Every finding on record at Fairmont Rehabilitation and Healthcare Center LLC

Based on record review, resident interview, and staff interview, the facility failed to ensure there were sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted each resident's rights, physical, mental, and psychosocial well-being. This was a random opportunity for discovery throughout the complaint survey process. Resident Identifiers: #78, #79, #74, and #65. Facility census: 97.Findings included: a) Resident Council MinutesA review of resident council minutes, completed on 07/21/26 at 5:55 PM, revealed the following issues: -During the 03/26/26 resident council meeting, residents expressed concern about low staffing in the nursing department.-During the 04/20/26 resident council meeting, residents expressed concern about not getting their evening showers and call lights not being answered in a timely manner.-During the 05/28/26 resident council meeting, residents expressed concern about not getting snacks in the evening. Residents also expressed concern about staff shortage in the nursing department resulting in longer wait times. b) Staff InterviewDuring an anonymous nurse interview, the nurse expressed the following concerns related to staffing in the building:Some days we only have three (3) Nurse Aides per side. We have a lot of two-person assist residents. Management wants each side of the building to send one Nurse Aide (NA) to the dining room. This leaves two (2) to serve meals on the floor. The nurse went on to report that residents are not always getting their scheduled showers because when they are staffed at the lowest level, it is hard for the NA's to get the showers done. The nurse also added that sometimes beds are left unmade and rooms left messy on the weekends. c) Resident #78 A medical record review was completed on 07/2226 at 8:56 AM. Resident #78's Bath Days were scheduled for Tuesday and Friday on the evening shift. A 30-day lookback showed the following issues: Tuesday, 06/30/26 - no documentation on recordFriday, 07/03/26 - no documentation on recordTuesday, 07/07/26 - no documentation on recordFriday, 07/10/26 - Resident received a bed bathTuesday, 07/14/26 - no documentation on record During an interview on 07/22/26 at approximately 4:50 PM, the acting Administrator and interim DON acknowledged the above-mentioned findings, which meant Resident #78 received one (1) of five (5) scheduled bed baths from 06/30/26 thru 07/14/26. No other information was given prior to exit. d) Resident #79 A medical record review was completed on 07/22/26 at 9:16 AM. Resident #79's Shower Days were scheduled for Monday and Thursday on the evening shift. A 30-day lookback showed the following issues: Thursday, 06/25/26 - Not Applicable was documented, indicating Resident #79 did not receive a bath or shower. Monday, 06/29/26 - Resident #79 received a shower.Thursday, 07/02/26 - Left blank, indicating Resident #79 did not receive a bath or shower.Monday, 07/06/26 - Left blank, indicating Resident #79 did not receive a bath or shower. During an interview on 07/22/26 at approximately 4:56 PM, the acting Administrator and interim DON acknowledged the above-mentioned findings, which meant Resident #79 received one (1) of four (4) scheduled showers from 06/25/26 thru 07/06/26. No other information was given prior to exit. e) Resident #74 During a review of a facility reportable, dated 07/16/26 at 12:55 PM, it was revealed that Nurse Aide (NA) #80 reported Licensed Practical Nurse (LPN) #51 made her put Resident #74 to bed when he did not want to go. It was reported that LPN #51 stated she did not care what he wanted. This incident happened on 07/14/26 on the 7:00 PM - 7:00 AM shift. Social Worker #107 interviewed Resident #74 regarding the incident. When asked if he wanted to go to bed that evening, he said he did not want to go to bed but was put to bed anyway. When asked who made him, he said the nurse. The facility's corrective action plan was noted to be education on customer service and resident preferences. During an interview on 07/22/26 at approximately 4:45 PM, the acting Administrator and Interim Director of Nursing (DON) acknowledged the fact that Resident #74's rights had been violated when he was forced to go to bed at the LPN's request. No further information was given prior to exit. f) Resident #65A medical record review, completed on 07/21/26 at 8:00 PM, revealed that Resident #65 had filed a grievance on 05/28/26 stating that Nurse Aides told her if she goes back to bed that they won't be able to get her up to attend the evening activities. Section C of Resident #65's annual minimum data set (MDS), with an assessment reference date of 05/01/26, reflected that resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating that she was cognitively intact. g) Facility AssessmentA review of the Facility Assessment was completed on 07/22/26 at 1:11 PM. The facility assessment noted, This staffing plan is based on the facility assessment, along with facility-based and community-based risk assessments to inform staffing decisions to ensure that there are a sufficient number of staff to care for the residents' needs. The facility assessment went on to outline the following staffing needs;-Evening Shift Nurse Aide Ratio of Staff to Residents or HPRD (Hours per Resident day) was documented as .97-Night Shift Nurse Aide Ration of Staff to Residents or HPRD was documented as 0.46.h) Review of Hours per Patient Day (HPPD) DataReview of the following 11 dates revealed the facility was not meeting the expected staffing levels:-02/19/26 Evening Nurse Aide (NA) Per Patient Day (PPD) was 0.45-02/19/26 Night Shift NA PPD was 0.33-02/20/26 Evening NA PPD was 0.45-02/20/26 Night Shift NA PPD was 0.33-03/27/26 Evening NA PPD was 0.48-03/27/26 Night Shift NA PPD was 0.33-04/06/26 Evening NA PPD was 0.45-04/06/26 Night Shift NA PPD was 0.27-04/08/26 Evening NA PPD was 0.57-04/09/26 Evening NA PPD was 0.42-04/09/26 Night Shift NA PPD was 0.32-04/10/26 Evening NA PPD was 0.66-04/10/26 Night Shift NA PPD was 0.26-04/16/26 Evening NA PPD was 0.51-04/16/26 Night Shift NA PPD was 0.28-04/21/26 Evening NA PPD was 0.53-04/21/26 Night Shift NA PPD was 0.26-04/23/26 Evening NA PPD was 0.65-04/23/26 Night Shift NA PPD was 0.29-04/26/26 Evening NA PPD was 0.44-04/26/26 Night Shift NA PPD was 0.25During an interview on 07/22/26 at approximately 5:00 PM, the acting Administrator and Interim Director of Nursing (DON) acknowledged the NA PPD hours failed to meet the expectation set forth in the facility assessement. No other information was given prior to exit.

Based on record review and staff interview, the facility failed to ensure resident preferences were honored related to when a resident was put to bed. This was a random opportunity for discovery throughout the complaint survey process. Resident Identifier: #74. Facility Census: 97. Findings included: a) Resident #74 During a review of a facility reportable, dated 07/16/26 at 12:55 PM, it was revealed that Nurse Aide (NA) #80 reported Licensed Practical Nurse (LPN) #51 made her put Resident #74 to bed when he did not want to go. It was reported that LPN #51 stated she did not care what he wanted. This incident happened on 07/14/26 on the 7:00 PM - 7:00 AM shift. Social Worker #107 interviewed Resident #74 regarding the incident. When asked if he wanted to go to bed that evening, he said he did not want to go to bed but was put to bed anyway. When asked who made him, he said the nurse. The facility's corrective action plan was noted to be education on customer service and resident preferences. During an interview on 07/22/26 at approximately 4:45 PM, the acting Administrator and Interim Director of Nursing (DON) acknowledged the fact that Resident #74's rights had been violated when he was forced to go to bed at the LPN's request. No further information was given prior to exit.

Based on record review and staff interview, the facility failed to ensure it reported results of all abuse/neglect investigations to the appropriate state offices within 5 working days of the incident and/or the initial report. This was true for two (2) of 10 facility reported incidents reviewed throughout the complaint survey process. Resident Identifiers: #63 and #14. Facility census: 97.Findings included: a) Resident #63 A record review was completed on 07/20/26 at 2:00 PM. It was noted that there was an Initial Reporting of Allegations regarding alleged resident-to-resident verbal abuse, dated 05/20/26, that was submitted to the appropriate state agencies. The Five-Day Follow-Up Investigation Report was not submitted to the appropriate state agencies until 06/15/26. Social Worker #8 reported, during an interview conducted on 07/21/26 at approximately 11:30 AM, that there had been a change in administrative leadership around that time and some items were later identified as needing to be followed-up on. b) Resident #14 A record review was completed on 07/20/26 at 2:00 PM. It was noted that there was an Initial Reporting of Allegations regarding alleged resident-to-resident physical abuse, dated 12/02/25, that was submitted to the appropriate state agencies. The Five-Day Follow-Up Investigation Report was not found in the facility's reportable file. During an interview on 07/22/26, Social Worker #8 reported that the five-day follow-up report had gone unsubmitted until surveyor intervention noting this particular report had been handled by previous administrative leadership and the five-day report must have been overlooked.

Based on observation, staff interview, electronic medical record review, and review of the facility's Abuse, Neglect, Exploitation policy, the facility failed to take corrective action to prevent further potential abuse/neglect by failing to complete education with staff on transfers. This was true of one (1) of five (5) residents reviewed for abuse during a complaint survey. Resident identifier: #102. Census: 97.Findings included:a) Resident #102A Summary of facility reported incident dated 06/05/26 at 9:40 AM at included:The resident reported that an aide hurt her leg when she was put to bed yesterday No visible injury; no bruising, scratches, lacerations, wounds, bleeding or redness; Redness did express pain upon assessment and facility immediately ordered xray Investigation initiated immediately; staff suspended pending the outcome of the investigation; staff and resident interviews initiated; body audits initiated for residents unable to be interviewed. The five-day-follow-up was reviewed. The five-day-follow-up was submitted to the state agency on 06/15/26 at 4:03 PM. The follow up review revealed: Resident #102 was found to have a fracture. The nurse aide (NA) was suspended pending an investigation. The investigation was conducted. Resident #102 was sent to the hospital for an initial follow up; doppler completed at hospital ruling out blood clot. Upon return from hospital Resident #102 continued to complain of pain; she was ordered an x-ray at that time. X-ray revealed a fracture. The facility completed interviews with staff regarding transfer status. Body audits/interviews were completed. Alleged victim confirmed suffering a fracture as a result of the event. The Nurse Aide was terminated.A review of Resident #102's Care Plan revealed, Resident transfers with extensive assist of two staff. A continued review of the facility reported incident (FRI) revealed Resident #1 had expressed pain related to her left leg. Resident was sent to the emergency room on [DATE]. The diagnosis report revealed Resident # 102 had a blood clot in her left calf and was started on Eliquis. She returned to the facility the same date.Continued review found that Resident #102 continued complaints of pain, the facility received a new order for Tramadol on 06/08/26.Subsequent review revealed an radiograph (X-ray) was obtained on 06/11/26 with diagnosis of a fracture of her fibula and tibia. On 07/22/26, a review of the reportable found education of staff following this substantiated inciden. On 07/22/26, approximately 3:00 PM an interview with the intriam Director of Nursing stated that there was education was completed for transfers to ensure the same type of incident did not reoccur.

Based on staff interview and record review, the facility failed to ensure a resident's discharge documentation was completed for a resident discharged to the hospital This failed practice had the potential to affect a limited number of residents. Resident Identifier: #100. Facility Census: 97. Findings included: a) Resident #100 Resident #100's medical record was reviewed for a discharge from the facility. The medical record did not contain a change of condition for discharge, the discharge location of the resident, a summary of the residents medical condition, a disposition of personal effects, or a disposition of medications. No discharge paperwork was completed and the discharge process was not followed. On 07/22/26 at 2:24 PM, the Administrator and Social Worker #107 reported the police were involved with the discharge. Social Worker #107 reported she thought the resident was transferred to (name of local hospital). Social Worker #107 reported she would look for discharge paperwork. No additonal information was given to the State Surveyor. At 3:55 PM. the State Surveyor reviewed the discharge with no documentation with the Administrator. The Administrator confirmed the lack of discharge notification and stated, I understand. The policy and procedure for Transferor discharge as related to transfer or discharge Documentation in the medical Record stated, 1. when the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider: a). The basis for the transfer or discharge; b. That an appropriate notice was provided to the resident and/or legal representative; c. The date and time of the transfer or discharge; d. The new location of the resident; e. The mode of transportation; f. A summary of the resident's overall medical, physical, and mental condition; g. Disposition of personal effects; h. Disposition of medications; i. Others as appropriate or as necessary, and j. The signature of the person recording the data in the medical record. I

Based on record review, resident interview, and staff interview, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain adequate grooming and hygiene. This was true for two (2) out of six (6) residents reviewed for showers throughout the complaint survey process. Resident Identifiers: #78, and #79. Facility census: 97.Findings included: a) Resident #78 A medical record review was completed on 07/2226 at 8:56 AM. Resident #78's Bath Days were scheduled for Tuesday and Friday on the evening shift. A 30-day lookback showed the following issues: Tuesday, 06/30/26 - no documentation on recordFriday, 07/03/26 - no documentation on recordTuesday, 07/07/26 - no documentation on recordFriday, 07/10/26 - Resident received a bed bathTuesday, 07/14/26 - no documentation on record During an interview on 07/22/26 at approximately 4:50 PM, the acting Administrator and interim DON acknowledged the above-mentioned findings, which meant Resident #78 received one (1) of five (5) scheduled bed baths from 06/30/26 thru 07/14/26. No other information was given prior to exit. b) Resident #79 A medical record review was completed on 07/22/26 at 9:16 AM. Resident #79's Shower Days were scheduled for Monday and Thursday on the evening shift. A 30-day lookback showed the following issues: Thursday, 06/25/26 - Not Applicable was documented, indicating Resident #79 did not receive a bath or shower. Monday, 06/29/26 - Resident #79 received a shower.Thursday, 07/02/26 - Left blank, indicating Resident #79 did not receive a bath or shower.Monday, 07/06/26 - Left blank, indicating Resident #79 did not receive a bath or shower. During an interview on 07/22/26 at approximately 4:56 PM, the acting Administrator and interim DON acknowledged the above-mentioned findings, which meant Resident #79 received one (1) of four (4) scheduled showers from 06/25/26 thru 07/06/26. No other information was given prior to exit.

