Every finding on record at Haven Health Sky Harbor, LLC

Based on closed record review, interviews, and review of the facility's policies and procedures, the facility failed to provide discharge information to the Resident's Representative (RR) in a language she understood for one of 2 sampled residents (Resident #4) regarding resident's rights. The deficient practice could result in the RR not understanding the resident's post-discharge care needs and instructions, potentially leading to unmet care needs following discharge.Findings include:Resident #4 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, tracheostomy status, spastic quadriplegic cerebral palsy, a stroke affecting the right side of the brain resulting in loss of movement on the left side of the body, and aphasia.A Care Plan, initiated on February 11, 2026, addressed the goal of establishing a pre-discharge plan. Interventions included coordinating a discharge plan with the interdisciplinary team and providing services according to the care plan.A Social Services Progress Note, dated February 12, 2026 at 12:58 P.M., revealed Social Services met with Resident #4 and the RR to conduct assessments. The note documented that Resident #4 was unable to answer questions and that a language-line interpretation service was utilized because the RR was Spanish-speaking.An admission Minimum Data Set (MDS) assessment, dated February 17, 2026, revealed a Brief Interview for Mental Status (BIMS) was not completed. However, the same MDS noted that Resident #4's cognitive skills for daily decision making were severely impaired. The MDS further noted that Resident #4 had no speech pattern, was rarely/never made himself understood, and rarely/never understood verbal content communicated to him.Review of a Respiratory Therapy Note, dated March 1, 2026, revealed the family was Spanish-speaking. The note documented that the RR was fluent in spoken English and that the resident's father spoke minimal English.Review of email correspondence from the Ombudsman dated May 11, 2026, regarding Resident #4's discharge planning and coordination of durable Medical Equipment (DME), revealed the RR reported that her interactions with the Director of Social Services had been conducted in English without the use of interpretation services. The email identified the RR as having limited English Proficiency and expressed concern that there was a possibility the RR had misunderstood instructions provided by the Director of Social Services.Review of the facility's response to the email, dated May 12, 2026 and sent by the Director of Nursing (Staff #33), revealed that according to the Director of Social Service, a Spanish-speaking interpreter had been with the RR during the interactions. Staff #33 further stated that, going forward, the facility would document the interpreter's identification number.Review of a progress note dated May 13, 2026 revealed staff spoke with the RR regarding caregiver and percutaneous endoscopic gastrostomy (PEG) tube training, including maintaining and programming the pump and cleaning the PEG-tube site. The note documented that a Certified Nursing Assistant (CNA) translated the information from English to Spanish. The RR declined the training and stated she knew how to care for Resident #4.Review of the facility's Discharge form, dated May 21, 2026 at 3:07 P.M., revealed the discharge information was documented in English. The form contained the RR's signature, dated May 22, 2026. However, the form contained no documented evidence that an interpreter was utilized during the provision of the discharge information and did not identify an interpreter or interpreter identification number.A Discharge summary, dated [DATE] at 3:07 P.M. noted that Resident #4 was to be discharged home with home health services. It also noted that written education regarding tube feeding, tracheotomy care and medications was provided to the RR. The discharge information was documented in English. There was no documented evidence that an interpreter was utilized to communicate the discharge information to the RR in Spanish or documentation identifying an interpreter or interpreter identification number. There was also no evidence that the written information was given to the RR in Spanish.A Progress Note, dated May 22, 2026 at 3:04 P.M. noted that Resident #4 was discharged home with family and that discharge instructions was given to the RR. There was no evidence the discharge instructions were relayed to the RR in Spanish. There was no documented evidence that an interpreter was utilized when discharge instructions were communicated to the RR.A discharge MDS assessment dated [DATE], noted that the resident had a planned discharge and was sent home under the care of an organized home health service organization.A complaint received on July 15, 2026 via the State Agency's complaint portal revealed an allegation that the RR had requested information related to Resident #4's medical care and DME to be communicated to her in Spanish and the facility did not provide Resident #4's discharge information to the RR in Spanish during the resident's discharge.An interview was conducted with the Ombudsman, on July 28, 2026 at 9:49 A.M. She explained that she was assisting the RR due to the RR not receiving an interpreter during the discharge process. She further explained that the RR had shared her concerns with the Ombudsman because she was not able to understand the medical terminology the facility used to explain how to provide care for Resident #4 and to coordinate the ordering and delivery of the necessary medical supplies the resident would need at home. The Ombudsman explained that she was able to communicate with the RR in Spanish.An interview was conducted on July 29, 2026 at 10:33 A.M. with Social Services/Resident Relations Manager (Staff #19). Staff #19 explained that the facility utilizes a language interpretation phone line when they are needing to speak with a resident or RR in a language other than English. He further explained that if a resident wishes to use a family member to interpret for them, staff will then document that. Staff #19 stated that he has never seen a discharge summary presented to a resident or their representative in a language other than English. He further stated that every time language services are utilized, it should be documented.An interview was conducted on July 29, 2026 at 1:20 P.M. with the Director of Nursing/Staff #33. Staff #33 recalled Resident #4 and shared that he had a ventilator and was airway dependent. She further shared that the RR had wanted to take Resident #4 home. Staff #33 also stated that, using an interpreter, it was communicated to the RR that the facility needed to get things in place for the resident before discharging him. She also shared that the RR had reached out and had gotten the resident's Long-Term case manager and the Ombudsman involved in the discharge process. Staff #33 reviewed Resident #4's clinical chart and shared that she only saw one Social Services note indicating a language interpretation services was provided to the RR. She further shared that she was not sure how the resident's discharge information was communicated to the RR leading up to and on the day of discharge. Staff #33 explained that her expectation was for staff to use an interpreter when communicating with non-English speaking residents and/or family, and to document the interpreter number and its use in the chart.A review was conducted of the facility's policy and procedure, titled Resident Rights - Translation and/or Interpretation of Facility Services, dated January 1, 2024. The policy and procedure stated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. It also noted that when written translation of vital information is unavailable, or impractical, the facility shall attempt to provide oral translation of vital documents. The document identified discharge instructions as a piece of vital information.

Based on clinical record reviews, staff interviews, facility documentation, and review of facility policies and procedures, the facility failed to ensure adequate supervision to prevent elopement for one (#21) of three sampled residents. The deficient practice could result in avoidable accidents, injury, or harm to residents.Findings include:Resident #21 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy, type 2 diabetes mellitus, atelectasis, dysphagia (oropharyngeal phase), cognitive communication deficit, unspecified dementia with agitation, acute kidney failure, anemia, long-term use of insulin, abnormalities of gait and mobility, generalized muscle weakness, lack of coordination, and adjustment disorder.Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #21 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The MDS also revealed that Resident #21 exhibited wandering behaviors one to three times during the assessment period. The MDS further indicated that Resident #21 required supervision or touching assistance for sitting to standing and for walking 10 feet, 50 feet with two turns, and 150 feet. The MDS documented that Resident #21 had utilized both a walker and wheelchair during the previous seven days.Review of Resident #21's care plan revealed a focus initiated January 29, 2026, for his diagnosis of dementia. Interventions included monitoring, documenting, and reporting changes in cognitive function, decision making, memory, recall, and general awareness to the provider.The care plan was revised on February 2, 2026, indicating that Resident #21 was at risk for functional self-care deficits and functional mobility limitations related to encephalopathy, diabetes mellitus, immunodeficiency, atelectasis, acute kidney failure, and weakness. Interventions included providing assistance with standing from a sitting position.Another care plan focus for Resident #21, revised February 4, 2026, identified behavior problems including wandering/exit-seeking behaviors, resistance to care, and non-compliance. Interventions included anticipating the resident's needs and providing education to the resident, family, and caregivers regarding support and compliance.Further review of Resident #21's progress notes revealed a daily skilled evaluation note dated February 14, 2026, which indicated that Resident #21 wandered in the hallway and appeared restless while in his room.Another daily skilled evaluation progress note dated February 21, 2026, documented that Resident #21 exhibited wandering behaviors and indicated that staff were to anticipate his needs.A skilled needs review progress note dated February 24, 2026, revealed that the anticipated discharge date for Resident #21 was March 2, 2026. Barriers to discharge planning included dementia, wandering, and elopement risk.Review of Resident #21's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that on March 1, 2026, at 7:00 a.m., Resident #21's blood sugar was tested and recorded in the clinical record. Medications scheduled during the morning medication pass, including Amlodipine and Losartan, were documented as administered as ordered.Review of a health status progress note dated March 1, 2026, revealed that Resident #21 was last seen at approximately 8:00 a.m. during the morning medication pass. His blood sugar was checked and medications were administered as ordered. Resident #21 informed the writer (Licensed Practical Nurse, LPN/Staff #73) that he was going to the dining room to wait for breakfast. The medication pass was completed at approximately 9:00 a.m. Staff #73 was then notified that Resident #21 could not be located within the facility.Upon Resident #21's return to the facility, the resident stated that he had consumed a large amount of coffee the night before, was unable to sleep, and was tired and wanted to go home. Resident #21 was assessed by Staff #73, and no immediate concerns were identified. Resident #21 was placed on 15- minute safety checks, security doors were closed for safety, and the provider was notified. Resident #21's family member returned the resident to the facility at 10:57 a.m.On March 2, 2026, additional interventions were added to Resident #21's care plan for wandering/exit-seeking behaviors, including increased safety checks.On March 2, 2026, a Wander Risk Evaluation was completed. The evaluation indicated that Resident #21 was forgetful or had a short attention span, did not understand what was being said at times, had independent mobility, had early dementia, was taking antidepressants, and had a known history of wandering. The evaluation concluded that Resident #21 had a wander risk score of 10.0, indicating a moderate risk for wandering.Interviews were conducted on March 3, 2026, regarding the March 1, 2026 incident:At 9:20 a.m., a telephone interview was conducted with Resident #21's family member he stated that due to Resident #21's condition he had access to the location of Resident #21's cell phone. On March 1, 2026, at approximately 9:00 a.m., the family member checked the location of Resident #21's phone and became alarmed when he observed that Resident #21 was no longer at the facility. He located his father approximately six miles away from the facility. Resident #21's family member explained that he determined that Resident #21 was riding a city bus traveling away from the facility and the family's home. He stated that he was able to contact Resident #21, locate him, and bring him into his car. He then called the facility and returned Resident #21 to the facility. He estimated that Resident #21 had been away from the facility for approximately one and a half hours.At 11:20 a.m., a telephone interview was conducted with Staff #73. Staff #73 stated that she was aware of Resident #21's tendency to wander and believed that the receptionist at the front desk was also aware of these tendencies. Staff #73 stated that Resident #21 would sometimes wander to different floors within the facility and should be redirected when exhibiting these behaviors.Staff #73 stated that on March 1, 2026, she observed Resident #21 during the morning medication pass at approximately 8:00 a.m. After checking his blood sugar and administering medications, Resident #21 stated that he was going to wait for breakfast in the dining room. At approximately 9:00 a.m., Staff #73 was notified by the on-duty charge nurse that Resident #21 had left the facility. Staff reported searching the facility and grounds. Staff #73 contacted Resident #21's son to confirm that the resident could not be located. Staff #73 stated that Resident #21 later returned to the facility accompanied by family members. At that time, she assessed the resident's skin and vital signs, and laboratory testing including a urine test and blood draw were ordered by the physician. Staff #73 stated that Resident #21 appeared to be in no distress upon his return.At 11:42 a.m., an interview was conducted with the on-duty receptionist (Staff #159). Staff #159 stated that each day from 8:00 a.m. to 6:00 p.m., the receptionist on duty identifies each person entering and exiting the exterior sliding door of the facility. The door is controlled by a push button from the reception desk. Staff #159 demonstrated the function of the button and stated that staff may also open the door from the outside using an access panel. Staff #159 stated that from 6:00 p.m. to 8:00 a.m., facility security staff monitor and operate the front door and observe individuals entering and exiting the facility. Staff #159 stated that she was not working on March 1, 2026, but stated that she was aware that Resident #21 had wandering tendencies and had witnessed him attempting to exit the facility on two previous occasions. She stated that she would alert staff when a resident attempted to leave the facility.At 11:54 a.m., an interview was conducted with Resident #21. Resident #21 stated that on March 1, 2026, he left the facility after a difficult night because he wanted to go home. Resident #21 stated that he had not slept well the previous night and that his family brought him back to the facility.At 1:54 p.m., an interview was conducted with the Director of Nursing (DON/Staff #54). Staff #54presented video surveillance footage from March 1, 2026, of Resident #21 leaving the facility. The video footage, time and date stamped March 1, 2026, at 7:27 a.m., showed no staff present in the lobby or at the door. Resident #21 was observed approaching the exterior door wearing a baseball hat and attempting to push and pull on the locked door. Seconds later, a staff member approached the door from the outside. The staff member and Resident #21 were observed exchanging words. Shortly afterward, Resident #21 exited the building. Staff #54 identified the staff member in the video as the facility security officer (Staff #215).At 2:03 p.m., a telephone interview was conducted with Staff #215. Staff #215 stated that he had worked security at the facility for approximately two years and had never previously witnessed a resident attempting to elope from the facility and was unaware that Resident #21 had wandering behaviors. He stated that he was typically stationed at the front desk but would periodically leave the desk to walk the exterior of the building and parking area to ensure security. He stated that on March 1, 2026, at approximately 7:30 a.m., he was returning from checking the exterior of the building and encountered Resident #21 at the front door. He stated that he did not recognize the individual and asked if he was visiting a resident. Staff #215 stated that Resident #21 nodded yes. Staff #215 asked what floor he was visiting and Resident #21 responded second floor. Staff #215 stated that family members sometimes stay overnight with residents and he did not find the situation unusual. Staff #215 stated that he observed Resident #21 standing outside the door for approximately two minutes and then leaving the property.At 2:25 p.m., a follow-up interview was conducted with Staff #54. Staff #54 stated that residents should be assessed for risk of wandering and elopement upon admission. Staff #54 acknowledged that Resident #21's wandering assessment was not documented at the time of admission but stated that the resident had been care planned. Staff #54 stated that front desk staff should be aware of residents who exhibit wandering or exit-seeking behaviors and that monitoring should occur through safety checks. Staff #54 stated that this situation did not meet her expectations for resident safety and acknowledged that potential harm from an elopement could include injury or death.Review of the facility's five-day investigation report, submitted March 6, 2026, revealed that the facility determined that the security guard did not follow standards and protocol for verifying whether the individual leaving the facility was a visitor or a resident. The report substantiated the elopement.Review of the facility policy titled Behavior/Mood/Cognition: Wandering and Elopements, effective January 1, 2024, revealed that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm. The policy further stated that if an employee observes a resident leaving the premises, the staff member should attempt to prevent the resident from leaving in a courteous manner.

Based on a review of the clinical record, staff interviews, and policies and procedures, the facility failed to ensure that residents were treated with dignity and respect during meal service for four out of six residents observed receiving dining assistance (Residents #10, #61, #72, and #107). The universe was 106, and the sample size was 22. This deficient practice could potentially affect all residents needing meal assistance by diminishing their sense of dignity and personhood.-Regarding Resident #10Resident #10 was admitted on [DATE], with the diagnosis that included chronic respiratory failure with hypoxia, tracheostomy status, quadriplegia, C1-C4 incomplete, hypertensive heart disease without heart failure, generalized anxiety disorder, major depressive disorder, recurrent adjustment disorder, unspecified, and schizoaffective disorder, bipolar type. A review of the care plan intervention initiated on February 21, 2024, revealed that Resident #10 had a focus on nutritional problems and functional self-care deficits related to Quadriplegia. Interventions included assistance with dining.-Regarding Resident #61Resident #61 was admitted on [DATE], with diagnosis that included polyneuropathy, unspecified type 2 diabetes mellitus with hyperglycemia, paroxysmal atrial fibrillation, adjustment disorders, major depressive disorder, recurrent, moderate, and neuromuscular dysfunction of the bladder, unspecified.A review of the care plan, initiated on February 13, 2025, revealed a focus that addressed nutritional problems, swallowing difficulties related to dysphagia, and malnutrition resulting from hemiplegia and functional self-care deficits. Interventions included assisted eating and dining.-Regarding Resident #72Resident #72 was admitted on [DATE], with a diagnosis that included chronic kidney disease, unspecified, dependent on renal dialysis, essential hypertension, hyperlipidemia, unspecified, anemia, unspecified, and thrombocytopenia, unspecified. A review of the care plan, date-initiated April 1, 2025, revealed a focus on nutritional problems and functional self-care deficits. Interventions include assisted dining, with support for eating and meal preparation as needed.-Regarding Resident #107Resident #107 was admitted on [DATE], with the diagnosis that included unspecified psychosis not due to a substance or known physiological condition, cerebral infarction, unspecified hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left non-dominant side, other paralytic syndrome following cerebral infarction, bilateral muscle weakness, and type 2 diabetes mellitus without complications. A review of the care plan, date-initiated August 29, 2023, revealed a focus on nutritional problems related to Stroke, Quadriplegia, DM-II, Hemiplegia, Muscle Weakness, and functional self-care deficits. Interventions included: one-on-one assistance with dining as needed.A lunch service dining observation was conducted on September 21, 2025, at 12:01 PM. This observation revealed that three staff members (Staff #148, #149, and #181) were observed providing meal assistance to four of six residents while standing. Staff #148 was observed standing between two residents (Residents #10 and #107) and assisted both with their meals. Staff #149 was observed standing while preparing the setup for one resident; however, they proceeded to sit down once the resident was ready. Staff #181 (Resident #61) was observed standing next to the final resident while completing both setup and meal assistance.Following the dining observation, interviews were conducted with the Staff #148, #149, and #181.On September 21, 2025, at 12:41 PM, an interview was conducted with Staff #148 (Restorative Nursing Aide/RNA), who stated that the group of residents within the dining room during dining services is residents on a list called a 'Feeding List'. The RNA identified 'Feeders' as residents who require one-on-one care during meals. The RNA noted that the term 'Feeders' is used when individuals are assisted with their eating. The expectation for residents placed on the 'Feeding List' requires one-on-one assistance with their meals. The RNA described one-on-one assistance with meals as sitting next to the resident to assist with 'feeding', and then to ensure that the resident is not being rushed while being 'fed.' The RNA stated that there had been occasions where they assisted two residents at a time, referencing the day of observation, and that she does her best to go back and forth between the residents.An interview was conducted on September 21, 2025, at 12:50 p.m. with Staff #181 (Licensed Practical Nurse/LPN). The LPN stated that residents located in the dining room are those who are unable to feed themselves and require assistance with eating their meals. The LPN explained that the expectation is that before meal services begin, the floor staff will 'figure out who the feeders are' and then ensure that hand hygiene is practiced between residents. The LPN stated that staff are expected to provide the resident with small bites at a slow pace that does not rush the resident. The LPN stated that the potential risk if dining assistance is not provided as expected from the facility is that the resident may lose their sense of dignity and self-respect if staff were to rush or provide dining assistance in a demeaning manner. An interview was conducted on September 21, 2025, at 1:01 PM with Staff #149 (LPN/Care Coordinator), who stated that within his role, he oversees the assisted dining program that the facility currently enforces. The Care Coordinator noted that there is a list of individuals who are determined to require assistance with dining. The Care Coordinator stated that residents who need one-on-one assisted dining are determined by therapy evaluations, assessments, and any notifications from other nurses and Certified Nursing Assistants (CNAs) regarding changes to their abilities. The Care Coordinator also stated that it is preferred for staff to provide dining assistance while sitting next to the resident; however, he noted that, depending on the device a resident is seated in, staff may need to adjust accordingly to be at the same height as the resident's shoulder. The Care Coordinator also stated that the assisted dining program is important, as it will meet the needs of the resident and ensure that their individual care plan is met, helping them receive all the required nutrients and meet their intake goals. The Care Coordinator stated that the residents who receive dining assistance vary in terms of their swallowing abilities and hand movements, and will undergo evaluations and assessments to determine their eligibility for dining assistance. The Care Coordinator further stated that the term 'feeders' should not be used; the expectation is that staff utilize the term assisted dining, as the usage of the term 'feed' or 'feeders' can pose a concern to a resident's dignity. The Care Coordinator stated that education had been provided to both Staff #148 and #181, as the terms 'feed' and 'feeders' were overheard by the Care Coordinator during the above-mentioned interviews with Staff #148 and #181.On September 21, 2025, at 3:42 PM, the facility provided the survey team with a list of residents who are care-planned with the standard intervention of assisted dining. This list included Residents #10, #61, #72, and #107.A joint resident council interview was conducted on September 22, 2025, at 11:26 AM with Residents #75 and #113. Both residents stated that they have heard the term 'feeders' used by staff. In the joint interview, both residents stated that the term is used when staff advises residents of where they have just come from or if they need to end their current care to provide help to 'feeders'. Both residents stated that although they do not require dining assistance, they feel sorry for residents who are called 'feeders,' as that could not be a good feeling to be perceived as helpless and needing staff to assist with eating. An interview was conducted on September 22, 2025, at 2:12 PM, with the Director of Nursing (DON/Staff #108), who stated that staff who are assisting with the assisted dining program will escort the residents to the dining room, will ensure hand hygiene is being completed in-between residents, and should be at a level with the resident's shoulders. The DON stated that staff are encouraged to provide one-on-one assistance and/or assist multiple residents with their meals. The DON stated that the facility can offer clothing protectors if requested by the resident. Staff should not rush the resident, show respect, and be seated rather than standing over the resident. The DON stated that if a staff member is observed standing next to a resident, or two residents, that is not within the facility's expectations, and will require re-education for the staff to be seated when providing residents with assistance with their meals. The DON stated that the term 'feeder' should not be utilized at all when referencing residents who require dining assistance. The DON further stated that these are the facility's expectations, as any action taken by a staff member that do not meet those expectations can pose a concern regarding the resident's dignity, as the resident may feel that staff are referring to them in a derogatory manner.A review of the facility policy titled Food Services: Assistance with Meals, with an in-effect date of January 1, 2024, revealed that residents shall receive assistance with meals in a manner that meets the individual needs of each resident. This policy also revealed that residents who can not feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals; keeping interactions with other staff to a minimum while assisting residents with meals, avoid the use of labels when referring to residents (ex. feeders); and, prevent the use of bibs or clothing protectors instead of napkins, unless requested by the resident.

