Every finding on record at Astoria Skilled Nursing and Rehabilitation

Based on observation, staff and resident interviews, record review and review of the facility mealtimes, the facility failed to ensure residents received a nourishing evening snack when there was more than 14 hours between a substantial evening meal and breakfast the following day, and failed to ensure no more than 14 hours passed between the evening meal and breakfast the next day unless approved by resident council. This affected four (Resident #16, #17, #34 and #37) residents of eight residents reviewed for food and nutrition. The facility census was 64. Findings include:Review of the facility's mealtimes provided by Dietary Manager (DM) #810 revealed breakfast would start in the dining room at 7:30 A.M. and hall trays would be passed beginning at 7:45 A.M., lunch would start in the dining room at 12:00 P.M. and hall trays would be passed beginning at 12:15 P.M., and dinner would start in the dining room at 4:30 P.M. and hall trays would be passed beginning at 4:45 P.M. There was approximately 14.75 to 15 hours between dinner time and breakfast time. Review of Resident #17's medical record revealed she was admitted to the facility on [DATE] with diagnoses including unspecified protein-calorie malnutrition, type two diabetes mellitus, and dementia. Review of the care plan for Resident #17 with a date initiated of 06/05/25 revealed the resident had a chewing deficit and required a pureed texture diet. An interview on 08/28/26 at 6:28 A.M. with Resident #17 revealed she stated she was hungry. An observation on 08/28/26 at 6:31 A.M. of the snack tray at the nurse's station of the unit where Resident #17 resided revealed there were three packs of graham crackers and two small bowls of sliced peaches on the tray. An interview on 08/28/26 at 6:31 A.M. with Licensed Practical Nurse (LPN) #804 at the time of the observation of the snack tray revealed Resident #17 had not received a snack off the snack tray because there were no snacks on the tray that would be appropriate to give for Resident #17's pureed diet order. LPN #804 confirmed there were three packs of graham crackers and two small bowls of peaches, and that was the snack tray that was provided for evening snack pass on 08/27/26. An observation on 08/28/26 at 7:16 A.M. of the breakfast meal service in the dining room by the 400, 500, and 600 units revealed Resident #1 was seated in her wheelchair at the table in the dining room. At 7:25 A.M. facility staff were observed escorting additional residents to the dining room. An observation on 08/28/26 at 7:55 A.M. revealed Resident #17 was observed sitting by the nurses' station asking the staff if there was anything to eat because she was hungry. An observation on 08/28/26 at 8:13 A.M. revealed the staff began passing out the meal to the residents in the dining room by the 400, 500 and 600 units, which was 43 minutes later than the scheduled 7:30 A.M. tray pass in the dining room. At 8:17 A.M. Resident #17 was observed in the dining room yelling at staff to bring her food. An interview on 08/28/26 at 10:53 A.M. with the Administrator verified breakfast service was to begin at 7:30 A.M. in the dining room, as stated in the mealtimes schedule. The Administrator confirmed there was 14.75 to 15 hours between dinner and breakfast. The Administrator stated this had not been a problem until now. An interview on 08/28/26 at 11:45 A.M. with DM #810 revealed breakfast tray line had started in the kitchen at 7:30 A.M. and it took approximately 30 to 40 minutes to finish the tray line. An interview on 08/28/26 at 12:53 P.M. with Resident #16 revealed he got hungry at night between dinner and breakfast. Resident #16 stated the facility did not provide snacks at night, and he relied on his brother to bring snacks in for him to keep in his room. An interview on 08/28/26 at 12:58 P.M. with Resident #34 revealed he got hungry at night, and the facility did not always have snacks available between dinner and breakfast time. An interview on 08/28/26 at 1:02 P.M. with Resident #37 revealed he got hungry at night between dinner and breakfast. Resident #37 stated he was diabetic and sometimes needed snacks between meals, but the facility did not offer substantial snacks, just small packages of crackers or cookies and nothing else to go with it. Resident #37 stated he would consider a peanut butter and jelly sandwich substantial, but the kitchen closed at 8:00 P.M. every night and residents could not get sandwiches after the kitchen closed. The facility was unable to provide evidence that Resident Council approved exceeding 14 hours between dinner and breakfast. This deficiency represents noncompliance investigated under Complaint Number 3106018.

Based on record review, interview, observation, and review of the facility policy and procedure, the facility failed ensure the smoking policy included information regarding safe smoking areas for independent smokers. This affected two residents (#8 and #53) of three residents (#8, #45, and #53) reviewed for smoking but had the potential to affect seven residents (#4, #8, #22, #23, #25, #30, and #53) the facility identified as independent smokers. The facility census was 68.Findings Include:Review of the medical record for Resident #8 revealed an admission date of 03/26/26. Diagnoses included above the knee amputation of the right leg, chronic obstructive pulmonary disease, and mantle cell lymphoma.Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #8 had moderately impaired cognition, required setup/clean for eating, partial/moderate assistance for toileting hygiene and transfers and supervision/touch assistance with bed mobility. The assessment also indicated the resident used tobacco.Review of the medical record for Resident #53 revealed an initial admission date of 12/29/25. Diagnoses included chronic obstructive pulmonary disease, depression, and sciatica on the right side. Review of the quarterly MDS assessment dated [DATE] revealed Resident #53 had intact cognition, was independent with eating, required supervision/touch assistance with toileting hygiene, bed mobility and transfers.Review of the list of the list of independent smokers provided by the facility revealed seven residents (#4, #8, #22, #23, #25, #30, and #53) the facility identified as independent smokers. Observation on 07/14/26 at 9:55 A.M. of the area of the facility and across the road from the facility revealed there was no sidewalk on either side of the road, there was no crosswalk, and the road was slightly narrow for one lane of traffic in each direction. There was a building to the right and directly across from the facility was a lot that had cars and a trailer, and to the left was another building. There were no signs indicating no smoking in these areas. Interviews on 07/14/26 at 12:45 P.M. and at 12:49 P.M. with Resident #8 and Resident #53 revealed there was a designated area in the back of the facility with designated times for smoking. Both residents stated they were told they had to go off the facility property, across the street from the facility to smoke outside of the designated smoking times. Both residents stated they were not sure why and Resident #53 felt it was not safe. Interview on 07/14/26 at 1:12 P.M. with the Administrator revealed residents who were deemed safe to smoke independently were told to smoke off the property if outside designated times. The Administrator stated the residents were choosing to go across the street on their own.Interview on 07/14/26 at 2:32 P.M. with the Administrator, Director of Nursing (DON), and Regional Quality Assurance Nurse (RQAN) #510 verified both Resident #8 and #53 were able to go off the property to smoke and that it had always been in place to go off property via a leave of absence (LOA). The Administrator verified it was not in the smoking policy. Review of the facility policy titled Smoking Policy-Residents, revised August 2022 revealed smoking was only permitted in designated resident smoking areas which were located outside of the building. The policy did not indicate that independent smokers had to sign out for LOA to go off the property to smoke outside of the designated smoking times.This deficiency represents non-compliance investigated under Complaint Number 3074255.

Based on observation, interview and review of facility policy, the facility failed to ensure foods were properly stored in the [NAME] Unit kitchenette. This had the potential to affect all 32 residents (#1, #3, #8, #10, #17, #18, #20, #21, #24, #27, #29, #33, #34, #37, #40, #41, #43, #44, #45, #46, #48, #50, #51, #56, #57, #61, #62, #64, #65, #69, #70 and #77) who resided on the [NAME] Unit. The facility census was 67.Findings include:Observation on 06/04/26 at 11:45 A.M. of the [NAME] Unit kitchenette refrigerator revealed two opened and undated individual apple sauce cups and two CoolCheck (insulated food pan) containers with undated resident food items in them (one container was dirty). Further observation of the kitchenette revealed on the first shelf of the left upper cabinet was an opened and undated half loaf of bread and an opened and undated container of chow main noodles. On the second shelf of the same cabinet containing food items, was a CoolCheck container and four empty red containers with a biohazard label on each of the containers. Concurrent interview with Nursing Scheduler (NS) #878 confirmed the two opened and undated individual apple sauce cups, the two CoolCheck containers with resident food items in them with one container being dirty, the opened and undated half loaf of bread, the opened and undated container of chow main noodles and the CoolCheck container and four red containers with biohazard labels on them stored in the same cabinet at food items. NS #878 stated the refrigerator was for the storage of resident food items, including snacks from the kitchen and food brought in by residents or their families. NS #878 confirmed that the biohazard containers should not have been stored in the cabinet with food items. NS #878 stated housekeeping was responsible for keeping the kitchenette and refrigerator clean, the aides were responsible for dating food items, and the nurses were responsible to clean the CoolCheck containers as they were used to keep nutritional supplements cold during medication pass and were not to be used for resident food items. Observation on 06/04/25 at 12:10 P.M. of the [NAME] Unit kitchenette, and concurrent interview with Housekeeping Supervisor (HS) #860 confirmed the biohazard containers were not to be stored in the kitchenette, the nurses were to clean the CoolCheck containers and aides were responsible to date food items. Further interview with HS #860 confirmed the refrigerator needed cleaned and the CoolCheck container was dirty. HS #860 stated she had been off for the past two days and was responsible for cleaning the [NAME] Unit kitchenette. HS #860 confirmed housekeeping cleaned the kitchenettes on both the East and [NAME] Units and on Fridays the outdated and unlabeled items were cleaned out. HS #860 stated cabinets were to be cleaned daily. Review of facility policy titled, Food Receiving and Storage policy, revised October 2017, revealed food services, or other designated staff, would maintain clean food storage areas at all times. Food items and snacks kept on the nursing units must be maintained as indicated: all food items must be placed in the refrigerator located at the nurses' station and labeled with a date and discarded after three days; all foods belonging to residents must be labeled with the resident's name and date; other opened containers must be dated and sealed or covered during storage; medications and blood or blood products may not be stored in the same refrigerator with food; and pesticides and other toxic substances and drugs would not be stored in the kitchen area or in store rooms for food.

Based on medical record review, interview, and facility policy review, the facility failed to ensure Resident #43 was free from a significant medication error. This affected one Resident (#43) of five reviewed for unnecessary medications. The facility census was 67.Findings include: Review of the medical record for Resident #43 revealed an admission date of 04/22/26 and diagnoses including cerebral infarction, essential hypertension, and chronic kidney disease.Review of a physician's order dated 04/22/26 revealed inject 1 milligram (mg) subcutaneously of Heparin Sodium (an injectable anticoagulant medication commonly used to prevent blood clots) 5000 unit per milliliter (Unit/mL) two times per day for prophylaxis. The order was discontinued on 04/24/26.Review of a physician's order dated 04/24/26 revealed inject 5000 units subcutaneously of Heparin Sodium 5000 Unit/mL two times per day related to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.Review of the Medication Administration Record (MAR) for April 2026 revealed the evening dose of Heparin on 04/23/26, 04/27/26, and 04/28/26 was marked as on hold. The morning dose of Heparin was blank on 04/24/26. The morning dose of Heparin on 04/25/26 was marked as see nurses note. Review of progress notes revealed a note dated 04/23/26 at 8:36 P.M. which revealed the facility was awaiting delivery of Resident #43's Heparin from pharmacy. An additional progress note dated 04/25/26 at 8:25 A.M. revealed the facility was awaiting delivery of Resident #43's Heparin from pharmacy. It was noted there were no doses left in the automated medication dispensing cabinet (Pyxis). Progress notes dated 04/28/26 at 4:30 A.M. and 04/28/26 at 8:01 P.M. revealed Resident #43's Heparin was on order.Interview on 06/08/26 at 12:14 P.M. with Regional Quality Assurance Nurse (RQAN) #798 confirmed Resident #43 had missed doses of Heparin medication on 04/23/26, 04/24/26, 04/25/26, 04/27/26, and 04/28/26. RQAN #798 indicated the facility kept two doses of Heparin in their e-kit.Review of the facility policy Administering Medications dated April 2019 revealed medications were administered in accordance with prescriber orders including any required time frames.This deficiency represents non-compliance investigated under Complaint Numbers 2960506, 2794766, and 2592902.

Based on observation, medical record review and staff interview, the facility failed to ensure admission assessments were completed timely upon admission. This affected one resident (Resident #66) of 26 residents reviewed for assessments. The facility also failed to ensure positioning aide devices were in place as ordered by the physician. This affected one resident (Resident #67) of five residents reviewed for accidents. The facility census was 67. Findings include: 1. Review of Resident #66's closed medical record revealed an admission date of 02/25/26 with diagnoses that included status post spinal surgery, intervertebral disc disease, spinal stenosis and diabetes mellitus. Review of the admission Minimum Data Set (MDS) 3.0 assessment with a reference date of 02/25/26 indicated an admission date of 02/25/26. Further review of the medical record revealed the admission nursing assessment was not completed until 02/26/26 at 5:50 P.M., one day after admission to the facility. Review of the resident's progress notes revealed no evidence of any notation made by medical staff of the resident arriving to the facility to identify the time the resident arrived at the facility. On 06/04/26 at 9:05 A.M., interview with the Director of Nursing (DON) verified the admission assessment was completed on 02/26/26, and not 02/25/26 which was the day the resident was admitted . The DON also verified no progress note was entered to indicate when Resident #66 arrived at the facility. 2. Review of the medical record for Resident #67 revealed an admission date of 03/21/23 with diagnoses that included cerebrovascular accident, osteoarthritis to the left hip and benign prostate hypertrophy. Further review of the medical record including physician's orders revealed on 03/16/26, the resident's physician ordered the use of a lateral support for trunk positioning in the wheelchair. Observation of Resident #67 on 06/02/26 at 9:10 A.M. revealed the resident was seated in a high-back wheelchair in the East unit dining room. The resident was asleep and leaning over the left arm rest of the wheelchair, poorly positioned. Continued observation at 9:18 A.M. revealed Resident #67 woke up and repositioned himself independent to a correct position in the wheelchair. At 9:19 A.M., the resident had again leaned over the wheelchair's left arm rest. Observation of Resident #67 on 06/02/26 at 3:21 P.M. revealed the resident asleep in his bed. The high-back wheelchair was observed in his room. There was no evidence of any left lateral support to the wheelchair observed at this time. On 06/02/26 at 3:55 P.M. observation and interview with the DON verified the left lateral support was not in place to Resident #67's high-back wheelchair as ordered.

Based on medical record review, observation, interview, and facility policy review, the facility failed to ensure a dependent resident received adequate assistance with nail care. This affected one Resident (#62) of three residents reviewed for activities of daily living. The facility census was 67.Findings include: Review of the medical record for Resident #62 revealed an admission date of 05/20/25 and diagnoses including acute respiratory failure with hypoxia, moderate protein calorie malnutrition, anxiety disorder, contracture of bilateral knees, muscle wasting and atrophy, and stage three chronic kidney disease.Review of Medicare Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #62 was cognitively intact. Resident #62 was dependent on staff assistance for bathing, dressing, personal hygiene, transfers, and mobility.Observation on 06/01/26 at 10:01 A.M. revealed Resident #62's fingernails appeared long and had visible debris under the nails.Interview on 06/01/26 at 10:01 A.M. with Resident #62 revealed he agreed his fingernails appeared long and dirty. Resident #62 stated no one had offered to cut them, so he had been biting them or trying rip them off.Observation and interview on 06/01/26 at 10:09 A.M. with Assistant Director of Nursing (ADON) #851 confirmed Resident #62's nails were long and dirty. ADON #851 stated nail care was completed by Certified Nursing Assistants (CNAs) on an as needed basis. ADON #851 asked Resident #62 if he would like his nails cut and he stated that he would like them cut.Review of the facility policy Fingernails/Toenails, Care of dated February 2018 revealed nail care included daily cleaning and regular trimming.This deficiency represents non-compliance investigated under Complaint Number 2794766.