Based on review of policies, records, resident interviews, and staff interviews, the facility failed to protect the residents' right to be free from abuse, resulting in mental anguish for Resident #47, #34, and #83. Specifically, Resident #73 was reportedly touching female residents in the breast and vaginal area. This situation indicates that an unlimited number of female residents had the potential to be affected. The facility's lack of action to identify this unwelcome sexual contact and prevent its recurrence placed Residents #47, #34, and #83 at continued risk of sexual abuse prior to Surveyor intervention. Using the reasonable person concept, the facility's failure to protect the residents' right to be free from sexual abuse/resident-to-resident sexual aggression more than likely resulted in mental anguish and psychosocial harm for Residents #47, #34, and #83. Resident identifiers: #47, #34, and #83. Facility census: 103.Findings included:a) Policy ReviewThe facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, with a revision date of 2021, stated that residents have the right to be from abuse which included sexual or physical abuse. It also mentioned a facility-wide commitment and resource allocation to protect residents from abuse by anyone, noting that it could be from other residents. Nowhere in the policy was there a definition of sexual abuse. However, the policy did direct that all possible incidents of abuse were to be identified and investigated. Additionally, the facility was to establish and implement a QAPI review and analysis of reports, allegations, or finding of abuse. It is important to note that at no point throughout the survey process did the facility report that they had self-identified Resident #73, who had capacity until mid-June 2025, as an individual who touched women without capacity in an unwanted sexual way. The facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, with a revision date of September 2022, stated that all reports of resident abuse are reported and thoroughly investigated by facility management. Findings of all investigations were documented and reported. This policy goes on to state: -If resident abuse is suspected, the suspicion must be reported immediately to the Administrator.-The allegation is immediately reported to the appropriate state agencies, the state long-term care Ombudsman, and the resident's legal representative. -Upon receiving any allegation of abuse, the Administrator is responsible for determining what actions (if any) are needed for the protection of residents. -All allegations are to be thoroughly investigated. -The individual conducting the investigation at a minimum will review the resident's medical record to determine if the resident's physical and cognitive status at the time of the incident. Observe the alleged victim, including his or her interactions with staff and other residents. Interview the person reporting the incident. Interview any witnesses to the incident. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Interview the resident's roommate, family members, and visitors. Document the investigation completely and thoroughly. -Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms.-Within five (5) business days of the incident, the Administrator will provide a follow-up investigation report which will describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. -The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. Review of the Long-Term Care Nursing Home Program Reporting Requirements guidance from the Office of Health Facility Licensure & Certification (OHFLAC) office describes sexual abuse as non-consensual sexual contact of any type with a resident.b) First Inappropriate Resident-to-Resident IncidentOn 01/26/24 at 5:30 PM, it was reported that Resident #73 and Resident #47 were unsupervised in the activity room. A staff member walked into the room and Resident #73 jumped and moved his hands from under Resident #47's shirt. At that time, Resident #73 had capacity and was believed to be cognitively intact. Resident #47 lacked capacity and had a BIMS of 09, indicating moderate cognitive impairment.The facility reported this incident to the appropriate state agencies as an unusual occurrence noting that the residents had reportedly touched each other. The facility intervention was to move Resident #47 to the opposite side of the building, body audits were performed, and safety checks initiated. There were no written statements from either resident.However, during an interview on 08/07/26 at 10:49 AM, Resident #47 reported she recalled the incident in question. She stated that [Resident #73's First Name] was the man that hurt her and repeatedly said that the facility does not believe her. Resident #47 described being in the activity room, Resident #73 pulling down his pants, taking her hand and making her touch his private parts. Resident stated, He put his hand in my shirt and touched my boob. She said she reported this to the facility. She also expressed fear of Resident #73.Resident #73 was not care planned for inappropriate physical sexual behavior related to unknown etiology until 03/04/24. The goal at that time was, Will only engage in sexual activity with consenting partners, No where in the electronic medical record was there documentation as to what the inappropriate sexual behavior was and who it involved. During an interview on 08/06/25 at 1:44 PM, the Director of Social Services stated that she could not report with 100% certainty but that to the best of her recollection the initial care plan for inappropriate sexual behavior may have involved Resident #104 who had since passed away. The Director of Social Services stated that the two (2) residents dated each other. Further record review revealed that around the 03/04/24 timeframe, Resident #104 had a BIMS score of 10, indicating moderate cognitive impairment. Resident #104 did not have capacity. The alleged relationship between the aforementioned residents was not care-planned. c) Second Inappropriate Resident-to-Resident IncidentA record review revealed that on 09/06/24 at 2:54 PM, there was a physician order for 15-minute safety checks for 72 hours. The facility was unable to provide documentation that the checks were done every 15 minutes as ordered. When initially asked the reason for the 15-minute checks, the Administrator could not produce an immediate answer. Later the Administrator produced a 09/06/24 reportable where Resident #47 had reported an allegation of sexual abuse involving Resident #73. It was noted that Resident #47 was crying and expressing fear. Resident #47 stated that Resident #73 touched her breast and down there. A written statement from LPN #200 read, On 09/06/24 this nurse went to the dining room area to give the resident (Resident #47) her medications. The resident reported to this nurse that [Resident #73's First and Last Name] touched her breast inappropriately on 09/05/24 while she was sitting in the dining room area watching her tablet.The facility's Five-Day Follow-Up did not verify the allegation. However, the facility looked into the date of 08/14/24 when Resident #47 was restricted to her room for COVID isolation. There was no mention of the 09/05/24 incident that was reported by resident and documented in a written statement by LPN #200. As she was sharing a copy of the reportable on 08/06/25 at 2:50 PM, the Administrator stated she was not familiar with the incident but had found the paperwork explaining what had happened. A physician determination of capacity, dated 05/21/24, reflected that Resident #73 did have capacity at the time of the incident. A quarterly MDS, with an assessment reference date of 09/22/24, reflected that Resident #47 had a BIMS score of 11, indicating moderate cognitive impairment. d) Documented Inappropriate Sexual Behavior - Resident #73Record review revealed documentation, on the October 2024 MAR, indicating some form of inappropriate sexual behavior on 10/09/24 and 10/20/24. The Administrator was asked, on 08/06/25 at approximately 4:00 PM, if the facility could provide documentation as to what those events were. On 08/07/25 at 8:45 AM, the Administrator reported she was unable to provide documentation and I'm not sure what those were from.Subsequent review of the paperwork provided by the facility revealed a 10/09/24 Nursing Note which read, Resident was sitting in the main hallway by the windows with his genitals hanging out and the front of his pants were shocked [soaked]. Asked him to put it away and he did.Record review revealed Resident #73 was not care planned for such behavior. e) Third Inappropriate Resident-to-Resident IncidentA 06/14/25 Nursing Note documented, Housekeeper found resident [#73] with his hands down a female resident's [#34] top fondling her breasts.A quarterly MDS, with an assessment reference date of 06/11/25, reflected that Resident #73 had a BIMS score of 14, indicating that he was cognitively intact. A physician of capacity, dated 05/14/25, reflected that resident had capacity.A quarterly MDS, with an assessment reference date of 06/2725, reflected that Resident #34 had a BIMS score of 00, indicating severe cognitive impairment. Resident #34 did not have capacity.A 06/16/25 note from the Physician Assistant stated, There was an episode over the weekend where he [Resident #73] inappropriately touched another resident [Resident #34]. His mood and behaviors have progressively worsened over time.The facility reportable noted that an investigation was conducted, the Residents were separated, and law enforcement was called. In the facility's Five-Day Follow-Up, the incident was verified that Resident #73 did inappropriately touch Resident #34. A 06/17/25 note from the Physician Assistant stated, Psych 360 has been consulted for his mood disorder.During a telephone interview on 08/06/25 at 2:41 PM, Floor Care Employee #81 reported he had walked around the corner and saw Resident #73 with his hands down Resident #34's top fondling her breasts. Resident #73 saw the floor care employee and immediately drew back his hand and moved his wheelchair away from her. The floor care employee stated he then reported what he witnessed to LPN #90. When asked if he had received any training / directive on paying close attention to Resident #73 when he was around women, the housekeeper replied he had not. When asked how he knew he should report what he witnessed he replied jokingly: First of all, I am not dumb. But it was also mentioned a long time ago like when I first started about what to report and to who. He then added that he knew Resident #73 had done something similar to Resident #83 in July.During an interview on 08/06/25 at 3:30 PM, LPN #90 stated she recalled the above-mentioned incident between Resident #73 and Resident #34. He seems to go towards women who are defenseless. LPN #90 reported she was also aware of the incident later that involved Resident #73 and Resident #83. She stated, I'm surprised she [Resident #83] didn't haul off and hit him. I don't know. Maybe she liked it.f) Fourth Inappropriate Resident-to-Resident IncidentOn 06/22/25, a Nursing Note documented, Resident [#73] attempted to put his hands down a female resident's shirt, residents were placed in different areas away from each other. There was no documentation to reveal the identity of the female resident involved in this incident. Additionally, there was no evidence that this incident was documented as a possible allegation of sexual abuse.g) Fifth Inappropriate Resident-to-Resident Incident Record review revealed that on 07/14/25 at 1:17 PM, the Activities Director reported that she witnessed Resident #73 hands inside of Resident #83 dress touching her breasts. A quarterly MDS assessment, with an assessment reference date of 05/22/25, reflected that resident had a BIMS score of 03, indicating severely impaired cognition. Although Resident #73's physician determination of capacity in mid-June 2025 had taken resident's capacity away, it is important to note at the time of the incident Resident had a BIMS of 14, which is indicative of a resident being cognitively intact. On 07/14/25 at 2:57 PM, there was a physician order given for 15-minute checks for 72 hours on Resident #73. The facility was unable to provide documentation that the checks were done every 15 minutes as ordered. In the facility's Five-Day Follow-Up report, under the corrective actions taken section, it read Residents normal behavior reported, and no corrective action needed. During an interview on 08/06/25 at 3:53 PM, the Activities Director reported she came around the corner and questioned, Hey, what are you doing? She went on to say Resident #73 yanked his hand back and immediately propelled himself into the dining room. She stated Resident #83 was just sitting there with a shocked look on her face. The Activities Director added, He knows what he is doing. She reported she began employment on 06/03/25 and was told by a nurse aide within days of working in the building that staff try to keep Resident #73 and Resident #83 separated. When asked if she felt any female residents tried to seek Resident #73 out she replied, Those ladies do not have the mental capacity to seek him out. They just like sitting in the hallway looking out the windows to nature watch and feel the sun on their faces. Aides take them there because it's closer to the dining room and to activities.During an interview on 08/06/25 at 1:44 PM, the Director of Social services reported that she had never done any training with staff members regarding Resident #73 [NAME] inappropriate sexually aggressive behaviors and how to intervene, and that to her knowledge no one had ever addressed it with staff. She indicated that staff just knew to separate the residents. There was nothing mentioned about staff knowing that they would need to report such instances. Additionally, the Director of Social Services reported that she had not interviewed the residents involved in the resident-to-resident incidents, had not interviewed other staff members, and had not interviewed other residents to determine if they had experienced anything similar or witnessed any other resident being inappropriately touched by Resident #73. The facility was unable to produce evidence that a referral had been made to Pscyh 360 for Resident #73 as per the physician order on 06/17/25. h) Witnessed Inappropriate Sexual BehaviorDuring an interview on 08/07/25 at 9:24 PM, Activity Assistant #136 reported the two times in the month of June 2025 she had witnessed resident's genitals exposed while he was in the hallway. The first instance was reported to the nurse on duty on the 400 Hall where residents resided. The second instance was reported to the Director of Nursing. There was no documentation to reflect this behavior in the resident's medical record nor is it a behavior that is part of his care plan. Using the reasonable person concept, one can conclude that having a random male place their hands inside of a woman's top to fondle her breast or taking the woman's hand and forcing her to touch his penis would result in serious psychosocial harm; therefore, the severity of this recipient's psychosocial harm from such abuse can be determined to be serious, rising to the immediate jeopardy level. The facility was notified of the Immediate Jeopardy (IJ) at 2:15 PM on 08/07/25. The facility submitted their plan of correction (POC) at 5:11 PM on 08/07/25. The State Agency (SA) approved the facility's POC at 6:30 PM on 08/07/25. The IJ began on 01/26/24 the date of the first incident between Resident #73 and female Resident #47. The IJ was abated at 7:40 PM on 08/07/25.The facility's approved abatement POC consisted of the following:1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #47, #34 and #83 were all affected by this deficient practice.a. Education to all employee on mandated reporting Abuse, protection of resident duringinvestigation and identifying sexual abuse for capacity to consent.b. Education to Admin, Don, SSD and IDT team on investigation and reportingc. Assailant is one on one supervision when out of bedd. Referral sent to SNF facilities for relocation of assailant. With POAs verbal permission.e. Appointments have been requested for emergency mental anguish and psychosocial harm evaluations for resident #47, #34 and #83.f. Started safety interviews on 8/6/25 with female residents. Nonverbal residents will beobserved for change in mood and sudden change in behavior and emotional state.g. Update policy on abuse.h. Updated Care Plans on identified residents.2. Address how the facility will identify other residents have the potential to be affected by the same deficient practice.a. All female residents have the potential to be affected by this deficient practice.b. Interviews are being conducted on all female residents for indication of abuse.c. No others were identified at this time.3. Address what measures will be put into place or systemic change made to ensure that the deficient practice will not reoccur.a. Education to all employee on mandated reporting Abuse, protection of resident during investigation and identifying sexual abuse for capacity to consent.b. Education to Admin, Don, SSD and IDT team on investigation and reporting.c. Update policy on abuse.-All staff education for abuse/ incident management started on 8/7/25 and prior to next scheduled shift, new hires will be trained upon hire and annual thereafter. -DON/designee will educate staff and IDT on behavior documentation and implementing person-centered interventions beginning on 08/7/2024.-Any resident displaying adverse behaviors that may lead to sexual misconduct with other residents will have interventions put in place, such as 15-minute behavior monitoring or 1-on-1 supervision, to prevent sexual misconduct with other residents. If a resident-to-resident sexual misconduct occurs, immediate interventions will be put in place to ensure the safety of both residents. NHA or designee will ensure the Medical Director is notified, the resident's family or responsible party is notified, and appropriate authorities are notified, i.e. police, ombudsman, DHHR occurrence reporting system. Administration will complete full investigation to include the abuse packet.4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluation for its effectiveness. The plan of correction must be integrated into the quality assurance system. The correction date will be the latest completion day on your accepted plan of correction.NHA or designee will review 24-hour report for sexual abuse and/or behavioral concerns during the daily clinical meeting Monday - Friday. Monday's review will include Friday, Saturday, and Sunday 24-hour reports as well. An audit form with a list of residents with potential sexual abuse and/or behavior concerns will be discussed in the daily clinical meeting with the IDT for tracking, trending and re-evaluation of interventions and effectiveness of resident care plan. Changes will be made according to the results of the documentation. This plan of correction will be monitored at the monthly Quality Assurance meeting for three months or until substantial compliance has been met.5. Include dates when the corrective action will be completed. Corrective action is completed 8/07/25.