Based on a review of the clinical record, staff interviews, and a review of policies and procedures, the facility failed to maintain and make accessible complete medical records necessary to investigate the cases of 7 residents reviewed (Resident #137, #138, #139, #140, #141, #142, and #144). The universe was 106, and the sample size was 22. The deficient practice prevented a thorough investigation and posed a potential risk to the current quality and safety of resident care.-Regarding Resident #137Resident #137 was admitted on [DATE], with a diagnosis that included osteomyelitis, pressure ulcer of the right lower back, unspecified stage, and central cord syndrome at C4, subs. An admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 15, indicating that Resident #137's cognition had been intact. This MDS assessment also revealed that Resident #137 had a pressure ulcer present and was determined to be at risk for further pressure ulcer development. This MDS assessment also revealed that this resident had been dependent on staff assistance with toileting and showering/bathing. A quarterly MDS dated [DATE], revealed that Resident #137 had been assessed, and there was no evidence of a pressure ulcer at the time of the assessment. There was no evidence of Resident #137's care plan, progress notes, orders, medication administration records/treatment administration records (MAR/TAR), and Certified Nursing Assistant (CNA) care tasks for transfers and brief changes, shower sheets, pressure ulcer assessments, wound assessments and skin assessments for the necessary months of review required to complete a thorough investigation, December 2022 and January 2023. -Regarding Resident #138Resident #138 was admitted on [DATE], with a diagnosis that included hyperosmolality, other seizures, hereditary ataxia, dysphagia, muscle weakness, delusional disorders, and retention of urine.A quarterly MDS assessment, dated June 16, 2025, revealed that no BIMS score was observed and that a mental status exam had been completed by staff, indicating that Resident #138 experienced memory difficulties. There was no evidence of Resident #138's care plan, progress notes, orders, MAR/TAR, and CNA care tasks for transfers and brief changes, shower sheets, pressure ulcer assessments, change of condition assessments, wound assessments, and skin assessments for the necessary months of review required to complete a thorough investigation, June and July 2022. -Regarding Resident #139Resident #139 was admitted on [DATE], with a diagnosis that included unspecified fracture of the lower end of the left tibia, subsequent encounter for closed fracture with routine healing, unspecified fracture of the shaft of the left fibula, subsequent encounter for closed fracture with routine healing, type 2 diabetes mellitus without complications, and muscle weakness.An admission MDS assessment dated [DATE], revealed a BIMS of 13, indicating that Resident #139's cognition had been intact. The MDS assessment also revealed that Resident #139 requires a 2+ person assist for transfers and bed mobility. The MDS assessment also revealed that Resident #139 required one person assist for eating, locomotion, dressing, and personal hygiene.There was no evidence of Resident #139's care plan, progress notes, orders, MAR/TAR, and CNA care tasks for transfers and brief changes, shower sheets, pressure ulcer assessments, wound assessments, and skin assessments for the necessary months of review required to complete a thorough investigation, November 2022. -Regarding Resident #140Resident #140 was admitted on [DATE], with the diagnosis that included a displaced oblique fracture of the shaft of the left fibula, subsequent encounter for closed fracture with routine healing, other fracture of the upper and lower ends of the left fibula, subsequent encounter for closed fracture with routine healing, type 2 diabetes mellitus without complications, and kidney transplant status.A change of condition MDS assessment dated [DATE], revealed that no BIMS score was observed, and a mental status exam had been completed by staff, indicating Resident #141 experienced memory difficulties.There was no evidence of Resident #140's care plan, progress notes, orders, MAR/TAR, and CNA care tasks for transfers and brief changes, shower sheets, pressure ulcer assessments, wound assessments, skin assessments, and discharge paperwork for the necessary months of review required to complete a thorough investigation, October and November 2022. -Regarding Resident #141Resident #141 was admitted on [DATE], with the diagnosis that included osteomyelitis of the vertebra, sacrum, and sacrococcygeal region; peripheral vascular disease, unspecified; and type 2 diabetes mellitus with hyperglycemia.A quarterly MDS assessment dated [DATE], revealed that no BIMS score was observed, and a mental status exam had been completed by staff, indicating Resident #141 experienced memory difficulties. The quarterly MDS assessment also revealed that a stage 4 pressure ulcer had been present at the time of admission, and had been determined at-risk for further pressure ulcer development.There was no evidence of Resident #141's care plan, progress notes, orders, MAR/TAR, and CNA care tasks for transfers and brief changes, shower sheets, pressure ulcer assessments, wound assessments, skin assessments, and any records request made by Resident #141 or their Power of Attorney (POA), and proof of appointment coordination for the necessary months of review required to complete a thorough investigation, September and October 2021. -Regarding Resident #142Resident #142 was admitted [DATE], with a diagnosis that included chronic respiratory failure, unspecified whether with hypoxia or hypercapnia.A quarterly MDS assessment dated [DATE], revealed a BIMS of 13, indicating that Resident #142's cognition had been intact. There was no evidence of Resident #142's care plan, progress notes, orders, MAR/TAR, and CNA care tasks for transfers and brief changes, shower sheets, pressure ulcer assessments, wound assessments, skin assessments, and change of condition assessment for the necessary review required to complete a thorough investigation. -Regarding Resident #144Resident #144 was admitted on [DATE], with the diagnosis of unstageable pressure ulcers of the left hip, right heel, and other sites; a stage 4 pressure ulcer of another site; bipolar disorder, unspecified; and anxiety disorder, unspecified.An admission MDS assessment dated [DATE], revealed a BIMS of 15, indicating that Resident #139's cognition had been intact.There was no evidence of Resident #144's care plan, progress notes, orders, MAR/TAR, and CNA care tasks for transfers and brief changes, shower sheets, pressure ulcer assessments, wound assessments, skin assessments, and change of condition assessment for the necessary review required to complete a thorough investigation. On September 21, 2025, at 2:51 PM, a documentation request was made to the facility to obtain copies of facility-reported incidents that occurred in July 2022, November 2022, and July 2023.On September 22, 2025, at 8:56 AM, an email was received from the Director of Nursing (#108), stating that there was no documentation to provide, as the requested documentation was dated before the facility's acquisition in August 2023.On September 22, 2025, at 10:11 AM, a documentation request was made to the facility to obtain copies of the resident records for Resident #144 for January 2022 and February 2022. An interview was conducted at this time with the Administrator (Staff #309), who stated that there was no documentation to provide, as the requested documentation was dated before the facility's acquisition in August 2023. The facility was advised that if documentation is not provided to complete a thorough investigation, it would be reviewed as a potential finding.On September 23, 2025, at 8:20 AM, a documentation request was made to the facility to obtain copies of employee records for a CNA who had worked at the facility in 2022. The Administrator stated that there was no documentation and would be unable to provide the requested documentation, as the requested documentation was dated before the facility's acquisition in August 2023.On September 23, 2025, at 12:12 PM, a documentation request that included a list of residents' #137, #138, #139, #140, #141, #142, and #144, as well as the necessary documentation required to complete a thorough investigation, was provided to the facility. The Clinical Operations Director (Staff #320) and the Administrator provided written documentation that stated the facility had no evidence of observable documentation, other than the MDS and face sheet.A policy titled, Medical Records: Retention of Medical Records, with an in effect date of January 1, 2024, revealed that the facility shall retain medical records in accordance with current applicable laws. The policy also revealed that the medical records of discharged residents will be retained for a period in compliance with relevant state and federal laws.

Based on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure an allegation of abuse was reported to mandated entities within 2 hours for one resident (#100). The deficient practice could lead to a delay in the investigation of an allegation of abuse leading to continued harm of a resident.Findings include:Resident #100 was admitted to the facility August 30, 2025, with diagnoses that included malignant neoplasm of colon, difficulty in walking, and atrial fibrillation.An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #100 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment.A physical therapy (PT) Daily Note dated September 10, 2025, revealed Resident #100's therapy session involved practice transferring from the wheelchair to the restroom as the resident needed to use the restroom.A Communication with Resident note dated September 10, 2025, at 1:27 P.M. revealed that the Director of Nursing (DON) spoke to the resident about concerns. All questions and concerns addressed.A care plan dated September 11, 2025, revealed the resident had a behavior problem of false accusations toward staff, with an intervention added for care in pairs.A Social Services Progress Note dated September 11, 2025, revealed that the social worker spoke with Resident #100 in her room, and that the resident had no concerns and no symptoms of distress or psychosocial harm including changes in mood, appetite, sleep, or activities.A facility self-report submitted to the State Agency on September 11, 2025, at 2:41 P.M. revealed that on September 11, 2025, at 7:30 A.M. a therapy staff stated that Resident #100 was emotionally abused stating that Resident #100's feelings were hurt by a Certified Nursing Assistant (CNA), when the CNA changed her and held the brief close to the resident's face. The report revealed that the CNA was immediately suspended.Review of the clinical record revealed that Resident #100 had a PT visit on September 10, 2025, but no evidence of a PT visit on September 11, 2025.A facility 5-day investigation report revealed that the date of the allegation was September 11, 2025, and that Resident #100 was alert with some confusion, and provided a statement that she felt that the female night staff member did not like her, and that the staff had changed her and held the brief close to the resident's face.The 5-day investigation report additionally revealed a staff statement from the assigned Licensed Practical Nurse (LPN / Staff #97), that on the evening of September 9, 2025, at around 8:00 P.M., Staff #97 entered Resident #100's room to give medication, and a CNA (Staff #143) was just exiting the room. Staff #97's statement revealed that then Resident #100 stated that Resident #100 had just said thank you to the CNA (Staff #143), but Staff #143 did not reply. The statement revealed that Staff #97 then said to Resident #100 that Staff #143 probably didn't hear you. Then, the statement revealed that when Staff #97 saw Staff #143 again, Staff #97 asked if Staff #143 heard Resident #100 say thank you, and that Staff #143 answered that no she had not heard the resident.The 5-day investigation report also revealed a statement from the Director of Nursing (DON / Staff #108). The DON's statement revealed that she had spoken to the CNA (Staff #143) who denied putting a brief in Resident #100's face. Additionally, the DON spoke with the assigned nurse (Staff #97) who stated she did not witness any mistreatment of any residents during her shift. Also, the report revealed that the DON spoke with a Physical Therapy Assistant (PTA / Staff #224), who stated Resident #100 stated that the CNA had put a diaper in her face and that the resident's feelings were hurt.The 5-day report revealed a conclusion that during the thorough investigation, the alleged perpetrator (Staff #143) was suspended, and that post-incident monitoring showed no psychosocial harm of Resident #100, and additionally, that the allegation of abuse was unable to be substantiated.A time punch report for the nurse (Staff #97) and the CNA (Staff #143) revealed the following:September 9, 2025:-Staff #97 punched in at 6:00 P.M. and out for the end of shift at 6:37 A.M. on September 10.-Staff #143 punched in at 6:10 P.M. and out for the end of shift at 6:17 P.M. on September 10.September 10, 2025:-Staff #97 did not punch in for a night shift on September 10-Septmeber 11, 2025-Staff #143 did not punch in for a night shift on September 10-September 11, 2025September 11, 2025:-Staff #97 did not punch in for a night shift on September 11-Septmeber 12, 2025-Staff #143 did not punch in for a night shift on September 11-September 12, 2025Despite no punch in time for Staff #143, the time punch report revealed that Staff #143 received 12 hours of regular pay on the date of September 11, 2025.An interview was conducted with a physical therapy assistant (PTA / Staff #224) on September 22, 2025, at 8:41 A.M. Staff #224 stated that she could not remember the exact date, but that she first heard of the allegation from Resident #100 on the date that Staff #224 was assisting Resident #100 onto the toilet in her room for the resident's therapy session (September 10, 2025), as the resident stated she needed to use the bathroom. Once the resident was on the toilet, Staff #224 stated that the resident told her about an incident that the resident stated occurred the night before. Staff #224 stated that the resident told her that last night, a night staff had taken off the resident's dirty brief and shook it in the resident's face, and that the resident stated that she was emotionally hurt by the incident. Staff #224 stated that this was a possible case of emotional abuse, so she reported it to the DON (Staff #108) because the Administrator was off that date. Staff #224 stated she reported it right after the therapy session (September 10, 2025), and that it was within 2 hours of hearing the resident's allegation. Staff #224 stated that she knew the DON then got a statement from Resident #100.An interview was conducted with a CNA (Staff #143) on September 22, 2025, at 9:09 A.M. Staff #143 stated that she received a text message from the DON on the morning of September 10, 2025, requesting for a phone call. Staff #143 stated that then she had a phone call with the DON on September 10, 2025, where she was notified of the allegation from Resident #100 that Staff #143 had put a dirty brief close to the resident's face on the night shift of September 9-10. Staff #143 stated that she was surprised to hear of the allegation, and that it did not happen, and that she had helped the resident get changed and the nurse had come in the room directly afterward. Staff #143 was requested to review her text and call log on her phone to confirm the date that the Staff #143 had a conversation with the DON about the allegation, and Staff #143 stated that it was September 10, 2025.A telephonic interview was conducted with an LPN (Staff #97) on September 23, 2025, at 10:06 A.M. Staff #97 stated that on the night shift of September 9-10, 2025, that she was passing evening medications and that she entered Resident #100's room, just as Staff #143 was leaving the room with dirty sheets in a bag. Staff #97 stated that Resident #100 stated that she believed Staff #143 was upset with her because she had told the CNA thank you and Staff #143 did not respond. Staff #97 stated that maybe Staff #143 did not hear the resident say thank you. Staff #97 stated that after she left Resident #100's room, she found Staff #143 and asked her if she had heard resident #100 say thank you because the resident believes you're mad at her. Staff #97 stated that Staff #143 said that she had not heard the resident say thank you. Staff #97 stated that the following morning, on September 10, 2025, she received a text message from the DON (Staff #108) requesting a phone call, and that Staff #97 then called the DON that day and the incident was discussed, along with the resident's allegation of the CNA holding a dirty brief near the resident's face. Staff #97 stated that the following day, on September 11, 2025, the Administrator (Staff #309) called her and asked her to write a statement about the incident, and Staff #97 stated that she did write the statement. Staff #97 was requested to review her text message and call log on her phone to confirm the date that Staff #97 had a conversation with the DON about the allegation, and Staff #143 stated that it was September 10, 2025.An interview was conducted with the Director of Nursing (DON / Staff #108) on September 23, 2025, at 10:26 A.M. The DON stated that if there is an allegation of possible abuse, that the facility staff separate the resident from the threat, report the incident within 2 hours to mandated entities, and then complete a thorough investigation. The DON stated that if the alleged perpetrator is a staff member, then the staff member is suspended until the investigation is completed. The DON stated that the importance of timely reporting is to ensure there is a proper investigation completed for the resident. Regarding the allegation of abuse from Resident #100, the DON stated that it was reported to her on September 11 by a therapist (Staff #224), when the resident told the therapist that she felt like the CNA was rude to her and the resident stated that the CNA waived a brief in front of her face. The DON also stated that Staff #143 is a night-shift CNA, and never works day shift, and that she was suspended pending the investigation. The DON stated that after receiving the allegation, the facility completed mandated reporting to the state agency and to non-emergent police. The DON stated that the Administrator-in-Training (AIT / Staff #301) took the first statements for the investigation. The DON stated that she could not recall if she herself had taken any statements from the nurse (Staff #97) or the CNA (Staff #143).An interview was conducted with the Administrator-in-Training (AIT / Staff #301) on September 23, 2025, at 10:44 A.M. Staff #301 stated that regarding the investigation of Resident #100's allegation of a CNA holding a brief near the resident's face, that he was not involved in the investigation at all, and did not take any statements, or ask any questions.An interview was conducted with the facility Administrator (Staff #309) on September 23, 2025, at 10:49 A.M. The Administrator stated that if there is an allegation of abuse, the resident would be separated from the alleged perpetrator and then the facility reports the allegation within 2 hours to mandated entities including to the State Agency, to the police, and to Adult Protective Services. Then, the Administrator stated that an investigation is conducted by the facility and that is submitted to the State Agency in 5 days. Regarding Resident #100's allegation, the Administrator stated that per the therapy staff, Resident #100 stated that her feelings were hurt by a CNA. The Administrator stated that he was out of town, and that the DON interviewed the staff members for their statements, and that Staff #143 was suspended pending the investigation. The Administrator stated that the allegation was reported to the mandated entities the same day that the therapist (Staff #224) brought it to the DON's attention, which was September 11, 2025. Additionally, the Administrator stated that the 12 hours of regular pay on Staff #143's time punch report was because the facility still provides pay to a staff member who is suspended pending an investigation if they are cooperating with the investigation.An interview was conducted on September 23, 2025, at 1:00 P.M. with Resident #100, who stated that she could not recall the date, but that she recalled an incident where a staff member put a dirty brief close to her face. Resident #100 stated that after the incident, that she was completely baffled, and scared of that staff member being so aggressive.An interview was conducted with a CNA (Staff #12) on September 23, 2025, at 1:32 P.M. Staff #12 stated that an allegation of abuse needs to be reported immediately to the Administrator or to the DON. Staff #12 also stated that there would be no reason why a brief should be close to a resident's face.Review of the facility policy titled Resident Rights/Dignity: Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated January 1, 2024, revealed that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility, adult protective services (where state law provides jurisdiction in long-term care), and law enforcement officials, where Immediately is defined as within two hours of an allegation involving abuse.Review of the facility policy titled: Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, effective January 1, 2024, revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on clinical record review, interviews, facility documentation and policy, the facility failed to ensure one resident (#145) received glaucoma medication according to admission orders. The deficient practice could lead to an increase in eye pressure, causing potentially worsening vision. Findings include:Resident # 145 was admitted to the facility on [DATE], with diagnoses that included secondary pulmonary hypertension, essential hypertension, and unspecified glaucoma. A review was conducted of the hospital History and Physical (H&P) report dated September 11, 2025, revealing the resident had a history of glaucoma with home medications that included brimonidine 0.1% ophthalmic solution and bimatoprost 0.01% ophthalmic solution. A review of the hospital discharge orders dated September 16, 2025, revealed the resident was to continue taking both bimatoprost 0.01% ophthalmic solution and brimonidine 0.1% ophthalmic solution. A physician order for brimonidine tartrate 0.1% solution, dated September 16, 2025 directs staff to instill one drop of solution in both eyes twice a day for eye pressure. The Medication Administration Record (MAR) does not support an active, hold, or discontinue order for the bimatoprost ophthalmic 0.01% solution. The admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview Mental Status (BIMS) score of 12, indicating the resident was cognitively intact. A review of the care plan revealed no focus for vision impairment or glaucoma needs for resident #145.An interview was conducted with resident #145 on September 21, 2025, at 6:59 a.m. The resident stated, I take eyedrops called Lumigan (bimatoprost ophthalmic 0.01% drops) for my glaucoma for like 15 years. I told them I need my meds, but they wouldn't give them to me! It could be harmful for me to wait for those medications, and I should have a say in what meds I'm taking!An interview was conducted with the resident's admission Licensed Practical Nurse (LPN/Staff #8) on September 23, 2025 at 1:52 p.m. The nurse admitted to being the party that was responsible for entering the resident's hospital discharge orders into the electronic health record. The nurse described that admitting a resident from a hospital involves the nurse reviewing the discharge orders, then transcribing those orders into the electronic clinical record. The nurse voiced the importance of clarifying orders with the reporting nurse and the provider if there are any concerns about the orders. The nurse mentioned that the facility has a pharmacy champion, that serves as a checks and balances system for medication admission orders. The nurse described the pharmacy champion role as identifying and following up on medications that require pre-authorizations, or that are high-cost. During the interview, Staff #8 reviewed the resident's discharge orders and compared it to the Medication Administration Record. The nurse verbalized that the order for the bimatoprost ophthalmic 0.01% drops were inadvertently omitted from the electronic health record, and would immediately correct to reflect the physician's orders. An interview was conducted with the MDS Coordinator/Pharmacy Cost Review Nurse (Staff # 149) on September 23, 2025 at 2:46 pm. Staff #149 revealed also being referred to as the facility's Pharmacy Champion. The nurse explained one function of the position involves finding alternatives for hi-cost medications. The nurse reviewed the order for the bimatoprost ophthalmic solution, and revealed that the eye drops would not have flagged for review, since eyedrops are generally affordable. The nurse further clarified that hi-cost meds and meds requiring prior authorization are medications that will raise an alert for review. A panel interview was conducted with the Director of Nursing (DON/Staff #108) and the Executive Director (ED/Staff # 309) on September 3, 2025 at approximately 2:53 p.m. During review of the resident's clinical record, the DON stated that the expectation that both of the resident's eye drops should have been transcribed over into the electronic clinical record. The DON stated that both drops should have been given as ordered, to avoid disease progression. The DON explained that residents can be a reliable and excellent source for medications taken at home. The DON stated that if a resident report missing a home medication, investigation and further follow-up should have occurred. A review of the facility policy titled Sensory Impairments-Clinical Protocol, effective January 1, 2024, directs that as part of the initial assessment, the staff and physician will help identify individuals with sensory impairments, including hearing, taste, vision, smell, and touch. In addition, the staff and physician will identify approaches to help the resident improve or compensate for sensory deficits. A review of the facility policy titled Orders/Receiving/Transcribing: Medication and Treatment Orders policy, effective January 1, 2024, calls for drugs and biological orders to be recorded on the physician's order sheet in the resident's chart.