Based on medical record review, interviews, and facility policy review, the facility failed to ensure resident were provided the opportunity to participate in care plan meetings. This affected two residents (#3 and #43) of three residents reviewed for care plan meetings. The facility census was 67.Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 04/18/26 and diagnoses included type II diabetes mellitus, end stage renal disease, acute and chronic respiratory failure with hypoxia, and chronic systolic congestive heart failure.Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #3 was cognitively intact.Review of the Care Conference Sheet and Care Plan Review dated 05/15/26 revealed a plan of care meeting was held including the interdisciplinary team and Resident #3's family was noted to teleconference to the meeting. There was no evidence of Resident #3 being invited to or participating in the care conference.Interview on 06/02/26 at 8:43 A.M. with Resident #3 revealed he had not attended or participated in a care plan meeting. Resident #3 stated he thought someone from his family participated but stated he would like to participate as well.Interview on 06/04/26 at 7:58 A.M. with the Administrator confirmed there were no additional care plan meetings with evidence of Resident #3's participation.2. Review of the medical record for Resident #43 revealed an admission date of 04/22/26 and diagnoses included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting non-dominant left side, and symptoms and signs involving cognitive functions following cerebral infarction.Review of the MDS admission assessment dated [DATE] revealed Resident #43 was cognitively intact.Review of the Plan of Stay Conference sheet dated 05/21/26 revealed a phone conference was held with Resident #43's daughter, Rehab Director #842, and Social Service Director (SSD) #843 to discuss an insurance cut and the plan for long term care. There was no evidence Resident #43 participated in the meeting.Interview on 06/01/26 at 9:34 A.M. with Resident #43 revealed she had not participated in a care plan meeting since admission.Interview on 06/04/26 at 8:25 A.M. with the Administrator confirmed there were no additional care plan meetings with evidence of Resident #43's participation.Review of the facility policy Care Planning - Interdisciplinary Team dated September 2013 revealed a comprehensive care plan would be developed within seven days of completion of the resident assessment. The resident and/or representatives were encouraged to participate in the development and revision of the care plan. Every effort would be made to schedule care plan meetings at the best time of day for the resident and family.

Based on medical record review and interview, the facility failed to ensure residents or their representatives were notified in writing of the facility's transfer and bed hold policy for Residents #13, #75, and #76. Additionally, the facility failed to notify the Office of the State Long-Term Care Ombudsman of Residents #75 and #76's transfers to the hospital. This affected three Residents (#13, #75, and #76) of three residents reviewed for hospitalizations. The facility census was 67.Findings include: 1. Review of the medical record for Resident #75 revealed an admission date of 01/24/25 and discharge date of 01/17/26. Diagnoses included chronic respiratory failure with hypoxia, morbid obesity, type II diabetes mellitus, depressive type schizoaffective disorder, personality disorder, and paranoid personality disorder. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #75 was cognitively intact. Review of a progress note dated 01/17/26 revealed Resident #75 called emergency medical services (EMS) due to thoughts of suicide. Resident #75 was on one-on-one supervision for safety. Review of progress note dated 01/18/26 revealed Resident #75 was transferred for inpatient psych stay for suicidal ideations. Further review of the medical record revealed there was no evidence Resident #75 was provided a copy of the transfer notice or a bed hold notice. There was no evidence the Office of the State Long-Term Care Ombudsman was notified of Resident #75's transfer to the hospital. Interview on 06/08/26 at 2:34 P.M. with the Administrator confirmed they were unable to provide evidence of transfer notice, bed hold, or notice to the Office of the State Long-Term Care Ombudsman for Resident #75's hospitalization. 2. Review of the medical record for Resident #76 revealed an admission date of 05/28/21 and discharge date of 04/21/26. Resident #76 was readmitted to the facility on [DATE]. Diagnoses included anxiety disorder, hypertension, type II diabetes mellitus, cognitive communication disorder, cirrhosis of the liver, and morbid obesity. Review of the Brief Interview for Mental Status (BIMS) score completed on 05/29/26 revealed Resident #76 had a severe cognitive impairment. Review of a progress note dated 04/21/26 revealed Resident #76 was transferred for inpatient psych stay for medication review and adjustment. Further review of the medical record revealed there was no evidence Resident #76 was provided a copy of the transfer notice or a bed hold notice. There was no evidence the Office of the State Long-Term Care Ombudsman was notified of Resident #76's transfer to the hospital. Interview on 06/08/26 at 2:34 P.M. with the Administrator confirmed they were unable to provide evidence of transfer notice, bed hold, or notice to the Office of the State Long-Term Care Ombudsman for Resident #76's hospitalization. 3. Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (CVA) with left-sided hemiparesis, diabetes mellitus, chronic respiratory failure with hypoxia, schizoaffective disorder, hypertension, anemia, post-traumatic stress disorder (PTSD), polyneuropathy, peripheral vascular disease (PVD), atrial fibrillation, insomnia, and aphasia. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 required moderate assistance with transfers, setup to maximum assistance with activities of daily living, was frequently incontinent of bladder, and occasionally incontinent of bowel.Review of a nursing progress note dated 04/10/26 at 12:10 P.M. revealed an order was received to send Resident #13 to the hospital for a stroke workup. The note documented the resident was sent to a local hospital and a voicemail was left for the resident representative.Review of a nursing progress note dated 04/11/26 at 6:45 P.M. revealed Resident #13 returned to the facility from the hospital in stable condition.Record review failed to reveal evidence Resident #13 or the resident representative was provided written bed-hold information at the time of the hospital transfer. Further review failed to reveal evidence a transfer/discharge notice was provided to the resident or resident representative.Interview with the Administrator on 06/08/26 at 2:34 P.M. confirmed there was no evidence Resident #13 or the resident representative had been provided transfer notice or bed-hold information related to the resident's hospital transfer.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain effective infection control standards during wound care. This affected one resident (#57) of three residents reviewed for wound care. The facility identified eight current residents with pressure ulcers at the time of the annual survey. The facility census was 67.Findings include: Record review revealed Resident #57 admitted on [DATE] with diagnoses including cerebrovascular accident (CVA), metabolic encephalopathy, polyneuropathy and dementia.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 had moderate cognitive impairment, required maximum assistance with activities of daily living and mobility, was frequently incontinent of bladder, occasionally incontinent of bowel, and reported occasional pain.Review of the care plan dated 04/24/26 revealed Resident #57 was identified as being at risk for impaired skin integrity with new wounds and increased nutritional needs related to wound healing. Interventions included to provide a therapeutic diet, obtain weekly weights and place interventions to promote skin integrity.Review of Resident #57's physician orders revealed a wound treatment order dated 05/13/26 for the right gluteal wound directing staff to cleanse the wound with wound wash, pat dry, apply collagen powder, and cover with Triad (a zinc-oxide based cream that provides a protective moisture barrier) twice daily and as needed for soilage. Resident had an additional order dated 05/13/26 for a low air loss mattress related to wound management. Continued review of the physician orders revealed an additional wound treatment order dated 05/20/26 called for the resident's sacral wound to be cleansed with wound wash, pat dry, apply Triad cream every shift and as needed. An additional order dated 05/27/26 for the left inner buttock wound directed staff to cleanse the wound with wound wash, pat dry, apply Triad cream every shift and as needed.Observation on 06/03/26 at 9:43 A.M. revealed Registered Nurse (RN) #870 with assistance from Certified Nursing Assistant (CNA) #872 providing wound care to Resident #57. RN #870 brought the wound treatment cart into the resident's room during wound care. During the treatment, RN #870 wore gloves while providing wound care and subsequently opened a drawer to obtain additional wound cleanser without removing gloves or performing hand hygiene. CNA #872 removed dirty gloves and donned clean gloves during the procedure without performing hand hygiene between glove changes. Following resident care, staff continued to touch environmental surfaces while still wearing the soiled gloves.Interview with the Director of Nursing/Infection Preventionist on 06/04/26 at 12:45 P.M. revealed wound treatment carts were not to be brought into resident rooms due to the potential for contamination and cross transmission of pathogens. The Director of Nursing/Infection Preventionist further stated staff were expected to perform hand hygiene following glove removal and prior to donning clean gloves and should not touch environmental surfaces with contaminated gloves.Review of the facility Wound Care Policy revealed staff were to wash and dry their hands thoroughly prior to wound care, after removal of dressings, and following completion of wound treatment. The policy further directed staff to take only the disposable supplies necessary for treatment into the resident room and indicated disposable supplies could not be returned to the treatment cart. This deficiency represents non-compliance investigated under Complaint Number 2592902.

Based on observation, family representative interview, staff interview, and medical record review, the facility failed to maintain complete and accurate medical records. This affected three residents (#2, #57, and #67) of seven residents reviewed for accuracy of records during the annual survey. The facility census was 67. Findings include: 1. Telephone interview with Resident #67's responsible party on 06/01/26 at 1:35 P.M. revealed on 03/10/26 the resident had a fall incident in the facility. Review of the medical record for Resident #67 revealed an admission date of 03/21/23 with diagnoses that included cerebrovascular accident, osteoarthritis to the left hip and benign prostate hypertrophy. Further review of the medical record including progress notes revealed no documentation of any fall or accident incident on 03/10/26. A progress note on 03/16/26 indicated the resident's responsible party was updated on prior incident and new interventions for fall prevention. On 06/02/25 at 3:50 P.M., an interview with the Director of Nursing (DON) indicated Resident #67 had an incident on 03/10/26 where he slid out of his wheelchair. Further interview with the DON on 06/03/26 at 10:35 A.M. verified the accident incident on 03/10/26 for Resident #67 was not documented in the medical record. 2. Review of Resident #2's medical record revealed an admission date of 02/01/24 with diagnoses that included presence of a percutaneous endoscopic gastrostomy (PEG) tube (used for providing liquid nutritional support via a tube straight to the stomach through a surgically created opening through the abdominal wall), cerebrovascular accident, diabetes mellitus, chronic kidney disease and protein-calorie malnutrition. Further review of the medical record including current physician's orders indicated on 04/17/26 Resident #2's tube feeding orders noted if the resident ate less than fifty percent of a meal to provide a 240 milliliter (ml) bolus of Nepro Carb Steady (liquid nutritional support) via the resident's PEG tube. Review of the Medication Administration Record (MAR) for Resident #2 revealed documentation each day for each meal indicating the percent of meal consumed and a check mark with the nurse's initials. It was unable to be determined if the tube feeding was provided or held based upon the physician's orders. On 06/02/26 at 12:35 P.M., an interview with Licensed Practical Nurse (LPN) #897 verified the MAR for Resident #2 did not indicate whether the tube feeding was held or administered and was unclear. On 06/02/26 at 12:40 P.M., an interview with the DON verified the MAR for Resident #2 did not indicate if the bolus tube feeding was held or administered. The DON stated the MAR needed to be clarified to ensure proper documentation based upon the percentage of meal consumed. 3. Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (CVA), metabolic encephalopathy, chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), dementia, hypertension, and obesity. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had a BIMS score of 9 indicating moderately impaired cognition and required extensive to maximum assistance with activities of daily living and mobility. Review of the care plan revised 05/20/26 revealed Resident #57 had actual skin integrity alterations including a left inner buttock Stage III pressure ulcer, right gluteal Stage II pressure ulcer, and sacral moisture associated skin damage (MASD). Review of the Skin Grid Pressure Assessments revealed the resident's left buttock pressure ulcer was documented as a Stage three (III) pressure ulcer (wound featuring full-thickness skin loss where subcutaneous fat is visible) on 05/13/26 and 05/20/26. Review of the Skin Grid Pressure assessment dated [DATE] revealed the same left buttock pressure ulcer was documented as a Stage two (II) pressure ulcer (partial-thickness skin loss that presents as a shallow red/pink open wound, a scrape, or an intact/ruptured blister and does not extend into subcutaneous tissue). Further review revealed the wound measurements and wound location remained consistent with the previously identified left buttock pressure ulcer. Review of consultant Wound Care documentation notes dated 05/13/26, 05/20/26, and 05/27/26 revealed the resident's left inner buttock wound continued to be identified as a Stage III pressure ulcer. Interview with Assistant Director of Nursing (ADON) #851 on 06/04/26 at 11:49 A.M. revealed the left buttock pressure ulcer had been incorrectly entered as a Stage II pressure ulcer on the 05/27/26 Skin Grid Pressure Assessment and should have been documented as a Stage III pressure ulcer. ADON #851 stated the Stage II documentation was entered in error. This deficiency represents non-compliance investigated under Complaint Number 2960506.

Based on resident representative interview, medical record review and staff interview, the facility failed to ensure timely notification was provided to a resident representative following an accident. This affected one (Resident #67) of five residents reviewed for accidents. The facility census was 67. Findings include: Review of the medical record for Resident #67 revealed an admission date of 03/21/23 with diagnoses that included cerebrovascular accident, osteoarthritis to the left hip and benign prostate hypertrophy. Further review of Resident #67's medical record, including progress notes, revealed no documentation of any fall, accident, or incident on 03/10/26. A progress note on 03/16/26 indicated the resident's responsible party was updated on a [unspecified] prior incident and new interventions for fall prevention. Telephone interview with Resident #67's responsible party on 06/01/26 at 1:35 P.M. revealed on 03/10/26, the resident had a fall incident in the facility and the responsible party was not notified until several days after the incident occurred. On 06/02/25 at 3:50 P.M., interview with the Director of Nursing (DON) indicated Resident #67 had an incident on 03/10/26 where he slid out of his wheelchair. Further interview with the DON on 06/03/26 at 10:35 A.M. verified the fall incident on 03/10/26 for Resident #67 was not documented in the medical record and the resident's responsible party was not notified until 03/16/26. This deficiency represents non-compliance investigated under Complaint Number 2960506.

Based on medical record review and staff interview, the facility failed to ensure residents were not receiving duplicate medication treatment for gastroesophageal reflux disease (GERD). This affected one (Resident #11) of five residents reviewed for medications. The facility census was 67.Findings include: Review of Resident #11's medical record revealed an admission date of 06/12/24 with diagnoses that include GERD, diabetes mellitus, and chronic kidney disease. Further review of the medical record including current physician's orders revealed on 07/16/25 Resident #11 was prescribed Famotidine (an oral medication used to treat GERD) 20 milligrams (mg) twice daily and on 08/21/25 was prescribed Pantoprazole (an oral medication used to treat GERD) 40 mg twice daily. Further review of the medical record including progress notes and physician and nurse practitioner examination notes revealed no evidence of any rationale indicating concurrent use of the two medications used to treat GERD. On 06/04/26 at 9:00 A.M., interview with the Director of Nursing (DON) verified no rationale was indicated for Resident #11 to be treated with duplicate medication therapy with Famotidine and Pantoprazole to treat the resident's GERD.

Based on observation, interview, and record review, the facility failed to ensure a comprehensive assessment and informed consent were completed prior to implementing bed rails for one resident (#57). The facility census was 67. Findings include: Record review revealed Resident #57 admitted on [DATE] with diagnoses including cerebrovascular accident (CVA), metabolic encephalopathy, polyneuropathy and dementia.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 had moderate cognitive impairment, required maximum assistance with activities of daily living and mobility, was frequently incontinent of bladder, occasionally incontinent of bowel, and reported occasional pain.Review of the Restraint Enabler Decision Tree dated 05/09/26 identified side rails as an enabler device. Further record review failed to reveal documentation of informed consent or a comprehensive assessment for the resident's side rail use.Observations of Resident #57 conducted throughout the survey period from 06/01/26 through 06/08/26 revealed bilateral half side rails in use while the resident was in bed. The resident was observed utilizing the side rails for repositioning and bed mobility.Interview with the Director of Nursing (DON) on 06/08/26 at 1:00 P.M. confirmed the facility was unable to provide documentation of informed consent for Resident #57's side rail use. The DON further confirmed the facility was unable to provide documentation of a comprehensive assessment for the resident's side rail use.