Based on policy review, record review, resident interview, and staff interview, the facility failed to protect the residents' right to be free from abuse that resulted in mental anguish for Residents #47, #34, and #83. Resident #73 was reportedly touching female residents in the breast and vaginal area. An unlimited about of female residents had the potential to be affected. The facility's failure to thoroughly investigate, correct, and prevent inappropriate sexual contact placed Residents #47, #34, and #83 at continued risk of sexual abuse prior to Surveyor intervention. This cread an immediate jeopardy situation. Facility census: 103.Findings included:a) Policy ReviewThe facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, with a revision date of 2021, stated that residents had the right to be from abuse which included sexual or physical abuse. It also mentioned a facility-wide commitment and resource allocation to protect residents from abuse by anyone, noting that it could be from other residents. Nowhere in the policy was there a definition of sexual abuse. However, the policy did direct that all possible incidents of abuse were to be identified and investigated. Additionally, the facility was to establish and implement a QAPI review and analysis of reports, allegations, or finding of abuse. It is important to note that at no point throughout the survey process did the facility report that they had self-identified Resident #73, who had capacity until mid-June 2025, as an individual who touched women without capacity in an unwanted sexual way. The facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, with a revision date of September 2022, stated that all reports of resident abuse are reported and thoroughly investigated by facility management. Findings of all investigations were documented and reported. This policy goes on to state: -If resident abuse is suspected, the suspicion must be reported immediately to the Administrator.-The allegation is immediately reported to the appropriate state agencies, the state long-term care Ombudsman, and the resident's legal representative. -Upon receiving any allegation of abuse, the Administrator is responsible for determining what actions (if any) are needed for the protection of residents. -All allegations are to be thoroughly investigated. -The individual conducting the investigation at a minimum will review the resident's medical record to determine if the resident's physical and cognitive status at the time of the incident. Observe the alleged victim, including his or her interactions with staff and other residents. Interview the person reporting the incident. Interview any witnesses to the incident. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Interview the resident's roommate, family members, and visitors. Document the investigation completely and thoroughly. -Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms.-Within five (5) business days of the incident, the Administrator will provide a follow-up investigation report which will describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. -The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. Review of the Long-Term Care Nursing Home Program Reporting Requirements guidance from the Office of Health Facility Licensure & Certification (OHFLAC) office describes sexual abuse as non-consensual sexual contact of any type with a resident.b) First Inappropriate Resident-to-Resident IncidentOn 01/26/24 at 5:30 PM, it was reported that Resident #73 and Resident #47 were unsupervised in the activity room. A staff member walked into the room and Resident #73 jumped and moved his hands from under Resident #47's shirt. At that time, Resident #73 had capacity and was believed to be cognitively intact. Resident #47 lacked capacity and had a BIMS of 09, indicating moderate cognitive impairment. The facility reported this incident to the appropriate state agencies as an unusual occurrence noting that the residents had reportedly touched each other. The facility intervention was to move Resident #47 to the opposite side of the building, body audits were performed, and safety checks initiated. There were no written statements from either resident.However, during an interview on 08/07/26 at 10:49 AM, Resident #47 reported she recalled the incident in question. She stated that [Resident #73's First Name] was the man that hurt her and repeatedly said that the facility does not believe her. Resident #47 described being in the activity room, Resident #73 pulling down his pants, taking her hand and making her touch his private parts. Resident stated, He put his hand in my shirt and touched my boob. She said she reported this to the facility. She also expressed fear of Resident #73.Resident #73 was not care planned for inappropriate physical sexual behavior related to unknown etiology until 03/04/24. The goal at that time was, Will only engage in sexual activity with consenting partners, No where in the electronic medical record was there documentation as to what the inappropriate sexual behavior was and who it involved. During an interview on 08/06/25 at 1:44 PM, the Director of Social Services stated that she could not report with 100% certainty but that to the best of her recollection the initial care plan for inappropriate sexual behavior may have involved Resident #104 who had since passed away. The Director of Social Services stated that the two (2) residents dated each other. Further record review revealed that around the 03/04/24 timeframe, Resident #104 had a BIMS score of 10, indicating moderate cognitive impairment. Resident #104 did not have capacity. The alleged relationship between the aforementioned residents was not care-planned. c) Second Inappropriate Resident-to-Resident IncidentA record review revealed that on 09/06/24 at 2:54 PM, there was a physician order for 15-minute safety checks for 72 hours. The facility was unable to provide documentation that the checks were done every 15 minutes as ordered. When initially asked the reason for the 15-minute checks, the Administrator could not produce an immediate answer. Later the Administrator produced a 09/06/24 reportable where Resident #47 had reported an allegation of sexual abuse involving Resident #73. It was noted that Resident #47 was crying and expressing fear. Resident #47 stated that Resident #73 touched her breast and down there. A written statement from LPN #200 read, On 09/06/24 this nurse went to the dining room area to give the resident (Resident #47) her medications. The resident reported to this nurse that [Resident #73's First and Last Name] touched her breast inappropriately on 09/05/24 while she was sitting in the dining room area watching her tablet.The facility's Five-Day Follow-Up did not verify the allegation. However, the facility looked into the date of 08/14/24 when Resident #47 was restricted to her room for COVID isolation. There was no mention of the 09/05/24 incident that was reported by resident and documented in a written statement by LPN #200. As she was sharing a copy of the reportable on 08/06/25 at 2:50 PM, the Administrator stated she was not familiar with the incident but had found the paperwork explaining what had happened. A physician determination of capacity, dated 05/21/24, reflected that Resident #73 did have capacity at the time of the incident. A quarterly MDS, with an assessment reference date of 09/22/24, reflected that Resident #47 had a BIMS score of 11, indicating moderate cognitive impairment. d) Documented Inappropriate Sexual Behavior - Resident #73Record review revealed documentation, on the October 2024 MAR, indicating some form of inappropriate sexual behavior on 10/09/24 and 10/20/24. The Administrator was asked, on 08/06/25 at approximately 4:00 PM, if the facility could provide documentation as to what those events were. On 08/07/25 at 8:45 AM, the Administrator reported she was unable to provide documentation and I'm not sure what those were from.Subsequent review of the paperwork provided by the facility revealed a 10/09/24 Nursing Note which read, Resident was sitting in the main hallway by the windows with his genitals hanging out and the front of his pants were shocked [soaked]. Asked him to put it away and he did.Record review revealed Resident #73 was not care planned for such behavior. e) Third Inappropriate Resident-to-Resident IncidentA 06/14/25 Nursing Note documented, Housekeeper found resident [#73] with his hands down a female resident's [#34] top fondling her breasts.A quarterly MDS, with an assessment reference date of 06/11/25, reflected that Resident #73 had a BIMS score of 14, indicating that he was cognitively intact. A physician of capacity, dated 05/14/25, reflected that resident had capacity.A quarterly MDS, with an assessment reference date of 06/2725, reflected that Resident #34 had a BIMS score of 00, indicating severe cognitive impairment. Resident #34 did not have capacity. A 06/16/25 note from the Physician Assistant stated, There was an episode over the weekend where he [Resident #73] inappropriately touched another resident [Resident #34]. His mood and behaviors have progressively worsened over time. The facility reportable noted that an investigation was conducted, the Residents were separated, and law enforcement was called. In the facility's Five-Day Follow-Up, the incident was verified that Resident #73 did inappropriately touch Resident #34. A 06/17/25 note from the Physician Assistant stated, Psych 360 has been consulted for his mood disorder.During a telephone interview on 08/06/25 at 2:41 PM, Floor Care Employee #81 reported he had walked around the corner and saw Resident #73 with his hands down Resident #34's top fondling her breasts. Resident #73 saw the floor care employee and immediately drew back his hand and moved his wheelchair away from her. The floor care employee stated he then reported what he witnessed to LPN #90. When asked if he had received any training / directive on paying close attention to Resident #73 when he was around women, the housekeeper replied he had not. When asked how he knew he should report what he witnessed he replied jokingly: First of all, I am not dumb. But it was also mentioned a long time ago like when I first started about what to report and to who. He then added that he knew Resident #73 had done something similar to Resident #83 in July.During an interview on 08/06/25 at 3:30 PM, LPN #90 stated she recalled the above-mentioned incident between Resident #73 and Resident #34. He seems to go towards women who are defenseless. LPN #90 reported she was also aware of the incident later that involved Resident #73 and Resident #83. She stated, I'm surprised she [Resident #83] didn't haul off and hit him. I don't know. Maybe she liked it.f) Fourth Inappropriate Resident-to-Resident IncidentOn 06/22/25, a Nursing Note documented, Resident [#73] attempted to put his hands down a female resident's shirt, residents were placed in different areas away from each other. There was no documentation to reveal the identity of the female resident involved in this incident. Additionally, there was no evidence that this incident was documented as a possible allegation of sexual abuse.g) Fifth Inappropriate Resident-to-Resident Incident Record review revealed that on 07/14/25 at 1:17 PM, the Activities Director reported that she witnessed Resident #73 hands inside of Resident #83 dress touching her breasts. A quarterly MDS assessment, with an assessment reference date of 05/22/25, reflected that resident had a BIMS score of 03, indicating severely impaired cognition. Although Resident #73's physician determination of capacity in mid-June 2025 had taken resident's capacity away, it is important to note at the time of the incident Resident had a BIMS of 14, which is indicative of a resident being cognitively intact. On 07/14/25 at 2:57 PM, there was a physician order given for 15-minute checks for 72 hours on Resident #73. The facility was unable to provide documentation that the checks were done every 15 minutes as ordered. In the facility's Five-Day Follow-Up report, under the corrective actions taken section, it read Residents normal behavior reported, and no corrective action needed. During an interview on 08/06/25 at 3:53 PM, the Activities Director reported she came around the corner and questioned, Hey, what are you doing? She went on to say Resident #73 yanked his hand back and immediately propelled himself into the dining room. She stated Resident #83 was just sitting there with a shocked look on her face. The Activities Director added, He knows what he is doing. She reported she began employment on 06/03/25 and was told by a nurse aide within days of working in the building that staff try to keep Resident #73 and Resident #83 separated. When asked if she felt any female residents tried to seek Resident #73 out she replied, Those ladies do not have the mental capacity to seek him out. They just like sitting in the hallway looking out the windows to nature watch and feel the sun on their faces. Aides take them there because it's closer to the dining room and to activities.During an interview on 08/06/25 at 1:44 PM, the Director of Social services reported that she had never done any training with staff members regarding Resident #73 [NAME] inappropriate sexually aggressive behaviors and how to intervene, and that to her knowledge no one had ever addressed it with staff. She indicated that staff just knew to separate the residents. There was nothing mentioned about staff knowing that they would need to report such instances. Additionally, the Director of Social Services reported that she had not interviewed the residents involved in the resident-to-resident incidents, had not interviewed other staff members, and had not interviewed other residents to determine if they had experienced anything similar or witnessed any other resident being inappropriately touched by Resident #73. The facility was unable to produce evidence that a referral had been made to Pscyh 360 for Resident #73 as per the physician order on 06/17/25. h) Witnessed Inappropriate Sexual BehaviorDuring an interview on 08/07/25 at 9:24 PM, Activity Assistant #136 reported the two times in the month of June 2025 she had witnessed resident's genitals exposed while he was in the hallway. The first instance was reported to the nurse on duty on the 400 Hall where residents resided. The second instance was reported to the Director of Nursing. There was no documentation to reflect this behavior in the resident's medical record nor is it a behavior that is part of his care plan. The facility's failure to thoroughly investigate, correct, and prevent inappropriate sexual contact. The facility's failure placed residents at risk for sexual abuse and serious psychosocial harm. The severity of the psychosocial harm from such abuse can be determined to be serious, rising to the immediate jeopardy level. The facility was notified of the Immediate Jeopardy (IJ) at 2:15 PM on 08/07/25. The facility submitted their plan of correction (POC) at 5:11 PM on 08/07/25. The State Agency (SA) approved the facility's POC at 6:30 PM on 08/07/25. The IJ began on 01/26/24 the date of the first incident between Resident #73 and female Resident #47. The IJ was abated at 7:40 PM on 08/07/25.The facility's approved abatement POC consisted of the following:1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. #47, #34 and #83 were all affected by this deficient practice.a. Education to all employee on mandated reporting Abuse, protection of resident during investigation and identifying sexual abuse for capacity to consent.b. Education to Admin, Don, SSD and IDT team on investigation and reportingc. Assailant is one on one supervision when out of bedd. Referral sent to SNF facilities for relocation of assailant. With POAs verbal permission.e. Appointments have been requested for emergency mental anguish and psychosocial harm evaluations for resident #47, #34 and #83.f. Started safety interviews on 8/6/25 with female residents. Nonverbal residents will be observed for change in mood and sudden change in behavior and emotional state.g. Update policy on abuse.h. Updated Care Plans on identified residents. 2. Address how the facility will identify other residents have the potential to be affected by the same deficient practice.a. All female residents have the potential to be affected by this deficient practice.b. Interviews are being conducted on all female residents for indication of abuse.c. No others were identified at this time. 3. Address what measures will be put into place or systemic change made to ensure that the deficient practice will not reoccur.a. Education to all employee on mandated reporting Abuse, protection of resident during investigation and identifying sexual abuse for capacity to consent.b. Education to Admin, Don, SSD and IDT team on investigation and reporting.c. Update policy on abuse.-All staff education for abuse/ incident management started on 8/7/25 and prior to next scheduled shift, new hires will be trained upon hire and annual thereafter. -DON/designee will educate staff and IDT on behavior documentation and implementing person-centered interventions beginning on 08/7/2024.-Any resident displaying adverse behaviors that may lead to sexual misconduct with other residents will have interventions put in place, such as 15-minute behavior monitoring or 1-on-1 supervision, to prevent sexual misconduct with other residents. If a resident-to-resident sexual misconduct occurs, immediate interventions will be put in place to ensure the safety of both residents. NHA or designee will ensure the Medical Director is notified, the resident's family or responsible party is notified, and appropriate authorities are notified, i.e. police, ombudsman, DHHR occurrence reporting system. Administration will complete full investigation to include the abuse packet.4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluation for its effectiveness. The plan of correction must be integrated into the quality assurance system. The correction date will be the latest completion day on your accepted plan of correction.NHA or designee will review 24-hour report for sexual abuse and/or behavioral concerns during the daily clinical meeting Monday - Friday. Monday's review will include Friday, Saturday, and Sunday 24-hour reports as well. An audit form with a list of residents with potential sexual abuse and/or behavior concerns will be discussed in the daily clinical meeting with the IDT for tracking, trending and re-evaluation of interventions and effectiveness of resident care plan. Changes will be made according to the results of the documentation. This plan of correction will be monitored at the monthly Quality Assurance meeting for three months or until substantial compliance has been met.5. Include dates when the corrective action will be completed. Corrective action is completed 8/07/25.