Based on clinical record reviews, staff and resident interviews, facility documentation and policy reviews, the facility failed to implement their written abuse policies and procedure for two residents (#1, #2). The deficient practice could place resident at risk for further abuse.Findings include:-Regarding Resident #1:Resident #1 was admitted to the facility on [DATE] with a diagnosis that included bilateral primary osteoarthritis of knee, anxiety disorder, syncope and collapse, and Type 2 Diabetes Mellitus (DM).A review of orders revealed Resident had orders for occupational therapy, physical therapy and speech therapy to eval and treat as needed if indicated on orders.A review of Resident's care plan dated June 17, 2025 revealed Resident was at risk for functional self-care deficits and/or functional mobility limitations related to osteoarthritis of the Knee, history of falls, DM, and weakness.A review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14.0, cognitively intact, behavioral symptoms not exhibited, and rejection of care and wandering behaviors were not exhibited.Another review of Resident's care plan dated June 22, 2025 revealed Resident had a communication problem related to Resident only speaks Spanish.A review of progress note dated July 22, 2025 at 6:34 AM revealed Resident was due for her morning medication and Staff #249 asked a CNA (certified nursing assistant) to accompany Staff #249 and assist with Spanish translation. The progress notes also revealed that Resident complaint about being forced to take medication and Resident wants the nurse to leave her medication on the table. The nurse stated that Resident had syncope attack when Resident gets upset/mad. Staff #249 progress note revealed that the Resident accused him of grabbing and touching her with the CNA. Staff #249 was just helping Resident put back her gown and just trying to make her safe to prevent her from falling because Resident was sitting at beside. Furthermore, the progress note revealed that after 15 minutes, Staff #249 and another staff tried to give Resident's medication while Resident was talking on the phone, and Resident acted like she fell asleep as soon as she saw the staff knocked and walked inside her room.Another review of care plan dated July 22, 2025 revealed Resident had a behavior problem related to resistive to care, false accusation towards staff and preference for female staff only. Interventions included to anticipate Resident's needs and cares in pairs.A review of rehab therapy progress note dated July 25, 2025 revealed a Spanish interpreter was utilized, at 10:00 AM, Resident #1 reported to physical therapy (PT) that resident was abused by a nurse in the facility. The progress notes revealed that resident was naked while finishing up with a shower, resident was about to fasten gown and resident couldn't because a male nurse came in without knocking and resident was attacked immediately. The progress notes revealed that he shook the resident a lot and the resident could not wake up or move. He grabbed the resident by the arms to put resident in bed. A female nurse came in and put the robe on the resident and left. Resident could not move because of epilepsy. Furthermore, the progress note revealed that the female nurse stated that she did not see anything and he stated that it was only one pill. But when the resident woke up, there were a lot of pills stuffed in the resident's mouth, resident could not swallow, resident spit them out and had a sour taste. The male nurse stated it was only one pill but resident took six tiny pills and three big ones placed in resident's mouth when resident was passed out, resident reported it to a nurse and the Spanish speaking nurse said she needs to apologize. In the morning the male nurse stayed by the door and did not want to enter the resident's room. A female nurse entered the room and Resident #1 stated to report him for bad behavior. The progress notes also revealed that PT was not able to notify the administrator due to the administrator was out on vacation and the other administrative staff were out until 3:00 PM. The progress note revealed that PT had a conversation with a unit manager/Staff #55 on July 25, 2025 at 12:00 PM and PT reported to the DON (director of nursing) and the building administrator.A review of progress notes and a Weekly Skin check and Wound assessment dated [DATE] revealed a registered nurse (RN) and a CNA that speaks Spanish conducted a head to toe assessment and observed Resident's skin to be clean, dry and intact, no open area, no redness, and no area of concerns noted.A review of facility's investigation report with an allegation date of August 4, 2025 revealed that the facility was notified by APS (Adult Protective Services) of an anonymous report of sexual abuse towards Resident #1. The facility report revealed that there was no staff member to suspend as the facility was unable to identify the alleged accuser and there was no staff identified by the accuser. Furthermore, the report revealed two staff statement. First statement was from a unit coordinator/Staff #65. The statement from Staff #65 revealed that the incident happened either Tuesday/Wednesday early morning. The nurse did not knock and resident was sitting up in the wheelchair. Resident had an episode where resident knew what was going on but was unable to move or talk and not sure if it was a syncopal episode. The Resident described the nurse as Hispanic male, dark hair, not too old, not too young, and does not speak Spanish. A female staff assisted the male nurse to get the resident back in bed. The resident was in pain and was given Tylenol but Resident was unable to swallow so the medicine was in the Resident's side of the mouth which the Resident stated that it tasted bitter. Resident #1 did not report any abuse to her knowledge. The second staff statement in the 5-day report was given by Staff #55/unit manager. Staff #55 statement revealed that On Friday 08/25/25 Staff #55 was informed of the Resident's experience that happened couple days ago. The PT revealed that resident was in a wheelchair when resident was in pain that froze her up and while resident was in the wheelchair, the CNA and nurse was attempting to wake resident up because resident appeared passed out. The resident was aware of what was going on but was not communicating verbally just grunting. Staff #55 statement also revealed that she noticed the pills in Resident's mouth were half dissolved. Furthermore, the August 4, 2025 investigation report finding and conclusion revealed that there was no staff member identified as an alleged perpetrator, Resident #1 and family stated that there was no sexual abuse, facility reported the complaint to APS, police, and DHS, and the allegation of abuse was unable to be substantiated.Resident #1 was discharged on August 7, 2025.-Regarding Resident #2:Resident #2 was admitted to the facility on [DATE] with a diagnosis that included speech and language deficit following nontraumatic intracerebral hemorrhage, metabolic encephalopathy, and end stage renal disease.A review of admission MDS assessment dated [DATE] revealed a BIMS score of no score recorded/space left blank, resident vision severely impaired and resident had no corrective lenses, behavioral symptoms were not exhibited, and rejection of care and wandering behaviors were not exhibited. A review of Resident's care plan dated April 22, 2025 revealed that resident was at risk for functional self care deficits and/or functional mobility limitations related to her diagnoses.Another review of Resident's care plan dated April 29, 2025 revealed that resident have delirium or an acute confusional episode, have impaired visual function, have impaired cognitive function/dementia or impaired thought processes, and at risk for bladder incontinence related to impaired mobility.A review of progress notes dated August 5, 2025 by CNA/Staff #106 revealed that resident refused a shower because it was too cold, even after staff offered to change the room temperature and shower the resident with warm water.A review of record titled, CNA Shower Sheet, dated August 5, 2025 revealed Resident #2 without a bruise, skin tear, red area, open area, fingernails and toenails were not cleaned or clipped, and facial hair not shaved. In addition, the sheet revealed a note that resident refused a shower or bath, resident was cold, and resident was informed that staff will turn off AC (air conditioning) but still resident refused to have a shower and would wait to have a bed bath the next day.A review of record titled, CNA Shower Sheet, dated August 8, 2025 revealed Resident's shower was completed.An interview was conducted on August 11, 2025 at 11:24 AM with a CNA/Staff #69. Staff #69 stated that abuse can be physical, mental, verbal, or financial. Staff #69 stated that if he was made aware of an allegation of abuse, he will report it to his charge nurse or supervisor so it will be documented and investigated for residents' safety. Staff #69 stated that he is not aware of any abuse incident since he has been in the facility.An interview was conducted on August 11, 2025 at 1:37 PM in the rehab director's office with occupational therapy (OT)/Staff #1. She stated that her role includes getting referral paperwork, doing chart reviews, observing precaution prior to walking in the resident's room, then she will ask the resident in depth question such as their prior level to preemptively plan for their discharge, and then she will set their discharge goals. And, based on the schedule, she discusses the plan with the resident such as upper or lower body strength, safety, fall prevention education, also educate family if family is at bedside. She stated that she uses a language line solution, it is a phone number to call and then select the language resident speak, if resident does not speak English. Regarding her abuse training, she stated that she will report an allegation of abuse immediately to the abuse coordinator which is the administrator. She is not aware of any abuse incident.An interview was conducted on August 11, 2025 at 1:50 PM in hallway 2100 with CNA/Staff #229. She stated that she works day shift from 6 AM through 6 PM. After clocking in, she first does a walk-in report with the night CNA going from one room to another. Then, she will start taking vital signs (VS). After taking all of her residents' VS, she will give the VS sheet to her nurse, and also will document the VS in the computer. She will assist her residents, get residents up, and sent residents to activities. When she has a resident, who does not speak English, her facility has a number she can call to assist in translation. She stated that she takes care of Spanish speaking residents and since she speaks Spanish herself, the other staff comes to her and ask her to assist them with translation. Regarding care in [NAME], she stated that the resident who have cares in [NAME] could be resident that made accusation against staff, and or are heavier. Regarding abuse, she stated that abuse can be sexual, psychological, financial, and verbal. And, when she witnesses or is made aware of any allegation of abuse, she will report it to the administrator, DON, or to her nurse. She stated that she heard a few residents who have mentioned that supposedly a staff placed a finger. She stated that most of the CNAs working in the units are female, except there is one male on the day shift. She stated that if a resident asks for a female to provide her care, usually their male CNA will look for a female CNA. She stated that a week ago, there was a rumor that Resident #2 who is still in the facility was one of the residents included in the rumor, but she does not know if the rumor was true or not.On August 11, 2025 at 2:03 PM, an interview was conducted with Resident #2. Resident #2 stated that she wants to go home. Resident #2 stated that there was an incident with a nurse who took her in a shower located in her room during the day and stuck her finger. The incident happened 2 or 3 weeks ago, on a Tuesday. Resident stated that she is blind, she can't see, and the staff stuck her finger in her private part, and the nurse stated to her you do not want to stink do you, and another incident were another nurse poured the medicine in her mouth. Resident stated that she informed a lady about the incident but could not remember the lady's name. On August 11, 2025, a follow up question with CNA/Staff #229 at the nursing station 2200 hall was conducted. Staff #229 stated that showers are provided by CNAs, nurses do not give showers, the CNAs use a shower sheet, Resident #2 shower days are on Tuesdays and Fridays, and showers are done in the resident's room.On August 11, 2025 at 2:45 PM, the administrator/Staff #28, DON/Staff #133, and AIT (administrator in training)/Staff #221 were made aware of an allegation of abuse involving Resident #2.On August 11, 2025 at 2:45 PM, the administrator stated that there were no allegations of abuse reported in the month of July and there was only one allegation of abuse for August.On August 11, 2025 at 5:14 PM, surveyor received a call back from physical therapy assistant (PTA)/Staff #3. Staff #3 stated that he works for this facility and provided services to Resident #1, sometimes three to four times per week. Staff #3 stated that Resident #1 complained about a nurse, this incident was already reported because the event happened in July, and it was recorded in the PT notes. Additionally, Staff #3 stated that Resident #1 mentioned to him that when Resident #1 was changing their gown, the nurse entered without knocking, Resident #1 was upset and on the same day when Resident #1 was lying down half asleep, the nurse came in their room and poured the medication and water in Resident #1's mouth. Resident #1 was choking when awaken. Resident #1 did not remember the nurse's name. Staff #3 stated that there were not a lot of male nurse in that facility.An interview was conducted on August 12, 2025 at 9:13 AM via phone with physical therapist (PT)/Staff #4. Staff #4 stated that she worked at the facility last month but does not remember the dates. She was driving during the interview and was unable to check dates at the moment, but she stated that everything was in the progress notes. She stated that she used an interpreter, there was no name of the nurse involved during the incident, Resident #1 was not aware of the male nurse's name, and the incident happened during the night shift.An interview was conducted on August 12, 2025 at 10:12 AM with a Unit Manager/Staff #55 in the conference room. Staff #55 stated that she works Tuesdays through Fridays from 10 AM through 8: 30 PM. Her responsibilities include making residents' rounds, doing narcotic audits, she is involved with admissions and discharges, and she follow up with families for any concerns. She stated that their dialysis residents go to dialysis. Regarding her abuse training, she stated that as soon as an abuse is identified, abuse is reported right away to the administrator, and if the administrator is not available, she reports the allegation of abuse to the DON. If DON is not available, she stated that the administrator or the DON are usually available. She stated that the type of abuse to report include physical, sexual, financial, verbal, and neglect. If she is made aware of an allegation of abuse, her responsibility is to report it to the administrator, she interviews the resident to get details, but her main responsibility is to inform the administrator and the DON. She stated that she was made aware of Resident #1's incident in July around by the end of July. She believes it was July 25, and Resident #1 already has been discharged . She stated that Resident #1 only speaks Spanish, the therapist stated that in the morning Resident #1 was sitting in the chair, Resident #1 remembered the staff were trying to wake her up. She stated that Resident #1 might have had a seizure because Resident #1 was out of it but knows what was going on but Resident #1 was unable to communicate, Resident #1's incident happened early in the morning during the night shift. The staff at that time was a nurse and a med tech. The nurse was Staff #249 and the Med tech was Staff #83. Staff #249 was not assigned to Resident #1 after the incident. Resident #1 was not sure when the incident happened, if it was on a Tuesday or Wednesday, Resident #1 described the male staff looking Hispanic and that is how Staff #55 figured it was Staff #249 and he was with a CMA (certified medical tech)/Staff #83. Both Staff #249 and Staff #83 were working that night shift. Staff #55 stated that after the incident, cares in pairs was implemented for Resident #1. Staff #55 stated that she informed the administrator via phone call of the incident on July 25 which was a Friday and she also spoke with the DON and she thinks that their Director of Rehab also informed the DON. Staff #4 was the therapist whom Resident #1 informed of the incident on July 25. Staff #55 stated that after reporting the incident to the administrator and DON, she went and interviewed Resident #1 with the wound care nurse, but resident was eating lunch and had a visitor and wanted them to come back later. The second visit to Resident #1 was with the unit coordinator to assist with translation. Staff #55 stated that the resident did not say the way the therapist had reported it to her. Staff #55 stated that the nurse came in the room while Resident #1 was half dress, and the nurse was trying to wake Resident #1 up by rubbing on Resident #1's chest because the nurse was concern that Resident #1 was altered and the staff placed Resident #1 back in bed. Staff #55 did not remember any other abuse incident, just this one for this year.An interview was conducted on August 12, 2025 at 11:17 AM in the 2200 nursing station with Staff #65. Staff #65 stated that as the unit coordinator, her responsibility includes setting up appointments and transportations, she speaks Spanish, she helps translates. She stated that she translated for one of the unit managers regarding an incident in July. She stated that her abuse training includes if she hears any allegation of abuse, she will report it to the administrator. She stated that if abuse is not reported, the abuse allegation will not get investigated, the resident is vulnerable, and the resident would feel unsafe in the facility.On August 12, 2025 at 11:30 AM, an exit interview was conducted with the administrator/Staff #28 and the DON/Staff #133 in the conference room. At 11:52 AM, the DON stated that when the physical therapist note had come up, she and the administrator spoke with the Director of Rehab. The DON does not remember when they spoke with the Director of Rehab. The DON stated that she also spoke with Resident #1 and Resident #1 denied the accusation. The DON stated that she had concerns with medication administration during the incident, and that is when the administrator reported the incident to the police, DHS (department of health services), which is in their 5-day report. The DON stated that the allegation of abuse was not reported to her and to the administrator and that they both learned of the allegation of abuse on a later date from APS, and that is when they filed it to the department and to the law enforcement. During the interview, the administrator stated that they verified the incident with Resident #1 and the family member and confirmed that nothing happened. The administrator stated that the physical therapy note was not reflecting the reality of what Resident #1 stated once Resident #1 and the family member were interviewed.A review of facility's policy titled, 003 - Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, in effect date of January 1, 2024 revealed Residents have the right to be free from abuse. (8) Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. (9) Investigate and report any allegations within timeframes required by federal requirements. (10) Protect residents from any further harm during investigations.