Based on medical record review, observation, interview, dialysis contract review, and facility policy review, the facility failed to ensure routine monitoring was completed prior to and following dialysis treatments. Additionally, the facility failed to provide evidence of ongoing communication and collaboration with the dialysis center. This affected one Resident (#3) of one resident reviewed for dialysis treatments. The facility census was 67.Findings include: Review of the medical record for Resident #3 revealed an admission date of 04/18/26 and diagnoses include type II diabetes mellitus, end stage renal disease, and essential hypertension.Review of a progress note dated 04/19/26 revealed Resident #3 had fistula (a surgically created connection between an artery and a vein, typically in the arm used to facilitate hemodialysis treatments) to the right arm with bruit (audible whooshing or humming sound heard when listening to the fistula with a stethoscope) and thrill (palpable vibration or buzzing sensation felt when you place your fingers over the fistula) present. Resident #3 noted to receive hemodialysis.Review of the physician's orders dated 04/19/26 revealed Resident #3 had hemodialysis treatments on Mondays, Wednesdays, and Fridays. Resident #3 had additional orders also dated 04/19/26 to send dialysis communication forms with the resident on dialysis treatment days, to obtain vital signs pre- and post-dialysis on Mondays, Wednesdays, and Fridays, and to monitor the dialysis site [fistula] for bruit and thrill as applicable. Review of the Minimum Data Set (MDS) admission assessment revealed Resident #3 was cognitively intact. Resident #3 received dialysis treatments.Review of the Treatment Administration Record (TAR) for April 2026, May 2026, and June 2026 (through 06/05/26) revealed no evidence the facility had monitored Resident #3's dialysis site for bruit and thrill. There was no evidence of monitoring of Resident #3's vital signs following dialysis treatments on 04/24/26, 04/29/26, 05/04/26, 05/06/26, 05/13/26, 05/18/26, and 05/27/26.Further review of the medical record revealed no evidence of dialysis communication forms were completed or sent with Resident #3 to dialysis treatments. Observation on 06/03/26 at 9:40 A.M. revealed Resident #3 was picked up for his scheduled dialysis treatment. Resident #3 did not have a dialysis communication form with him. Interview on 06/03/26 at 11:01 A.M. with Registered Nurse (RN) #868 revealed Resident #3 went to dialysis treatments. RN #868 stated Resident #3 had a fistula. RN #868 stated she would check over Resident #3 prior to dialysis treatments for blood glucose check and vital signs. RN #868 stated the dialysis center faxed over pre and post treatment pages. RN #868 stated Resident #3 did not have any kind of communication binder or pre- or post-dialysis assessments in the electronic medical record (EMR).Interview on 06/03/26 at 8:07 A.M. with the Director of Nursing (DON) and Regional Quality Assurance Nurse (RQAN) #798 revealed the dialysis center faxed reports to the facility. The DON indicated they normally send a communication form with the resident to dialysis. RQAN #798 indicated dialysis keeps the forms and confirmed she was unable to provide evidence the facility completed communication forms with dialysis. The DON provided a dialysis communication binder for review. The DON was unable to provide evidence of monitoring of bruit and thrill and monitoring of vital signs post-dialysis on 04/24/26, 04/29/26, 05/04/26, 05/06/26, 05/13/26, 05/18/26, and 05/27/26.Interview on 06/04/026 at 8:14 A.M. with Assistant Director of Nursing (ADON) #851 revealed the facility did not send any paperwork with Resident #3 to dialysis. ADON #851 indicated the dialysis center faxed her copies of their reports.Review of the dialysis communication binder revealed there was a copy of the face sheet, a copy of code status, and a copy of current orders. There were also blank copies of a dialysis communication form. There were no forms that had been previously completed. The facility had copies of post dialysis communication forms from the dialysis center.Review of facility policy, End-Stage Renal Disease, Care of a Resident with dated September 2010 revealed an agreement would state how communication would exchange between facilities. Review of the Long-Term Care Facility Outpatient Dialysis Service Coordination Agreement dated 09/11/25 revealed the long-term care facility shall provide interchange of information useful or necessary for care of end stage renal disease (ESRD) residents. Both parties shall ensure there was documented evidence of collaboration of care and communication.

Based on medical record review, observation, interview, and facility policy review, the facility failed to maintain safe and responsible smoking practices. This affected two Residents (#13 and #24) of 25 sampled residents. The facility census was 67. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 04/15/24 and diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type II diabetes mellitus, and bipolar type schizoaffective disorder.Review of a Smoking assessment dated [DATE] revealed Resident #13 had cognitive loss and visual deficits which required Resident #13 to have supervision during smoking. The facility would store Resident #13's lighter and cigarettes. 2. Review of the medical record for Resident #24 revealed an admission date of 03/23/26 and diagnoses including chronic obstructive pulmonary disease, dementia with behavioral disturbance, and essential hypertension. Further review of the medical record revealed Resident #24 was not identified as a smoker.Interview on 06/01/26 at 1:00 P.M. with the Administrator revealed the smoking area was at the back of the facility. The Administrator showed the smoking area which was near the dumpster area with ashtrays.Observation on 06/03/26 at 9:56 A.M. revealed more than 10 cigarette butts on the ground and nearby combustible trash in the courtyard by the 400 hallway. This courtyard was not identified as a smoking area, so no ashtrays nor a metal can were readily available. Interview on 06/03/26 at 9:56 A.M. with Regional Maintenance Director #797 observed and verified the presence of cigarette butts in a non-smoking area.Observation on 06/03/26 at 10:40 A.M. revealed more than 10 cigarette butts on the ground and nearby combustible trash in the courtyard by 100 hallway. This courtyard was not identified as a smoking area, so no ashtrays nor a metal can were readily available.Interview on 06/03/26 at 10:40 A.M. with Regional Maintenance Director #797 observed and verified the presence of cigarette butts in a non-smoking area.Observation on 06/04/26 at 11:34 A.M. revealed Resident #13 and #24 sitting in the courtyard by the 400 hallway. Resident #13 and #24 were observed to have a lit cigarette. There were no staff observed supervising the two residents. It was unclear where the cigarettes or lighter had come from.Interview on 06/04/26 at 11:36 A.M. with Registered Nurse (RN) #799 confirmed Resident #13 and #24 were observed to have a lit cigarette in the 400 hallway courtyard and were unsupervised. RN #799 stated she was unsure of the smoking safety needs of Resident #13 and Resident #24.Review of the undated smoking times provided by the facility revealed staff would assist residents with smoking at 6:00 A.M., 10:00 A.M., 1:00 P.M., 3:00 P.M., 6:00 P.M., and 9:00 P.M. Review of the facility policy Smoking Policy - Residents dated August 2022 revealed smoking was only permitted in designated resident smoking areas. Ashtrays would be available in smoking areas. Any resident with smoking privileges that required monitoring shall have direct supervision of staff or family while smoking. Residents were not permitted to give smoking materials to other residents.

Based on observation, interview, record review, and facility policy review, the facility failed to provide the necessary treatment to promote healing of a pressure ulcer for one resident (#57) of three residents reviewed for pressure ulcers. The facility identified eight residents with current pressure ulcers at the time of the annual survey. The facility census was 67. Findings include: Record review revealed Resident #57 admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (CVA), metabolic encephalopathy, polyneuropathy and dementia.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 had moderate cognitive impairment, required maximum assistance with activities of daily living and mobility, was frequently incontinent of bladder, occasionally incontinent of bowel, and reported occasional pain.Review of the care plan revised 05/20/26 revealed Resident #57 had actual skin integrity alterations including a left inner buttock pressure wound, right gluteal fold pressure wound, and sacral moisture associated skin damage (MASD). The care plan further directed staff to encourage and assist with turning and repositioning with routine rounds and as needed. Additional interventions included the use of a pressure-relieving mattress and follow-up by the facility's wound care team.Review of consultant wound care notes dated 05/13/26 revealed Resident #57 had a right gluteal stage two pressure ulcer (a partial-thickness wound involving the epidermis and/or dermis and typically presents as a shallow, open wound) which was noted to have declined. The note identified poor compliance with offloading (strategic redistribution of pressure and friction away from a vulnerable or ulcerated area to promote healing) as a contributing factor. Further documentation revealed education was provided to staff and the resident regarding the importance of offloading to promote wound healing and recommended pressure reduction interventions and repositioning per facility protocol. Subsequent wound care follow up notes dated 05/20/26 and 05/27/26 continued to include recommendations for pressure reduction and repositioning interventions.Observation of Resident #57 on 06/03/26 at 8:53 A.M. revealed Resident #57 was lying on her right side in bed. A follow-up observation at 9:43 A.M. during wound care revealed the resident remained positioned on her right side. Following completion of wound care, STNA #872 offered to place a pillow under the resident's hip. Resident #57 stated she was comfortable. No education was provided to the resident regarding the benefits of turning and repositioning to promote wound healing. Subsequent observations at 10:30 A.M., 11:00 A.M., 12:30 P.M., and 1:42 P.M. revealed Resident #57 remained positioned on her right side in bed. During the observation period, staff were not observed assisting the resident with turning or repositioning.Interview with Resident #57 on 06/03/26 at 10:35 A.M. revealed staff asked her if she wanted to turn once in awhile. Resident #57 stated she was unaware that turning and relieving pressure from her wounds would assist with healing and stated she would turn if she knew it would help. Resident #57 further stated staff occasionally offered a pillow under her hip but had not explained the importance of turning and repositioning for wound healing.Interview with Certified Nursing Assistant (CNA) #872 on 06/08/26 at 9:46 A.M. revealed she attempted to keep Resident #57 comfortable and would sometimes allow the resident to remain in the same position when the resident complained of pain associated with her sacral wounds and stated she was comfortable. CNA #872 stated she had educated the resident on the need to turn and reposition; however, she believed the resident forgets.Review of the facility Wound Care Policy revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. The policy directed staff to use supportive devices as instructed during wound care. After wound care was completed, position the bed linens and resident for comfort. The policy indicated to report other information in accordance with facility policy and professional standards of practice. This deficiency represents non-compliance investigated under Complaint Number 2592902

Based on observation and interview, the facility failed to ensure past survey results were available in a prominent area accessible to residents. This affected twelve residents (#8, #13, #16, #22, #25, #30, #31, #43, #52, #63, #64, and #68) who were in attendance at the Resident Council interview during the annual survey and had the potential to affect all residents of the facility. The facility census was 67. Findings include: Interview on 06/02/26 at 2:00 P.M. with Residents #8, #13, #16, #22, #25, #30, #31, #43, #52, #63, #64, and #68, during the Resident Council interview, revealed each had no knowledge of where the facility's past survey results were kept, nor did any of the residents know if they were available for review without having to request them.Observation on 06/04/26 at 11:34 A.M. revealed a notice measuring approximately eight inches by six inches on the reception desk stating, Past survey results available upon request. Continued observation revealed a small note measuring approximately seven inches by three inches to the left of the main entryway in a display case which stated, Past survey results are available upon request. Observation on 06/04/26 at 11:36 A.M. revealed Resident #8 entered the facility through the main entryway, utilizing a wheelchair for mobility. Further observation revealed the display case containing the notice that past survey results were available upon request was above the resident's eye level. Interview on 06/04/26 at 11:45 A.M. with Resident #8 confirmed the height of the display case at the entrance of facility was too high for residents in wheelchairs to view notices in the display case. Resident #8 stated he had not noticed the posting at the reception desk with information on how to access past survey results. Interview on 06/08/26 at 10:43 A.M. with Receptionist #859 revealed the facility's past survey results were kept in a binder behind the reception desk and residents needed to ask for the binder to review the facility's survey history. Continued interview with Receptionist #859 revealed no residents had requested to view the survey binder. Interview on 06/08/26 at 1:15 P.M. with Activity Director (AD) #852 confirmed the facility's past survey results were located in a binder behind the reception desk and residents had to ask to see the past survey results. AD #852 verified the facility's past survey results were not accessible to residents in any other area.