Based on staff interviews, electronic medical record, facility record review and Operation Policy the facility failed to implement their written policy for thoroughly investigating allegations of sexual abuse. This was true of one (3) of three (3) residents reviewed for sexual abuse. Resident identifiers: #34, #83 and #47. Facility census: 103.A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, with a revision date of 2021, revealed that residents had the right to be from abuse which included sexual or physical abuse. It also mentioned a facility-wide commitment and resource allocation to protect residents from abuse by anyone, noting that it could be from other residents. Nowhere in the policy was there a definition of sexual abuse. However, the policy did direct that all possible incidents of abuse were to be identified and investigated. Additionally, the facility was to establish and implement a QAPI review and analysis of reports, allegations, or finding of abuse. The facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, with a revision date of September 2022, stated that all reports of resident abuse were to be reported and thoroughly investigated by facility management. Findings of all investigations were to be documented and reported. This policy went on to state:If resident abuse is suspected, the suspicion must be reported immediately to the Administrator. The allegation is immediately reported to the appropriate state agencies, the state long- term care Ombudsman, and the resident's legal representative. Upon receiving any allegation of abuse, the Administrator is responsible for determining what actions (if any) are needed for the protection of residents. All allegations are to be thoroughly investigated. The individual conducting the investigation at a minimum will review the resident's medical record to determine if the resident's physical and cognitive status at the time of the incident. Observe the alleged victim, including his or her interactions with staff and otherresidents. Interview the person reporting the incident. Interview any witnesses to the incident. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Interview the resident's roommate, family members, and visitors. Document the investigation completely and thoroughly. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms. Within five (5) business days of the incident, the Administrator will provide a follow-up investigation report which will describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. Resident #73 On 06/22/25, a Nursing Note documented, Resident [#73] attempted to put his hands down a female resident's shirt, residents were placed in different areas away from each other. There is no evidence that this incident was documented as a possible allegation of sexual abuse. Resident #67On 01/26/24 at 5:30 PM, it was reported that Resident #73 and Resident #67 were unsupervised in the activity room. A staff member walked into the room and Resident #73 jumped and moved his hands from under Resident #67's shirt. At that time, Resident #73 had capacity and was believed to be cognitively intact. Resident #67 lacked capacity and had a BIMS of 09, indicating moderate cognitive impairment. The facility reported this incident to the appropriate state agencies as an unusual occurrence noting that the residents had reportedly touched each other. The facility intervention was to move Resident #67 to the opposite side of the building, body audits were performed, and safety checks initiated. There were no written statements from either resident.A reportable review dated 09/06/24 revealed Resident #67 had reported an allegation of sexual abuse involving Resident #73. It was noted that Resident #67 was crying and expressing fear. Resident #67 stated that Resident #73 touched her breast and down there. A written statement from LPN #200 read, On 09/06/24 this nurse went to the dining room area to give the resident (Resident #67) her medications. The resident reported to this nurse that [Resident #73's First and Last Name] touched her breast inappropriately on 09/05/24 while she was sitting in the dining room area watching her tablet.The facility's Five-Day Follow-Up did not verify the allegation. However, the facility investigated the date of 08/14/24 when Resident #67 was restricted to her room for COVID isolation. There was no mention of the 09/05/24 incident that was reported by Resident #67 and documented in a written statement by LPN #200. Resident #34A review of a reportable found a sexual abuse allegation on 06/14/25 where Resident #73 had his hand down Resident #34's shirt. A review of the quarterly MDS, with an assessment reference date of 06/27/25, reflected that Resident #34 had a BIMS score of 00, indicating severe cognitive impairment. Resident #34 did not have capacity. A review of the 5 Day report revealed the incident was verified Resident #73. Resident #73 did inappropriately touch Resident #34. Resident #83A review of a reportable found a sexual abuse allegation on 07/14/25. The reportable stated that Resident #73 inappropriately touched Resident #83. On 07/14/25 at 1:17 PM, the Activities Director reported that she witnessed Resident #73's hands inside of Resident #83's dress touching her breasts. A quarterly MDS assessment, with an assessment reference date of 05/22/25, reflected that the resident had a BIMS score of 03, indicating severely impaired cognition.In the facility's Five-Day Follow-Up report, under the corrective actions taken section, it read Residents normal behavior reported, and no corrective action needed. During an interview on 08/06/25 at 1:44 PM, the Director of Social services reported that she had never done any training with staff members regarding Resident #73's inappropriate sexually aggressive behaviors and how to intervene. Resident #73 said that to her knowledge no one had ever addressed it with staff. She indicated that staff just knew to separate the residents. There was nothing mentioned about staff knowing that they would need to report such instances. She also reported that she had never obtained staff statements or residents statements about abuse and interviews were not conducted on all female residents for possible sexual abuse.

Based on facility record review, medical record review, and interview, the facility failed to ensure a resident's Medical Power of Attorney (MPOA) was notified immediately concerning an allegation of abuse and to keep the MPOA updated on the findings. This practice affected two (2) of four (4) residents reviewed. Resident identifiers: #34. Facility census: 103.Findings include: R a) Resident #34On June 14, 2025, a sexual abuse allegation was reported involving Resident #73, who had his hand down Resident #34's shirt. An investigation was conducted, and the residents were separated. Law enforcement, the MPOA, the Director of Nursing (DON), and the Administrator (ADM) were all notified. A quarterly MDS assessment on 06/27/25, showed Resident #34 with a BIMS score of 00, indicating severe cognitive impairment and lack of capacity. The 5-Day report verified the incident, confirming that Resident #73 inappropriately touched Resident #34. During an interview on 08/07/25, at 12:20 PM, Resident #34's responsible party stated she was initially made aware of a possible incident on June 14, 2025, but was later informed by the facility that it did not happen.