Based on clinical record review, staff and resident interviews, facility documentation and policy review, the facility failed to ensure that an allegation of abuse for two resident (#1, #2) was reported to the State Agencies in a timely manner. The deficient practice could place residents at risk for further abuse.Findings include:-Regarding Resident #1:Resident #1 was admitted to the facility on [DATE] with a diagnosis that included bilateral primary osteoarthritis of knee, anxiety disorder, syncope and collapse, and Type 2 Diabetes Mellitus (DM).A review of orders revealed Resident had orders for occupational therapy, physical therapy and speech therapy to eval and treat as needed if indicated on orders.A review of Resident's care plan dated June 17, 2025 revealed Resident was at risk for functional self-care deficits and/or functional mobility limitations related to osteoarthritis of the Knee, history of falls, DM, and weakness.A review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14.0, cognitively intact, behavioral symptoms not exhibited, and rejection of care and wandering behaviors were not exhibited.Another review of Resident's care plan dated June 22, 2025 revealed Resident had a communication problem related to Resident only speaks Spanish.A review of progress note dated July 22, 2025 at 6:34 AM revealed Resident was due for her morning medication and Staff #249 asked a CNA (certified nursing assistant) to accompany Staff #249 and assist with Spanish translation. The progress notes also revealed that Resident complaint about being forced to take medication and Resident wants the nurse to leave her medication on the table. The nurse stated that Resident had syncope attack when Resident gets upset/mad. Staff #249 progress note revealed that the Resident accused him of grabbing and touching her with the CNA. Staff #249 was just helping Resident put back her gown and just trying to make her safe to prevent her from falling because Resident was sitting at beside. Furthermore, the progress note revealed that after 15 minutes, Staff #249 and another staff tried to give Resident's medication while Resident was talking on the phone, and Resident acted like she fell asleep as soon as she saw the staff knocked and walked inside her room.Another review of care plan dated July 22, 2025 revealed Resident had a behavior problem related to resistive to care, false accusation towards staff and preference for female staff only. Interventions included to anticipate Resident's needs and cares in pairs.A review of rehab therapy progress note dated July 25, 2025 revealed a Spanish interpreter was utilized, at 10:00 AM, Resident #1 reported to physical therapy (PT) that resident was abused by a nurse in the facility. The progress notes revealed that resident was naked while finishing up with a shower, resident was about to fasten gown and resident couldn't because a male nurse came in without knocking and resident was attacked immediately. The progress notes revealed that he shook the resident a lot and the resident could not wake up or move. He grabbed the resident by the arms to put resident in bed. A female nurse came in and put the robe on the resident and left. Resident could not move because of epilepsy. Furthermore, the progress note revealed that the female nurse stated that she did not see anything and he stated that it was only one pill. But when the resident woke up, there were a lot of pills stuffed in the resident's mouth, resident could not swallow, resident spit them out and had a sour taste. The male nurse stated it was only one pill but resident took six tiny pills and three big ones placed in resident's mouth when resident was passed out, resident reported it to a nurse and the Spanish speaking nurse said she needs to apologize. In the morning the male nurse stayed by the door and did not want to enter the resident's room. A female nurse entered the room and Resident #1 stated to report him for bad behavior. The progress notes also revealed that PT was not able to notify the administrator due to the administrator was out on vacation and the other administrative staff were out until 3:00 PM. The progress note revealed that PT had a conversation with a unit manager/Staff #55 on July 25, 2025 at 12:00 PM and PT reported to the DON (director of nursing) and the building administrator.A review of progress notes and a Weekly Skin check and Wound assessment dated [DATE] revealed a registered nurse (RN) and a CNA that speaks Spanish conducted a head to toe assessment and observed Resident's skin to be clean, dry and intact, no open area, no redness, and no area of concerns noted.A review of facility's investigation report with an allegation date of August 4, 2025 revealed that the facility was notified by APS (Adult Protective Services) of an anonymous report of sexual abuse towards Resident #1. The facility report revealed that there was no staff member to suspend as the facility was unable to identify the alleged accuser and there was no staff identified by the accuser. Furthermore, the report revealed two staff statement. First statement was from a unit coordinator/Staff #65. The statement from Staff #65 revealed that the incident happened either Tuesday/Wednesday early morning. The nurse did not knock and resident was sitting up in the wheelchair. Resident had an episode where resident knew what was going on but was unable to move or talk and not sure if it was a syncopal episode. The Resident described the nurse as Hispanic male, dark hair, not too old, not too young, and does not speak Spanish. A female staff assisted the male nurse to get the resident back in bed. The resident was in pain and was given Tylenol but Resident was unable to swallow so the medicine was in the Resident's side of the mouth which the Resident stated that it tasted bitter. Resident #1 did not report any abuse to her knowledge. The second staff statement in the 5-day report was given by Staff #55/unit manager. Staff #55 statement revealed that On Friday 08/25/25 Staff #55 was informed of the Resident's experience that happened couple days ago. The PT revealed that resident was in a wheelchair when resident was in pain that froze her up and while resident was in the wheelchair, the CNA and nurse was attempting to wake resident up because resident appeared passed out. The resident was aware of what was going on but was not communicating verbally just grunting. Staff #55 statement also revealed that she noticed the pills in Resident's mouth were half dissolved. Furthermore, the August 4, 2025 investigation report finding and conclusion revealed that there was no staff member identified as an alleged perpetrator, Resident #1 and family stated that there was no sexual abuse, facility reported the complaint to APS, police, and DHS, and the allegation of abuse was unable to be substantiated.Resident #1 was discharged on August 7, 2025.-Regarding Resident #2:Resident #2 was admitted to the facility on [DATE] with a diagnosis that included speech and language deficit following nontraumatic intracerebral hemorrhage, metabolic encephalopathy, and end stage renal disease.A review of admission MDS assessment dated [DATE] revealed a BIMS score of no score recorded/space left blank, resident vision severely impaired and resident had no corrective lenses, behavioral symptoms were not exhibited, and rejection of care and wandering behaviors were not exhibited. A review of Resident's care plan dated April 22, 2025 revealed that resident was at risk for functional self care deficits and/or functional mobility limitations related to her diagnoses.Another review of Resident's care plan dated April 29, 2025 revealed that resident have delirium or an acute confusional episode, have impaired visual function, have impaired cognitive function/dementia or impaired thought processes, and at risk for bladder incontinence related to impaired mobility.A review of progress notes dated August 5, 2025 by CNA/Staff #106 revealed that resident refused a shower because it was too cold, even after staff offered to change the room temperature and shower the resident with warm water.A review of record titled, CNA Shower Sheet, dated August 5, 2025 revealed Resident #2 without a bruise, skin tear, red area, open area, fingernails and toenails were not cleaned or clipped, and facial hair not shaved. In addition, the sheet revealed a note that resident refused a shower or bath, resident was cold, and resident was informed that staff will turn off AC (air conditioning) but still resident refused to have a shower and would wait to have a bed bath the next day.A review of record titled, CNA Shower Sheet, dated August 8, 2025 revealed Resident's shower was completed.An interview was conducted on August 11, 2025 at 11:24 AM with a CNA/Staff #69. Staff #69 stated that abuse can be physical, mental, verbal, or financial. Staff #69 stated that if he was made aware of an allegation of abuse, he will report it to his charge nurse or supervisor so it will be documented and investigated for residents' safety. Staff #69 stated that he is not aware of any abuse incident since he has been in the facility.An interview was conducted on August 11, 2025 at 1:37 PM in the rehab director's office with occupational therapy (OT)/Staff #1. She stated that her role includes getting referral paperwork, doing chart reviews, observing precaution prior to walking in the resident's room, then she will ask the resident in depth question such as their prior level to preemptively plan for their discharge, and then she will set their discharge goals. And, based on the schedule, she discusses the plan with the resident such as upper or lower body strength, safety, fall prevention education, also educate family if family is at bedside. She stated that she uses a language line solution, it is a phone number to call and then select the language resident speak, if resident does not speak English. Regarding her abuse training, she stated that she will report an allegation of abuse immediately to the abuse coordinator which is the administrator. She is not aware of any abuse incident.An interview was conducted on August 11, 2025 at 1:50 PM in hallway 2100 with CNA/Staff #229. She stated that she works day shift from 6 AM through 6 PM. After clocking in, she first does a walk-in report with the night CNA going from one room to another. Then, she will start taking vital signs (VS). After taking all of her residents' VS, she will give the VS sheet to her nurse, and also will document the VS in the computer. She will assist her residents, get residents up, and sent residents to activities. When she has a resident, who does not speak English, her facility has a number she can call to assist in translation. She stated that she takes care of Spanish speaking residents and since she speaks Spanish herself, the other staff comes to her and ask her to assist them with translation. Regarding care in [NAME], she stated that the resident who have cares in [NAME] could be resident that made accusation against staff, and or are heavier. Regarding abuse, she stated that abuse can be sexual, psychological, financial, and verbal. And, when she witnesses or is made aware of any allegation of abuse, she will report it to the administrator, DON, or to her nurse. She stated that she heard a few residents who have mentioned that supposedly a staff placed a finger. She stated that most of the CNAs working in the units are female, except there is one male on the day shift. She stated that if a resident asks for a female to provide her care, usually their male CNA will look for a female CNA. She stated that a week ago, there was a rumor that Resident #2 who is still in the facility was one of the residents included in the rumor, but she does not know if the rumor was true or not.On August 11, 2025 at 2:03 PM, an interview was conducted with Resident #2. Resident #2 stated that she wants to go home. Resident #2 stated that there was an incident with a nurse who took her in a shower located in her room during the day and stuck her finger. The incident happened 2 or 3 weeks ago, on a Tuesday. Resident stated that she is blind, she can't see, and the staff stuck her finger in her private part, and the nurse stated to her you do not want to stink do you, and another incident were another nurse poured the medicine in her mouth. Resident stated that she informed a lady about the incident but could not remember the lady's name. On August 11, 2025, a follow up question with CNA/Staff #229 at the nursing station 2200 hall was conducted. Staff #229 stated that showers are provided by CNAs, nurses do not give showers, the CNAs use a shower sheet, Resident #2 shower days are on Tuesdays and Fridays, and showers are done in the resident's room.On August 11, 2025 at 2:45 PM, the administrator/Staff #28, DON/Staff #133, and AIT (administrator in training)/Staff #221 were made aware of an allegation of abuse involving Resident #2.On August 11, 2025 at 2:45 PM, the administrator stated that there were no allegations of abuse reported in the month of July and there was only one allegation of abuse for August.On August 11, 2025 at 5:14 PM, surveyor received a call back from physical therapy assistant (PTA)/Staff #3. Staff #3 stated that he works for this facility and provided services to Resident #1, sometimes three to four times per week. Staff #3 stated that Resident #1 complained about a nurse, this incident was already reported because the event happened in July, and it was recorded in the PT notes. Additionally, Staff #3 stated that Resident #1 mentioned to him that when Resident #1 was changing their gown, the nurse entered without knocking, Resident #1 was upset and on the same day when Resident #1 was lying down half asleep, the nurse came in their room and poured the medication and water in Resident #1's mouth. Resident #1 was choking when awaken. Resident #1 did not remember the nurse's name. Staff #3 stated that there were not a lot of male nurse in that facility.An interview was conducted on August 12, 2025 at 9:13 AM via phone with physical therapist (PT)/Staff #4. Staff #4 stated that she worked at the facility last month but does not remember the dates. She was driving during the interview and was unable to check dates at the moment, but she stated that everything was in the progress notes. She stated that she used an interpreter, there was no name of the nurse involved during the incident, Resident #1 was not aware of the male nurse's name, and the incident happened during the night shift.An interview was conducted on August 12, 2025 at 10:12 AM with a Unit Manager/Staff #55 in the conference room. Staff #55 stated that she works Tuesdays through Fridays from 10 AM through 8: 30 PM. Her responsibilities include making residents' rounds, doing narcotic audits, she is involved with admissions and discharges, and she follow up with families for any concerns. She stated that their dialysis residents go to dialysis. Regarding her abuse training, she stated that as soon as an abuse is identified, abuse is reported right away to the administrator, and if the administrator is not available, she reports the allegation of abuse to the DON. If DON is not available, she stated that the administrator or the DON are usually available. She stated that the type of abuse to report include physical, sexual, financial, verbal, and neglect. If she is made aware of an allegation of abuse, her responsibility is to report it to the administrator, she interviews the resident to get details, but her main responsibility is to inform the administrator and the DON. She stated that she was made aware of Resident #1's incident in July around by the end of July. She believes it was July 25, and Resident #1 already has been discharged . She stated that Resident #1 only speaks Spanish, the therapist stated that in the morning Resident #1 was sitting in the chair, Resident #1 remembered the staff were trying to wake her up. She stated that Resident #1 might have had a seizure because Resident #1 was out of it but knows what was going on but Resident #1 was unable to communicate, Resident #1's incident happened early in the morning during the night shift. The staff at that time was a nurse and a med tech. The nurse was Staff #249 and the Med tech was Staff #83. Staff #249 was not assigned to Resident #1 after the incident. Resident #1 was not sure when the incident happened, if it was on a Tuesday or Wednesday, Resident #1 described the male staff looking Hispanic and that is how Staff #55 figured it was Staff #249 and he was with a CMA (certified medical tech)/Staff #83. Both Staff #249 and Staff #83 were working that night shift. Staff #55 stated that after the incident, cares in pairs was implemented for Resident #1. Staff #55 stated that she informed the administrator via phone call of the incident on July 25 which was a Friday and she also spoke with the DON and she thinks that their Director of Rehab also informed the DON. Staff #4 was the therapist whom Resident #1 informed of the incident on July 25. Staff #55 stated that after reporting the incident to the administrator and DON, she went and interviewed Resident #1 with the wound care nurse, but resident was eating lunch and had a visitor and wanted them to come back later. The second visit to Resident #1 was with the unit coordinator to assist with translation. Staff #55 stated that the resident did not say the way the therapist had reported it to her. Staff #55 stated that the nurse came in the room while Resident #1 was half dress, and the nurse was trying to wake Resident #1 up by rubbing on Resident #1's chest because the nurse was concern that Resident #1 was altered and the staff placed Resident #1 back in bed. Staff #55 did not remember any other abuse incident, just this one for this year.An interview was conducted on August 12, 2025 at 11:17 AM in the 2200 nursing station with Staff #65. Staff #65 stated that as the unit coordinator, her responsibility includes setting up appointments and transportations, she speaks Spanish, she helps translates. She stated that she translated for one of the unit managers regarding an incident in July. She stated that her abuse training includes if she hears any allegation of abuse, she will report it to the administrator. She stated that if abuse is not reported, the abuse allegation will not get investigated, the resident is vulnerable, and the resident would feel unsafe in the facility.On August 12, 2025 at 11:30 AM, an exit interview was conducted with the administrator/Staff #28 and the DON/Staff #133 in the conference room. At 11:52 AM, the DON stated that when the physical therapist note had come up, she and the administrator spoke with the Director of Rehab. The DON does not remember when they spoke with the Director of Rehab. The DON stated that she also spoke with Resident #1 and Resident #1 denied the accusation. The DON stated that she had concerns with medication administration during the incident, and that is when the administrator reported the incident to the police, DHS (department of health services), which is in their 5-day report. The DON stated that the allegation of abuse was not reported to her and to the administrator and that they both learned of the allegation of abuse on a later date from APS, and that is when they filed it to the department and to the law enforcement. During the interview, the administrator stated that they verified the incident with Resident #1 and the family member and confirmed that nothing happened. The administrator stated that the physical therapy note was not reflecting the reality of what Resident #1 stated once Resident #1 and the family member were interviewed.A review of facility's policy titled, 003 - Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, in effect date of January 1, 2024 revealed Residents have the right to be free from abuse. (8) Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. (9) Investigate and report any allegations within timeframes required by federal requirements. (10) Protect residents from any further harm during investigations.

