed the fire department was dispatched to the facility for an unresponsive male. They arrived on scene at 4:46 A.M. and when the crew entered the room, the resident was laying supine on the floor of his room with the lights out. There was coffee ground emesis all over the floor and the staff were doing chest compressions. The resident was pulled out into the hallway by the fire department staff and compressions continued. They departed the facility at 5:12 A.M. The fire department record noted Resident #42 was last known/seen at 9:00 P.M. on 05/26/24 by facility staff. Per EMS, Resident #42's blood sugar was 509 mg/dl at 5:03 A.M. Review of the hospital emergency room report dated 05/27/24 revealed emergency medical services (EMS) were called to the facility for an unresponsive resident. They reported the nursing staff stated Resident #42 was last seen at 9:00 P.M. and then when they went to check on him in the morning, he was found unresponsive. EMS stated when they got to the facility CPR had already been initiated and Resident #42 was on the ground. Resident #42 had a return of spontaneous circulation and was transported to the emergency room. Resident #42 was unresponsive, his pupils were four millimeters and fixed, breath sounds were present, he had an indentation in his chest from the [NAME] (chest compression machine) and he was tachycardic (rapid heart rate). The resident's blood glucose was 607 mg/dl with normal being 70 to 100 mg/dl. The resident was admitted to the intensive care unit. Review of the staff assignment sheet dated 05/26/24 revealed STNA #542 and #505 were scheduled on the [NAME] unit from 3:00 P.M. to 11:00 P.M. and STNA #578 and #575 were scheduled on the East wing from 3:00 P.M. to 11:00 P.M. with STNA # 501 coming in at 9:00 P.M. to float both the [NAME] and East units. However, STNA #575 had reported off. Resident #42 resided on the [NAME] unit. The normal staff assignment was two aides on each unit with an aide floating between both sides. Review of the staff time punches from 05/26/24 revealed STNA #501 worked 9:15 P.M. to 8:15 A.M., STNA #575 had not worked (called off), STNA #542 worked 2:45 P.M. to 11:30 P.M., STNA #578 had not worked, and STNA #505 worked 4:25 P.M. to 7:00 A.M. Review of a facility investigation revealed the facility had witness statements that were typed and not handwritten by the following staff who signed the witness statements: The witness statement signed by STNA #506 dated 05/27/24 revealed on 05/27/24 at around 4:32 A.M., STNA #506 was walking down the 100 hallway, and he noticed Resident #42's door was open. He looked into the room and observed Resident #42 leaning over in the wheelchair. He went to get LPN #433 and STNA #501. LPN #433 instructed him to go get Registered Nurse (RN) #411. He went to get her then waited at the front of the building for the EMS. The witness statement signed by STNA #501 dated 05/27/24 revealed on 05/27/24 at 4:33 A.M., STNA #501 was notified by STNA #506 that Resident #42's door was open and the resident was unresponsive in the wheelchair. He went into the room and observed the resident sitting in his wheelchair by his dresser. He had dark brown emesis on his mouth and on the floor. STNA #501 instructed STNA #506 to go get LPN #433. LPN #433 checked the resident's code status and stated the resident was a full code. She arrived at the room and they placed the resident on the floor. LPN #433 instructed STNA #501 to call 911. EMS arrived and they placed the resident in the hallway and continued CPR. STNA #501 spoke to RN #413 on the telephone. The witness statement dated 05/27/24 and signed by LPN #433 revealed on 05/27/24 at 4:35 A.M. LPN #433 was notified by STNA #506 that when he was walking by Resident #42's room he was unresponsive sitting in the wheelchair. She checked his code status in the computer and verified in his chart that he was a full code. She then went to his room and observed resident slumped over in his by his dresser with dark brown coffee ground emesis on his nose, mouth and front of shirt and on the ground. She performed sternal rub and the resident did not respond. She felt for pulse and no pulse was noted. STNA #501 assisted her in placing resident on the floor. She initiated CPR and instructed STNA #506 to go get RN #411 from the other unit. As she was performing CPR, she instructed STNA #501 to call 911. RN #411 took over CPR and the both rotated chest compressions and breaths with ambu bag until EMS arrived. EMS arrived at 4:46 A.M. and took over CPR. EMS performed