Based on policy review, observation, staff interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance to prevent accidents. The facility failed to provide a fire blanket, fire extinguisher, a metal can with a self-closing lid, and staff supervision when Resident #25 was observed smoking in the designated smoking area. Additionally, treatment carts were left unlocked and unattended on the 100 Hallway and the 300 Hallway. Resident Identifier: #25. Facility Census: 106.The facility's failure to follow their Smoking Policy by not providing a fire blanket, fire extinguisher, a metal can with a self-closing lid, and staff supervision when Resident #25 was observed outside smoking in the designated smoking area placed all smoking residents currently residing in the facility at risk for serious bodily harm and/or death. These failures were determined to place all smoking residents in an Immediate Jeopardy (IJ) situation. The facility was notified of the Immediate Jeopardy (IJ) at 7:38 PM on 07/30/25. The State Office approved the facility Plan of Correction (POC) at 9:25 AM on 07/31/25. After observation, staff interview, review of facility documentation, and record review determining the implementation of the POC, the IJ was abated at 9:25 PM on 07/31/25.The IJ started on 07/30/25 at 7:38 P:M and ended on07/31/25 at 9:25 AM.Findings included:a) Resident #25 On 07/30/25 at 11:35 AM, Resident #25 was observed outside with Resident #20 in the designated smoking area. Further observation revealed there was no fire blanket, fire extinguisher, or a metal container with a self-closing lid. A review of the facility's smoking Policy and Procedure, dated October 2017, on 07/30/25 at 12:15 PM, revealed:-The objective of the smoking policy was to promote safety for residents within the facility. It noted that facility staff would provide materials and assist each resident during the posted smoking times, in the designated area.-The policy stated residents may not keep any smoking materials in their room, or on their person.-Residents who smoke were to smoke with direct staff monitoring. It stated a staff member would be assigned to the smoking area during established smoking times for resident safety and supervision.-The assigned staff member was expected to carry a communication device to establish contact with the nursing staff in the event of an emergency-Employee expectations were to monitor residents in the smoking area; provide a fire blanket and fire extinguisher; empty ashtrays into metal containers with a self-closing cover containing sand to reduce risk of fire. Additional guidelines for staff were to monitor the smoking area, distribute cigarettes, conduct walking rounds to observe and intervene for safety issues, and to light cigarettes.During an interview with Resident #25 on 7/30/25 at 12:35 PM, he stated he kept his cigarettes and lighter in the top drawer of his bedside table. He stated that he kept them out on his table today and went out to smoke. He stated that Nurse Aide #53 knew he was going out to smoke today. He stated Resident #20 lit his cigarette for him.Review of Resident #25's smoking evaluation, 07/25/25 at 4:45 PM, noted resident was to be a supervised smoker.On 7/30/25 at 1:00 PM, during a separate interview with Resident #25, he stated his Quadriplegia diagnosis stemmed from an accident where he had fallen off a ladder and broke his neck. The resident reported he was working with therapy to address contractures / stiff hands because of the accident. The Life Safety Surveyor reported that Resident #25 had asked if he would help pick up resident's water tumbler that had fallen in his lap because the resident was unable to pick it up by himself.During an interview on 07/30/25 at 11:50 AM, the Director of Nursing (DON) confirmed that Resident #25 had been in the designated smoking area. The DON also confirmed there was no fire blanket, fire extinguisher, or metal container with a self-closing lid in the resident smoking area at this time. She believed they had been ordered.The facility was notified of the Immediate Jeopardy (IJ) at 7:38 PM on 07/30/25. The State Office approved the facility Plan of Correction (POC) at 9:25 AM on 07/31/25. After observation, staff interview, review of facility documentation, and record review determining the implementation of the POC, the IJ was abated at 9:25 PM on 07/31/25.The Administrator, on 07/30/25 at 11:57 AM, confirmed that the facility had placed an order for a fire extinguisher and a metal container with a self-closing lid approximately two (2) weeks ago. The Administrator also stated that the facility did have fire blankets and acknowledged none had been placed in the designated smoking area for residents. Observation, on 7/30/25 at 3:41 PM, revealed the treatment cart in the 100 hall was left unlocked and unattended in the hall near the Nurses Desk. The surveyor was able to open the drawer without staff noticing. On 7/30/25 at 3:42 PM, LPN #77, acknowledged that he had left the treatment cart unlocked and unattended while he answered a phone call.On 7/3012025 in response to immediate Jeopardy citation F0689 the facility took the following immediate actions: -Ensured resident smoking area contained smoking blanket which was secured in designated area; a metal container with a self-closing lid was placed in area; and fire extinguisher provided-The facility acquired smoking items from smoking residents, and these items were placed in a secure container where these items will be kept when not in use inside locked med room.-The facility immediately initiated education on the smoking policy for residents to staff and residents. At[ staff on shift of 7-30-25 were educated and atl incoming staff will be educated prior to starting next shift.-Facility established designated posted smoking times for the residents and an accompanying smoking assignment list of staff who will be providing supervision of residents who smoke with supervision or assistance.-Care plans have been updated for our smoking residents-Facility policy has been updated effective 7130/25 at 5:45 pm-All current smoking resident assessments were reviewed by DON to be accurate and true with no necessary changes from original assessmentObservation, on 7/30/25 at 3:41 PM, revealed the treatment cart in the 100 hall was left unlocked and unattended in the hall near the Nurses Desk. The surveyor was able to open the drawer without staff noticing. On 7/30/25 at 3:42 PM, LPN #77, acknowledged that he had left the treatment cart unlocked and unattended while he answered a phone call. 300 Hall Treatment CartOn 07/28/25 at 3:45 PM, An observation of an unlocked, unattended treatment cart on the 300 Hall. The cart was in a place easily accessible allowing access to medication / treatment supplies by residents, unauthorized persons, or visitors. On 07/28/25 at 4:02 PM, during an interview with the Registered Nurse (RN) #105 it was confirmed the treatment cart was unlocked. RN #105 verified that the treatment cart should not be unlocked when unattended. She closed and locked the treatment cart at this time.No further information was provided prior to the end of the survey on 08/04/25 at 4:30 PM.

Based on interview, record review and investigation, the facility's management, by their inaction, and decisions in administering the facility, contributed to the following deficient practice, namely a failure to train, educate, and verify the competency of the nursing staff to ensure that they could appropriately assess and care for the resident population residing in the facility. Resident Identifiers: Resident #7 and Resident #45. Facility Census: 106.Findings Include:During a review of the records for Resident #7 and Resident #45 on 07/28/25 at approximately 1:00 PM it was revealed that the nursing staff were assessing and documenting the presence and patency of a non-existent AV access, and in addition failing to correctly assess the resident's dialysis accesses for patency, and infection as prescribed by the physician.a) Resident #7During an interview with Resident #7 on 07/28/25 at approximately 3:14 PM, resident stated that she had been on dialysis since 2016. The resident went on to state that her dialysis access was a permacath. She further stated that she went to dialysis on Mondays, Wednesdays. and Fridays. She also stated that she had never had an AV fistula or graft.Record review on 07/28/25 at 10:00 AM revealed a physician's order dated 06/19/25 which statedDialysis: Site of AV shunt Check bruit and Thrill every shift!Record review and interview revealed that Resident #7 did NOT have an AV access shunt. Despite this fact, eight (8) nurses, the RN Unit Manager and the Director of Nursing (DON) signed off / documented over a period of approximately six (6) weeks that they had successfully assessed the residents shunt for patency. Ongoing record review on 07/30/25 at approximately 9:00 AM revealed that from 06/19/25 to 07/29/25 the following staff members had documented that they had assessed the resident's AV access, and had heard the bruit and felt the thrill over the access for bruit and thrill.During an interview with the Administrator and the Director of Nursing (DON) on 07/30/25 at approximately 11:00 AM. They were notified that the nursing staff were assessing and documenting that Resident #7 had a patent AV fistula/graft. The DON stated, As soon as you brought it up I knew that I had worked that unit and assessed that resident. Most times there is so much to be checked off that we automatically click the boxes.b) Resident #45During an interview on 07/30/25 at approximately at approximately 1:22 PM. Resident #45 had just returned to the facility after her dialysis treatment. Record review revealed that resident has a Brief Interview for Mental Status (BIMS) of 15 and is very cognizant of her care requirements and diet. She stated that her access had been revised at the hospital on [DATE] because she had some issues during dialysis. Resident displayed her right arm which had a large dressing over the lower area of her AV fistula. Upon being asked about the monitoring of her access, resident stated that the nursing staff checked her access sometimes!Record review revealed that Resident # 45 too had an order for monitoring of her AV access for bruit and thrill every shift.When Resident #45 was asked about the frequency of the assessments of her AV access, resident stated It was last checked a few weeks ago by that nurse (LPN) #77. Resident stated that no one had checked it since then. Resident #45 went on to state that the dialysis clinic had educated her about checking her access, and she stated that she usually checked it in the mornings.Record review revealed that the assessments were documented every shift by the nursing staff.A review of the facility assessment on 07/30/25 at approximately 9:00 AM revealed that it does not address any training for hemodialysis, or on the care and treatment of residents on dialysis.During an interview with the DON on 07/30/25 at 4:20 PM, the DON stated, We don't have any training! she further stated that she has been the DON since August of 2024, and she has not seen any dialysis training.The facility nursing staff's inability to accurately assess an AV access for patency creates a serious potential for harm to any dialysis patient in the facility. Assessing, and identifying a non-patent AV access allows for an immediate revision of the access, or the insertion of a temporary dialysis catheter to allow the residents to continue receiving their life saving dialysis treatments.

Based on interview and observations the facility failed to provide residents a confidential way to file a written grievance. This findings had the potential to affect more than a limited number of residents. Facility census: 96. Findings included:a) Grievances On 07/30/25 at 1:40 PM during a Resident Council meeting it was revealed there was no confidential way to file a grievance without telling a staff member. On 07/30/25 at 2:15 PM an observation found no grievance forms readily available throughout the facility. The grievances forms were located at the front of the building behind closed non-handicap accessible double doors with a wander guard lock. During an interview, on 07/30/25 at 2:32 PM, the Administrator stated that the residents could get a form at the nurse's station by asking a staff member or at the front of the building behind the double doors. She also confirmed that most residents would need help getting through the doors to obtain the grievance forms.

Based on record review and staff interview, the facility failed to report a five day follow up on allegations of abuse or neglect in a timely fashion to the appropriate state agencies. This was a random opportunities for discovery. Resident identifiers: #82. Facility census: 106.a) Resident #82 On 04/10/25, the facility shared an Initial Reporting of Allegations regarding alleged mental/verbal abuse to Resident #82 by Licensed Practical Nurse (LPN) #201 where she called resident an asshole. In an interview, 7/30/24 at 9:10 AM, the Administrator acknowledged the facility had failed to submit a five (5) day follow up to the appropriate state agencies. The administrator reported the facility's investigation into this incident, as well as any staff education, could not be found due to new ownership and files before 05/2025 were not available.

Based on interviews and record review, the facility failed to provide dependent residents with the assistance needed for showers and personal hygiene. This was true for three (3) of four (4) residents sampled. Resident Identifiers: #24, #72 and #76. Facility Census: 106. Findings Includea) Resident #24During an interview on 07/29/2025 at 10:39 AM, Resident #76 stated that she was scheduled for showers on Tuesday and Friday. The resident explained that the availability of showers depended on staffing levels. She further stated that she was admitted on [DATE] and her first shower occurred on 07/15/25. Record review on 07/29/25 at approximately 10:45 AM revealed that Resident #24 had received a shower on 07/15/25 and 07/19/25. The record also revealed that Resident #24 refused showers on 07/22/25 and 07/25/25. Resident denies refusing showers. She stated, I'll take anything that I can get. b) Resident #72 During an interview with Resident #72 on 07/29/25 at approximately 12:06 PM, the resident stated that she was admitted on [DATE]. Resident #72 stated that she had received a bed bath on 07/14/25. Record review on 07/29/25 at 11:30 AM revealed that Resident #72 received the following:bed bath 07/14/25shower 07/16/25bed bath 07/23/25Resident #72 went on to state that she would be lucky if she could get two baths a week. c) Resident #76 On 07/29/25 at approximately 1:13 PM, Resident #76 stated that she was scheduled for two (2) showers a week. She said that she could request showers, but it depended on who was working. If the staff didn't feel like showering her, she would get a bed bath instead. Resident #76 denied refusing a shower or a bed bath. 07/29/25 2:00 PM record review revealed the following:Refused to shower at 8:45 PM on 07/01/25Shower at 8:44 PM on 07/04/25Shower at 8:33 PM on 07/08/25Bed bath at 9:34 PM on 07/11/25Refused a shower at 10:05 PM on 07/15/25Bed bath at 7:31 PM on 07/25/25. Records reveal that Resident #76 did not receive a bed bath or shower for a period of nine (9) days, between 07/15/25 and 07/25/25 During an interview with the Administrator on 07/30/25 at approximately 10:55 AM, the Administrator provided shower logs and stated that they were accurate. During an interview on 07/29/25 at approximately 3:45 PM, with Nursing Assistants (NAs) #34, #53, and #107, they stated that there were times when, in the evenings, it was difficult to get all the residents on the schedule.