Based on clinical record review, staff and resident interviews, facility documentation and policy review, the facility failed to investigate an allegation of abuse in a timely manner for two residents (#1, #2). The deficient practice could place residents at risk for further abuse.Findings include:-Regarding Resident #1:Resident #1 was admitted to the facility on [DATE] with a diagnosis that included bilateral primary osteoarthritis of knee, anxiety disorder, syncope and collapse, and Type 2 Diabetes Mellitus (DM).A review of orders revealed Resident had orders for occupational therapy, physical therapy and speech therapy to eval and treat as needed if indicated on orders.A review of Resident's care plan dated June 17, 2025 revealed Resident was at risk for functional self-care deficits and/or functional mobility limitations related to osteoarthritis of the Knee, history of falls, DM, and weakness.A review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14.0, cognitively intact, behavioral symptoms not exhibited, and rejection of care and wandering behaviors were not exhibited.Another review of Resident's care plan dated June 22, 2025 revealed Resident had a communication problem related to Resident only speaks Spanish.A review of progress note dated July 22, 2025 at 6:34 AM revealed Resident was due for her morning medication and Staff #249 asked a CNA (certified nursing assistant) to accompany Staff #249 and assist with Spanish translation. The progress notes also revealed that Resident complaint about being forced to take medication and Resident wants the nurse to leave her medication on the table. The nurse stated that Resident had syncope attack when Resident gets upset/mad. Staff #249 progress note revealed that the Resident accused him of grabbing and touching her with the CNA. Staff #249 was just helping Resident put back her gown and just trying to make her safe to prevent her from falling because Resident was sitting at beside. Furthermore, the progress note revealed that after 15 minutes, Staff #249 and another staff tried to give Resident's medication while Resident was talking on the phone, and Resident acted like she fell asleep as soon as she saw the staff knocked and walked inside her room.Another review of care plan dated July 22, 2025 revealed Resident had a behavior problem related to resistive to care, false accusation towards staff and preference for female staff only. Interventions included to anticipate Resident's needs and cares in pairs.A review of rehab therapy progress note dated July 25, 2025 revealed a Spanish interpreter was utilized, at 10:00 AM, Resident #1 reported to physical therapy (PT) that resident was abused by a nurse in the facility. The progress notes revealed that resident was naked while finishing up with a shower, resident was about to fasten gown and resident couldn't because a male nurse came in without knocking and resident was attacked immediately. The progress notes revealed that he shook the resident a lot and the resident could not wake up or move. He grabbed the resident by the arms to put resident in bed. A female nurse came in and put the robe on the resident and left. Resident could not move because of epilepsy. Furthermore, the progress note revealed that the female nurse stated that she did not see anything and he stated that it was only one pill. But when the resident woke up, there were a lot of pills stuffed in the resident's mouth, resident could not swallow, resident spit them out and had a sour taste. The male nurse stated it was only one pill but resident took six tiny pills and three big ones placed in resident's mouth when resident was passed out, resident reported it to a nurse and the Spanish speaking nurse said she needs to apologize. In the morning the male nurse stayed by the door and did not want to enter the resident's room. A female nurse entered the room and Resident #1 stated to report him for bad behavior. The progress notes also revealed that PT was not able to notify the administrator due to the administrator was out on vacation and the other administrative staff were out until 3:00 PM. The progress note revealed that PT had a conversation with a unit manager/Staff #55 on July 25, 2025 at 12:00 PM and PT reported to the DON (director of nursing) and the building administrator.A review of progress notes and a Weekly Skin check and Wound assessment dated [DATE] revealed a registered nurse (RN) and a CNA that speaks Spanish conducted a head to toe assessment and observed Resident's skin to be clean, dry and intact, no open area, no redness, and no area of concerns noted.A review of facility's investigation report with an allegation date of August 4, 2025 revealed that the facility was notified by APS (Adult Protective Services) of an anonymous report of sexual abuse towards Resident #1. The facility report revealed that there was no staff member to suspend as the facility was unable to identify the alleged accuser and there was no staff identified by the accuser. Furthermore, the report revealed two staff statement. First statement was from a unit coordinator/Staff #65. The statement from Staff #65 revealed that the incident happened either Tuesday/Wednesday early morning. The nurse did not knock and resident was sitting up in the wheelchair. Resident had an episode where resident knew what was going on but was unable to move or talk and not sure if it was a syncopal episode. The Resident described the nurse as Hispanic male, dark hair, not too old, not too young, and does not speak Spanish. A female staff assisted the male nurse to get the resident back in bed. The resident was in pain and was given Tylenol but Resident was unable to swallow so the medicine was in the Resident's side of the mouth which the Resident stated that it tasted bitter. Resident #1 did not report any abuse to her knowledge. The second staff statement in the 5-day report was given by Staff #55/unit manager. Staff #55 statement revealed that On Friday 08/25/25 Staff #55 was informed of the Resident's experience that happened couple days ago. The PT revealed that resident was in a wheelchair when resident was in pain that froze her up and while resident was in the wheelchair, the CNA and nurse was attempting to wake resident up because resident appeared passed out. The resident was aware of what was going on but was not communicating verbally just grunting. Staff #55 statement also revealed that she noticed the pills in Resident's mouth were half dissolved. Furthermore, the August 4, 2025 investigation report finding and conclusion revealed that there was no staff member identified as an alleged perpetrator, Resident #1 and family stated that there was no sexual abuse, facility reported the complaint to APS, police, and DHS, and the allegation of abuse was unable to be substantiated.Resident #1 was discharged on August 7, 2025.-Regarding Resident #2:Resident #2 was admitted to the facility on [DATE] with a diagnosis that included speech and language deficit following nontraumatic intracerebral hemorrhage, metabolic encephalopathy, and end stage renal disease.A review of admission MDS assessment dated [DATE] revealed a BIMS score of no score recorded/space left blank, resident vision severely impaired and resident had no corrective lenses, behavioral symptoms were not exhibited, and rejection of care and wandering behaviors were not exhibited. A review of Resident's care plan dated April 22, 2025 revealed that resident was at risk for functional self care deficits and/or functional mobility limitations related to her diagnoses.Another review of Resident's care plan dated April 29, 2025 revealed that resident have delirium or an acute confusional episode, have impaired visual function, have impaired cognitive function/dementia or impaired thought processes, and at risk for bladder incontinence related to impaired mobility.A review of progress notes dated August 5, 2025 by CNA/Staff #106 revealed that resident refused a shower because it was too cold, even after staff offered to change the room temperature and shower the resident with warm water.A review of record titled, CNA Shower Sheet, dated August 5, 2025 revealed Resident #2 without a bruise, skin tear, red area, open area, fingernails and toenails were not cleaned or clipped, and facial hair not shaved. In addition, the sheet revealed a note that resident refused a shower or bath, resident was cold, and resident was informed that staff will turn off AC (air conditioning) but still resident refused to have a shower and would wait to have a bed bath the next day.A review of record titled, CNA Shower Sheet, dated August 8, 2025 revealed Resident's shower was completed.An interview was conducted on August 11, 2025 at 11:24 AM with a CNA/Staff #69. Staff #69 stated that abuse can be physical, mental, verbal, or financial. Staff #69 stated that if he was made aware of an allegation of abuse, he will report it to his charge nurse or supervisor so it will be documented and investigated for residents' safety. Staff #69 stated that he is not aware of any abuse incident since he has been in the facility.An interview was conducted on August 11, 2025 at 1:37 PM in the rehab director's office with occupational therapy (OT)/Staff #1. She stated that her role includes getting referral paperwork, doing chart reviews, observing precaution prior to walking in the resident's room, then she will ask the resident in depth question such as their prior level to preemptively plan for their discharge, and then she will set their discharge goals. And, based on the schedule, she discusses the plan with the resident such as upper or lower body strength, safety, fall prevention education, also educate family if family is at bedside. She stated that she uses a language line solution, it is a phone number to call and then select the language resident speak, if resident does not speak English. Regarding her abuse training, she stated that she will report an allegation of abuse immediately to the abuse coordinator which is the administrator. She is not aware of any abuse incident.An interview was conducted on August 11, 2025 at 1:50 PM in hallway 2100 with CNA/Staff #229. She stated that she works day shift from 6 AM through 6 PM. After clocking in, she first does a walk-in report with the night CNA going from one room to another. Then, she will start taking vital signs (VS). After taking all of her residents' VS, she will give the VS sheet to her nurse, and also will document the VS in the computer. She will assist her residents, get residents up, and sent residents to activities. When she has a resident, who does not speak English, her facility has a number she can call to assist in translation. She stated that she takes care of Spanish speaking residents and since she speaks Spanish herself, the other staff comes to her and ask her to assist them with translation. Regarding care in [NAME], she stated that the resident who have cares in [NAME] could be resident that made accusation against staff, and or are heavier. Regarding abuse, she stated that abuse can be sexual, psychological, financial, and verbal. And, when she witnesses or is made aware of any allegation of abuse, she will report it to the administrator, DON, or to her nurse. She stated that she heard a few residents who have mentioned that supposedly a staff placed a finger. She stated that most of the CNAs working in the units are female, except there is one male on the day shift. She stated that if a resident asks for a female to provide her care, usually their male CNA will look for a female CNA. She stated that a week ago, there was a rumor that Resident #2 who is still in the facility was one of the residents included in the rumor, but she does not know if the rumor was true or not.On August 11, 2025 at 2:03 PM, an interview was conducted with Resident #2. Resident #2 stated that she wants to go home. Resident #2 stated that there was an incident with a nurse who took her in a shower located in her room during the day and stuck her finger. The incident happened 2 or 3 weeks ago, on a Tuesday. Resident stated that she is blind, she can't see, and the staff stuck her finger in her private part, and the nurse stated to her you do not want to stink do you, and another incident were another nurse poured the medicine in her mouth. Resident stated that she informed a lady about the incident but could not remember the lady's name. On August 11, 2025, a follow up question with CNA/Staff #229 at the nursing station 2200 hall was conducted. Staff #229 stated that showers are provided by CNAs, nurses do not give showers, the CNAs use a shower sheet, Resident #2 shower days are on Tuesdays and Fridays, and showers are done in the resident's room.On August 11, 2025 at 2:45 PM, the administrator/Staff #28, DON/Staff #133, and AIT (administrator in training)/Staff #221 were made aware of an allegation of abuse involving Resident #2.On August 11, 2025 at 2:45 PM, the administrator stated that there were no allegations of abuse reported in the month of July and there was only one allegation of abuse for August.On August 11, 2025 at 5:14 PM, surveyor received a call back from physical therapy assistant (PTA)/Staff #3. Staff #3 stated that he works for this facility and provided services to Resident #1, sometimes three to four times per week. Staff #3 stated that Resident #1 complained about a nurse, this incident was already reported because the event happened in July, and it was recorded in the PT notes. Additionally, Staff #3 stated that Resident #1 mentioned to him that when Resident #1 was changing their gown, the nurse entered without knocking, Resident #1 was upset and on the same day when Resident #1 was lying down half asleep, the nurse came in their room and poured the medication and water in Resident #1's mouth. Resident #1 was choking when awaken. Resident #1 did not remember the nurse's name. Staff #3 stated that there were not a lot of male nurse in that facility.An interview was conducted on August 12, 2025 at 9:13 AM via phone with physical therapist (PT)/Staff #4. Staff #4 stated that she worked at the facility last month but does not remember the dates. She was driving during the interview and was unable to check dates at the moment, but she stated that everything was in the progress notes. She stated that she used an interpreter, there was no name of the nurse involved during the incident, Resident #1 was not aware of the male nurse's name, and the incident happened during the night shift.An interview was conducted on August 12, 2025 at 10:12 AM with a Unit Manager/Staff #55 in the conference room. Staff #55 stated that she works Tuesdays through Fridays from 10 AM through 8: 30 PM. Her responsibilities include making residents' rounds, doing narcotic audits, she is involved with admissions and discharges, and she follow up with families for any concerns. She stated that their dialysis residents go to dialysis. Regarding her abuse training, she stated that as soon as an abuse is identified, abuse is reported right away to the administrator, and if the administrator is not available, she reports the allegation of abuse to the DON. If DON is not available, she stated that the administrator or the DON are usually available. She stated that the type of abuse to report include physical, sexual, financial, verbal, and neglect. If she is made aware of an allegation of abuse, her responsibility is to report it to the administrator, she interviews the resident to get details, but her main responsibility is to inform the administrator and the DON. She stated that she was made aware of Resident #1's incident in July around by the end of July. She believes it was July 25, and Resident #1 already has been discharged . She stated that Resident #1 only speaks Spanish, the therapist stated that in the morning Resident #1 was sitting in the chair, Resident #1 remembered the staff were trying to wake her up. She stated that Resident #1 might have had a seizure because Resident #1 was out of it but knows what was going on but Resident #1 was unable to communicate, Resident #1's incident happened early in the morning during the night shift. The staff at that time was a nurse and a med tech. The nurse was Staff #249 and the Med tech was Staff #83. Staff #249 was not assigned to Resident #1 after the incident. Resident #1 was not sure when the incident happened, if it was on a Tuesday or Wednesday, Resident #1 described the male staff looking Hispanic and that is how Staff #55 figured it was Staff #249 and he was with a CMA (certified medical tech)/Staff #83. Both Staff #249 and Staff #83 were working that night shift. Staff #55 stated that after the incident, cares in pairs was implemented for Resident #1. Staff #55 stated that she informed the administrator via phone call of the incident on July 25 which was a Friday and she also spoke with the DON and she thinks that their Director of Rehab also informed the DON. Staff #4 was the therapist whom Resident #1 informed of the incident on July 25. Staff #55 stated that after reporting the incident to the administrator and DON, she went and interviewed Resident #1 with the wound care nurse, but resident was eating lunch and had a visitor and wanted them to come back later. The second visit to Resident #1 was with the unit coordinator to assist with translation. Staff #55 stated that the resident did not say the way the therapist had reported it to her. Staff #55 stated that the nurse came in the room while Resident #1 was half dress, and the nurse was trying to wake Resident #1 up by rubbing on Resident #1's chest because the nurse was concern that Resident #1 was altered and the staff placed Resident #1 back in bed. Staff #55 did not remember any other abuse incident, just this one for this year.An interview was conducted on August 12, 2025 at 11:17 AM in the 2200 nursing station with Staff #65. Staff #65 stated that as the unit coordinator, her responsibility includes setting up appointments and transportations, she speaks Spanish, she helps translates. She stated that she translated for one of the unit managers regarding an incident in July. She stated that her abuse training includes if she hears any allegation of abuse, she will report it to the administrator. She stated that if abuse is not reported, the abuse allegation will not get investigated, the resident is vulnerable, and the resident would feel unsafe in the facility.On August 12, 2025 at 11:30 AM, an exit interview was conducted with the administrator/Staff #28 and the DON/Staff #133 in the conference room. At 11:52 AM, the DON stated that when the physical therapist note had come up, she and the administrator spoke with the Director of Rehab. The DON does not remember when they spoke with the Director of Rehab. The DON stated that she also spoke with Resident #1 and Resident #1 denied the accusation. The DON stated that she had concerns with medication administration during the incident, and that is when the administrator reported the incident to the police, DHS (department of health services), which is in their 5-day report. The DON stated that the allegation of abuse was not reported to her and to the administrator and that they both learned of the allegation of abuse on a later date from APS, and that is when they filed it to the department and to the law enforcement. During the interview, the administrator stated that they verified the incident with Resident #1 and the family member and confirmed that nothing happened. The administrator stated that the physical therapy note was not reflecting the reality of what Resident #1 stated once Resident #1 and the family member were interviewed.A review of facility's policy titled, 003 - Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, in effect date of January 1, 2024 revealed Residents have the right to be free from abuse. (8) Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. (9) Investigate and report any allegations within timeframes required by federal requirements. (10) Protect residents from any further harm during investigations.

Based on record reviews, staff interviews, and facility policy and procedure review, the facility failed to maintain accurate documentation surrounding the death of two residents (#2 and #6). The sample size was 3. The deficient practice can result in inadequate records being kept regarding the extent of a resident's death in the facility. Findings include: -Resident #2 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of rectum, secondary and unspecified malignant neoplasm of inguinal and lower limb lymph nodes; other diseases of mediastinum, not elsewhere classified. An admission MDS (minimum data set) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 12, indicating that Resident #2 may need extra assistance with daily activities or tasks and may be experiencing cognitive decline. A review of a progress note dated [DATE] revealed that the resident expired around 12:10pm, and that the expiration was confirmed by two Licensed Practical Nurses (LPN) and one Registered Nurse, who notified internal and external parties. A discharge evaluation dated [DATE] revealed that a circumstance surrounding the death of Resident #2 was that this resident had been on hospice services. A review of the resident's blood pressure summary revealed that no vitals were recorded on [DATE]. A review of the resident's pulse summary revealed that no vitals were recorded on [DATE]. An interview with the Director of Nursing (DON/Staff #127) was conducted on [DATE] at 11:36AM, where Staff # advised that any documentation surrounding an event where a resident is a code blue or coding, which signifies a life-threatening medical emergency requiring immediate resuscitation efforts, can be found on their electronic health record systems within the progress notes of the specific resident. An interview with an LPN (Staff #52) was conducted on [DATE] at 2:56PM, where Staff # stated that in the event that a resident is a code blue or coding, the facility expects staff to record and document a complete vital check with current blood sugar levels within a change of condition progress note, which is then given to paramedics at time of arrival, to ensure continuity of care. On [DATE] at 5:39PM, an email was received from the DON (Staff #127) to provide a human remains release form and a discharge evaluation for Resident #2. An interview with the DON (Staff #127) was conducted on [DATE] at 10:47AM, where Staff # stated that the facility expects staff to complete documentation within their electronic health record platform, and any other additional documentation surrounding the change of condition and release of human remains is expected to be uploaded to the electronic health record as well. Staff # also stated that they were not able to locate documentation surrounding the death of Resident #6, indicating that the facility has no record of the death of Resident #6 in their electronic health record, or, within their physical paper documentation management system. -Resident #6 was admitted to the facility on [DATE] with diagnoses that included unspecified atrial fibrillation, cerebral infarction, unspecified; chronic obstructive pulmonary disease, unspecified. An admission MDS (minimum data set) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 09, indicating that Resident #6 may have had difficulty with some cognitive tasks and may have needed assistance with daily activities. A review of the resident's blood pressure summary revealed that no vitals were recorded on [DATE]. However, vitals were recorded at 10:59AM on [DATE]. A review of the resident's pulse summary revealed that no vitals were recorded on [DATE]. However, vitals were recorded at 10:59AM on [DATE]. A review of a progress note dated [DATE] revealed that the resident had been found at 1808 military time (6:08PM), on his back by a Certified Nursing Aide (CNA) who immediately initiated a 'rapid response code' to begin chest compressions due to the resident being observed with no breath and no heartbeat. The note also revealed that 911 emergency services were called, an AED (Automated External Defibrillator) had been used at 1818 (6:18PM), which had stated, no shock advised, indicating that the device had analyzed the heart rhythm and determined that a shock is not necessary or beneficial, and the resident may have a non-shockable rhythm like asystole or pulseless electrical activity (PEA), to which, the facility resumed cardiopulmonary resuscitation until emergency services arrived at 1820 (6:20PM), and pronounced the resident deceased . An interview with the DON (Staff #127) was conducted on [DATE] at 11:36AM, where Staff # advised that any documentation surrounding an event where a resident is a code blue or coding, which signifies a life-threatening medical emergency requiring immediate resuscitation efforts, can be found on their electronic health record systems within the progress notes of the specific resident. An interview with an LPN (Staff #52) was conducted on [DATE] at 2:56PM, where Staff # stated that in the event that a resident is a code blue or coding, the facility expects staff to record and document a complete vital check with current blood sugar levels within a change of condition progress note, which is then given to paramedics at time of arrival, to ensure continuity of care. On [DATE] at 5:39PM, an email was received from the DON (Staff #127) to provide clarity regarding Resident #6, stating that the facility was unable to locate any documentation surrounding the death of resident #6. An interview with the DON (Staff #127) was conducted on [DATE] at 10:47AM, where Staff # stated that the facility expects staff to complete documentation within their electronic health record platform, and any other additional documentation surrounding the change of condition and release of human remains is expected to be uploaded to the electronic health record as well. Staff # also stated that they were not able to locate documentation surrounding the death of Resident #6, indicating that the facility has no record of the death of Resident #6 in their electronic health record, or, within their physical paper documentation management system. A facility policy titled, End of life care: death of resident, documenting revealed that all information pertaining to a resident's death must be recorded in the nurses' notes. A facility policy titled, Emergency/first aid: emergency procedure - cardiopulmonary resuscitation revealed the basic life support sequence that staff is expected to utilize. A facility policy titled, Documentation: charting and documentation revealed that any changes in the residents medical, physical, functional or psychosocial condition should be documented in the medical records of the resident to facilitate communication between the interdisciplinary team.