Based on observation and interview, the facility failed to ensure a list of advocacy groups, including contact information, was easily accessible to residents in wheelchairs. This affected nine (#8, #13, #16, #22, #25, #43, #52, #64 and #68) of twelve residents who attended the Resident Council interview and utilized wheelchairs for mobility. The facility identified 47 (#1, #2, #3, #4, #7, #8, #9, #10, #11, #12, #13, #16, #18, #22, # 23, #25, #26, #29, #32, #33, #34, #36, #37, #38, #39, #40, #41, #42, #43, #44, #46, #48, #49, #50, #51, #52, #56, #57, #58, #59, #62, #64, #65, #67, #68, #76 and #77) residents who utilized wheelchairs for mobility. The facility census was 67.Findings include:Interview on 06/02/26 at 2:00 P.M. with Residents #8, #13, #16, #22, #25, #30, #31, #43, #52, #63, #64, and #68, during the Resident Council interview, revealed the residents did not know where the list of advocacy groups with contact information was located within the facility. Residents #8, # 13, #16, #22, #25, #43, #52, #64 and #68 utilized wheelchairs for mobility.Observation on 06/04/26 at 11:34 A.M. revealed a display case on the wall to the left of the main door of the facility containing a listing of advocacy groups with contact information. Continued observation revealed a notice, located approximately four to five feet high, on the receptionist's desk with the local Ombudsman's contact information.Observation on 06/04/26 at 11:36 A.M. revealed Resident #8 entered the facility through the main entrance, utilizing his wheelchair for mobility. Further observation revealed the display case containing the list of advocacy groups was above the resident's eye level. Interview on 06/04/26 at 11:45 A.M. with Resident #8 confirmed the height of the display case at the entrance of facility was too high for residents in wheelchairs to view. Resident #8 stated he had not noticed the Ombudsman information at the receptionist's desk.Interview on 06/08/26 at 10:43 A.M. with Receptionist #859 revealed they had some requests for the Ombudsman's contact information and pointed out there was an informational sheet on the desk with contact information. Interview on 06/08/26 at 1:15 P.M. with Activity Director (AD) #852 confirmed the only location for the full list of advocacy groups was located in the display case near the main entrance of the facility and there were no other accessible lists posted in the facility.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of a facility investigation, employee file review, manufacturer guideline review, policy review and interview, the facility failed to ensure Resident #100 was transferred safely with a mechanical (Hoyer) sling lift resulting in a fall with major injury.Actual harm occurred on 09/11/25 when Resident #100, who was dependent on two staff members and the use of a mechanical sling lift with transfers, sustained a fall and a right hip fracture when being transferred from his bed to wheelchair with only the assistance of one staff member, Certified Nursing Assistant (CNA) #50 and the Hoyer lift. During the transfer, the lift tipped, Resident #100 fell to the floor, was emergently transferred to hospital and admitted with a closed right hip fracture. The resident was discharged from the hospital and admitted to another facility. This affected one resident (#100) of five residents reviewed for accidents/falls. The facility census was 65.Findings Include: Review of the closed medical record for Resident # 100, revealed an admission date of 08/23/22 and a discharge date of 09/11/25 with diagnoses including multiple fractures of ribs, unspecified side, subsequent encounter for fracture with routine healing, syncope and collapse, and anxiety disorder.Review of Resident #100's care plan, revised 07/09/24, revealed Resident #100 had an activity of daily living (ADL) deficit. An intervention (dated 12/09/24) included in the care plan indicated the resident required a mechanical lift for transfers.Review of the fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 10 out of 15. The resident was assessed to be dependent on staff with the use of a mechanical (Hoyer) lift for all transfers, and dependent on staff for bed mobility.Review of a nursing progress note dated 09/11/25 at 9:27 A.M., authored by Registered Nurse (RN) #5, revealed the nurse was called to the resident's room. Upon arrival the resident was lying on the floor with the Hoyer pad under him. Pain was noted when the resident tried to move his leg. Review of a facility investigation report, dated 09/11/25, revealed Resident #100 was being transferred via mechanical lift on 09/11/25 by CNA #50. During the transfer, the Hoyer lift tipped over resulting in Resident #100 falling to the floor. Nursing staff were immediately called to the resident's room to assess him for injuries; Emergency Medical Services (EMS) were called, and Resident #100 was transferred to the hospital.Review of CNA #50's witness statement dated 09/11/25 revealed she was transferring Resident #100 alone and the Hoyer lift tipped over. In review of the findings, the facility confirmed CNA #50 was self-transferring Resident #100 with the use of a Hoyer lift. (This was not the facility procedure to transfer residents with the Hoyer/mechanical lift using one staff).Interview on 10/30/25 at 9:39 A.M. with CNA #30 revealed she was working with CNA #50 on 09/11/25, but not on the same unit. CNA #50 did not ask CNA #30 for assistance with Hoyer lift transfers. However, after the incident occurred, CNA #50 asked CNA #30 for assistance getting Resident #100 up off the floor. CNA #30, CNA #50 and CNA #20 went to Resident #100's room and immediately called for the nurse, RN #5. Interview on 10/30/25 at 9:49 A.M. with CNA #20 revealed she was working with CNA #50 on 09/11/25 but not on the same unit. CNA #50 did not ask CNA #20 for assistance with Hoyer lift transfers. However, CNA #30 and CNA #50 did ask CNA #20 for assistance with Resident #100 after the incident occurred. Upon entering the room, they immediately called for the nurse, RN #5. Interview on 10/30/25 at 4:19 P.M. with RN #5 revealed CNA #50 was working the same unit as RN #5 on 09/11/25 and the CNA did not ask for assistance with transferring Resident #100 with the Hoyer lift. The CNAs working did notify her Resident #100 was on the floor and RN #5 immediately assessed him and called for the Director of Nursing (DON). Resident #100 was transferred to the ER.Interview with the DON on 10/30/25 at 11:06 A.M. confirmed Resident #100 fell while he was being transferred by staff using a Hoyer lift. She stated, based on the facility investigation, CNA #50 was using the Hoyer lift to transfer Resident #100 by herself, which was not the guidance provided in the manufacturer's guidelines and not according to facility policy, the lift tipped and Resident #100 fell to the floor resulting in a right hip fracture. The DON verified the resident did not return after hospital discharge but was admitted to another facility. The DON shared, following the incident, the facility completed the investigation, and initiated a plan of correction for this situation, which included education for nurses and CNAs, audit of residents who required mechanical lifts to ensure the lifts were being used appropriately, and mechanical lift transfer audits three times a week for four weeks with concerns being shared with Quality Assurance (QA) Committee. The DON revealed the corrective actions had been completed.Review of CNA #50's employee file revealed a hire date of 08/27/25 and acknowledgement of facility policies and procedures dated 08/27/25. Further review revealed a suspension disciplinary action dated 09/11/25 for the employee being in violation of prohibited behavior as described in the employee handbook. The violation was of an established policy, procedure or risk. Also contained in the employee file was a termination disciplinary action dated 09/15/25 with the nature of the disciplinary action to be the employee was in violation of prohibited behavior as described in the employee handbook for failure to follow the Hoyer lift policy. Review of facility policy titled Using a Mechanical Lifting Machine revised July 2017 revealed the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It was not a substitute for manufacturer's training or instructions. General guidelines at least two nursing assistants are needed to safely move a resident with a mechanical lift.Review of the facility policy titled Managing Falls and Fall Risk revised March 2018 revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of facility's mechanical lift manual dated 2022, for Invacare Reliant 450/600 revealed Although Invacare recommends that two assistants be used for all lifting preparation and transferring from and transferring to procedures, the equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the healthcare professional for each individual case.The deficient practice was corrected on 10/10/25, when the facility completed the following corrective actions: On 09/11/25, CNA #50 who was responsible for the error was immediately educated on transferring a resident with a mechanical lift and had a transferring competency completed by the DON with no new variances identified.On 09/11/25, CNA #50 was suspended by the DON and Administrator. As a result of the employee's failure to follow the Hoyer Lift policy, CNA #50 was terminated on 09/15/25.On 09/11/25, the MDS coordinator completed a full audit of residents (#10, #11, #13, #14, #15, #27, #29, #52, #56, #58, #59 and #100) with mechanical lifts to ensure mechanical lifts were being used appropriately and per policy by staff.On 09/11/25 direct care staff; 10 RNs, 11 LPNs, and 37 CNAs were educated on proper transferring. Staff were required to complete a mechanical lift demonstration by DON/designee. A plan for new staff to be educated upon hire as part of orientation was also implemented. Beginning 09/12/25 the DON/designee began auditing mechanical lift transfers for three residents, three times a week, for four weeks. The audits were completed on 10/10/25.Variances were corrected immediately upon discovery and education provided as needed. The results of the audits were reported to the facility quality assurance (QA) committee monthly. On-going compliance would be maintained through recommendations of the committee. No transfer injuries occurred between 09/12/25 and 10/30/25. This deficiency demonstrates non-compliance investigated under Master Complaint Number 2620511 and Complaint Number 2615493.

THE FOLLOWING SURVEY FINDINGS PERTAINS TO AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of weather information at www.timeanddate.com, review of the police report, review of the facility's Self-Reported Incident (SRI) investigation, resident representative interview, staff interview, and facility policy review, the facility failed to provide adequate interventions and supervision to prevent the elopement of a severely cognitively impaired resident. This resulted in Immediate Jeopardy when Resident #12, who was severely cognitively impaired and high risk for wandering and elopement, exited the facility in the early morning hours on [DATE] and was found by a concerned citizen/Good Samaritan walking in the middle of the road approximately 0.55 miles away from the facility. The resident was dressed in a t-shirt, pajama pants and had no shoes on. Local weather temperatures were approximately 46 degrees Fahrenheit during this time. The police were called on [DATE] at 4:16 A.M. by this Good Samaritan and the resident was transported to the hospital for evaluation. Prior to the incident, Resident #12 required the use of a wander guard device and there was no verifiable evidence the wander guard was in place on the night of the elopement. This affected one resident (Resident #12) out of three residents reviewed for elopement. The facility census was 60. On [DATE] at 10:05 A.M., the Administrator, Director of Clinical Services #101, Regional Compliance Specialist, and Regional Director of Operations #118 were notified Immediate Jeopardy began on [DATE] when Resident #12 exited the facility during the overnight hours without staff knowledge and was located 0.55 miles away from the facility in the middle of the road by a Good Samaritan, who notified local law enforcement on [DATE] at 4:16 A.M. Facility staff were unaware of Resident #12's absence until local law enforcement notified them the resident was located outside the facility on [DATE] at 4:35 A.M. The Immediate Jeopardy was removed and the deficiency was corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at 4:35 A.M., local law enforcement called facility and spoke with Licensed Practical Nurse (LPN) #107. Law enforcement officers stated they located Resident #12 walking and were taking him to the hospital for an assessment.On [DATE] from 4:35 A.M. to 4:40 A.M., LPN #107 and Registered Nurse (RN) #108 completed a head count of all residents. All other residents were present and accounted for with no variances noted.On [DATE] at 4:40 A.M., LPN #107 attempted to notify Resident #12's Responsible Party of Resident #12 leaving the facility and being taken to the hospital by law enforcement and had to leave a message.On [DATE] from 4:45 A.M. to 5:17 A.M., LPN #107 notified RN Manager #109 of Resident #12 leaving the facility and being taken to the hospital by law enforcement. RN Manager #109 notified the Administrator.On [DATE] at 5:00 A.M., RN Manager #109 attempted to contact Resident 12's Responsible Party with no answer and had to leave a message.On [DATE] from 7:00 A.M. to 7:10 A.M., RN Manager #109 called and spoke with the hospital nurse for an update on Resident #12. The hospital nurse stated Resident #12 appeared to be in good health, was free of any injuries or adverse outcomes, was absent of any distress, and they were monitoring him. On [DATE] at 8:15 A.M., RN #111 spoke with Resident #12's Responsible Party (RP) and notified the RP of Resident #12 leaving the facility and being taken to hospital by law enforcement.On [DATE] at 9:30 A.M., Resident #12 returned to the facility accompanied by paramedics. RN #111 obtained vital signs and assessed Resident #12. Resident #12's Responsible Party was notified of the resident's return to the facility and present at bedside at the time of assessment. Resident #12 was non-verbal, had non-sensical speech, and was unable to provide any pertinent information due to cognitive impairment.On [DATE] at 9:30 A.M., Resident #12's wander guard was placed back on by RN #111 and Resident #12 was placed on one-on-one (1:1) supervision.On [DATE] from 9:00 A.M. to 1:57 P.M., RN Manager #109, Administrator, and Assistant Director of Nursing (ADON) #103, Therapy Director #112, and Housekeeping Supervisor #113 educated facility staff on the Wandering/unsafe resident policy, Behavioral Assessment, Intervention, and Monitoring policy, ensuring interventions were in place for residents with exit seeking behaviors which may include but was not limited to 15 min checks, 1:1, and wander guards, ensuring interventions were put back in place when residents returned from the hospital, and not giving residents or families the door code.On [DATE] from 9:30 A.M. to 10:17 A.M., RN #101 audited resident orders and care plans for wander guards. Any variances were corrected immediately upon audit.On [DATE] from 10:00 A.M. to 11:30 A.M., Receptionist #114 and Maintenance Director #115 audited all residents with wander guards for functioning, placement, and to ensure all were within expiration date. All were placed properly, functioning appropriately, and not expired. No variances were noted.On [DATE] from 10:00 A.M. to 11:30 A.M., Maintenance Director #115 audited all exit doors and the wander guard system at all doors to ensure proper function. On [DATE] from 10:30 A.M. to 12:00 P.M., RN #101 audited 30 days of current resident progress notes to ensure if behaviors consistent with exit seeking were noted, then residents had appropriate interventions in place. On [DATE] at 12:00 P.M., Resident #12's Nurse Practitioner (NP) #116 was notified of Resident #12 leaving the facility and being taken to hospital by law enforcement with return to facility. On [DATE] from 12:00 P.M. to 12:15 P.M., the Administrator audited the facility records of exit door function checks for the last 30 days. On [DATE] from 12:00 P.M. to 2:00 P.M., ADON #103 completed elopement and wandering risk assessments on all in-house residents. On [DATE] from 12:45 P.M. to 12:54 P.M., an elopement drill was completed by Maintenance Director #115. On [DATE] from 2:00 P.M. to 2:10 P.M., an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the facility correction plan including ongoing compliance.On [DATE] from 3:45 P.M. to 4:15 P.M., ADON #103 educated all current resident responsible parties via phone that they were to ensure staff let them in and out the doors when the front door was locked and should not enter the code themselves or let anyone else out without staff assistance.On [DATE] from 3:45 P.M. to 4:00 P.M., SecureCare was called and the front door code was changed by Maintenance Staff #117.On [DATE], the Care Conference form was updated by the Administrator to include education for new families and a reminder for others to request staff assistance with doors when locked, not put in code themselves or assist anyone else out of facility.On [DATE], Resident #12's care plan was updated by RN #101 to include wandering and elopement risk with interventions including 1:1 as needed, monitor and report changes in behaviors, orient to new surroundings, provide diversional activities of interest as needed (based on the activities assessment completed on [DATE] at the time of admission), redirect as needed, and wander guard with placement and function checks as ordered. Beginning on [DATE], nursing staff would monitor the effectiveness of interventions for Resident #12 by reviewing point of care (POC) documentation five days weekly Monday through Friday and conducting a 72-hour review on Monday for weekend POC. CNAs would report behaviors to the charge nurse if behaviors were not resolved with interventions. In addition, 1:1 (staff) supervision would continue for Resident #12 until discharge.Beginning on [DATE], if a call off occurred for a person doing 1:1 supervision, the Administrator would be immediately notified and re-assign floor staff, management staff, or other department staff to cover 1:1 as appropriate. The Administrator would oversee 1:1 coverage scheduling.Beginning on [DATE], all new hires and agency staff would be educated regarding the facility's Wandering/unsafe resident policy, Behavioral Assessment, Intervention, and Monitoring policy, ensuring interventions are in place for residents with exit seeking behaviors which may include but was not limited to 15 min checks, 1:1, and wander guards, ensuring interventions are put back in place when residents return from the hospital, and not giving residents or families the door code.Beginning on [DATE], the Administrator or designee would review all door checks five times a week for four weeks to ensure all doors were checked and functioning appropriately. All variances would be corrected upon discovery and education/follow-up would be provided as deemed necessary.Beginning on [DATE], Maintenance Director #115 or designee would conduct elopement drills weekly for four weeks to ensure staff respond accordingly. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.Beginning on [DATE], the DON or designee would assess all residents with wander guards to ensure proper placement, function and expiration three times a week for a period of four weeks. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.Beginning on [DATE], the Administrator or designee would audit the wander guard system and resident accessible exit doors to ensure they were functioning properly three times a week for a period of four weeks to ensure all doors were intact and functioning properly, including alarm. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.Beginning on [DATE], the DON or designee would complete elopement and wandering risk assessments for facility residents weekly for period of four weeks to ensure no changes in behavior patterns or acute changes in condition affecting mental status were present placing residents at risk for elopement and ensuring that appropriate and effective interventions were in place. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.Beginning on [DATE], the DON or designee would audit progress notes five times weekly for a period of four weeks to ensure any residents with behaviors that increase risk for elopement or exit seeking have appropriate interventions in place.Beginning on [DATE], the Administrator or Designee would interview two visitors three times weekly for four weeks to ensure visitors were aware they were not to enter door codes when the door was locked and should wait for staff assistance to exit facility, as well as not let anyone else out without staff assistanceBeginning on [DATE], the facility Quality Assurance (QA) committee would review audits weekly to ensure compliance. Variances would be corrected Immediately upon discovery and education provided. Results of these audits would be reported to the facility quality assurance committee. Ongoing compliance would be maintained by recommendations of the facility quality assurance committee. Findings include: Review of the medical record for Resident #12 revealed an admission date of [DATE] with diagnoses including senile degeneration of brain, anxiety disorder, encephalopathy, and type two diabetes mellitus. Review of the admission Nursing Observation, dated [DATE] at 5:58 P.M., revealed Resident #12 was alert and oriented to person only. Resident #12 required limited assistance for walking in his room and in the corridor. Review of the wandering risk assessment, dated [DATE] at 6:13 P.M., revealed Resident #12 was at high risk for wandering with a score of 12. The assessment indicated Resident #12 was disoriented, did not understand surroundings, admitted within the last month, ambulated with one assist, had a diagnosis of Alzheimer's disease, and had a history of wandering. Review of the Brief Interview for Mental Status (BIMS) assessment, dated [DATE] at 6:14 P.M., revealed Resident #12 had severe cognitive impairment with a score of 0 out of 15. Review of the elopement risk assessment, dated [DATE] at 6:15 P.M., revealed Resident #12 was physically capable of leaving the building, was confused to time and place, and displayed wandering behaviors. Interventions included a wander guard (a device intended to alarm/alert staff when they approach or exit secured areas) Review of the progress note dated [DATE] at 4:06 A.M. revealed on [DATE] at approximately 11:57 P.M., Resident #12 experienced a seizure, paramedics were called, and paramedics transported Resident #12 to the emergency room for evaluation on [DATE] at 12:30 A.M.Review of LPN #107's witness statement (obtained [DATE]) indicated when paramedics were attempting to transport Resident #12 to the hospital on [DATE] around 12:30 A.M., the door alarms were sounding due to the resident's wander guard, and the paramedics cut the wander guard off Resident #12 at that time. Review of the progress note dated [DATE] at 6:30 A.M. revealed Resident #12 returned from the hospital at that time and vitals were obtained, skin was assessed, morning medication was provided, and the physician and family were notified of the resident's return. The note did not include any information regarding a wander guard being applied upon the resident's return to the facility. Review of RN #119's witness statement (obtained [DATE]) indicated she was the nurse who re-admitted Resident #12 upon returning from the hospital on [DATE] at 6:30 A.M. and she was unaware that Resident #12 required a wander guard. RN #119 did not verify whether Resident #12 had a wander guard or not and did not assess the resident's need for a wander guard. Review of the progress note dated [DATE] at 11:19 A.M. revealed Resident #12 appeared very tired and the resident's nurse practitioner was notified. There were no progress notes written between [DATE] at 11:19 A.M. and [DATE] at 4:35 A.M. Review of the facility's incident log revealed an elopement incident for Resident #12 on [DATE] at 4:35 A.M. Review of CNA #122's witness statement (obtained [DATE]) indicated Resident #12 was wandering the building, he was re-directed to watch television, CNA #122 went to complete rounds, and at some point a door alarm was going off but other staff responded so she continued to do her work. Review of CNA #123's witness statement (obtained [DATE]) indicated Resident #12 was wandering throughout the building during the night and staff were attempting to keep the resident occupied with television, snacks, and conversation. The statement included at 2:30 A.M., CNA #123 observed another staff member escort Resident #12 back to his room. Review of RN #108's witness statement (obtained [DATE]) indicated Resident #12 was wandering during the night throughout the building and staff attempted to redirect with snacks, television, and conversation. Around 2:30 A.M., Resident #12 appeared to be very tired and was escorted back to his room. Review of LPN #107's witness statement (obtained [DATE]) indicated Resident #12 set off the door alarm on the 200-hall around 3:00 A.M. and was redirected at that time, however, the resident continued to walk up and down the hallway. Review of CNA #121's witness statement (obtained [DATE]) indicated Resident #12 would not stay in his room and was walking throughout the building, setting off the door alarm on the 200-hall during her shift. The statement included CNA #121 last saw Resident #12 walking in the hall around 3:30 A.M. Review of CNA #106's witness statement (obtained [DATE]) indicated they last saw Resident #12 walking back and forth in the hallway on [DATE] at 3:50 A.M. and redirection attempts were unsuccessful. Review of LPN #107's witness statement (obtained [DATE]) indicated she worked night shift on [DATE] and Resident #12 went to the hallway doors, which caused the alarms to sound, and she assumed the (resident's) wander guard had been re-applied. LPN #107 did not assess Resident #12 to verify that the wander guard had been re-applied. LPN #107 indicated Resident #12's responsible party had informed staff upon admission that wandering and pacing were normal behaviors for Resident #12, so they allowed the resident to do so and redirected as needed. LPN #107 received a phone call from local law enforcement on [DATE] at 4:35 A.M. informing her that Resident #12 had been found while walking and they were taking the resident to the emergency room for evaluation. LPN #107's statement also indicated the front doors were locked, however, the family members of another resident were letting themselves in and out of the building throughout the night without staff assistance and LPN #107 believed Resident #12 followed someone out the door as they left. Review of CNA #120's witness statement (obtained [DATE]) indicated Resident #12 was observed walking up and down the hallway on [DATE] at 3:45 A.M. and that CNA #106 attempted to get Resident #12 to lay down at 3:50 A.M., which the resident refused. CNA #120's statement further revealed other residents had family members in the facility throughout the night who knew the code to the doors and were going in and out without staff assistance. CNA #120 indicated Resident #12 must have followed someone out the door. Review of the historical weather information, obtained from https://www.timeanddate.com/weather/usa/[NAME]/historic?month=10&year=2025, revealed on [DATE] around 3:51 A.M. the outside temperature was 46 degrees Fahrenheit, and the skies were clear. Review of police report #2510545 revealed law enforcement received a call on [DATE] at 4:16 A.M. from a concerned citizen (Good Samaritan) regarding a man walking in the road wearing a t-shirt, pajama pants, and no shoes. Law enforcement arrived on scene on [DATE] at 4:29 A.M. and identified the man as Resident #12. Law enforcement officers called the facility to notify them that they had located Resident #12, facility staff confirmed Resident #12 was supposed to be in their care, and facility staff were unable to provide a response as to how this happened. Review of the progress note dated [DATE] at 4:35 A.M. revealed the facility received a phone call from local law enforcement, who found Resident #12 walking outside the facility with no apparent injuries. The police officers took Resident #12 to the hospital for an assessment. Immediate interventions upon return would be a wander guard and one-on-one (1:1) staff supervision. Review of the progress note dated [DATE] at 9:30 A.M. revealed Resident #12 returned from the hospital at that time, vitals were obtained, Resident #12 was placed on 1:1 supervision, and a wander guard was placed on the resident's right ankle. Review of the functional abilities and goals assessment, dated [DATE] at 1:18 P.M., revealed Resident #12 required (staff) supervision or touching assistance for putting on/taking off footwear, lying to sitting on edge of bed, sit to stand, transfers, walking 10 feet, walking 50 feet, walking 150 feet, going up and down a one-step curb, going up and down up to 12 steps, and did not utilize a wheelchair or scooter. Review of the elopement care plan, initiated [DATE], revealed Resident #12 was at risk for elopement or wandering due to impaired cognition. Interventions included one-on-one staff as needed ([DATE]), monitor and report changes in behavior ([DATE]), orient resident to new surroundings ([DATE]), provide diversional activities of interest ([DATE]), redirect as needed ([DATE]), and wander guard with placement and function checks as ordered ([DATE]). Review of the physician's orders for Resident #12 revealed an order for a wander guard to be placed to right ankle and check placement and function every shift dated [DATE]. On [DATE] at 1:01 P.M., an interview with RN Manager #109 revealed on the day of the incident, she got a call that Resident #12 was taken to the hospital by the police. RN Manager #109 said she notified the Administrator and ADON #103. RN Manager #109 stated Resident #12 had been wandering quite a bit that night and staff tried to re-direct with activities and snacks but were unsuccessful. RN Manager #109 revealed staff reported to her Resident #12 was last seen about 30-45 minutes prior to the call from the police. RN Manager #109 confirmed on the previous night, Resident #12 had to be transported to the hospital and the paramedics cut the wander guard off Resident #12 at that time. On [DATE] at 1:40 P.M., an interview with CNA #106 revealed following admission Resident #12 had been wandering around the halls and it was impossible to chase someone around for 12 hours and get all other assigned duties completed at the same time. CNA #106 said Resident #12 would not sit for long periods of time and was going door to door all night long. CNA #106 said Resident #12 was supposed to have a wander guard, but it had been cut off when he went to the hospital the night before. CNA #106 said the wander guard must not have been put back on because it would have alarmed when the resident left the facility if it had been in place. CNA #106 revealed Resident #12 had set off the alarm on the egress door on the hallway, but he thought Resident #12 followed someone out the front sliding doors because those doors stay open for several seconds once they are unlocked. On [DATE] at 2:12 P.M., an interview with Resident #12's Responsible Party revealed Resident #12 went to the hospital in the middle of the night Friday ([DATE]) and the resident's wander guard had been removed at the time he left the facility. The Responsible Party indicated she believed facility staff neglected to replace the wander guard upon his return to the facility on Saturday ([DATE]). She further revealed when Resident #12 admitted , she informed the facility of his wandering behaviors and the need for a wander guard at all times. On [DATE] at 4:19 P.M., an interview with the Administrator verified the witness statements obtained from staff reflected the on-duty nurse was unaware of Resident #12's need for a wander guard upon his return to the facility on [DATE] at 6:30 A.M. The Administrator also verified on [DATE] Resident #12 was located approximately one-half mile away from the facility. Attempts to contact LPN #107 and RN #108, who were on duty at the time of the incident, were unsuccessful during the investigation. Review of the facility policy titled Wandering and Elopements, revised [DATE], revealed the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment. If at risk for wandering or elopement, resident care plans would include strategies and interventions to maintain the resident's safety. If a resident goes missing, the elopement/missing resident emergency procedure would be initiated to: a) determine if the resident was out on authorized leave; b) if not on authorized leave, initiate a search of the building and premises; and c) if unable to locate the resident, notify the Administrator, the DON, the resident's legal representative, the attending physician, and law enforcement officials. This deficiency represents non-compliance investigated under Complaint Number 2642643.