Based on Interview, and record review, the facility failed to ensure that the nursing staff were adequately educated and trained in the assessment and care of residents on dialysis. This failed practice had the potential to cause serious harm to any dialysis resident in the facility. The facility's failure to monitor and ensure that the nursing staff were accurately assessing resident's dialysis accesses, placed all residents on dialysis, currently residing in the facility at risk for serious bodily harm and/or death. These failures were determined to place all dialysis residents in an Immediate Jeopardy (IJ) situation. This was true for two (2) of two (2) residents sampled. Resident Identifiers: Resident #7 and Resident #45. Facility Census: 106. The facility was notified of the Immediate Jeopardy (IJ) at 11:47 AM 07/31/25. The State Office approved the facility's POC at 2:27 PM on 07/31/25. After observation, staff interview, review of facility documentation, and record review determining the implementation of the POC, the IJ was abated at 7:31 PM on 07/31/25. The IJ started on 06/19/25 at 6:00 PM and ended on 07/28/25 at 7:00 PM. The facility's approved abatement POC consisted of the following: 1. All dialysis patients were assessed with no identified concerns; Patient orders were corrected; MD notified and no new orders; All dialysis patients orders and labs were audited with no identified concerns. Resident's care plans were reviewed and updated. 2. Facility assessment was updated to include Hemodialysis Catheters-access and care of for licensed nursing staff. 3. Education was initiated immediately on 07/30/25 as part of facility ad hoc POC and continued into 07/31/25 for all licensed nursing staff. 4. Facility Hemodialysis Catheter policy was reviewed with no changes.5. Facility licensed nursing orientation was updated to include HD catheter care and access competency and education.6. DON or designee audits orders three times a week. DON or designee will observe nurse following doctor's orders correctly three times a week times 4 weeks. Then orders will be reviewed one time a week and observations will be completed once a week, times 8 weeks.7. Audit tools will be used and reviewed weekly with IDT team. DON or designee will perform hemodialysis training upon hire as part of orientation and annual competencies. Additional training will be provided by DON or designee as needed. All competencies' reviews will be turned in to NHA for compliance validation. Findings Include:a) Resident #7During an interview with Resident #7 on 07/28/25 at approximately 3:14 PM, resident stated that she had been on dialysis since 2016. The resident went on to state that her dialysis access was a permacath. She further stated that she went to dialysis on Mondays, Wednesdays. and Fridays. She also stated that she had never had an AV fistula or graft.Record review on 07/28/25 at 10:00 AM revealed a physician's order dated 06/19/25 which statedDialysis: Site of AV shunt Check bruit and Thrill every shift!Record review and interview revealed that Resident #7 did NOT have an AV access shunt. Despite this fact, eight (8) nurses, the RN Unit Manager and the Director of Nursing (DON) signed off / documented over a period of approximately six (6) weeks that they had successfully assessed the residents shunt for patency. Ongoing record review on 07/30/25 at approximately 9:00 AM revealed that from 06/19/25 to 07/29/25 the following staff members had documented that they had assessed the resident's AV access, and had heard the bruit and felt the thrill over the access for bruit and thrill:Director of Nursing (DON) on 06/26/25Registered Nurse (RN) supervisor #17 on 07/07/25, 07/16/25, and 07/21/25RN #101 on 06/23/25, 06/24/25, 06/27/25, 06/29/25, 07/02/25, 07/03/25, 07/07/25, 07/08/25, 07/11/25, 07/16/25, 07/21/25, 07/25/25, 07/26/25 and 07/26/25RN #121 on 07/05/25 and 07/20/25RN #55 on 07/25/25Licensed Practical Nurse (LPN) #77 on 06/27/25, 07/01/25, 07/02/25, 07/10/25, and 07/19/25.LPN #120 on 07/01/25LPN #32 on 06/19/25, 06/20/25, 06/24/25, 06/25/25, 06/28/25, 06/29/25, 06/30/25, 07/03/24, 07/04/25, 07/08/25, 07/09/25, 07/12/25, 07/13/25, 07/14/25, 07/17/25, 07/18/25, 07/22/25, 07/23/25, 07/26/25, and 07/27/25.LPN #87 on 06/20/25, 06/21/25, 06/22/25, 06/25/25, 06/26/25, 07/05/25, 07/06/25, 07/10/25, 07/14/25, 07/20/25, 07/23/25, 07/24/25 and 07/28/25.LPN #92 on 06/21/25. 06/22/25, 06/23/25, 07/06/25, 07/11/25, and 07/15/25.During interviews with the nursing staff and the unit manager, no one could remember which arm they had checked, and remained silent with a shocked look on their faces when it was addressed that resident did not have an AV access shunt that could be checked for bruit and thrill. During an interview with the Administrator and the Director of Nursing (DON) on 07/30/25 at approximately 11:00 AM. They were notified that the nursing staff were assessing and documenting that Resident #7 had a patent AV fistula/graft. The DON stated, As soon as you brought it up I knew that I had worked that unit and assessed that resident. Most times there is so much to be checked off that we automatically click the boxes.During another interview with RN #101 at 6:31 PM on 07/30/25. RN #101 stated that he had assessed resident's access for bruit and thrill. When asked which arm he had assessed, RN stated the right arm!Upon being notified that the resident did not have an AV access in either arm, RN appeared surprised and did not say anything more. b) Resident #45During an interview on 07/30/25 at approximately at approximately 1:22 PM. Resident #45 had just returned to the facility after her dialysis treatment. Record review revealed that resident has a Brief Interview for Mental Status (BIMS) of 15 and is very cognizant of her care requirements and diet. She stated that her access had been revised at the hospital on [DATE] because she had some issues during dialysis. Resident displayed her right arm which had a large dressing over the lower area of her AV fistula. Upon being asked about the monitoring of her access, resident stated that the nursing staff checked her access sometimes!Record review revealed that Resident # 45 too had an order for monitoring of her AV access for bruit and thrill every shift.When Resident #45 was asked about the frequency of the assessments of her AV access, resident stated It was last checked a few weeks ago by that nurse (LPN) #77. Resident stated that no one had checked it since then. Resident #45 went on to state that the dialysis clinic had educated her about checking her access, and she stated that she usually checked it in the mornings.Record review revealed that the assessments were documented every shift by the nursing staff.A review of the facility assessment on 07/30/25 at approximately 9:00 AM revealed that it does not address any training for hemodialysis, or on the care and treatment of residents on dialysis.During an interview with the DON on 07/30/25 at 4:20 PM, the DON stated, We don't have any training! she further stated that she has been the DON since August of 2024, and she has not seen any dialysis training.The facility nursing staff's inability to accurately assess an AV access for patency creates a serious potential for harm to any dialysis patient in the facility. Assessing, and identifying a non-patent AV access allows for an immediate revision of the access, or the insertion of a temporary dialysis catheter to allow the residents to continue receiving their life saving dialysis treatments.

Based on facility record review and staff interviews, the facility failed to complete Nurse Aides (NA) annual evaluations. This was true for two (5) of five (5) reviewed for staffing during the Long-Term Survey Process (LTCSP). Nurse Aide Identifiers: #70, #56, #10, #96, and #100. Facility census: 106. Findings included:a) A facility records review revealed, NA #70, NA #56, NA #10, NA #96 and NA#100 did not receive their 12-month evaluation. During an interview on 07/30/25 at 1:25 PM the Administrator confirmed there was no annual evaluations completed for NA #70, NA #56, NA #10, NA #96 and NA#100 . She stated that NA evaluations were something the facility needs to work on getting completed.

Based on record review and staff interview the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. This failed practice had the potential to affect all residents in the facility. Facility census: 106. In an interview with the Kitchen Manager #60, on 07/31/25 at 10:30AM, he stated his Food Handlers Certification had expired on 07/06/25 and stated he thought he had a 30 day grace period and that he andEmployee #19 were scheduled for a Food Handler's Course on 07/31/25. He also stated that he was a salaried worker and works at least 40 hours weekly. On 07/31/25 at 10:35AM, during a record review of kitchen staff certifications, it was verified that employees identified as #60 and #19 were working in the kitchen on expired Food Handlers Certifications. Both employees certifications expired on 07/06/25.A review of the employee kitchen schedule on 07/31/25 at 2:00PM verified that Employee #19 worked on July 7, 8, 11, 12, 13, 16, 22, 24, 25, 27, 29, and 30, 2025 after his certification had expired on 07/06/2025.

Based on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. This is true for the Kitchen and Nourishment Room. This had the potential to affect all residents in the facility. Facility census 106.Findings included:a) On 07/28/25 at 11:27 AM, during Initial Brief Tour of Kitchen, with the Dietary Kitchen Manager #60 who acknowledged the following: -Walk In Cooler: 1 tray of sweet potato wedges and 1 tray of blended vegetables with no covering or labels and a package of celery left open to air with no labels or dates. -Reach In Cooler: 1 larger tray with salad cups and blue berry desert cups, and a small tray of pickle cups uncovered, unlabeled and undated.2 (two) wrapped sandwiches with unlabeled/undated. -Utensil drawers: all 4 utensil drawers were observed with all utensils scattered and not in the same direction. -Pots and Pans Lid Storage: It was observed that dirty pot lids were stored with clean lids on the storage rack. On 07/29/25 at 1:30 PM, during a Brief Tour of the 100 Hall Nourishment Room, with the Dietary Kitchen Manager #60 who acknowledged the following in the freezer:-1 box of frozen Banquet Pot Pie and 4 small tubs of ice not labeled or dated. On 07/30/25 at 1:00 PM a review facility policy, Food Storage: Cold Foods. Procedures stated All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Based on record review and staff interview, the facility failed to document the vaccination status of each staff member (i.e., immunized or not). This was a random opportunity for discovery. Facility census: 106.During an interview on 07/30/25 at approximately 3:50 PM, the Director of Nursing (DON) reported that the facility only had a total number of staff that received COVID vaccine. The facility did not have any documentation readily available that detailed which staff had received or had not received the COVID vaccine.