Based on clinical record review, interviews, and review of the facility policies, the facility failed to ensure that the care plan for one resident (#22) was updated according to the resident's preferences following a five-day investigation of a complaint. The deficient practice could result in suboptimal care planning to meet the resident's preferences. Findings include: Resident #22 was admitted to the facility on [DATE] with a diagnosis of unilateral primary osteoarthritis to the right hip, epilepsy, mood affective disorder, psychosis and adjustment disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12. Indicating that the resident has moderate cognitive impairment. Resident #22 reported on October 7, 2024 at 6:00 PM that when a Certified Nursing Assistant (CNA) came to her room to provide incontinence care, she was popped in the butt. Resident was not able to provide a date or time when the alleged incident occurred, but she did give a brief description of the CNA. The facility launched an investigation on October 7, 2024 through October 11, 2024 and it was determined that the allegation was unsubstantiated. In the investigation notes, it stated, care plan has been updated to include 2 care givers for incontinent cares and per res request-female caregivers. Review of the care plan dated September 19, 2024 with a revision on October 8, 2024, revealed the care plan was not revised to include the requested change in care regarding the resident was to have 2 female caregivers for incontinence care. An interview was conducted on October 22, 2024 at 1:30 PM with Director on Nursing, (DON, staff #13). When asked if the care plan had been updated to 2 female care givers for incontinence care as was stated in the facility investigation report, staff #13 stated, no; and that, it was not in the care plan, it was an alert that was across her chart in the electronic medical records. That's going to be a problem isn't it. Review of State Operations Manual (SOM), Appendix PP (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17), revealed each resident has the right to participate in choosing treatment options and must be given the opportunity to participate in the development, review and revision of his/her care plan. Residents also have the right to refuse treatment. The residents's care plan must be reviewed after each assessment, as required, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on closed record review, staff interviews, review of facility documentation and policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure a safe and appropriate transfer of one resident (#1). The deficient practice could result in residents not receiving appropriate care and services during the transition of care. Findings include: Resident #1 was admitted on [DATE] with diagnoses of cerebral palsy, chronic respiratory failure with hypoxia, polyneuropathy, dysphasia, and scabies. The care plan dated April 2, 2024 included that the resident was ventilator dependent related to respiratory failure. Interventions included to assess for signs/symptoms of hypoxia such as altered level of consciousness, irritability, listlessness and cyanosis; chest physio-therapy as ordered; keep head of bed elevated above 30 degrees; maintain spare trach at bedside; maintain ventilator settings as ordered; to monitor oxygen saturation while resident was on mechanical ventilatory support and/or during weaning process; and trach care twice in a 24-hour period. A care plan dated April 3, 2024 revealed the resident required tube feeding and was dependent with tube feeding and water flushes. Interventions included to check for and record tube placement and gastric contents/residual volume per facility protocol; and to see physician orders for current feeding orders The Minimum Data Set (MDS) admission assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete the interview. The MDS revealed the resident was on special treatments such as high concentration continuous oxygen therapy, scheduled and as needed suctioning, tracheotomy care, and invasive mechanical ventilator. The care plan dated April 15, 2024 included that the resident had impaired cognitive function, dementia or impaired thought processes. Interventions included to administer medications as ordered; communicate regarding resident's capabilities and needs; and to engage the resident in simple, structured activities that avoid overly demanding tasks. Another care plan dated April 15, 2024 revealed that the resident had a communication problem related to confusion. Interventions included to anticipate and meet needs; and, to use effective strategies and communication techniques which enhance interaction. The social service progress note dated May 6, 2004 revealed that the state insurance prescreens, benefits, covered services and application process for continued placement was discussed resident #1 who did not want the insurance and would like to return back to the out-of-state facility where he came from. The social service progress note dated May 8, 2024 included resident #1 came from an out-of-state facility that was closed due to flooding. Per the documentation, the out of state facility where resident #1 transferred out from was still not in operation and had no plans to open until December 2024. The social service progress note dated May 8, 2024 revealed the resident would like to go back to the state where he came from due to having his whole family residing there; and, he wanted to go to a sister facility of the old out-of-state facility where he came from. The social service progress note dated June 28, 2024 included a discussion with the resident family about having resident #1 closer to home so family can visit. The social service progress note dated June 28, 2024 revealed that social service reached out to the out-of-state facility for bed availability. Another progress note dated June 28, 2024 revealed that social service reached out to another out-of-state facility for bed availability. The social service progress note dated July 8, 2024 revealed that the social service reached out to the out-of-state facility (where the resident came from) via phone and through email asking for assistance to relocate the resident back. Another social service progress note dated July 8, 2024 included that social service reached out to another out-of-state facility requesting any update on accepting resident #1; and that, social services was told that the out-of-state facility did not have an available bed for the resident. Another social service progress note dated July 8, 2024 revealed that social service reached out to additional eight out-of-state facilities provided by resident's family. Per the documentation, three facilities were not accepting residents on vents or trachs (tracheostomy); one facility not taking admissions due to full capacity; one facility had no male beds available; and three facilities did not answer the call and a message to call back was left. The interdisciplinary team (IDT) care plan conference note dated July 8, 2024 included that the family of resident #1 would like the resident to stay at the facility until the resident was able to be placed in the out-of-state facility where he came from. The social service progress note dated July 18, 2024 included that social service reached out to another out-of-state facility. The documentation included that the out-of-state facility did not have a subacute rehab and were unable to take the resident. The nurse practitioner (NP) note dated July 18, 2024 included that the resident looked chronically ill, was alert, nodded in response to questions, had nonlabored breathing and was on a ventilator via trach (tracheostomy). Assessments included cerebral palsy, quadriplegia and chronic respiratory failure s/p (status post) trach. Another social service progress note dated July 18, 2024 revealed that case management discussed the transfer update with the resident. The documentation included that during the discussion, the resident moved his head up and down indicating yes confirmation to go back to the state where he came from; and when asked about state insurance application option, the resident moved his head from side to side indicating no. Further, the documentation included that the resident was asked whether he would go back to a hospital out-of-state (where he came from) if no facilities would accept his transfer; and that, the resident moved his head up and down indicating a yes confirmation in response. The physician progress note dated July 19, 2024 revealed that the resident had a known history of ventilator dependent respiratory failure, was tetraplegic with spasticity and cerebral palsy. Plan included adjust ventilator settings as needed, tracheostomy care twice daily, aspiration precautions and suction as needed A daily skilled evaluation note dated July 20, 2024 revealed that skilled care services provided were wound care, respiratory therapy/services, respiratory aspiration, gastrostomy feeding, physical and occupational therapy services; and tracheostomy care. Per the documentation, the resident had shortness of breath while lying flat, oxygen and ventilator were in use and the resident had a Foley catheter in place. The social service progress note dated July 22, 2024 revealed that all placement options were exhausted in the resident's home state. Per the documentation, to honor the resident wishes to go back to his home state, resident was willing to go to the hospital in his home state. It also included that the resident was asked one more time if he was willing to stay and apply for state insurance and the resident signal 'NO' with the movement of his side to side. Further, the note included that to honor resident wishes the facility paid for the resident's transport to his home state; and that, the resident was aware and understood that he will be transported per his wishes to the hospital in his home state. The skilled needs review note dated July 23, 2024 included that resident expected to be discharged to community; and that the resident needed long term care (LTC) placement. Per the documentation, application to state insurance for LTC placement was submitted but the resident did not want the state insurance and wanted to be discharged to his home state. Further, the documentation included that the anticipated discharge date was July 25, 2024 and the resident will be discharged to another facility. The social service note dated July 24, 2024 included that the resident was informed per his wishes will be sent to a hospital in his home state today and the facility would pay for transportation; and that, the resident acknowledged understanding signal 'yes' by moving his head up and down. Per the documentation, multiple options were attempted including applying for state insurance, sending referrals to facilities in the resident's home state per the resident and family request, and communication with the social worker from the resident's previous facility; but, were all unsuccessful. Another social service note dated July 24, 2024 revealed that the resident was informed that the transfer will happen on July 25, 2024 with a pick-up time of 7:30 a.m. with a non-emergent ambulance. Per the documentation, the resident acknowledged and understood by moving his head up and down indicating a yes response. A late entry social service note dated July 24, 2024 included that the resident was notified that his last covered day for skilled services was July 25, 2024 due to exhausting his skilled nursing facility benefits days. Per the documentation, resident confirmed wanting to discharge to his home state. Despite documentation that the resident had an anticipated discharge scheduled on July 25, 2024, the clinical record revealed no physician order for the resident's discharge or transfer. The discharge summary dated July 24, 2024 revealed that resident was transferred to a hospital via non-emergent transport. Per the documentation, the physician, director of nursing (DON) and executive director (ED were notified. According to the documentation, resident self-initiated the hospital transfer to his home state; and, measures were taken to stabilize resident prior to the determination to transfer. It also included that the current reconciled medication list was provided to the resident/representative and the subsequent provider via paper based method (e.g. fax, copies, printouts). The documentation did not include which paper based method was used. The discharge and transfer assessment completed by the administrator dated July 24, 2024 included that the resident was transferred to an out of state short term general hospital; and the responsible party, physician, DON and ED were notified. The documentation also included that transportation was arranged through a non-emergent transportation. It also included that the resident was on contact precautions for C. aureus (fungus) and CRE (Carbapenem-resistant Enterobacterales-bacteria). the section on the name of the nurse report was given at the hospital was blank. There was also no documentation found in the clinical record of the name of the receiving provider; and, any communication made by the facility to the receiving provider regarding resident's assessed needs and condition at the time of transfer. There was also no evidence of any confirmation that a discharge summary and/or instruction were received by the receiving provider. The social service progress note dated July 29, 2024 revealed that a staff from the out-of-state hospital where resident transferred to was asking how the decision to discharge the resident to the out-of-state hospital was made. Per the documentation, the facility the hospital staff that resident had requested multiple times to go back to his home state and declined applying for the state insurance. Further, the documentation included that to honor his wishes, the facility sent the resident to his home state so he could continue with his LTC benefits. The SA complaint tracking system included that a report was submitted on July 30, 2024 that resident#1 was brought to the hospital emergency department on July 26, 2024; and that, the ambulance called the emergency department 10 minutes to arrival. The documentation included that the hospital was not notified by the facility that they were sending the resident to the hospital; and that, the facility provided a letter, admission record and medication list that was given to the emergency department staff by the ambulance crew. It also included that the ambulance crew told the hospital nurse that the facility's discharge planner called and told the ambulance crew to send the resident to the hospital as the final destination. Further, the documentation included that there was no accepting physician at the hospital, there was no report called to the hospital and it was unknown to the hospital that the resident was coming until the ambulance notified the hospital in route. It also included that at the date and time of the report, the resident was taking up a bed in the intensive care unit (ICU) for ventilation management; and, the hospital notified the resident's family who was not aware of the resident's transfer to the hospital. An interview with the social worker (SW/staff #14) and the case management (CM/staff #16) was conducted on August 1, 2024 at 10:14 a.m. The SW stated that discharge planning was discussed with team members such as providers to ensure residents are discharged appropriately with services and medical equipment they need. The CM stated that a discharge was dependent on the IDT meeting and the equipment needed upon discharge was consulted with therapy; and that, the facility work with a placement agency to find a place that specializes with trachs or vent residents for appropriate placement. The CM said that once resident placement was approved, the facility would coordinate with a group home or the facility the resident was going and make sure the paperwork such as medication, disposition, face sheet, all clinical record was in line. Both the SW and CM stated that residents were transferred out to a hospital for critical needs with physician approval; but, if residents transferring out to another facility are due to family or resident request. An interview was conducted on August 1, 2024 at 3:00 pm with a licensed practical nurse (LPN/staff #10) who stated that resident discharge happens when residents were stable enough; or, when facility was not equipped to handle care; or, the resident required more advanced care so they go to the hospital. The LPN said that when the residents were discharged , the resident had to be safe to leave the building; and that, she would give a report to the receiving nurse and ensure that the receiving facility are able to provide the necessary care for the resident needed. The LPN said that when giving the report to the receiving nurse, she would give the following information: code status, allergy, history, current treatments, any precautions, mobility/transfer, information regarding care of the resident, and MAR (medication administration record) when the last time the patient was medicated and with what medication received. The LPN said that the CM informs staff where the resident was discharging or when a patient was being admitted or arriving. She stated that for a hospital discharge/transfer, the facility uses the eInteract/Transfer form; and that, residents were only transferred to the hospital for true emergencies and higher level of care needed. The LPN said that in these cases, she would call and give a verbal report to the receiving facility so the receiving facility have an idea on how to take care of the resident and for continuity of care. She stated that the eInteract has a spot to fill out and document who she gave the report to, to what hospital the resident went; and, the receiving facility gets a paper upload/fax of the discharge documents. An interview was conducted on August 1, 2024 at 3:09 pm with another LPN (staff #12) who stated that the case manager would let her know when patient was getting discharged . She stated that if patient was going to another facility and this was prearranged, she would contact the receiving facility to provide report on the resident's status. The LPN said that if she was unable to get a hold of the receiving nurse, she will leave her direct number for the receiving nurse to call back. She stated that once the resident leaves the facility, she would document everything such as who she spoke to, what the resident left with as far as belongings and document everything in the progress notes. The LPN stated that the facility uses a transportation company specialized on trachs and vents; and, when transferring residents with vent or trach, the nurse and the respiratory therapist are in the room to ensure the correct settings of the airway equipment. She stated that she would then call the family or responsible party and document in the progress note what time the resident left or was picked up, who she contacted at the receiving facility. Regarding resident #1, the LPN stated that the resident was sent to the hospital twice for having a hard time breathing. She stated that the resident was alert, unable to sign a consent, was nonverbal, was able to read his lips when he is talking, speaks in low whisper, nods his head, and can give a verbal consent. In another interview conducted with CM (staff #16) and discharge coordinator (staff #28) on August 1, 2024 at 4:23 p.m., the CM stated that her role included assessment and screening of all the needs of the resident, speaking to the resident and family and honor their wishes regarding the discharge. Regarding resident #1, the CM stated that the resident's discharge was difficult; and that, she had care conference with resident's family and was informed that out-of-state facility where the resident came from was flooded. The CM said that the resident was then sent to the facility via a paid transport from the out-of-state hospital. The CM said that the resident's family wanted resident #1 to be back in his home state; and, she told the family that the facility can attempt to apply for the state insurance for resident #1. The CMA also said that had no NOMNC (Notice of Medicare Non-Coverage) because his benefits were exhausted; and that, the resident was adamant to going back to his home state. The CM also said that the discharge assessment dated [DATE] was done by the administrator (staff #26); and that, the documentation in the discharge assessment only have the name of the out-of-state hospital the resident was transferred to and did not include the name of nurse that was given a report to. The discharge coordinator (staff #28) stated that she ensures that all discharges were executed for all residents; and, all resident has a safe discharge. The discharge coordinator said that she was the one who set up the transportation which specialized with trachs and vents for resident #1. The discharge coordinator also said that the discharge for resident #1 was resident-driven; and, it was the resident's choice to return to the out-of-state hospital where he came from prior to admission at the facility. Further, the discharge coordinator said that there was no report given to the receiving facility; and, the only document with resident's history was in a packet and was sent with the transportation crew when the resident left the facility. The discharge coordinator also said that the discharging nurse did not give a report regarding the resident's discharge to the receiving out-of-state hospital. During an interview conducted with the director of nursing (DON/staff #18), the assistant DON (ADON/staff #20) and the clinical compliance specialist (staff #22) conducted on August 1, 2024 at 5:10 p.m., the DON stated that residents were assessed for adequate and safe discharge before a discharge/transfer; and, the case management manages the resident's discharge from beginning to end and in between and ensures that transportation provides the services required for the patient. The DON stated that the expectation was that the discharging nurse would give a report to the receiving facility or give their number to receive a call back from the receiving facility. A review of the clinical record was conducted with the DON and ADON during the interview. The DON and the ADON both stated that there was no documentation found in the clinical record that a report regarding the transfer of resident #1 was given to the receiving out-of-state hospital. A phone interview was conducted with resident's family member on August 2, 2024 at 8:41 a.m. The family member stated that he received a call on July 25, 2024 from the emergency room of the out-of-state hospital; and that, he was not aware of the transfer and this was the first time he heard about this. The family member also said that the resident was transported via the ambulance for 5 hours to the out-of-state hospital. He stated that the facility did not contact him regarding transferring the resident out; and, the last time he spoke with the facility was in the first week of July but never heard back since. Review of facility policy on Admissions/Transfers/Discharges: Transfer or Discharge Notice effective date January 1, 2024 revealed the residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge. The policy also included that the resident and representative are notified in writing of the following information: -The specific reason for the transfer or discharge; -The effective date of the transfer or discharge; -The location to which the resident is being transferred or discharge -An explanation of the resident's rights to appeal the transfer or discharge to the state, including the name, address, email and telephone number of the entity which receives appeal hearing request; -Information about how to obtain, complete and submit an appeal request; and -How to get assistance completing the appeal process; -The facility bed-hold policy; -The name, address, and telephone number of the Office of the State Long -term Care Ombudsman; -The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies); -The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities (as applies); and -The name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices. Review of facility policy titled, Admissions/Transfers/Discharges: Transfer or Discharge Documentation effective date January 1, 2024 revealed that when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to provide and ongoing program of activities designed to meet the interest and the physical, mental, and psychological well-being of two residents (#48 and #37). The deficient practice could result in a decline in physical and social skills. Findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included blindness in right and left eye, deaf non-speaking, aphasia following cerebral infarction. The care plan dated September 7, 2023 revealed a communication problem related to a hearing deficit and impaired cognition include the goal that the resident will be able to make her basic needs known. Interventions included that the staff will anticipate and meet the needs of the resident, and staff will be conscious of the resident's position when in groups, activities, and the dining room to promote proper communication with others. and discuss with the resident/family concerns or feelings regarding communication difficulty. Review of the Activities Data Collection and Review (assessment) dated September 8, 2023 revealed that the resident was assessed for one-to-one sensory activities and does not participate in group activities at this time. The minimum data set (MDS) dated [DATE] included a staff assessment for mental status score of 3 indicating the resident had a severe cognitive impairment. Review of the transfer task sheet dated February 2024 revealed that the resident was not transferred out of bed for 11 days out of 29. The task sheet for one-to-one activities dated February 2024 did not reveal documentation of activity participation from February 1, 2024 to February 14, 2024. When the resident did participate in a one-to-one activity, the specific activity was not documented and the activity is documented as passive. There was no documentation of group activities occurring. Review of the transfer task sheet dated March 2024 revealed that the resident was not transferred out of bed for 22 days out of 31. The task sheet for one-to-one activities dated March 2024 did not reveal documentation of activity participation from March 20, 2024 to March 31, 2024. When the resident did participate in a one-to-one activity, the specific activity was not documented and the activity is documented as passive. There was no documentation of group activities occurring. Review of the transfer task sheet dated April 2024 revealed that the resident was not transferred out of bed for 18 days out of 30. Review of the activity task sheet dated April 2024 did not reveal activity participation. ` Review of all the activity task sheets, such as one-to-one activities, exercise/sports, family/friend visits, arts and crafts, Bingo, group events, ice cream social, lunch to go, manicure, music, nourishment snack, outdoor activities, room visits, sensory stimulation, special events/parties, reminisce, and walking/wheeling club did not reveal documentation for the last 30 days. On May 5, 2024 at 8:31 a.m., the resident observed in her wheelchair in her room. She was wearing a helmet and facing the television. During an interview conducted on April 29, 2024 at 12:06 p.m. with the resident's mother stated that the facility doesn't provide the resident with anything and just lets the resident stay in bed. She stated that the resident is not provided a sign language interpreter. An interview was conducted on May 2, 2024 at 8:49 a.m. with the Activities Manager (staff #8607), who stated that she completes an activities assessment for each resident annually. She reviewed the resident's assessment and stated that the resident participates in sensory activities and comes out of her room to play bingo. She recommended that the resident come out of her room to participate in group activities at least twice week. She stated that the most current assessment doesn't include group activities, but it was a mistake and the resident is appropriate for group activities. It is hard for her to understand what the resident needs because the resident communicates through hand sign language, but no one has taught her to sign with the resident and she would have liked to have been able to communicate with her. Staff #8607 stated that the purpose of the activities is to help the resident emotionally, mentally, physically and it helps with depression. She reviewed the April attendance for activities and stated that resident does a lot of one-to-ones in her room and didn't have any activities documented for March 2023. An interview was conducted on May 2, 2024 at 10:28 a.m. with the Occupational Therapist (OT/staff #664), who stated that she is monitoring the activities program and it is her expectation that the Activities Manager documents activity participation of each resident. She stated that the resident make noises, but it doesn't really bother anyone, and there is no reason why the resident can't participate in group activities. Staff #664 stated that the resident could go outside, and might like to be present for Bingo, music, ice cream socials, snacks, and could possibly work with larger beads. She doesn't know why the resident is not attending group activities and stated that the purpose of group activities is socialization and it can be very isolating if the resident is staying in her room. She stated that the facility schedules a sign language interpreter to communicate with the resident for more serious things, such as splinting and the interpreter has stated that the resident does understand to a certain extent. An interview was conducted on May 2, 2024 at 11:30 a.m. with the RN, Clinical Compliance Director (#4909) and the acting Administrator (staff #3911). During the interview, the Activity Manager's job description was reviewed and staff #4909 agreed that it was the Activity Manager's job to assess the residents' participation and appropriateness of the activities, which was not being done. Staff #3911 reviewed the activity task sheets and stated that there is no documentation for activities at this time and this issue can go to QAPI. An interview was conducted on May 5, 2024 at 1:51 p.m. with a Staffing Coordinator/certified nursing assistant (CNA/staff #7750), who stated that the resident is able to open her hands and fingers and can sometimes hold a piece of bread, cup, and milk carton. The resident can put the milk carton to her mouth and will attempt to drink with assistance. She stated that the resident is able to hold a hair brush, but not brush her hair. Staff #7750 stated that the resident attended Bingo this morning and just sat there, staff did not provide hand-over-hand assistance to help the resident participate. She would have to see if the resident could handle large beads to participate in beading. The facility policy, Activities and Social Services dated January 2011 states that the interdisciplinary Care Team will evaluate the individual's personal history and preferences, and will consider his/her medical condition and prognosis in identifying relevant recreational and cultural activities.