Based on closed record review, review of hospital records, facility policy and procedure review and interview, the facility failed to timely identify a change in Resident #60's respiratory condition to ensure the resident was provided timely and adequate care. This affected one resident (#60) of three residents reviewed for death. Actual harm occurred beginning on [DATE] when the facility failed to adequately and timely treat respiratory complications exhibited by Resident #60, who was a Full Code (advance directives), non-verbal and had a tracheostomy, which included labored breathing, the resident testing positive for Coronavirus (COVID-19) and being treated with an antibiotic for pneumonia. Licensed Practical Nurse (LPN) #500, who had not provided care to Resident #60 prior to [DATE], failed to notify Physician #511 regarding Resident #60's labored breathing as well as the resident having no secretions when suctioned. Resident #60 was found on [DATE] at 5:10 A.M. by LPN #500 with no vital signs, cardiopulmonary resuscitation (CPR) was initiated, and Resident #60 was transferred to the hospital. Findings included: Review of the closed medical record revealed Resident #60 was admitted to the facility on [DATE] with diagnoses including respiratory failure, pneumonia, encephalopathy, protein-calorie malnutrition, thyrotoxicosis, asthma, epilepsy, pacemaker status, transient ischemic attacks, tracheostomy, anxiety disorder, depression, acute kidney failure, adult failure to thrive, and diabetes. Resident #60 passed away at the hospital on [DATE]. Review of a handwritten baseline plan of care dated [DATE] revealed Resident #60 had behaviors related to touching and manipulating her tracheostomy. Interventions included one on one and conversations to calm and reassure. Review of a handwritten baseline plan of care dated [DATE] revealed Resident #60 had behaviors related to touching and manipulating her tracheostomy. Interventions included using towels or fidget balls for diversional activity, educating the need to not handle her tracheostomy, and medication review related to anxiety. Review of the progress note dated [DATE] at 12:30 P.M. revealed Resident #60 was suctioned via inline suction, oxygen continued at four liters (L) and her oxygen saturation (SpO2) was 95 percent (%)(normal range being 95% to 100%, though some people with chronic respiratory issues may have a normal range around 90%). Resident #60's daughter was at the facility earlier and Resident #60 was suctioned, pulled up in bed, in an upright position, oxygen was at four liters, and a nebulizer treatment was given. SpO2 was maintained at 90% to 94%. Resident #60 was alert, and her skin was warm and dry to touch. Resident #60's daughter requested if anything changed to give her a call. At 12:30 A.M. Resident #60's daughter was notified Resident #60 was suctioned and her SpO2 was 95%. Review of the nursing progress note dated [DATE] at 1:48 A.M. revealed at 12:30 A.M., Resident #60 was suctioned and her oxygen continued to be at four liters with a SpO2 level of 95%. At 1:15 A.M. the nurse was called to the resident's room by the nursing assistant, stating the resident did not look right. Once at the bedside the resident's eyes were rolled back in her head, she was able to move her arms and her SpO2 was 70% on four liters of oxygen, she was warm to touch and continued to be non-responsive. The resident's SpO2 was dropping to 60% on oxygen via her tracheostomy. Attempts to suction her obtained no secretions. Resident #60 continued to have shallow breath and her SpO2 was continuing to drop. The nurse called for assistance from the registered nurse on the other floor, a non-rebreather venti-mask was obtained and connected to the oxygen. The resident's SpO2 was not improving. Resident #60's respirations stopped, and (chest) compressions were started. Resident #60 was not breathing. The Artificial Manual Breathing Unit (Ambu)-bag was connected to her oxygen (tracheostomy) and rescue breaths were continued until Emergency Medical Services (EMS) arrived. Rescue measures continued and a heart rate of 95 beats per minute (bpm)(normal ranges from 60 to 100 bpm) showed on the monitor. The resident was taken to the hospital and the daughter was called. Review of a progress note dated [DATE] at 3:24 A.M. revealed Resident #60 was at the hospital and placed on a Bipap (machine that supports breathing) and a further update could be obtained at a later time. A progress noted dated [DATE] at 3:32 A.M. revealed the hospital stated Resident #60 was on a ventilator and admitted for further observation. Review of the hospital notes from [DATE] revealed Resident #60 was admitted to the hospital for acute on chronic respiratory failure with hypoxia. It noted the resident was found to be unresponsive by nursing home staff and CPR was initiated. Upon arrival at the hospital the resident had a decent amount of secretions from her tracheostomy and some dried secretions, and there was concern for a possible mucus plug. The resident was placed on a ventilator. The notes included the resident was cachectic (an appearance of extreme loss of muscle and fat mass, often associated with chronic illness) and ill appearing. The notes indicate a high troponin level (indicating damage to the heart muscle) and a high white blood cell count (indicating an infection). The hospital nurse practitioner noted diagnostic impressions as acute on chronic hypoxemic respiratory failure status post chronic tracheostomy, severe sepsis, suspected aspiration pneumonia, and a non-ST-elevation myocardial infarction (NSTEMI)(a type of heart attack where a part of the heart isn't getting enough oxygen). Cardiology was consulted and blood cultures were obtained. There were no additional medical notes related to additional radiologic studies, laboratory services, specific diagnoses, discharge orders, or physician/nurse's notes available to review from the resident's hospital stay. Review of a plan of care dated [DATE] revealed Resident #60 was a full code. Interventions included CPR to be initiated in the event of cardiac arrest and to notify the physician of a change in condition. Review of a progress note dated [DATE] timed 3:04 P.M. revealed Resident #60 was re-admitted to facility. There were no additional notes or records related to updates to the resident's status, discharge plans or discharge orders. Review of Resident #60's physician's orders, dated [DATE] and discontinued on [DATE], revealed the resident was placed on a ventilator at assisted control with settings for Tidal volume (amount of air delivered for each breath) at 18 for 350 milliliters and the Positive End-Expiatory Pressure (the pressure remaining in the residents airways at the end of exhalation) at positive 5.0. The orders also included an order for oxygen to maintain SpO2 greater than 92% and an order to suction via tracheostomy as needed for pulmonary hygiene from [DATE] to [DATE]. Review of the Respiratory Therapist (RT) note dated [DATE] at 11:42 P.M. revealed the nurse called the RT at home via Facetime (a video phone call). The nurse was not able to get the low Tidal volume alarm on the ventilator to stop. The RT suggested several options and nothing worked. The RT instructed the nurse to put the resident back on oxygen, and she was on her way into the facility. Upon arrival, the RT noticed the resident needed suctioned which she had watched the nurse do while they were previously Facetiming. Resident #60's secretions were very thick and copious. The RT called for help and called for the code cart. The RT began bagging 15 liters of oxygen to assist the resident. No chest compressions were necessary, only assistance with breathing. Resident #60's SpO2 remained 58% to 65% until the paramedics arrived. Review of hospital discharge paperwork for Resident #60 revealed she was admitted to the hospital on [DATE] and was discharged back to the facility on [DATE]. The hospital discharge information noted the resident was still a full code, her transfer of care prognosis was poor, and they submitted education material related to community-acquired pneumonia (including instructions to contact the healthcare provider for worsening shortness of breath) with new orders for the antibiotic, Doxycycline 100 milligrams twice daily (with no specified length of time), and no new orders for oxygen therapy. There were no medical notes related to radiologic studies, laboratory services, specific diagnoses, or physician/nurses notes available to review from the resident's hospital stay. Review of the RT progress note dated [DATE] at 12:36 A.M. revealed Resident #60 arrived at the facility at approximately 9:45 P.M. [indicating the night before, on [DATE]]. The resident's SpO2 was 92% to 93% on five liters of oxygen (via tracheostomy). The resident was not ventilator dependent upon her re-admission on [DATE]. The note included the resident was suctioned four times with a small amount of thick white secretions obtained. The RT suggested the nurse's suction the resident about every two to three hours to keep the resident's airway clear. The RT checked the resident's inner cannula for patency, placed it back in and changed the gauze under the tracheostomy. Review of the progress note dated [DATE] at 5:43 P.M. revealed the physician was in for a visit and ordered the antibiotic Doxycycline 100 milligrams twice daily for 10 days for pneumonia, clarifying the length of time the resident was to be on the antibiotic. The resident's responsible party (RP) was notified. Review of the RT progress note dated [DATE] at 10:28 P.M. revealed Resident #60 was on three liters of oxygen with a SpO2 of 98%. The RT decreased her to two liters of oxygen and her SpO2 was 97%. She was suctioned three times with a moderate amount of thick white secretions obtained without incident. She was given two scheduled breathing treatments which she tolerated well. Tracheostomy care was completed, and the inner cannula was examined for patency and put back in place. Review of the RT progress note dated [DATE] at 10:04 P.M. revealed Resident #60 remained on two liters of oxygen with a SpO2 of 97%. She received two scheduled breathing treatments, and she tolerated them well. She was suctioned four times with moderate amounts of very thick white secretions obtained without incident. Tracheostomy care was completed, and the inner cannula was examined for patency and put back in place. Review of the Five-Day Medicare Minimum Data Set assessment dated [DATE] revealed Resident #60 had severely impaired cognition and was dependent on staff for all activities of daily living (ADL). The MDS included Resident #60 was on continuous oxygen therapy, required intermittent suctioning, had a tracheostomy and was admitted with an invasive mechanical ventilator. Review of Resident #60's [DATE] physicians orders revealed the resident was a full code (indicating CPR was to be performed if someone's heart stopped beating or their breathing stopped), tracheostomy to be changed every three months, tracheostomy care twice daily, vital signs twice daily, change tracheostomy dressing every night shift and as needed, droplet isolation precautions due to COVID-19, monitor for signs and symptoms of aspiration pneumonia and notify the physician or nurse practitioner of any abnormal findings. Medication orders included Budesonide suspension 0.5 milligrams per two milliliters inhalation every 12 hours for shortness of breath, Doxycycline 100 milligram tablets twice daily via percutaneous endoscopic gastrostomy (PEG) tube for 10 days, and Ipratropium-albuterol solution 0.5 milligrams per three milliliter inhalation four times daily for pneumonia. Resident #60 did not have an order for mechanical ventilation in [DATE], contrary to the MDS assessment on [DATE]. Review of Resident #60's [DATE] Medication Administration Record (MAR) and TAR revealed her vital signs for day shift on [DATE] included blood pressure 141/64 millimeters of mercury(mmHg)(normal range being around 120/80), pulse 86 beats per minute (bpm)(normal range being around 60 to 100 bpm), temperature 98.1 degrees Fahrenheit (F)(normal range being from 97.8 degrees F to 99.1 degrees F), respirations were 18 breaths per minute (normal range being around 12 to 20), and a SpO2 98%. During the night shift vital sign documentation included blood pressure 108/58, pulse 86 bpm, temperature 98.8 degrees F, respirations 21 breaths per minute, and SpO2 at 98%. Review of the nursing progress note dated [DATE] at 7:34 P.M. revealed Resident #60 was currently on Doxycycline for pneumonia. She had increased yellowish secretions noted during suctioning and coughing. She had no signs of respiratory distress or discomfort. The resident's lung sounds were noted to have rhonchi (lung sounds characterized as a low-pitched continuous sound that resembles snoring or gurgling) when auscultated. The head of the resident's bed was elevated to a 60-degree angle for lung expansion. Her temperature was 97.3 degrees F. Review of the late entry progress notes dated [DATE] at 7:50 P.M., created on [DATE] at 2:06 P.M. by Regional Nurse #600, revealed the physician was in the facility earlier in the day and was aware of Resident #60's continued yellow secretions, and no new orders were noted. However, there was no physician progress note from this date. Review of the SpO2 documentation in the resident's medical record revealed on [DATE] the SpO2 for Resident #60 was 79% at 7:59 A.M. on room air. Oxygen was administered at three liters and her oxygen level came up to 90%. Review of the late entry progress note dated [DATE] at 7:54 A.M., created on [DATE] at 7:55 A.M. by Unit Manager #513, revealed Resident #60 was tested for COVID-19 and was positive. The note included the physician and the resident's responsible party were notified. There were no other nursing progress notes entered on [DATE] related to the resident's condition/status. Review of the plan of care dated [DATE] revealed Resident #60 was at risk for complications related to COVID-19. Interventions included notifying the physician of a worsening condition and to complete a respiratory assessment per facility protocol. Review of the plan of care dated [DATE] revealed Resident #60 was at risk for respiratory complications related to tracheostomy status and was at risk for dislodgement due to her removing her tracheostomy (nursing progress notes included incidents of resident removal on [DATE], [DATE] and [DATE]). Interventions included administering humidified oxygen as prescribed, assessing respiratory rate, depth and quality every shift, assessing tracheostomy incision for redness, warmth, tenderness and exudate, ensuring tracheostomy ties were secured, and suction as necessary. Record review revealed there was no documented evidence of a respiratory/tracheostomy care plan prior to [DATE]. Review of the nursing progress note (authored by LPN #500) dated [DATE] at 7:11 A.M. revealed Resident #60 was having labored breathing when LPN #500 arrived for her shift [the LPN worked on [DATE] at 7:00 P.M. through [DATE] at 7:00 A.M.]. In shift report, the off going nurse stated Resident #60 was positive for COVID-19. LPN #500 noted at 7:00 P.M. [on [DATE]] she administered night medications and checked the resident's SpO2 which was 92%. Resident #60 was suctioned and very little mucous came out. At around 11:00 P.M. [on [DATE]] while the nursing assistants were doing rounds the nurse checked on Resident #60 and she was still having labored breathing and at that time she called the RT [RT #700] to check and see what the resident's baseline (condition) was. The RT informed her that this was the resident's normal. She suctioned her and the resident's SpO2 was 98%. The nursing assistants did rounds at 1:30 A.M. [on [DATE]] with no change in the resident status. Resident #60 was suctioned at 3:30 A.M. with a small amount of mucous obtained. The note included the nurse visually laid eyes on the resident around 4:45 A.M. At approximately 5:10 A.M. the nurse headed down the hall and noticed Resident #60 did not seem to be breathing. She checked for a pulse, called for help, had the aide get a second nurse, and the crash cart. The second nurse called the EMS, a board was placed under the resident, a third nurse began CPR, and the writer/nurse gave breaths through an Ambu-bag. The second nurse took over for this nurse and she went to the nurse's station to print out her face sheet and medication list. EMS arrived and took over performing CPR. The daughter was notified immediately, and the physician was called to inform her of the situation, but she did not answer. It was noted also that at some point between 11:00 P.M. and midnight, the resident's daughter had called the facility for an update and the nurse informed her of what the RT told her about the resident being at her baseline. Review of the nursing progress note dated [DATE] at 5:31 A.M. revealed Resident #60 was transported to the hospital via EMS with CPR in progress to the hospital. Review of the nursing progress note dated [DATE] at 7:57 A.M. revealed the facility received a call from the hospital indicating Resident #60 had passed away. Review of Resident #60's nurse's notes and RT notes from [DATE] through [DATE] revealed no documented evidence that the resident had previously had labored breathing or that it was normal for the resident. On [DATE] at 11:35 A.M. an interview with Regional Registered Nurse #522 revealed Physician #511 was not actually in the building as charted on [DATE] at 7:50 P.M. However, Resident #60 was being treated for pneumonia and yellow secretions at that time. Regional Registered Nurse #522 stated she was not with the company in [DATE]; Additionally, the nurse who wrote the late entry note (Regional Nurse #600) no longer worked for the company. On [DATE] at 11:50 A.M. an interview with Physician #511 revealed Resident #60 was aphasic (unable to speak) after a stroke, she had a tracheostomy and had several re-hospitalizations due to respiratory failure and sepsis. She stated she had spoken to the family several times about updating the resident's code status from full code to do-not-resuscitate (DNR), but they would not change it. She verified she was never called on the night Resident #60 expired. She stated with this resident; she would have had her transferred to the hospital if she was having labored breathing. She stated the only thing she could think of as to why they did not call her or send her out was because there had been times when she was having trouble breathing and she had a mucous plug. She stated the nurses were usually able to suction it out and the resident would be fine afterwards. She stated that she could not speak for the nurse on duty regarding why the nurse did not call her. On [DATE] at 3:56 P.M. an interview with LPN #500 revealed she had not worked at the facility in a while, and this day [[DATE] into [DATE]] was her first time working with Resident #60. She stated she received report from the previous nurse, but she was unsure of the nurse's name. She stated the only thing the previous nurse told her was that Resident #60 had COVID-19, she was pretty much okay, and she was in isolation. She stated she received a call from the resident's daughter around 11:00 P.M. calling to check up on her mom. She stated when she went in to give Resident #60 her medication, she was having trouble breathing so she asked the nursing assistant if it was normal and the nursing assistant stated sometimes the resident had trouble breathing. She stated she called the RT [RT #700] on Facetime and turned the camera around to ask her if her breathing was normal and she also asked the RT if the resident was on hospice. The LPN revealed the resident did not talk, but was awake. She stated the RT told her the resident was like that [indicating her breathing was normal], and the RT never told her Resident #60 might have a mucous plug. She stated she attempted to suction her three times and did not get hardly any mucous out. She stated if she would have known about the mucus plug, she would have done something, but stated she was not told this until after the resident had passed away. She stated other staff told her that she needed to put saline in the resident's tracheostomy to loosen up secretions. She stated Resident #60 was completely dry when she suctioned her. LPN #500 stated she had never had to put saline down a tracheostomy before so she would have had to have someone show her how to do that. She stated she did not go get the other nurse for assistance with the resident until she found the resident not breathing. She stated she called a code [indicating an emergency code for staff to respond as a resident needed immediate medical attention, usually due to cardiac or respiratory arrest], and the other two nurses came over and started CPR. The squad got to the facility fast and took over CPR. She stated she called the daughter and the physician to notify them of what had happened. She stated the doctor did not seem surprised. She stated she never thought to call the doctor earlier in the night because the RT told her this was normal for the resident. On [DATE] at 5:10 P.M. an interview with RT #700 revealed she had been the RT for the facility since 2000. She stated the nurses would Facetime her after hours (when she wasn't working onsite) if they needed to. She was knowledgeable about Resident #60 and stated Resident #60 would get a mucous plug quite often and they would have to suction her very vigorously to get the mucous plug out. She stated when she had a mucus plug, her oxygen saturations would drop, but she would be fine after they removed the mucous plug. She stated it was a little hard to tell with the resident if she had mucous because staff could not always tell when the resident needed suctioned. She stated with most people you could automatically tell if they needed suctioned, but not with Resident #60, so she always told the nurses to make sure they went in and suctioned her even if she did not look like she needed suctioned. She stated the night Resident #60 passed away, LPN #500 called her and asked her if Resident #60 always looked like she was distressed and RT #700 told her yes, she always looked a little bit distressed. She stated her oxygen saturation was up and down, but stated she did not believe the resident's oxygen saturations would be up in the 92% and 98% range if she had a mucous plug. She stated LPN #500 called her around 11:30 P.M. and at that time she did not believe Resident #60 needed to be transferred to the hospital. She stated she had been off that day, so she didn't treat Resident #60 that day. She stated her schedule was to work four days per week from 3:00 P.M. through 11:00 P.M. and that she was the only RT on staff for the facility so she was on-call at all other times. On [DATE] at 10:40 A.M. an interview with Vital Statistics Staff #400 revealed Resident #60's death certificate indicated she expired from respiratory failure. On [DATE] at 11:30 A.M. an interview with Regional Registered Nurse #522 revealed when Resident #60 went out to the hospital on [DATE], they had weaned her off the ventilator and she came back to the facility on oxygen only with humidification. On [DATE] at 2:25 P.M. an interview with Regional Registered Nurse #522 confirmed Resident #60 did not have an actual physician order for oxygen or humidified oxygen when she came back from the hospital on [DATE]. She further confirmed there should have been an order for oxygen with parameters for its use for Resident #60. On [DATE] at 4:10 P.M. a follow-up interview with RT #700 revealed the last day she actually worked with, and assessed Resident #60, was on [DATE]. The RT revealed she could not state what was wrong with Resident #60 on [DATE] or [DATE] as she had not personally assessed the resident on these dates. On [DATE] at 10:01 A.M. an email communication from Regional Registered Nurse #522 revealed that one on one was provided as needed for Resident #60. If the behavior of touching/manipulating her tracheostomy was observed, she would be one on one until determined it was no longer necessary by the team, however, the behavior was not an ongoing issue but was left on the care plan as a precaution. On [DATE] at 1:50 P.M. an interview with RT #700 revealed she did not remember if Resident #60 had oxygen on when she Facetimed the nurse (on [DATE]). She stated Resident #60 did not always need oxygen because it was not an issue of saturation for her and she would not necessarily need the oxygen with labored breathing, because she felt it could be more of a hindrance due to her grabbing at things all the time. On [DATE] at 11:15 A.M. an interview with Family Member #817 revealed she called the nursing home for an update every couple hours for Resident #60. She stated on [DATE] the last time she had called the nursing home to check on her mother was around 2:30 A.M. She stated it was LPN #500's first night working with her mother and the nurse told her she had called the RT to get Resident #60's baseline. She stated LPN #500 never told her that her mother was having trouble breathing or had labored breathing. She stated the only time her mother had trouble breathing was when she got junky and needed to be suctioned, then she would be fine. She stated her mother was fidgety and would grab at her tracheostomy and feeding tube, but she had brought in fidget toys for her to play with and they did help with her grabbing at stuff. On [DATE] at 11:40 A.M. an interview with LPN #500 revealed Resident #60 was not messing with her tracheostomy the night of [DATE] into [DATE]. She stated the resident had oxygen on, but she could not remember at what flow rate. Review of the facility policy titled, Change in Residents Condition or Status, dated [DATE] revealed the facility would promptly notify the resident, his or her attending physician, and the RP of changes in the resident's medical or mental condition and/or status. The nurse would notify the resident's physician or physician on -call when there had been an incident involving the resident, significant change in the resident physical or mental condition, and the need to transfer the resident to the hospital. This deficiency represents non-compliance investigated under Master Complaint Number OH00165463.