Based on medical record review and staff interview, the facility failed to ensure residents receiving antihypertensive (high blood pressure) medications were adequately assessed and the physician was notified when blood pressures (BPs) were not within physician ordered parameters for two (2) of seven (7) residents reviewed for unnecessary medications during Stage 2 of the survey. A physician's orders [REDACTED].#32's systolic blood pressure (SBP) was greater than 180 millimeters of mercury (mmHg - the unit used to measure blood pressures) or less than 90 mmHg or the diastolic blood pressure (DBP) was over 90 or under 50 mmHg. Review of the resident's blood pressures for the period of 03/18/15 through 04/22/15, revealed they were out of the established critical parameters on fifteen (15) occasions; however, the physician was not notified. On 04/23/15 at 4:00 p.m., a discussion with Licensed Practical Nurse (LPN) #60 and Registered Nurse (RN) #43 confirmed the critical blood pressures for Resident #32. They agreed there was no evidence of physician notification. This lack of physician notification placed more than a limited number of individuals residing in the facility at risk for a potential life threatening medical event. At 5:44 p.m. on 04/23/15, the administrator (NHA) and director of nursing were notified of an immediate jeopardy. Upon request, the facility obtained a list from the pharmacy of all residents residing in the facility with the BP parameter order. The DON stated there were approximately 70 residents with an order to notify the physician when a resident's BP was outside of the ordered parameters. Based on this list, another resident was randomly selected for review (Resident #50). This additional review also revealed the lack of physician notification when Resident #50's blood pressures were outside of the ordered parameters. After this was brought to the attention of the facility, Resident #32's physician was notified immediately of the BPs outside of the ordered parameters. An order was received to monitor the resident's BPs every four (4) hours over the next 24 hours and report any irregularities to the physician. On 04/24/at 8:30 a.m., the immediate jeopardy was removed, after which no deficient practice remained. Resident identifiers: Residents #32 and #50. Facility census: 111. Findings include: a) Resident #32 On 04/23/15 at 8:07 a.m., a review of the medical record revealed Resident #32 had [DIAGNOSES REDACTED]. Resident #32 was admitted to the facility on [DATE]. A review, of the physician's orders [REDACTED]. In addition, the admission physician orders, in the section entitled Ancillary Orders, noted vital signs (BP (blood pressure), pulse, respirations, and temperature) were ordered every shift x (times) 14 days then once weekly x 4 weeks then every month - notify MD (medical doctor) if SBP (systolic BP) > (greater than) 180 or < (less than) 90 or if DBP (diastolic BP) >90 or <50. A review of the April 2015 recapitulation orders revealed, on 03/31/15, an order for [REDACTED].>180 or <90 or if DBP >90 or <50. A continued review of the medial record revealed vital signs (VS) were recorded in the nurses' notes. Review of the nurses' notes, from 03/18/15 through 04/22/15, revealed the following blood pressures which were outside of the parameters for which the physician needed contacted: 03/18/15 at 1:20 a.m., BP 88/58 SBP < 90 03/19/15 at 2:00 a.m., BP 128/95 DBP >90 03/19/15 at 4:30 a.m., BP 85/59 SBP <90 03/24/15 at 9:00 a.m., BP 102/48 DBP <50 03/25/15 at 3:00 a.m., BP 82/55 SBP <90 03/30/15 at 2:45 a.m., BP 86/63 SBP <90 03/31/15 at 4:00 a.m., BP 86/64 SBP <90 04/06/15 at 9:00 a.m., BP 138/96 DBP >90 04/10/15 at 1:00 a.m., BP 84/64 SBP <90 04/14/15 at 1:00 a.m., BP 88/63 SBP <90 04/14/15 at 10:25 a.m.BP 161/91 DBP >90 04/17/15 at 4:00 a.m., BP 60/37 SBP <90 and DBP <50 04/18/15 at 2:55 a.m., BP 87/57 SBP <90 04/22/15 at 3:10 a.m., BP 88/49 SBP <90 and DBP <50 04/22/15 at 2:25 a.m., BP 80/44 SBP <90 and DBP <50 There was no evidence the physician was notified of these critical BPs for which the physician should have been contacted. On 04/23/15 at 4:09 p.m., a discussion was conducted with Licensed Practical Nurse (LPN) #60 and Registered Nurse (RN) #43. Upon inquiry, LPN #60 did not offer any explanation regarding why the physician was not notified of the critical BPs. The LPN stated VS, which included the BP, were taken twice daily for residents receiving skilled services. RN #43 stated the night shift nurse should have notified the physician of the low BPs. The RN confirmed the physician was not notified. b) Resident #50 On 04/27/15 at 10:23 a.m., a review of the medical record revealed Resident #50 had [DIAGNOSES REDACTED]. Resident #50 was admitted to the facility on [DATE]. A review of the physicians orders, on 04/27/15 at 10:37 a.m., revealed, upon re-admission on 01/26/15 from an acute care hospital, the physician ordered Metroprolol ([MEDICATION NAME]) 25 mg twice daily [MEDICAL CONDITION](high blood pressure). On 03/28/15, the physician increased the [MEDICATION NAME] from 25 mg twice daily to 50 mg twice daily. On 04/15/15, the physician increased the dose of [MEDICATION NAME] to 75 mg twice daily. The physician also ordered the resident's BP to be taken twice a day for one week. The March 2015 recapitulation (recap) orders, in the section Ancillary Orders, noted vital signs were ordered every shift x 14 days then once weekly x 4 (four) weeks then every month - notify MD (medical doctor) if SBP >180 or <90 of if DBP >90 or <50. A review of the April 2015 recapitulation orders revealed, on 03/31/15, vital signs once weekly for 28 days. 04/28/15 vital signs every month - notify MD if SBP >180 or <90 or if DBP >90 or <50. There was no evidence the physician was notified of any of the following critical blood pressures between 02/08/15 and 04/23/15. 02/08/15 at 10:30 a.m., BP 149/93 DBP >90 02/10/15 at 2:00 p.m., BP 161/99 DBP >90 02/11/15 at 1:30 p.m., BP 148/96 DBP >90 02/13/15 at 4:00 a.m., BP 193/105 SBP >180 and DBP >90 02/13/15 at 12:35 p.m., BP 150/100 DBP >90 02/15/15 at 11:00 a.m., BP 157/84 DBP >90 02/17/15 at 1:35 a.m., BP 151/95 DBP >90 02/17/15 at 10:45 a.m., BP 170/98 DBP >90 02/18/15 at 1:25 p.m., BP 157/99 DBP >90 02/19/15 at 11:20 a.m., BP 184/87 SBP >180 02/20/15 at 2:00 a.m., BP 154/97 DBP >90 02/20/15 at 10:40 a.m., BP 169/98 DBP >90 02/21/15 at 10:30 a.m., BP 170/99 DBP >90 02/22/15 at 10:20 a.m., BP 170/97 DBP >90 02/23/15 at 2:10 a.m., BP 169/98 DBP >90 02/24/15 at 10:10 a.m., BP 151/97 DBP >90 02/25/15 at 4:00 p.m., BP 188/95 SBP >180 and DBP >90 02/27/15 at 3:15 a.m., BP 189/81 SBP >180 and DBP >90 02/27/15 at 10:30 a.m., BP 167/96 DBP >90 02/28/15 at 4:00 a.m., BP 169/92 DBP >90 02/28/15 at 1:30 p.m., BP 156/98 DBP >90 03/03/15 at 10:20 a.m., BP 204/96 SBP >180 and DBP >90 03/04/15 at 11:00 a.m., BP 175/94 DBP >90 03/06/15 at 2:20 a.m., BP 190/102 SBP >180 and DBP >90 03/07/15 at 2:05 a.m., BP 193/95 SBP >180 and DBP >90 03/08/15 at 1:25 a.m., BP 191/98 SBP >180 and DBP >90 03/11/15 at 4:00 a.m., BP 152/92 DBP >90 03/11/15 at 1:20 p.m., BP 199/93 SBP >180 and DBP >90 03/16/15 at 10:30 a.m., BP 201/94 SBP >180 and DBP >90 03/19/15 at 2:00 a.m., BP 150/98 DBP >90 03/21/15 at 2:30 a.m., BP 172/95 DBP >90 03/21/15 at 10:25 a.m., BP 191/97 SBP >180 and DBP >90 03/22/15 at 11:00 a.m., BP 185/97 SBP >180 and DBP >90 03/23/15 at 2:25 a.m., BP 148/96 DBP >90 03/25/15 at 10:25 a.m., BP 190/90 SBP >180 03/26/15 at 11:15 a.m., BP 190/90 SBP >180 03/28/15 at 1:00 p.m., BP 162/94 DBP >90 03/31/14 at 10:15 a.m., BP 190/84 SBP >180 04/02/15 at 9:00 a.m., BP 167/108 DBP >90 04/02/15 at 10:00 a.m., BP 156/100 DBP >90 04/06/15 at 9:00 a.m., BP 157/100 DBP >90 04/11/15 at 9:00 a.m., BP 198/96 SBP >180 and DBP >90 04/12/15 at 9:00 a.m., BP 190/98 DBP >90 04/12/15 at 2:00 p.m., BP 164/98 DBP >90 04/15/15 at 9:00 a.m., BP 202/110 SBP >180 and DBP >90 04/16/15 at 7:00 a.m., BP 155/98 DBP >90 04/21/15 at 3:40 p.m., BP 166/97 DBP >90 04/23/15 at 11:05 a.m., BP 155/104 DBP >90 c) A plan to abate the Immediate Jeopardy was submitted on 04/23/15 at 7:20 p.m. Review of the plan by survey team and consultation with Program Manager I was conducted at 8:10 p.m., on 04/23/15. The plan included a method of correction including monitoring Resident #32 ' s blood pressure every four (4) hours, re-educating all nursing staff, and ongoing monitoring of all residents receiving medications with parameters requiring physician notification. The immediate jeopardy was abated on 04/24/15 at 8:30 a.m., after review of records to ensure the facility's corrective action plan was implemented.

Based on record review, staff interview, confidential family interview, and review of facility incident / accident reports, the facility failed to ensure the resident environment remained as free of accident hazards as was possible, including freedom from the aggressive behaviors of Resident #119, and that each resident received adequate supervision to prevent physical abuse by Resident #119. Documentation throughout Resident #119's medical record and facility incident reports revealed numerous episodes of aggressive behavior, including entering other resident rooms and rummaging in their things, as well as striking and pinching others on at least six (6) occasions during his seventy-seven (77) day stay at the facility. The aggressive behaviors of Resident #119 resulted in at least six (6) recorded resident-to-resident physical altercations (involving Residents #23, #30, #45, #17, #7, and #25). The final aggressive episode resulted in physical injury to Resident #25, who sustained a bruised eye and skin tears to his arm. In the weeks and months leading up to Resident #25's injuries, the facility's administrative staff and interdisciplinary team failed to: - Identify the need for increased supervision in the facility (occupied by other elderly, debilitated residents) related to Resident #119's behaviors. (The resident had a prior personal history of frequent aggressive behaviors with his family members of which facility staff should have been aware.) - Evaluate and analyze the frequency, intensity, and duration of his physically abusive behaviors and identify causal / contributing factors, in order to develop appropriate interventions to reduce / eliminate these behaviors and ensure the safety of others; - Implement interventions, including providing adequate supervision, consistent with the needs, goals, and plans of care of both Resident #119 (the aggressor) and the other residents of the facility, in order to reduce the risk of resident-to-resident altercations; and/or - Monitor the effectiveness of the interventions and modify the interventions as necessary when it was apparent the interventions did not result in sustainable changes in Resident #119's aggressive behavior. One (1) family member, who was confidentially interviewed, revealed they voiced concerns about the safety of other residents (due to Resident #119's behavior) to nursing staff of the facility; however, there was no documented evidence by facility staff of this conversation. (Identifiers withheld due to request for confidentiality.) The failure of the facility to identify and eliminate or effectively mitigate the potential hazards in the environment posed by Resident #119's aggressive behaviors resulted in the physical abuse of six (6) residents (Residents #23, #30, #45, #17, #7, and #25) with resulting injury to Resident #25. It also presented the potential for more than minimal harm to all residents of the facility who were subjected to the overall hostile environment created by Resident #119. Facility census: 117. Findings include: a) Resident #119 Review of the medical record of Resident #119 revealed the resident had been admitted to an area acute care hospital from his home on 04/12/10. The history and physical examination He has also had acting out behaviors including hitting his family members and getting increasingly violent." The resident was admitted to the nursing home from this hospitalization on [DATE]. Review of the resident's care plan revealed, on 06/09/10, a plan of care for psychotropic drug use had been implemented which listed all of the resident's mood altering medications and the behaviors which they were intended to treat. The only changes made to the plan were hand written entries at the time of medication changes. There was no mention of non-pharmacologic interventions to prevent (e.g., modification of environmental triggers, additional supervision, diversional activities, etc.) or resolve aggressive behaviors, nor were changes made to interventions to be used by staff following incidents where Resident #119 had physically attacked other residents. - b) Resident #30 A facility incident report stated that, on 06/15/10 at 1:40 p.m., Resident #119 approached Resident #30, who was sitting in the hallway, and "hit him in the face". There was no noted physical injury to Resident #30. The report further stated staff "separated residents". Review of Resident #30's most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 04/07/10, described this resident as weighing 134# and being totally dependent on staff for bed mobility, ambulation, etc. He could provide for none of his own needs. This resident would not have been able to independently walk or get away from Resident #119. - c) Resident #45 A facility incident report stated that, on 06/15/10 at 9:00 p.m., after hitting a different resident earlier in the day, Resident #119 was "ambulating in the hallway, went into room (room # of Resident #45) and hit resident on L (left) arm". The report stated there was no injury to Resident #45 and the residents were separated. The physician for Resident #119 was notified, and an order for [REDACTED]. The order was changed the next day to two (2) mg two (2) times daily. - d) Resident #17 A facility incident report stated that, on 07/11/10 at 8:10 p.m., Resident #119 entered the room of Resident #17 while the resident was lying in the bed and "hit the resident (#17) multiple times in the head". Again, there was no injury noted and the residents were separated. The most recent MDS for Resident #17, an abbreviated quarterly assessment with an ARD of 06/16/10, stated this resident [AGE] year old could only walk and move about in the bed with the assistance of two (2) staff; this resident would not have been able to independently walk or get away from Resident #119. - e) Resident #7 A facility incident report stated that, on 07/11/10 at 8:30 p.m., twenty (20) minutes after hitting Resident #17, Resident #119 entered the room of Resident #7 and, when asked to leave, "struck (Resident #7) beside the R (right) side of the mouth". The report stated Resident #7 was not injured and a stop sign was put on his door. - f) Resident #23 A facility incident report stated that, on 07/21/10 at 7:50 a.m., this resident was lying in bed and Resident #119 came into her room and started pinching her legs. This report also stated that Resident #23 was not injured and "other resident was removed from her room". Review of Resident #23's most recent available MDS, an abbreviated quarterly assessment with an ARD of 04/21/10, stated this [AGE] year old resident weighed 139# and was dependent on staff for any transfer. This resident would not have been able to independently walk or get away from Resident #119. - g) Resident #25 A facility incident report stated that, on 08/06/10, Resident #25 reported to facility staff that Resident #119 entered his room and walked over to his bed. When he (#25) yelled for him (#119) to leave, Resident #119 hit him (#25). Two (2) skin tears were noted on the resident's left arm and his right cheek was slightly edematous when assessed by staff immediately after the incident. The resident complained of no pain. When observed on 08/11/10 at 11:00 a.m., Resident #25 was noted to have a bruised discoloration on the outside parameter of his right eye. This resident had experienced a stroke and had minimal use of his right side. He was able to call out for help. - h) A facility registered nurse (RN - Employee #26), who was designated as in charge in the absence of the administrator and the director of nurses, was interviewed on several occasions during the two (2) day investigation. This nurse confirmed there was no evidence of attempt by facility staff to identify and eliminate causative factors of Resident #119's aggressive behaviors or to assign additional supervision for the resident and avoid aggressive behaviors. She was unaware that some of the physical altercations had been repeated in short time spans on the same days. This nurse felt there had been attempts to move the resident to a more appropriate setting without success, but no evidence of these attempts could be provided. This nurse did also confirm that Resident #119 was not confined to the unit of the facility on which he resided, but he did wonder throughout the facility. This nurse stated that staff was aware of the behaviors of Resident #119 since his admission, but they did not expect it to escalate to the point it did when he hit Resident #25. - i) Social service progress notes found on the medical record of Resident #119 disclosed no evidence of attempts to transfer / move the resident to another setting to assure the safety of other facility residents prior to his transfer on 08/09/10. A facility social worker (Employee #5), when interviewed on 08/11/10 at approximately 4:00 p.m., confirmed these notes as accurate and complete.