CPR with chest compressions and then moved the resident to the hallway and hooked the resident up to the [NAME] Chest compression system. EMS placed an AED on the resident and resident did not have a heart rhythm, EMS shocked the resident. After the resident was shocked, he got a heart rhythm. EMS stopped compressions and were bagging (ventilation) the resident while placing him on the stretcher. EMS transported the resident to the hospital at 5:10 A.M. As the resident was leaving the facility, EMS stated he had a pulse and a heart rhythm. LPN #433 called the physician at 5:35 A.M. and left her a voice mail. She then called the resident's wife at 5:38 A.M. and notified her of the incident and that EMS transported resident to the hospital. Additional investigative information (dated 05/27/24), contained on different papers also typed and signed by staff were provided as noted below: a. STNA #501 had clocked in around 9:15 P.M. on 05/26/24 and was assisting on the East unit then around 10:30 to 10:40 P.M., he went to [NAME] unit to help Hoyer (mechanical lift) and clean up two residents. Around 11:10 P.M., STNA #542 told STNA #501 she had stayed over to clean up a resident on 200 Hall. Around 1:30 A.M. STNA #501 was doing rounds and noted Resident #42's bedroom door to be closed as normal. Around 3:40 A.M., a resident in the 100 Hall had put his call light on and when STNA #501 was walking back down hall, he noted (Resident #42's) bedroom door was still closed. Around 4:30 A.M. STNA #501 was at the nurse's station when STNA #506, yelled for him to come to Resident #42's room because the resident was up in his chair. b. STNA #506 came into work on 05/26/24 at around 10:45 P.M. and STNA #542 told him she had stayed longer to help and that a resident on the 100 Hall still needed to be Hoyered into bed. At around 3:30 A.M., two residents had turned on their call lights on the 100 Hall so he responded to both. When he was coming back down the hall, he noted Resident #42's door was closed as usual then a little after 4:00 A.M STNA #501 remarked that Resident #42 must be sleeping good because he had not turned his call light on, which was not abnormal after returning from LOA visits. He stated when disturbed overnight in the past by STNAs the resident would become aggressive and combative and per resident demands, they were not to go into his room without permission and he would ring when he was wet. Both the STNAs prepared to do their final rounds and check and changes. At around 4:30 A.M. STNA #506 was going down the 100 Hall after caring for a resident when he noted Resident #42's bedroom door and bathroom door were both open, which was abnormal. From hallway, STNA #506 could see Resident #42 slouched over in his wheelchair and immediately yelled for other STNA #501, to come to room and then he ran to get his nurse. c. STNA #542 stated Resident #42 had returned to his room shortly after 7:00 P.M. and she went into his room to toilet and change him and at that time she had offered to lay him down in bed. Resident #42 refused stating no, you have things to do, I'll stay up a while. She explained to him she had time to lay him down if he wanted and he stated no, I'll sit up a while; I'm fine. At around 10:30 P.M. she went to check on the resident again and he was clean and dry, sitting in wheelchair, watching television. She again offered to lay him down and he said, I'm alright. Get everyone else to bed I'll wait. She told him if he waited then midnights would have to put him to bed. He said that was fine as long as that one girl doesn't do it.'' At around that time STNA #501 came over to the [NAME] unit to help STNA #542 finish up for the night; they had to lay down two residents who required the Hoyer and provided care to these residents. At that time, STNA #542 went over the [NAME] side resident's needs, explaining that on the 300 Hall one resident was still up, on the 200 Hall two residents still needed changed, and on the 100 Hall, one resident's catheter needed emptied and one resident needed laid down. STNA #501 stated he would change the one resident on 200 hall while STNA #542 changed the other. Shortly after 11:00 P.M. STNA #542 went to the two STNAs at the nurse's station and updated them on one resident who returned from the hospital now needed a two assist, told them Resident #42 still needed laid down, and told them the resident she changed was having a bowel movement and would need cleaned up when she was finished. STNA #542 clocked out around 11:30 P.M. d. LPN #433 was assigned to Resident #42 the night of 5/26/24, at around 10:00 P.M. she gave him his nighttime medications and told STNA #542 Resident #42 had received his medication and she need to have STNA #501 assist her in laying him down prior to leaving. LPN #433 had finished her medication pass in that hall at approximately 10:20 P.M. before going to her next hall. She finished her med pass around 11:30 P.M. and came to the nurse's station where STNA #542 was speaking to the other two STNAs but had not informed them of Resident #42's refusal to lay down. Shortly after 4:30 A.M. LPN #433 was at the computer working through her morning medication pass when STNA #506 came and told her about Resident #42's condition. She was on his computer chart and saw he was a full code which she verified in the resident's paper chart and ran to the room. STNA #501 was already in resident's room. On 05/29/24 at 11:00 A.M. an interview with STNA #542 revealed she had worked 3:00 P.M. to 11:00 P.M. on 05/26/24. She stated Resident #42 was out with his wife until around supper time. She stated she was the only aide working on the [NAME] unit. She stated the last time she checked on Resident #42 was between 9:00 P.M. and 10:00 P.M. She stated he was fine. She stated he was a really sweet guy, and he knew she was working by herself so he told her he would wait until she got time to put him to bed. She stated he normally went to bed between 7:00 P.M. and 9:00 P.M. She stated STNA #501 came over to the [NAME] unit at around 10:30 P.M. to help her put another resident to bed. She stated she told STNA #501 and #506 that Resident #42, Resident #7 and Resident #43 were still up and she had not changed Resident #16 or Resident #32 yet. She confirmed the other staff knew Resident #42 was still up in his wheelchair. Further interview on 05/29/24 at 11:00 A.M. with STNA #542 revealed she had not been working on the [NAME] unit, as the staff assignment dated 05/26/24 indicated, she had been working on the East unit and STNA #505 had worked on the [NAME] unit. She stated she was the only staff member on the East unit from 7:00 P.M. to 10:30 P.M. At 9:15 P.M. STNA #501 was to assist her, however he did not come over to the East unit until around 10:30 P.M. On 05/29/24 at 5:10 P.M. an interview with STNA #506 revealed he came in on 05/26/24 at 10:45 P.M., got report from STNA #542 who stated she only had Resident #48 left to do. So, he went to clock in and her and STNA #501 went to put Resident #48 in bed. He stated he did not know Resident #42 was still up until he went past his room at around 4:30 A.M. doing last rounds. He stated the resident's door had been closed all night until they did last rounds and it was open which was weird. He stated he does not take care of Resident #42 because the resident's wife does not allow him in his room. He stated he could honestly say he never checked on him all night. He stated he could not speak for anyone else. He stated STNA #575 had called off, and he saw STNA #501, STNA# 542 and STNA #578 were working that night when he came in. He stated he never saw STNA #505 but he never went over to her side. On 05/30/24 at 10:45 A.M. an interview with Family Member #622 revealed she had taken Resident #42 out overnight on 05/25/24 and brought him back to the facility at 4:00 P.M. on 05/26/24. She stated the resident was fine the whole time he was out with her. She stated he usually liked to get ready for bed around 6:30-7:00 P.M. because it was easier for him to use his urinal with a gown on so he does not have to call the aides to help him. She stated he gets his Keppra (medication) at 9:00 P.M. and it completely wipes him out so he needs to be in bed when he gets it. She stated she spoke to LPN #433 about what had happened. She stated LPN #433 told her she gave him the resident his Keppra and insulin around 10:00 P.M. that night then Resident #42 had asked her to be put to bed. She stated LPN #433 told her no one put him to bed or checked on him until 4:30 A.M. She stated the resident was to be checked on every two hours and they did not do it. She stated they left him up all night and nobody checked on him. She stated the Director of Nursing was saying the resident refused to go to bed and she charted he had refused. She stated how would she know she was not even there. She stated Resident #42 never refused to go to bed plus he told LPN #433 he had wanted to go to bed at 10:00 P.M. The family member then started crying and apologized for crying indicating this was all still so