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 [DATE] 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 [DATE] 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 [DATE]. This affected one resident (#42) of six residents reviewed for change of condition. The facility census was 60. On [DATE] at 3:45 P.M. the Administrator, [NAME] President of Operations #81 and Regional Director of Operations #510 were notified Immediate Jeopardy occurred on [DATE] 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 [DATE] 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 [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions. On [DATE] from 5:30 P.M. to 7:24 P.M. Regional Quality Assurance Registered Nurse (RQARN) #800 audited ,d+[DATE] 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 [DATE] from 5:40 P.M. to 8:05 P.M. Assistant Director of Nursing (ADON) #403 audited ,d+[DATE] 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 [DATE] 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. ,d+[DATE] staff educated confirm understanding. On [DATE] 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. ,d+[DATE] staff educated confirm understanding. On [DATE] at 5:26 P.M. the facility Medical Director was notified of the Immediate Jeopardy related to quality of care and treatment. On [DATE] 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. ,d+[DATE] of staff educated confirm understanding. On [DATE] 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. ,d+[DATE] of staff educated confirm understanding. On [DATE] 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 ,d+[DATE] resident care plans reviewed had fall interventions for placement in common area when up in wheelchair. No variances identified. On [DATE] 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 ,d+[DATE] care plans reviewed had like intervention to check every two hours. No variances identified. On [DATE] 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 [DATE] 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 [DATE] 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 [DATE], 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 [DATE]. Review of the plan of care dated [DATE] and revised on [DATE] 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 [DATE] and revised on [DATE] 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 [DATE] and revised on [DATE] 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 [DATE] 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 [DATE]. 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 [DATE] 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 [DATE] 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 [DATE]. Review of the facility document Resident Temporary Leave of Absence for Resident #42 revealed the resident's wife brought the resident back on [DATE] at 4:00 P.M. Review of the [DATE] medication administration record (MAR) revealed on [DATE] 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 [DATE]. Review of the nursing progress notes revealed an entry on [DATE] at 4:09 P.M. Resident returned from LOA with wife. In addition, review of the MAR for the [DATE] 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 [DATE] revealed on [DATE] 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 [DATE] 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 [DATE] 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 [DATE], 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 [DATE] 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 [DATE] 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 [DATE] 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 [DATE] 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 [DATE] revealed on [DATE] 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 [DATE] revealed on [DATE] 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 [DATE] and signed by LPN #433 revealed on [DATE] 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 [DATE]), 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 [DATE] 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 [DATE] 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 [DATE], 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 [DATE] at 11:00 A.M. an interview with STNA #542 revealed she had worked 3:00 P.M. to 11:00 P.M. on [DATE]. 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 [DATE] at 11:00 A.M. with STNA #542 revealed she had not been working on the [NAME] unit, as the staff assignment dated [DATE] 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 [DATE] at 5:10 P.M. an interview with STNA #506 revealed he came in on [DATE] 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 [DATE] at 10:45 A.M. an interview with Family Member #622 revealed she had taken Resident #42 out overnight on [DATE] and brought him back to the facility at 4:00 P.M. on [DATE]. 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:,d+[DATE]: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 upsetting to her. She again stated the resident had been fine when he was at home. She stated she wished she would have gotten him out (discharged to home) of the facility sooner. She stated the plan was for the resident to be discharged home with her on [DATE]. She stated the resident (her husband) and STNA #506 did not get along, so she did not want STNA #506 taking care of him. On [DATE] at 3:00 P.M. an interview with Regional Quality Assurance RN # 800 confirmed NA meant not applicable on the [DATE] MARS on [DATE] at 9:00 P.M. for his Glargine insulin. On [DATE] at 8:45 P.M. an interview with LPN #433 revealed on the morning of [DATE] the aides working came and got her around 4:45 A.M. stating Resident #42 was slumped over in his wheelchair. She went to Resident #42's room and told STNA #506 to go get the other nurse working and the crash cart. She stated STNA #501 was standing beside Resident #42, she called out his name, did a sternal rub and checked his pulse. She stated she could not feel a pulse so her and STNA #501 place him on the floor and she started CPR until the EMS came. She stated RN # 411 assisted her with CPR. She stated the last time she saw Resid [TRUNCATED]