Based on record review, observation, resident interview, staff interview, and physician interview, the facility failed to provide necessary care and services to assist one (1) of twenty (20) sampled residents in attaining or maintaining her highest practicable level of physical well-being, by failing to obtain routine laboratory testing as ordered by the physician for a resident with a [DIAGNOSES REDACTED].#108, who was subsequently found to be dehydrated and hyperkalemic. Labs, obtained only after surveyor intervention, revealed the resident was dehydrated and hyperkalemic (elevated serum potassium level), and the physician discontinued the diuretic therapy and ordered the administration of intravenous IV fluids (to rehydrate the resident), medications to alter the resident's serum potassium level, and repeat labs. During this period of active physician intervention, the facility failed to document periodic nursing assessments (including vital signs) and the resident's response to treatment. Resident identifier: #108. Facility census: 112. Findings include: a) Resident #108 Review of Resident #108's medical record revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. 1. Record review, on 03/02/10, revealed physician orders [REDACTED]. However, the most recent test results, dated 08/31/09, revealed the following abnormal lab values: - Potassium - high at 5.6 (normal range 3.5 - 5.2) - Chloride - high at 115 (normal range 97 - 108) - Carbon [MEDICATION NAME] - low at 17 (normal range 20 - 32) - BUN - high at 39 (normal range 5 - 26) - Creatinine - high at 3.02 (normal range 0.57 - 1.00) - Estimated Glomerular Flow Rate (eGRF - a test for monitoring kidney function) - low at 15 (normal range > 59) (Note: Abnormally high values of BUN, creatinine, and potassium are indicative of impaired kidney function; abnormally low values of eGFR are indicative of kidney damage. Abnormally high values of BUN, creatinine, and potassium are also indicative of dehydration.) Further record review revealed the addition of a diuretic, [MEDICATION NAME] 40 mg daily, which was initiated on 12/02/09. No lab results were available for November 2009 or February 2010. Observation of, and interview with, this resident, on 03/02/10 at 8:30 a.m., revealed a pleasantly confused lady who was clean in appearance and well groomed. During this conversation, she threw back the covers and spoke of her TED hose lying at the foot of her bed, saying she would need them on. Both of her legs were [MEDICAL CONDITION], more so on the left, and her finger made an imprint on her left lower thigh when she touched it. On 03/02/10, a medical records person (Employee #12) reviewed the resident's thinned record on file and was unable to find the physician-ordered laboratory tests listed above since 08/31/09. On 03/02/10 at approximately 11:15 a.m., these findings were reported to the director of nursing (DON), who stated she would notify the physician and request an order for [REDACTED]. 2. Medical record review, on 03/03/10, revealed a physician notification form dated 03/02/10 at 11:45, regarding the missing November 2009 and February 2010 labs (BUN, creatinine, and electrolytes). Labs, collected at 12:04 p.m. and reported at 2:12 p.m. on 03/02/10, yielded the following abnormal results: - Potassium - high at 6.1 (normal range 3.5 - 5.2) - Chloride - high at 111 (normal range 97 - 108) - BUN - high at 51 (normal range 5 - 26) - Creatinine - high at 3.53 (normal range 0.57 - 1.00) - eGRF - low at 12 (normal range > 59) Upon notification of these abnormal results, the physician gave orders, on 03/02/10 (with no timed entry for the telephone order), to discontinue the [MEDICATION NAME], give Potassium Chloride 30 meq (additional potassium for an individual who already had an abnormally high serum potassium level), and administer 1000 cc intravenous fluids of D5W (5% [MEDICATION NAME] and water) at a rate of 100 cc per hour with repeat labs in the morning. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 3. Record review, on 03/04/10, revealed repeat labs, collected at 7:23 a.m. and reported at 12:13 p.m. on 03/03/10, yielded the following abnormal results: - BUN - high at 49 (normal range 5 - 26) - Creatinine - high at 3.29 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) Review of physician's orders [REDACTED]. Review of nursing notes found an entry, dated 03/03/10 at noon, stating, "2nd (second) blood draw done to confirm K+ (potassium) level before administering [MEDICATION NAME]." A subsequent entry, at 2:00 p.m. on 03/03/10, noted an elevated potassium level of 5.8 with [MEDICATION NAME] given. Another entry, also at 2:00 p.m. on 03/03/10, noted more lab work was scheduled for the morning. 4. Labs, collected at 1:21 a.m. and reported on 03/04/10 (time of report not noted), yielded the following abnormal results: - Potassium - within normal limits at 4.8 (normal range 3.5 - 5.2) - BUN - high at 45 (normal range 5 - 26) - Creatinine - high at 3.42 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) 5. Interview with the nurse (Employee #38), on 03/04/10 at 11:45 a.m., revealed the facility uses a tickler file in a file box at each nurse's station to record the months or the weeks in a month when repeating lab work is due for specific residents. When asked, she said this is the third hall in which this resident has resided since admission to the facility last year. 6. Interview with the assistant director of nursing (ADON - Employee #4), on 03/04/10 at 2:00 p.m., revealed they were wondering about the physician's orders [REDACTED].#21 replied in the affirmative. According to the ADON, Employee #21 said she called the physician the next morning, on 03/03/10, before giving the [MEDICATION NAME]. 7. During interview with the physician on 03/04/10 at 2:15 p.m., he said his primary focus initially was to hydrate the resident. He said the nurse told him about the 6.1 potassium level 03/02/10. When asked about the order for potassium chloride, he explained he knew the potassium level would drop when she was re-hydrated. 8. Review of nursing notes for 03/02/10, 03/03/10, and the night shift on 03/04/10, found no assessments or vital signs documented during the time the resident was being re-hydrated and being treated for [REDACTED]. 9. Review of the resident assessment protocol (RAP) summary on the resident's comprehensive admission assessment (dated as completed on 06/06/09) found the interdisciplinary care team decided to not address dehydration / fluid maintenance on this resident's care plan, even though her admitting [DIAGNOSES REDACTED]. Review of the current care plan revealed the problem statement: "At nutritional risk r/t (related to): Therapeutic diet r/t Stg IV CRF (Stage IV [MEDICAL CONDITION])." There was a box to also mark "Dehydration", but the interdisciplinary care team chose not to mark this. The goals associated with this problem statement were: "Resident will consume at least 75% of most meals" and "Weight will remain stable +/- 5 lbs adm (admission weight) 135 lb (also noted +3 [MEDICAL CONDITION] to BLE (bilateral lower extremities)". The interventions to assist the resident in achieving these goals included: "Monitor labs as ordered / available." .

Based on record review, observation, resident interview, staff interview, and physician interview, the facility failed to provide necessary care and services to assist one (1) of twenty (20) sampled residents to ensure the resident maintained acceptable parameters of fluid and electrolyte balance, by failing to develop and implement a care plan to address fluid and electrolyte balance for a resident with a [DIAGNOSES REDACTED]. These failures resulted in actual harm to Resident #108, who was subsequently found to be dehydrated and hyperkalemic. Labs, obtained only after surveyor intervention, revealed the resident was dehydrated and hyperkalemic (elevated serum potassium level), and the physician discontinued the diuretic therapy and ordered the administration of intravenous IV fluids (to rehydrate the resident), medications to alter the resident's serum potassium level, and repeat labs. Resident identifier: #108. Facility census: 112. Findings include: a) Resident #108 Review of Resident #108's medical record revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. 1. Record review, on 03/02/10, revealed physician orders [REDACTED]. However, the most recent test results, dated 08/31/09, revealed the following abnormal lab values: - Potassium - high at 5.6 (normal range 3.5 - 5.2) - Chloride - high at 115 (normal range 97 - 108) - Carbon [MEDICATION NAME] - low at 17 (normal range 20 - 32) - BUN - high at 39 (normal range 5 - 26) - Creatinine - high at 3.02 (normal range 0.57 - 1.00) - Estimated Glomerular Flow Rate (eGRF - a test for monitoring kidney function) - low at 15 (normal range > 59) (Note: Abnormally high values of BUN, creatinine, and potassium are indicative of impaired kidney function; abnormally low values of eGFR are indicative of kidney damage. Abnormally high values of BUN, creatinine, and potassium are also indicative of dehydration.) Further record review revealed the addition of a diuretic, [MEDICATION NAME] 40 mg daily, which was initiated on 12/02/09. No lab results were available for November 2009 or February 2010. Observation of, and interview with, this resident, on 03/02/10 at 8:30 a.m., revealed a pleasantly confused lady who was clean in appearance and well groomed. During this conversation, she threw back the covers and spoke of her TED hose lying at the foot of her bed, saying she would need them on. Both of her legs were [MEDICAL CONDITION], more so on the left, and her finger made an imprint on her left lower thigh when she touched it. On 03/02/10, a medical records person (Employee #12) reviewed the resident's thinned record on file and was unable to find the physician-ordered laboratory tests listed above since 08/31/09. On 03/02/10 at approximately 11:15 a.m., these findings were reported to the director of nursing (DON), who stated she would notify the physician and request an order for [REDACTED]. 2. Medical record review, on 03/03/10, revealed a physician notification form dated 03/02/10 at 11:45, regarding the missing November 2009 and February 2010 labs (BUN, creatinine, and electrolytes). Labs, collected at 12:04 p.m. and reported at 2:12 p.m. on 03/02/10, yielded the following abnormal results: - Potassium - high at 6.1 (normal range 3.5 - 5.2) - Chloride - high at 111 (normal range 97 - 108) - BUN - high at 51 (normal range 5 - 26) - Creatinine - high at 3.53 (normal range 0.57 - 1.00) - eGRF - low at 12 (normal range > 59) Upon notification of these abnormal results, the physician gave orders, on 03/02/10 (with no timed entry for the telephone order), to discontinue the [MEDICATION NAME], give Potassium Chloride 30 meq (additional potassium for an individual who already had an abnormally high serum potassium level), and administer 1000 cc intravenous fluids of D5W (5% [MEDICATION NAME] and water) at a rate of 100 cc per hour with repeat labs in the morning. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 3. Record review, on 03/04/10, revealed repeat labs, collected at 7:23 a.m. and reported at 12:13 p.m. on 03/03/10, yielded the following abnormal results: - BUN - high at 49 (normal range 5 - 26) - Creatinine - high at 3.29 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) Review of physician's orders [REDACTED]. Review of nursing notes found an entry, dated 03/03/10 at noon, stating, "2nd (second) blood draw done to confirm K+ (potassium) level before administering [MEDICATION NAME]." A subsequent entry, at 2:00 p.m. on 03/03/10, noted an elevated potassium level of 5.8 with [MEDICATION NAME] given. Another entry, also at 2:00 p.m. on 03/03/10, noted more lab work was scheduled for the morning. 4. Labs, collected at 1:21 a.m. and reported on 03/04/10 (time of report not noted), yielded the following abnormal results: - Potassium - within normal limits at 4.8 (normal range 3.5 - 5.2) - BUN - high at 45 (normal range 5 - 26) - Creatinine - high at 3.42 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) 5. During interview with the physician on 03/04/10 at 2:15 p.m., he said his primary focus initially was to hydrate the resident. He said the nurse told him about the 6.1 potassium level 03/02/10. When asked about the order for potassium chloride, he explained he knew the potassium level would drop when she was re-hydrated. 6. Review of the resident assessment protocol (RAP) summary on the resident's comprehensive admission assessment (dated as completed on 06/06/09) found the interdisciplinary care team decided to not address dehydration / fluid maintenance on this resident's care plan, even though her admitting [DIAGNOSES REDACTED]. Review of the current care plan revealed the problem statement: "At nutritional risk r/t (related to): Therapeutic diet r/t Stg IV CRF (Stage IV [MEDICAL CONDITION])." There was a box to also mark "Dehydration", but the interdisciplinary care team chose not to mark this. The goals associated with this problem statement were: "Resident will consume at least 75% of most meals" and "Weight will remain stable +/- 5 lbs adm (admission weight) 135 lb (also noted +3 [MEDICAL CONDITION] to BLE (bilateral lower extremities)". The interventions to assist the resident in achieving these goals included: "Monitor labs as ordered / available." .