Based on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure pain medications were administered as ordered for one resident (#68). The deficient practice could result in resident receiving unnecessary medication and overmedicated. Findings include: Resident #68 was admitted on [DATE] with diagnoses of acute respiratory failure, critical illness myopathy, and Type II Diabetes. The care plan dated August 14, 2023 revealed that the resident was at risk for pain. Interventions included to anticipate the resident's need for pain relief and respond as soon as possible to any complaint. A physician order dated November 2, 2023 included for Tramadol HCI (narcotic analgesic) oral tablet 50 mg give 25 mg enterally every 12 hours as needed for pain 6-10. The minimum data set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 14 indicating the resident had intact cognition. Review of the medication administration record (MAR) for February through April 2024 revealed that Tramadol was administered on the following dates: -February 1 and February 22 for a pain level of 5; -March 3, 2024 for a pain level of 4; -March 29, 2024 for a pain level of 5; -April 7, 2024 for a pain level of 4; and, -April 10, 2024 for a pain level of 5. The clinical record revealed no documentation of the reason why Tramadol was administered outside of the physician ordered pain parameters; and that, the physician was notified. An interview was conducted on April 30, 2024 at 3:26 p.m. with a licensed practical nurse (LPN/staff #6757) who stated that PRN (as needed) pain medications include a pain scale. The LPN stated that the residents were assessed for pain and she would review the PRN pain medication order to ensure the resident's pain level was within the ordered pain parameter. The LPN said that pain scales were used to ensure that the resident will not be not over or under medicated. During the interview a review of the clinical record was conducted with the LPN who stated that records showed that Tramadol was administered outside of the physician ordered pain parameter to resident #68. During an interview conducted on May 2, 2024 at 3:34 p.m., with the Director of Nursing (DON/staff #4558) and [NAME] President of Clinical Operations (VPCO/staff #2908), the DON stated that pain medications prescribed on a PRN basis needed a pain scale; and that, it was her expectation that nurses assess the pain level prior to administration and document the pain level. The DON also said that there was a risk of over or under medicating a resident if the pain medication was administered outside of the physician ordered pain parameters. The VPCO stated that they have identified the administration of pain medication as a problem in the last couple of months; and, it was being addressed through quality assurance and performance improvement (QAPI). The facility policy, Pain Management: Administering Pain Medications dated January 2024 included a purpose to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice. Further, the policy included a procedure to administer pain medications as ordered.

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that food items that were unsafe for resident consumption were discarded; and, the facility failed to ensure a clean and sanitary environment was maintained in the kitchen. The facility census was 98. The deficient practice could result in a potential for food borne illness and resident safety. Findings include: An initial tour of the kitchen was conducted with the dietary manager (staff #2809) on April 29, 2024 at 7:20 a.m. There was a 10-pound box of Romaine lettuce in an unsealed plastic bag in the walk-in refrigerator. There was also 10-pound box of snap peas that had white fuzzy growth on the snap peas. The dietary manager stated the bag was approximately one-third full; and, there was approximately two pounds of snap peas remaining in the box. The dietary manager stated that the lettuce leaves were wilted and some of the leaves were brown around the edges; and, the pea pods were no longer good because there was something growing on the pea pods. Further, the dietary manager stated that the lettuce should have been removed and should not be served to the residents; and that, the cook was supposed to check the produce to ensure that food items were still fresh daily. An interview was conducted with the Operations Manager (staff #2910) on May 2, 2024 at 4:08 p.m. She stated that it was her expectation that produce was checked daily and food with mold should be discarded. She also stated that mold spores create a risk of illness to the residents. The facility policy titled, The Dining Experience: Objectives included that resident meals will be served in a sanitary environment with proper food handling procedures. The facility policy, Food Storage dated 2018 included that sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored in an area that is clean, dry, and free from contaminants. 47911 -An observation was conducted on April 30, 2024 at 9:50 a.m. There were approximately 4 off-white particles measuring approximately 2 to 3 centimeters in length, stuck in between the round holes of the floor mat, directly in front of the food service area. There was also a personal cell phone found on the food preparation counter. An interview was conducted on April 30, 2024 at 10:01 a.m. with the dietary manager (staff #2809 who stated that the cell phone should not be on the food preparation counter. The dietary manager then immediately removed the phone and placed it in the office area. The dietary manager stated that his expectation was that cell phones be put away and not stored on surfaces where food might be prepared; and that, the risk would be an infection control issue for the facility. Further, the dietary manager stated that the cell phone found on food preparation area belonged to a dietary aide (staff #7841). An interview was conducted on April 30, 2024 at 10:11 a.m. with the dietary aide (staff #7841) who stated that the cell phone found on the food preparation counter belonged to her and that, it should not have been in the food service area. She stated that she had received training on not placing or storing personal items in the meal preparation areas in the kitchen, and that the risk was infection control. In later observations conducted on April 30, 2024 at 11:53 a.m. and May 1, 2024 at 7:23 a.m., revealed that the off-white particles continued to be found in floor mat. During the test tray observation conducted on April 30, 2024 at 12:54 p.m. there was a blue substance which was approximately 1 centimeter in length that was found on a meal tray. In an interview with the dietary manager conducted on April 30, 2024 at 1:01 p.m., the dietary manager stated that the blue substance found the test tray appeared to be a piece from a plastic glove, and that it was the same color as the gloves currently utilized in the kitchen. The dietary manager also stated that this probably happened when the pork for lunch was being cut because staff wear gloves while touching the meat to slice it. The dietary manager also said that finding a foreign particle, such as this, in food did not meet his expectations and that the presence of non-food items on meal trays could cause potential health issues. An interview conducted on May 1, 2024 at 8:06 a.m. with the operations manager (staff #2910) and the dietary manager (staff #2809). The dietary manager said that it was an expectation that no foreign objects are found in the food and that the risk to the residents could include getting the residents sick or a resident chocking. The operations manager stated that kitchen staff normally utilize clear gloves but they had run out and were utilizing the blue gloves at this time. In an interview with the dietary manager (staff #2910) and acting administrator (staff #3911), conducted on May 1, 2024 at 8:15 a.m. the dietary manager stated that the expectation was that there would be no personal items kept in the kitchen area; and that, having a cell phone on the kitchen counter was an infection control issue. The acting administrator said that his expectation was that the kitchen floor-mat was raised every evening and the staff mop underneath the mat to ensure the floor was clean and that the risk for not doing this would be an infection control issue as well. A review of the facility guideline and procedure manual on Cleaning Rotation revealed that items to be cleaned daily include the kitchen and dining room floors. Review of the facility policy on Infection Control dated 2013, revealed that it is the facility's policy to maintain an active infection control program with the focus on a safe, and sanitary environment to help prevent the development and transmission of disease and infection.

Based on clinical record review, staff interviews, review of facility documentation, and policy, the facility failed to ensure that the electronic health record for resident #48 was complete and accurately documented. The sample size was 20. The deficient practice could result in incomplete and/or inaccurate clinical records. Findings include: Resident #48 was admitted on [DATE] with diagnoses including aphasia, dysphagia, major depressive disorder-recurrent, schizophrenia, generalized anxiety disorder, deaf, and blindness-right eye. A review of the quarterly MDS (minimum data set) dated November 23, 2024 revealed a BIMS (brief interview of mental status) score of 99, suggesting severe cognitive impairment. A review of the plan of care (POC) response history, denoting the caregiver task of eating, for resident #48 on May 1, 2024 revealed that the resident had refused breakfast; however, the facility video revealed that staff #5901, had provided the meal tray and assisted with breakfast. The breakfast entry on the POC for May 1, 2024 was noted to have been made by staff #4901, CNA. Further documentation on May 1, 2024 for the lunchtime meal revealed documentation in the POC that the resident had eaten at 2:15 P.M.; however, per surveyor observation on the unit, resident #48 had not received her lunch tray at or before 2:15 P.M. on May 1, 2024. Review of the POC response history for resident #48 on April 30, 2024 revealed that the resident had consumed between 26% to 50% for dinner, which was documented by staff #2691, LPN (licensed practical nurse); however, facility video documentation revealed that the dinner tray had been delivered by staff #2901, CNA and not staff #2691. Review of the POC response history on April 20, 2024 for resident #48 revealed no evidence of any documentation for lunch intake and or refusal. Review of the POC response history for April 16, 2024 for resident #48 revealed meal intake documentation for 2 entries at 4:57 P.M. and one for 5:00 P.M. The POC response history revealed no documentation for breakfast. Review of the POC response history for April 14, 2024 revealed only 2 entries, one at 8:48 A.M and one at 2:09 P.M. The POC response history revealed no documentation for dinner. An interview was conducted on May 1, 2024 with staff #2691, LPN at 2:30 P.M. Staff #2691 stated that all CNA related tasks are documented in the POC. She stated that she also documents on the POC, as she is the unit manager. A follow-up interview was conducted with staff #2691, LPN on May 2, 2024 at 7:40 A.M. Staff #2691 stated that the documentation on May1, 2024 and on April 30, 2024 may have been made in error. She stated that she may have had another resident's information in front of her when she made the entries. She stated that the risk for not documenting accurately under the correct resident could include, not knowing what they had actually consumed. An interview was conducted on May 2, 2024 at 10:31 A.M. with staff #2901, CNA in the presence of staff #6833 ADON (assistant director of nursing). Staff #2901 stated that resident #48 requires assistance with eating and that she has to be fed. He was unsure when the dinner tray arrived on April 30, 2024 but stated that he recalled that the resident had refused dinner that night when he delivered her tray. He stated that he does his own charting and is unsure why there was entry by someone else indicating that the resident had eaten, when she had not. He stated that he was not aware of anyone charting on behalf of other staff. An interview was conducted on May 5, 2024 at 8:41 A.M. with staff #2910, Operations Director and staff #3911 Acting Administrator. Staff #3911 stated that the expectation is that documentation is accurate regarding residents and that the entries documenting resident care are made by those staff members providing the care or that entries, at minimum, are verified to ensure accuracy. Staff #3911 stated that the risk for entries being made by others and not verified could include inaccurate documentation in the resident's health record and that the facility can't follow-up clinically as needed when documentation is inaccurate. A review of the facility policy entitled documentation, revised January 1, 2024 revealed that documentation in the medical record will be objective and not opinionated or speculative, complete and accurate; however, the POC response history was noted to be incomplete, inaccurate and speculative. Furthermore, it was noted that documentation will include the date and time of the service as well as the name and title of the individual providing the care; however, the POC revealed instances where the time of service was observed to be inaccurate or missing and instances where other staff had entered information incorrectly for staff who had actually provided resident care.

Based on staff interviews, and review of facility documentation and policies, the facility failed to ensure that the QAA (quality assessment and assurance) committee developed and implemented action plans on identified problem related to PRN (as needed) pain medication administration. Findings include: In an interview conducted on May 2, 2024 at 3:34 p.m., with the Director of Nursing (DON/staff #4558) and the [NAME] President of Clinical Operations (Staff #2908). Staff #4558 stated that pain medications prescribed on an as needed basis (PRN) need a pain scale and it is her expectation that nurses assess the pain level prior to administration and document the pain level. She also stated that there is a risk of over or under medicating a resident if the pain medication is administered outside to the pain scale. Staff #2908 stated that they have identified the administration of pain medication as a problem in the last couple of months, and it is being addressed through quality assurance and performance improvement (QAPI). An interview was conducted on May 6, 2024 at 11:24 a.m., with the Acting Administrator (staff #3911), Operations Manager (staff #2910) and the Director of Nursing (DON/staff #4558). Staff #3911 stated that during QAA committee meetings they discuss reviews, activities reports, clinical staff reports. Recently mock surveys and issues were also brought up. Medical parameters, specifically following parameters i.e. for insulin was a problem. He noted that it is a challenge to determine what should be prioritized. Criteria for prioritization can either be based on which can be resolved quicker or priority of importance that impacts care. In December 13, 2023, there was a mock survey and they started in-servicing for specifically for administration of pain medication and general parameters. Staff #3911 stated that monitoring varies from 4-6 weeks to see if it is addressed. The Resource Registered Nurse (RN), [NAME] President of Clinical Operations (staff #2908) joined the interview on May 6, 2024 at 11:34 a.m. Staff #2908 stated that in early December they identified PRN pain meds, and administering pain medications outside of parameters. The findings were disclosed to the administrator and the DON. The education and audits were written up and tools were provided. The DON was responsible for educating the staff and was assigned on late December - early January. Education was completed by the previous DON, who left around mid-March. The info was then handed to the new DON. The ADON (staff #6833) was the interim DON. Audits were supposed to be done. The Medication Administration Report (MAR) was supposed to be audited to check if the parameters were met. The frequency of the audits were supposed to be followed-up. Once the audit was completed, the outcome was to be presented at the next QAPI (Quality Assurance and Performance Improvement) meeting. The reason for the review is to determine if the facility has improved and if there a need to improve or adjust. Staff #2908 stated that she would need to see if a PIP (Performance Improvement Plan) was instituted or if it was just an audit and education which is not an official plan. The decision to make it an official PIP or an internal audit (audit and education) is determined by the frequency of the errors. In a follow-up interview with staff #2908 (Resource RN, [NAME] President of Clinical Operations) conducted on May 6, 2024 at 12:25 p.m., she noted that pain review had no other findings other than multiple residents were given PRN medications outside of parameters. She noted that commendation was to do staff education and audits. Staff #2908 stated that they cannot provide the mock survey. She indicated that she is unable to tell who determined the recommendation and how often since it all occurred during the previous administrator and DON. She also noted that they cannot provide documentation since the folks in-charge at the time did not submit the documents. Staff #2908 said she did not see a PIP and that the assumption is that it was an education and audit. She also indicated that she understands that this is a finding. Review of the Quality Assurance and Performance Improvement (QAPI) policy version 0917, indicated that the primary purpose of the QAPI program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of residents. It indicated that systems are in place to monitor care and services. The policy also indicated that care processes and outcomes are monitored using performance indicators. These are measured against quality benchmarks and targets that the facility has established. The policy titled Quality Assurance and Performance Improvement Action Steps version 0917, indicated that one of the steps is taking systemic action targeted at the root causes of identified problems. This encompass the utilization of corrective actions that provide significant and meaningful steps to improve processes and do not depend on staff to simply do the right thing.