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 stated that was not the first time he had tried anything. She stated he was always coming up to her and she would just tell him to get away from her. She stated she thought he had a crush on her. She stated the staff were right there when it happened and saw him do it, so she did not have to report it to anyone. On 05/22/24 at 12:10 P.M. an interview with DON revealed they had placed Resident #4 on 1:1 supervision after the second time (on 03/26/24) he was found wandering in the spa room with Resident #61. She stated she was not aware of an incident with Resident #51, and stated she would have to look into why the psychiatric note said she was called into visit (Resident #4) due to hypersexual activity and it was reported he was touching another resident's breast and was caught with his pants down with another (resident). On 05/22/24 at 2:15 P.M. an interview with STNA #500 revealed she had witnessed the incident between Resident #4 and #51 (on 04/09/24). She stated Resident #51 was in her wheelchair sitting in the TV lounge when Resident #4 walked up to her and bent down towards Resident #51. She stated Resident #4 was hard of hearing so she though he was bending down to hear something Resident #51 was saying but then Resident #51 yelled out to stop and when she looked over Resident #4 had Resident #51's whole breast in his hand, he had picked her breast up and let [TRUNCATED]

Based on record review and interview, the facility failed to ensure Resident #81 was assessed timely following a change in condition. Actual harm occurred when Resident #81 was not assessed and treated timely follwoing a change in condition after experiencing left sided weakness, a reduced ability to hold her head up and drooling to the left side of her mouth until approximately seven hours after the concerns were reported. Resident #81 was hospitalized and admitted with a diagnosis of ischemic stroke. This finding affected one resident (Resident #81) of three residents reviewed for quality of care. Findings include: Review of Resident #81's medical record revealed she was admitted on [DATE] with diagnoses including chronic atrial fibrillation, essential hypertension and need for assistance with personal care. Review of Resident #81's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited moderate cognitive impairment and required supervision setup help only for bed mobility, transfers, walk in room, toilet use, personal hygiene and bathing. Review of Resident #81's Physical Therapy (PT) Treatment Encounter Note dated 10/08/22 at 11:58 A.M. revealed a fall was reported on 10/08/22 in the morning per nursing. It was discussed with nursing changes in Resident #81's status, coordination and strength. She needed more assistance for mobility and a wheelchair was provided for the ability of the State tested Nursing Assistants (STNAs) to get the resident to and from the bathroom and bed as needed. She had left sided weakness, decreased coordination in the upper extremities and lower extremities and a reduced ability to hold her head up. Drooling was noted to the left side of the her mouth. She did not acknowledge a change other than feeling weak in her legs and a decline in function overall was noted. Review of Resident #81's medical record revealed no evidence the physician was notified or the resident was properly assessed following physical therapy's report of a change in condition. Review of Resident #81's progress note dated 10/08/22 at 7:20 P.M. indicated the resident was observed on the floor in her room this morning and no injury was noted. The physician, administration and niece were aware. Resident #81 denied hitting her head. The medical record contained no evidence of the fall prior to this time, or details of the assessment to conclude no injury. The facility was unable to provide a fall investigation related to this fall. Review of Resident #81's Fall Investigation report dated 10/08/22 at 7:25 P.M. revealed at approximately 7:00 P.M. she was observed lying on her left side on the floor between her restroom and bedroom. Her speech was not clear, her left arm was weak and her hand grasps were unequal. She had a left side facial droop and no injuries were noted. She was sent to the hospital. Review of Resident #81's progress note dated 10/08/22 at 7:39 P.M. revealed at approximately 7:00 P.M. she was observed lying on her left side on the floor between the restroom and bedroom. She was confused and her speech was not clear. Her left arm and hand grasps were unequal. She moved all extremities well except for the left arm and a left sided facial droop. She was sent to the hospital for an evaluation and treatment. Review of Resident #81's progress note dated 10/09/22 at 2:25 P.M. revealed she was admitted on [DATE] at 2:24 A.M. for an acute ischemic stroke. Interview on 02/02/23 at 8:11 A.M. with Licensed Practical Nurse (LPN) #820 indicated she got to work at 6:00 P.M. on 10/08/22 when Resident #81 fell . She indicated she fell at some point in the early afternoon and again during shift change. She stated she was told by Physical Therapy Assistant (PTA) Rehab Director #824 that the resident had a change in condition from a fall earlier in the day and she told LPN #910 the resident had left sided weakness and drooling. Interview on 02/02/23 at 8:42 A.M. with PTA Rehab Director #824 confirmed she reported Resident #81's change in condition to LPN #910 early in the afternoon which included decreased overall function, decreased speed and movement, extremity grasp weakness and was required to be placed in a wheelchair when she was normally ambulatory. She also indicated there overall a weakness and she was flexed over and drooling out of the left side of her mouth. Telephone interview on 02/02/23 at 9:00 A.M. of LPN #910 with the Director of Nursing (DON) in attendance indicated Resident #81 had a fall on her shift but she could not state the exact time or date of the fall. She stated she filled out an incident report and notified the family and physician but she was unaware of who she talked to. She stated it was too long ago and she could not remember the details. A second interview on 02/02/23 at 9:10 A.M. of LPN #820 with the DON in attendance confirmed she received in report on 10/08/22 at approximately 6:00 P.M. that Resident #81 had sustained a fall earlier in the day. She stated before her shift report was finished, the STNA came and told her that Resident #81 had sustained another fall. She stated she went in and assessed Resident #81 who had an obvious change in condition including left sided weakness with a left sided facial droop. She stated she immediately sent her out to the hospital. Interview on 02/02/23 at 10:17 A.M. with Acting Administrator #999 revealed she interviewed LPN #910 who admitted to Resident #81 sustaining a fall on 10/08/22 in the morning at some point and she did not fill out a fall investigation. She did document the fall prior to her end of shift in the resident's progress notes. The documentation did not include what interventions were in place to prevent the fall and/or new interventions to prevent further falls. Administrator #999 confirmed LPN #910 did not document in Resident #81's medical record the assessment when it was reported to her of a change in condition and any follow-up that was completed. She stated she felt it was more of a documentation issue rather than a care concern. Review of the Change in Condition policy revised 05/2017 revealed the facility shall promptly notify the resident, his or her attending physician and representative (sponsor) of changes in the resident's medical condition and/or status. This deficiency represents noncompliance investigated under Complaint Number OH00137041.

Based on medical record review and staff interviews, the facility failed to provide interventions to prevent a resident from disconnecting her ventilator (a mechanical device required for the breathing) and removing her [CONDITION(S)] (tube inserted through the neck into the trachea to allow a person to breath). This resulted in Immediate Jeopardy for one resident (Resident #67) when she disconnected the ventilator and removed her [CONDITION(S)] on [DATE] and expired. This affected one resident (Resident #67) of four residents (#7, #29, #59, and #67) reviewed for ventilator/[CONDITION(S)] care. The facility census was 65. On [DATE] at 12:31 P.M. the Administrator, the Director of Operations, and the Clinical Operations Specialist/Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 9:11 A.M. when Resident #67 disconnected her [CONDITION(S)] tubing from the ventilator for the first time since her admission on [DATE]. The facility did not implement any interventions to prevent this from reoccurring. Resident #67 disconnected her [CONDITION(S)] tubing again on [DATE] at 10:15 A.M. and was sent to the emergency room . Resident #67 returned to the facility on [DATE] at 2:56 P.M. with no new interventions implemented. On [DATE] at 7:21 P.M. a progress note indicated Resident #67 had been observed removing the ventilator tubing throughout the day. The note revealed later that evening while State tested Nursing Assistant (STNA) #915 was passing dinner trays, she heard an alarm and found Resident #67 had disconnected herself from the ventilator and removed her [CONDITION(S)] with the balloon still inflated and had the [CONDITION(S)] ties in her hand. LPN #901 inserted a new [CONDITION(S)] and suctioned Resident #67. Resident #67's oxygenation level went up to 85% then there was a sudden decline to 71%. Emergency services were called and found Resident #67 without vital signs when they attached her to a monitor. Resident #67 had a do not resuscitate orders in place and no further life saving measures were implemented. The Immediate Jeopardy was removed on [DATE] at 6:54 P.M. when all staff had been educated on [CONDITION(S)] care, nursing staff had been educated on the supervision of residents with behaviors, and all other residents with tracheostomies/ventilators were reassessed. Additionally, the facility implemented the following corrective actions: · On [DATE] at 10:35 A.M. the Vice President of Operations (VOP) #920, the Administrator, and the Clinical Operations Specialist/DON began educating all respiratory therapy staff, all licensed nursing staff, all direct care staff, and all non- direct care staff on residents with tracheostomies/ventilators. The education included how to manage behaviors related to device removals and non-compliance. The education included immediate reporting and proper documentation of respiratory device removal and the location of interventions to prevent device removing behaviors. Staff were directed to notify the physician of any such behaviors and to complete additional assessments of interventions in place, their effectiveness and need for possible changes to interventions. The education was completed for all staff members on [DATE] at 6:54 P.M. · On [DATE] from 4:20 P.M. to 5:40 P.M. a clinical operations meeting was held with the Administrator, the Clinical Operations Specialist/DON, the Clinical Resource Specialist, minimum data set (MDS) Nurse #904, Social Service Designee (SSD) #903, VPO #920, Corporate Director of Clinical #918, and Physical Therapy Assistant #910 in order to audit the medical records for all residents with tracheostomies/ventilators (Residents #7, #29, and #59) to include identification of any behaviors or instances when their [CONDITION(S)], ventilator, or respiratory device was removed or disconnected, behaviors placing residents at risk for unplanned extubation or removal, and to ensure appropriate interventions were on the resident's care plans and care cards. No behaviors related to removing their tracheostomies/ventilators were identified for any of these residents. · On [DATE] from 5:55 P.M. to 6:15 P.M. a Quality Assurance committee meeting which included the Administrator, the Clinical Operations Specialist/DON, Medical Director, MDS Nurse #904, SSD #903, and department heads developed a plan for the Clinical Operations Specialist/DON/Designee to audit progress notes for at least five residents' with respiratory devices five times a week for a period of four weeks to identify if residents displayed any behaviors related to respiratory device removal, if identified behaviors were reported immediately and if interventions were properly implemented. The Clinical Operations Specialist/DON/Designee will interview 10 staff members weekly for four weeks to confirm all device removing behaviors have been immediately reported to the charge nurse and administrative staff. · Review of the three medical records for Residents #7, #29 and #59, who had tracheostomies/ventilators, revealed they were alert and oriented and had no behaviors of attempting to remove their tracheostomies/ventilators. Although the Immediate Jeopardy was removed on [DATE] at 6:54 P.M., the facility remains out of compliance with a Severity Level 2 (no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #67 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #67's most recently updated plan of care dated [DATE] revealed no interventions were implemented to prevent Resident #67 from disconnecting herself from the ventilator or removing her [CONDITION(S)]. Review of Resident #67's progress notes by Psych 360, psychiatric services, on [DATE] and [DATE] revealed the resident was seen for symptoms of agitation and anxiety. Behaviors listed were banging her remote and toy baby bottles on the tray table. Interventions were for provision of a calm environment, reassure resident, music therapy, pet therapy, massage, art therapy, and breathing exercises. There was no documentation of Resident #67 pulling at her [CONDITION(S)] or ventilator tubing. Review of Resident #67's nursing progress note dated [DATE] at 9:11 A.M., authored by Registered Nurse #919, revealed the resident kept disconnecting her mechanical ventilator at the [CONDITION(S)] connection site. There was no documentation to indicate the physician, psychiatric services, or supervisory nursing staff were notified of this behavior to alter the treatment plan for Resident #67. Review of Resident #67's respiratory progress note, authored by Respiratory Therapist #921, dated [DATE] at 10:15 A.M., revealed the resident's ventilator was disconnected, her lips were purple, and the resident was mouthing the words that she could not breath. RT #921 reconnected the tubing to the ventilator and suctioned the resident which yielded a small bloody mucous plug. Resident #67's oxygen level did not improve so RT #921 removed the ventilator and provided rescue breathing using an Ambu bag, which brought Resident #67's oxygen level to 100%. This note revealed suctioning was not getting many secretions out and RT #921 sent housekeeping staff to get the nurse. The progress note revealed RT #921 placed Resident #67 back on the ventilator to administer an as needed breathing treatment (medication to thin mucous and secretions), and the resident's skin color returned to pink. The progress note revealed after the breathing treatment Resident #67's oxygen level was only 81% (normal oxygen levels are 90% to 100%) and the nurse notified the nurse practitioner. The nurse practitioner directed Resident #67 to be sent to the hospital for low oxygen levels. Resident #67 returned later that day at 2:56 P.M. with no new orders. Review of Resident #67's discharge, return to facility anticipated, MDS 3.0 assessment dated [DATE] revealed she had moderate cognitive impairment, exhibited no physical behaviors but would threaten, scream, or curse at others. Resident #67 required extensive assist of two staff for transfers and mobility. Resident #67's was assessed to use an invasive mechanical ventilator for respiration/breathing while in the facility. Review of the nursing progress note dated [DATE] at 7:21 P.M. revealed Resident #67 was observed removing her [CONDITION(S)] [ventilator tubing] throughout the day. The note indicated STNA #915 was passing the evening meal trays, she noted Resident #67 had removed the ventilator tubing and had her [CONDITION(S)] in her hand with the balloon still inflated. The nurse inserted a new [CONDITION(S)], [reattached her to the ventilator] and suctioned Resident #67. Resident #67's oxygenation level was at 85% but then dropped to 71%. Facility staff called 911 and emergency services arrived and Resident #67's oxygenation level was below 70%. At 6:35 P.M., Resident #67 was without respirations and a pulse. Resident #67 had a do not resuscitate order in effect and no further life saving measures were implemented. Interview on [DATE] at 10:46 A.M. with Resident #67's daughter revealed her mother would frequently disconnect her [CONDITION(S)] tubing. Interview on [DATE] at 1:02 P.M. with RT #902 revealed Resident #67 removed her tubing from the ventilator three to four times a week. RT #902 said Resident #67 would often put the ventilator tubing on her baby dolls as if she were using the tubing to feed her babies. RT #902 said she would spend one on one time with Resident #67 to distract her from unhooking herself from the ventilator. Resident #67's plan of care was not updated to include this intervention. Interview on [DATE] at 1:26 P.M. with Licensed Practical Nurse (LPN) #900 revealed Resident #67 disconnected her [CONDITION(S)] circuit (tubing which connected her [CONDITION(S)] to her ventilator) as frequently as multiple times an hour and said it was an every-day occurrence. LPN #900 said it calmed Resident #67 down to be up in her chair in the common area or to play with her baby dolls. Resident #67's plan of care was not updated to include these interventions. Interview on [DATE] at 1:30 P.M. with the Administrator, as Resident #67's [CONDITION(S)] care plan was provided to the surveyor, revealed the resident did not have a care plan for behaviors of removing her [CONDITION(S)] tubing/ventilator tubing. The Administrator said the [CONDITION(S)] care plan only directed staff to ensure the [CONDITION(S)] ties (stings or ties that held the [CONDITION(S)] in place) were secure at all times. Interview on [DATE] at 3:37 P.M. with Physician #700 revealed it calmed Resident #67 when she was taken to the common area and assisted up in a chair. When asked if Resident #67 frequently removed her [CONDITION(S)] tubing, Physician #700 responded that she would defer that question to respiratory therapy staff. Interview on [DATE] at 4:12 P.M. with LPN #901, the nurse on duty at the time of Resident #67's death, revealed Resident #67 was not agitated on [DATE], but the resident was confused and often tinkered with her [CONDITION(S)]/ventilator tubing. LPN #901 revealed on [DATE] when she entered the room, Resident #67 had the [CONDITION(S)] ties in her hands and had removed the [CONDITION(S)] with the inflated balloon. LPN #901 revealed she inserted a new [CONDITION(S)] and suctioned the resident. LPN #901 said Resident #67's oxygenation levels came up to 85%. She said the resident was alert and made eye contact with her and then her color would turn gray, and her oxygen level would drop into the 70%s. LPN #901 said her oxygen levels would come back up to the 80%s and then would drop back into the 70%s. She said 911 was called and when the emergency squad arrived, they hooked her up to their machine and informed the nurse the resident had flatlined (absence of a heartbeat). Interview on [DATE] at 4:26 P.M. with STNA #915 revealed while she was passing dinner meal trays, she heard Resident #67's ventilator alarm sounding and went to the resident's room. STNA #915 said she observed Resident #67 with her hands up by her neck and the STNA witnessed the resident removing her [CONDITION(S)] with the balloon inflated. STNA #915 said earlier in the shift, Resident #67 had been constantly pulling at her [CONDITION(S)] tubing. STNA #915 said Resident #67 was offered her baby dolls and one on one interaction with staff yet the resident continued to repeatedly pull at her [CONDITION(S)] tubing. STNA #915 revealed Resident #67 pulled at her [CONDITION(S)] tubing nearly every day. STNA #915 verified Resident #67 was confused and would use her [CONDITION(S)] tubing as a baby bottle at times to feed her baby dolls. Interview on [DATE] at 9:07 A.M. with Nurse Practitioner (NP) #912 revealed she was notified of Resident #67 disconnecting her [CONDITION(S)] tubing [DATE]. NP #912 said Resident #67 was easily redirected by staff and if staff would go in and talk to her, she would calm down. NP #912 said Resident #67 seemed to be anxious in her room when she was alone. NP #912 indicated she had not been made aware of concerns from staff related to Resident #67's behaviors of pulling off her [CONDITION(S)]/ventilator tubing. She verified as needed medications for anxiety had not been requested or ordered. NP #912 said she was notified Resident #67 had removed her [CONDITION(S)] and ventilator on [DATE] and staff had difficulty maintaining the resident's oxygen levels, and 911 had been called. Resident #67 then expired. Interview on [DATE] at 4:02 P.M. with Vice President of Operations (VOP) #920 confirmed Resident #67 had previously disconnected her ventilator tubing from her [CONDITION(S)]. VOP #920 said she felt no harm had come to Resident #67 in the past because of her disconnecting her ventilator tubing and confirmed interventions to prevent her from disconnecting the ventilator tubing or removing the [CONDITION(S)] were not included in Resident #67's care plan and interventions were not documented. VOP #920 revealed interventions were passed along verbally during shift to shift report. This deficiency substantiates Complaint Number OH 239.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, record review, review of staff disciplinary action, advance directive and cardiopulmonary resuscitation (CPR) policy review, the facility failed to provide necessary care and services when staff failed to continue CPR and call emergency medical services for Resident #6 who was found without vital signs and was designated as a full code. This resulted in Immediate Jeopardy for one of eight residents reviewed whose wish to be resuscitated was not honored resulting in her death. The facility identified 46 residents who required full resuscitative measures. The facility census was 71. On [DATE] at 3:00 P.M. the administrator and the vice president of operations were notified Immediate Jeopardy began on [DATE] at approximately 1:01 P.M. when Resident #6 was found without vital signs, CPR was initiated by Licensed Practical Nurse (LPN) #20 for five to seven minutes until LPN #21 informed her incorrectly Resident #6 was a Do Not Resuscitate (DNR) status and CPR was stopped. At no time was emergency medical services called. Resident #6 required full resuscitation. The January, 2017 signed physician's orders [REDACTED]. The Immediate Jeopardy was removed and the deficient practice was corrected on [DATE] at 5:30 P.M. when the facility implemented the following corrective actions: On [DATE] at 1:30 P.M. the administrator initiated a comprehensive investigation. On [DATE] at 1:45 P.M. a quality assurance performance improvement plan was developed and initiated by the administrator. On [DATE] at 2:30 P.M. LPN #21 was suspended. On [DATE] from 3:00 P.M. to 11:00 P.M. all 21 facility nurses, seven Registered Nurses (RNs) and 14 LPNs, were re-educated by LPN #28 regarding code status protocols. Observation of the sign in sheet dated [DATE] verified attendance. On [DATE] Code status was added to the nurse orientation. On [DATE] at 5:30 P.M. all charts were audited by LPN #28 for accuracy and to ensure code status papers were under the advance directive tab. On [DATE] LPN #28 initiated weekly mortality review audits to evaluate whether code status protocols were correctly implemented for 100% of resident deaths. On [DATE] random audits to validate accuracy of code status against physician orders [REDACTED]. On [DATE] the surveyor interviewed two LPNs (#22 and #23) and three RNs (RN #24, #25 and #26). All five nursing staff demonstrated knowledge of where to find the code status for residents and their responsibilities to ensure each resident's correct code status was checked and followed. On [DATE] the surveyor reviewed seven additional resident deaths, one occurring after the death of Resident #6. The code status was followed. On [DATE] at 7:20 A.M. the surveyor reviewed nine resident records (Residents #20, #29, #31, #39, #54, #64, #68, #70 and #75) and verified the code status was located in the advance directive tab and the orders were accurate. Findings include: Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was alert and oriented, displayed no behavioral symptoms, required supervision or limited assistance with activities of daily living and was not receiving Hospice services. Review of the advanced directive care plan initiated on [DATE] and last revised on [DATE] revealed Resident #6's code status was do not resuscitate-comfort care (DNR-CC). Review of the Palliative coordinated care plan initiated [DATE] and revised on [DATE] revealed Resident #6's code status was full code. Review of the January, 2017 signed physician orders [REDACTED]. Review of the social service note dated [DATE] at 2:01 P.M. revealed a team meeting was held and Hospice services would end on [DATE]. The resident was noted to be a bit anxious about ending Hospice services. The social service note dated [DATE] revealed a Home Choice application was submitted for potential discharge home. The social service note dated [DATE] indicated Resident #6 continued to work toward discharge. The social service note dated [DATE] indicated the resident was planning on a discharge to home with support from family until waiver services were initiated. The last social service note dated [DATE] indicated Resident #6 was assisted in contacting an insulin supplier because she was interested in their product for home going. Review of the progress note dated [DATE] at 5:44 P.M. by LPN #20 indicated a state tested nurse aide (STNA) reported Resident #6 was non-responsive. The nurse found the resident blue in the face and hands. She was absent of radial pulse. LPN #20 documented that she rolled Resident #6 from her left side onto her back and began CPR. Another nurse notified Palliative care and the physician. The physician pronounced the resident deceased . Interview with the Palliative care nurse, RN #30, on [DATE] at 9:43 A.M. revealed she saw Resident #6 on [DATE] and had no concerns. RN #30 said she received a call on [DATE] at 1:10 P.M. and was notified Resident #6 had expired. She said she arrived at the facility on [DATE] at 1:15 P.M. to find Resident #6 lying in bed on her back, her head on two pillows, and her right arm elevated on a folded blanket. She was without vital signs. She said this was not a position for CPR. She approached LPN #21 at the nurse's station; she was on the phone with the physician. RN #30 was told by LPN #21 that basically all morning Resident #6 was sleepy, snoring and hard to arouse. RN#30 was told the STNAs checked on her a couple of times and noticed at 1:00 P.M. she had passed. She was told CPR was not done and the emergency squad was not called. RN #30 said she told LPN #21 Resident #6 was a full code and her face dropped. RN #30 reported this to the administrator. Interview with the unit manager, LPN #28, on [DATE] at 12:00 P.M. revealed she was working on [DATE] and heard LPN #21 say Resident #6 was a DNR. LPN #28 then heard LPN #21 again confirm the resident was a DNR and she observed LPN #20 stop CPR. Interview with LPN #20 on [DATE] at 12:20 P.M. revealed an STNA reported Resident #6 did not look right. She said it was not her resident but she responded. LPN #20 said she found the resident's face and hands to be blue, gray, and dusky and her skin to be cool and clammy. Resident #6 was without vital signs. She instructed the STNA to get her help, get the crash cart and for LPN #21 to call the physician, the palliative care nurse and the family. She said she rolled Resident #6 from her side onto her back and began CPR. She did not know for how long but said it seemed like forever. She said she stopped compressions when she heard the resident was a DNR. She said she did not think emergency medical services (911) was called. Interview with LPN #21 on [DATE] at 10:23 A.M. revealed she was off her routine that day because she had to work the other side of the building that she was not familiar with. She said she gave Resident #6 her morning medication. She checked on her again finding her asleep and snoring. She said LPN #28 requested she go work the other side of the building. She said she had not passed the noon medications. Then a STNA called for the nurses because she thought Resident #6 had passed away. She said Resident #6 was found without vital signs. Her hands, face and feet were blue. She called the physician and palliative care nurse. She said the palliative care nurse got to the facility quickly and asked if CPR or the emergency squad was called. She said she told the palliative care nurse that the resident had DNR orders so CPR and emergency services were not implemented. Review of the investigative summary for Resident #6 dated [DATE] revealed Resident #6 was found unresponsive by the STNA when the STNA was delivering her lunch tray. An STNA went to find the East nurses to tell them the resident was non-responsive. LPN #20 assessed Resident #6 and found no pulse, no respiration and no heart rate. The resident's body was blue at the mouth and hands. Resident #6 was cold and clammy to the touch. LPN #20 rolled Resident #6 from the left side onto her back and began compressions. She stated the rate was 30 compressions to 2 respirations. LPN #21 went to call the Palliative RN and family. The STNA went to find the unit manager to help. The unit manager, LPN #28, paused briefly to ask LPN #21 if she checked the code status and LPN #21 replied loudly DNR-CC. Resident #6 had been on Hospice services but in June, 2016 she was changed to Palliative care. She had been up earlier in the day sitting on the side of her bed and checked several times throughout the morning and the STNAs found her sleeping and snoring. Once LPN #28 entered the resident's room, LPN #20 asked did I hear DNR-CC and LPN #28 said yes. LPN #20 stopped compressions. Resident #6 remained unresponsive the entire time. The family began to arrive, the palliative care RN called the physician who gave her an order to pronounce the death. Interview with LPN #21 revealed she thought Resident #6 was a DNRCC and was unaware of a potential change in code status. She (LPN #21) was suspended pending investigation. Review of LPN #21's personnel record revealed she was disciplined because she did not check a code status on a resident who was found non-responsive. This was a violation of policy and she was suspended pending the outcome of the investigation. Review of the advance directive policy dated November, 2016 revealed upon admission the admission director would inform the resident and sponsor on advance directives. Advance directives included living wills and DNR orders. If there was interest they would be referred to the social service department. Once the forms were completed a copy would be kept in the front of the medical record after the attending physician reviewed it. All advance directives would be reviewed quarterly and on an as needed basis. Review of the CPR (cardiopulmonary resuscitation) policy and procedure dated May, 2009 revealed staff were to determine unresponsiveness, breathlessness, absence of pulse, start emergency oxygen, instruct an individual to contact the physician for further orders for care, instruct an employee to call 911, initiate CPR, reassess, if pulse and respirations were absent continue CPR and evaluate resident after performing four cycles and continue CPR until qualified help (paramedics) arrive and assume responsibility for the code, a physician pronounces the death or orders to discontinue CPR if the individual administering CPR becomes physically exhausted and unable to continue with no one to relieve them and if the resident was deemed to be a DNR. Review of the facility's orientation book revealed it contained the policy and procedure for CPR and advance directives. These were added to the orientation, competency/skills checklist and evaluation form.