Based on review of the clinical record, staff interviews, facility documentation, policy and procedure, the facility failed to ensure that one resident's (#48) communication deficit was appropriately care planned and implemented. The deficient practice could result in a plan of care that did not meet the resident's needs. Findings include: Resident # 48 was admitted on [DATE] with diagnoses which included blindness, deafness, dysphasia, anxiety disorder, aphasia, schizophrenia, and major depressive disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had highly impaired hearing and unclear speech. The MDS noted that the resident was rarely/never understood and rarely/never understands. Furthermore, the MDS indicated that the resident had severely impaired vision. The MDS assessment also noted that the resident was dependent for cares. Further review of the annual MDS dated [DATE] indicated that the resident's diagnoses included aphasia, Cerebrovascular Accident (CVA)/Transient Ischemic Attack (TIA)/stroke, anxiety disorder, schizophrenia, blindness, and deafness. The communication care plan revised September 7, 2023 indicated that the resident has a communication problem regarding hearing deficit and impaired cognition. The care plan indicated a goal which noted that resident will be able to make basic needs known. Interventions included to anticipate and meet needs, be conscious of positioning when in groups, activities to promote communication with others. A care plan pertaining to the resident's impaired visual function dated September 7, 2023 indicated a goal in which resident will have no indications of acute eye problems. Interventions included to have resident's room and things arranged to promote independence. However, further review of the care plan did not indicate the resident's method of communication. Additionally, the care plan did not state how staff can communicate with resident in order to meet her needs. Additionally, review of the resident's clinical record revealed that the last time an interpreter was used was for the October 10, 2023 Nurse Practitioner (NP) visit. The progress note for the visit indicated that the interpreter was available but that the resident does not respond. However, further review of the care plan did not indicate any update to address communication deficits or identify that resident needs American Sign Language (ASL) - tactile services. A telephonic initial interview was conducted with resident #48's mother on April 29, 2024 at 11:47 a.m. Resident #48's mother indicated that she had asked the facility numerous times to provide an interpreter for the resident so that the resident can communicate her needs. However, this has not been routinely accommodated. Resident #48's mother indicated that the resident communicates via tactile sign language. She noted that her daughter gets scared/startled when staff provides care without warning or communicating what is going on. A telephonic interview was conducted on May 2, 2024 at 3:11 p.m. with a representative (Receptionist/Scheduler/staff #666) of a language access company (interpretation service). Staff #666 noted that in the last three months, there was a request for an interpreter in February that they were not able to fill. Prior to that the last two sessions was from December 12, 2023 and November 7, 2023. The representative noted that the only resident they service at the facility is resident #48. Staff #666 indicated that the resident requires American Sign Language (ASL) - tactile since she is deaf and blind. She noted that their company has a contract with the facility and that the facility pays when services are provided. Staff #666 indicated that they are should be contacted during the monthly Nurse Practitioner (NP) visits to provide interpretation services. During a follow-up telephonic interview with resident #48's mother conducted on May 5, 2024 at 12:59 a.m., she noted that Medicare pays for interpreter so she does not understand why the facility refuses to get an interpreter for her daughter. She noted that without an interpreter her daughter is not able to communicate her needs and the facility is not able to accurately understand her needs. A telephonic interview was attempted on May 5, 2024 at 1:34 pm with the Program Coordinator of a Non-Profit Interpretation Service (staff # 8989). Voice mail left. An interview with a Licensed Practical Nurse (LPN/staff #8888) was conducted on May 6, 2024 at 9:18 a.m. The LPN indicated that for residents with communication deficits, especially for those that have specific communication deficit it is helpful for staff to know how to communicate with the resident. Sometimes, certain residents require staff to have specific training even by a professional in order for them to be able to communicated and meet needs. Staff #8888 indicated that if a resident needs an interpreter to facilitate communication then it should be part of the care planned. The LPN also noted that in the case of resident #48, since she communicates via American Sign Language (ASL) - tactile, then there should be a tactile interpreter and have staff learn basics in order to communicate with the resident. Staff #8888 noted that the impact of a care plan not addressing specific issues such as communication deficits can affect care if the care plan is not updated which means it is not appropriate and can cause problems for both the resident and the staff. A telephonic interview was attempted on May 7, 2024 at 2:10 p.m. with the Program Coordinator of a Non-Profit Interpretation Service (staff # 8989). No response, voice mail left. A telephonic interview with the Program Coordinator of a Non-Profit Interpretation Service (staff # 8989) was conducted on June 10, 2024 at 11:12 a.m. Staff #8989 indicated that she had known resident #48 for 8 years. She noted that resident #48 uses American Sign Language (ASL) - tactile to communicate since she is deaf and blind. She indicated that she had told the facility numerous times that resident needs ASL-tactile to communicate. Furthermore, she had indicated that she informed the facility that due to the resident not getting ASL-tactile communication services, the resident is losing her ability to communicate due to lack of her language use. The resident is not being communicated to in the language that she recognizes which causes the resident to forget and get stuck when she is communicating in ASL-tactile. Due to the lack of use of her language and isolation this is causing her not to understand and not be as responsive. She also indicated that it makes it hard for the resident when she is not familiar with the interpreter and it is important to have object that she can relate to the person in order for her to recognize and be familiar with an individual. Staff #8989 also indicated staff should communicate to resident via ASL-tactile to explain to her what is going on around her so she can understand and not be weary when she is being touched. An interview was conducted with both the Director of Nursing (DON/staff #4558) and the Assistant Director of Nursing (ADON/staff # 6833) on May 6, 2024 at 10:08 a.m. The DON indicated that her expectation is that residents would have a way to communicate their needs and for staff to understand residents' needs. Staff #4558 indicated that the impact of residents not being able to communicate their needs is that staff would not understand what the resident is requesting. The DON also noted that the expectation regarding care plans is that it is targeted towards residents' needs and individualized towards them. Staff #4558 also noted that the care plan is there to assist staff in providing care. The impact of a care plan not addressing issues specific to the resident is that the staff might not know what they are doing and not have information to care for the resident. Review of the facility policy titled Personal Care: Sensory Impairments - Clinical Protocol in effect as of January 1, 2024 indicated that the staff and physician will identify risk factors for sensory deficits or complications of sensory deficits. Furthermore, the policy noted that the staff and physician will identify approaches to help the resident improve or compensate for sensory deficits. The policy also indicated that the physician and staff will adjust interventions based on the results of these interventions and on subsequent changes in the resident's condition, prognosis, and function. The facility policy titled Assessments/Care Planning: Care Plans, Comprehensive Person-Centered in effect as of January 1, 2024 indicated that it is the facility's policy to include measurable objectives and timetable to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Furthermore, assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observations, clinical record review, family and staff interviews, and facility policy and procedure, the facility failed to provide care and services related to communication for one resident (#48) assessed with communication/language deficit. The deficient practice could result in residents not maintaining their communication abilities. Findings include: Resident # 48 was admitted on [DATE] with diagnoses which included blindness, deafness, dysphasia, anxiety disorder, aphasia, schizophrenia, and major depressive disorder. A neurology note dated May 19, 2023 indicated that resident #48 is bed ridden and needs tactile sign language to communicate. The note revealed that the resident has a complex medical history. She was born deaf, and had been high functioning for many years. However, she developed [NAME] syndrome and retinal detachment and lost her vision in her 30's. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had highly impaired hearing and unclear speech. The MDS noted that the resident was rarely/never understood and rarely/never understands. Furthermore, the MDS indicated that the resident had severely impaired vision. The MDS assessment also noted that the resident was dependent for cares. The MDS indicated unable to determine if resident need or want an interpreter to communicate with a doctor or health care staff. Further review of the annual MDS dated [DATE] indicated that the resident's diagnoses included aphasia, Cerebrovascular Accident (CVA)/Transient Ischemic Attack (TIA)/stroke, anxiety disorder, schizophrenia, blindness, and deafness. The communication care plan revised September 7, 2023 indicated that the resident has a communication problem regarding hearing deficit and impaired cognition. The care plan indicated a goal which noted that resident will be able to make basic needs known. Interventions included to anticipate and meet needs, be conscious of positioning when in groups, activities to promote communication with others. A care plan pertaining to the resident's impaired visual function dated September 7, 2023 indicated a goal in which resident will have no indications of acute eye problems. Interventions included to have resident's room and things arranged to promote independence. However, further review of the care plan did not indicate the resident's method of communication. Additionally, the care plan did not state how staff can communicate with resident in order to meet her needs. There was no mention that the resident's form of communication/language is American Sign Language - tactile (ASL-tactile) due to her being blind and deaf. Review of the resident's clinical record revealed that the last time an interpreter was used was back in October 10, 2023 for a Nurse Practitioner (NP) visit. The progress note for the visit indicated that the interpreter was available but that the resident did not respond. However, further review of the resident's clinical record did not indicate any updates or interventions to address the resident's communication deficits or evaluate potential decline in communication skills. Additionally, the clinical record does not identify that the resident utilizes ASL-tactile to communicate. Review of the facility assessment completed January3, 2024 indicated that the facility accepts residents with vision and hearing impairments. Additionally, the staff training/education and competencies section noted that education and training will include communication for effective communication for direct care staff. A telephonic initial interview was conducted with resident #48's mother on April 29, 2024 at 11:47 a.m. Resident #48's mother indicated that she had asked the facility numerous times to provide an interpreter for the resident so that the resident can communicate her needs. However, this has not been routinely accommodated. Resident #48's mother indicated that the resident communicates via tactile sign language. She noted that her daughter gets scared/startled when staff provides care without warning or communicating what is going on. During an interview with the Occupational Therapist (OT/staff #664) conducted on May 2, 2024 at 10:28 a.m., they noted that a sign language interpreter for resident #48 only comes out for serious things such as splinting and the interpreter noted that resident can communicate to an extent. Staff #664 noted that resident #48 is both deaf and blind. Due to this it is difficult to communicate with this resident. A telephonic interview was conducted on May 2, 2024 at 3:11 p.m. with a representative (Receptionist/Scheduler/staff #666) of a language access company (interpretation service). Staff #666 noted that in the last three months, there was a request for an interpreter in February that they were not able to fill. Prior to that the last two sessions was from December 12, 2023 and November 7, 2023. The representative noted that the only resident they service at the facility is resident #48. Staff #666 indicated that the resident requires American Sign Language (ASL) - tactile since she is deaf and blind. She noted that their company has a contract with the facility and that the facility pays when services are provided. Staff #666 indicated that they are should be contacted during the monthly Nurse Practitioner (NP) visits to provide interpretation services. An interview was conducted with a Restorative Nursing Assistant (RNA/staff #2753) on May 3, 2024 at 12:04 p.m. Staff #2753 stated that when resident #48 first arrived at the facility, her mother showed them basic signs to communicate with the resident. The RNA indicated that the resident's mother shared how to signal pain or hungry. Staff #2753 indicated that they always have ring on so that resident #48 knows how to identify them. This is basically an object specific to them to help the resident know who it is. They then touch the resident's leg first then signs name. Staff #2753 noted that each day is different for resident #48. Lately resident #48 have not been responding and refuses cares. They believe that it is potentially due to approach or interaction that the resident has had that day. Additionally, staff #2753 indicated that they noticed that resident #48 had been sleeping a lot more lately in the last 2-months. The RNA noted that this might be because the mother was not in the facility as much and she was the one that the resident communicated in ASL-tactile regularly. During an interview with a Certified Nursing Assistant (CNA/staff #7901) conducted on May 5, 2024 at 8:50 a.m., staff #7901 stated that they rub resident #48's hands to her know that they are there. They noted that they stroke her arm to let her know that they are changing her. Rubs spoon on lips to let the resident know that they are feeding her, and if the resident pushes away then that means she is refusing. Staff #7901 stated that in all honesty, they do not know how to communicate with resident #48 since they do not know sign language. The CNA noted that the resident's mom informed them that the resident understands sign language but they never received training from the facility on sign language. Staff #7901 said that the resident's mother said to rub the resident's arm/hands to let the resident know that they are there. An interview was conducted with a CNA (staff #4901) on May 5, 2024 at 9:02 a.m. Staff #4901 noted that they communicate with resident #48 by talking to her and touching her blouse to let her know they are changing her blouse. The CNA noted that she touches her slowly so she does not scare her. Staff #4901 stated that resident #48 knows sign language. However, the facility did not offer training in sign language. The CNA noted that sometimes resident #48 is yelling but they do not know what she needs. Staff #4901 noted that they try to get the resident up but she sometimes sleep all day. The CNA noted that if they were taught some sign language, then they would be able to communicate with the resident. Furthermore, staff #4901 stated that sometimes resident #48 is having behaviors but they do not know the reason for the behavior. They noted that an interpreter have been brought in to communicate with her. However, they said that they are not aware of anyone in the facility knowing tactile sign language. Staff #4901 said that they do not know how staff communicates with the resident during activities or how they tell resident #48 about activities. When resident #48 is yelling, it is sometimes yelling out for her mom, and they report it to the nurse. The CNA noted that it is unknown if anyone sits with the resident during bingo and movies and does not know how resident interacts during activities since the resident is blind and deaf. Staff #4901 noted that the nurse assigned to the resident today is registry and so it is unknown how he is communicating with resident #48. In an interview with the Resource, Clinical Compliance Director (staff #4909) conducted on May 5, 2024 at 9:36 a.m., she stated that to the best of her knowledge, the facility did not train any staff on tactile sign language. During a follow-up interview with the Resource, Clinical Compliance Director (staff #4909) conducted on May 5, 2024 at 10:07 a.m., she agreed that there are inconsistencies of how staff communicated with resident #48. She noted that staff were trained on some sort. Staff #4909 stated that yes, the facility should meet the needs of the resident since they accepted her and the facility assessment noted that her condition is something that they are capable of handling. She also noted that the mom is not responsible for training the staff. During a follow-up telephonic interview with resident #48's mother conducted on May 5, 2024 at 12:59 a.m., she noted that Medicare pays for interpreter so she does not understand why the facility refuses to get an interpreter for her daughter. She noted that without an interpreter her daughter is not able to communicate her needs and the facility is not able to accurately understand her needs. Resident #48's mother indicated that when resident #48 pushes away during cares it is because she does not know what is going on. She noted that resident #48 was high-functioning but that she has had a decline in her abilities since she is not being afforded the opportunity and assistance to communicate and do things for herself. Resident #48's mother indicated that resident #48 is being isolated by not being given a chance to communicate in her known language which is ASL-tactile. She also noted that when resident #48 is yelling it is because the resident is trying to indicate that she needs something and there is no one there that can communicate to her in ASL-tactile. Resident #48's mother stated that she has informed staff that instead of closing the door when the resident is yelling, they need to see what is going on and what she needs. However, her concerns have not been listened to or addressed. She also noted that on the most recent care conference, an ASL-tactile interpreter was not utilized. Resident #48's mother indicated that the Program Coordinator of a Non-Profit Interpretation Service (staff #8989) who has known the resident for a long time has informed the facility of concerns regarding the resident's decline in capabilities but similarly the concerns were not addressed. She indicated to contact staff #8989 so that they can provide additional information. Resident #48's mother also noted that she never trained anyone in the facility to communicate in ASL-tactile. She did show basic signs to a staff such as bathroom, eat, water, hurting, and where is the pain. She noted that ASL-tactile is intricate to train so she never trained anyone. She did tell the staff that they have to sign in the resident's hands. An interview was conducted with the Staffing Coordinator/Certified Nursing Assistant (SC/CNA/staff #7750) on May 5, 2024 at 4:27 p.m. Staff #7750 stated that resident #48's mother showed them a few tricks on how to communicate with the resident. She indicated that typically, the one assigned to the resident are the ones familiar with her. Staff #7750 noted that all CNAs are trained to work with resident #48. She also stated that if you pick a CNA they would be able to show how they communicate with the resident. Staff #7750 stated that when resident #48 yells out, they go in there and rubs her hand to console her. When asked if this is the same process for other residents, she noted that they ask other residents what is wrong to determine what needs to be done. She noted that she does not know how to ask resident #48 in the same way so she instead would touch her mouth to see if she is hungry, touch the top of her briefs to see if she is wet. She noted that it is basically a process of elimination. Staff #7750 stated that she does not know how to ask if resident #48 is in pain. When asked if it is important for her to know how to ask if resident is in pain, she noted that it is important. She indicated that sometimes resident #48 yells for her mom and they go in there, hold her hand to console her. When asked if this is what she would do for other residents she noted that she would ask the resident if they wanted her to contact their mom. When they do call the mom, she comes in and consoles the resident. An interview with a Licensed Practical Nurse (LPN/staff #8888) was conducted on May 6, 2024 at 9:18 a.m. The LPN noted that in the case of resident #48, since she communicated in ASL-tactile, then there should be an ASL-tactile interpreter and have staff learn basics in order to communicate with resident. Staff #8888 stated that since this resident is blind, deaf, and have contractures, you have to approach her carefully. The LPN noted that when cares is being provided such as medication administration, they reach her mouth and give her what she needs to take. Staff #8888 noted that it is not easy communicating with the resident since they do not know ASL-tactile. The LPN noted that it would be nice and helpful if they are able to communicate with her. A telephonic interview was attempted on May 7, 2024 at 2:10 p.m. with the Program Coordinator of a Non-Profit Interpretation Service (staff # 8989). No response, voice mail left. An interview was conducted with both the Director of Nursing (DON/staff #4558) and the Assistant Director of Nursing (ADON/staff # 6833) on May 6, 2024 at 10:08 a.m. The DON indicated that her expectation is that residents would have a way to communicate their needs and for staff to understand residents' needs. Staff #4558 indicated that the impact of residents not being able to communicate their needs is that staff would not understand what the resident is requesting or needs. A telephonic interview with the Program Coordinator of a Non-Profit Interpretation Service/interpreter (staff # 8989) was conducted on June 10, 2024 at 11:12 a.m. Staff #8989 indicated that she had known resident #48 for 8 years. She noted that resident #48 uses American Sign Language (ASL) - tactile to communicate since she is deaf and blind. She indicated that she had told the facility numerous times that resident needs ASL-tactile to communicate. Furthermore, she had indicated that she informed the facility that due to the resident not getting ASL-tactile communication services, the resident is losing her ability to communicate due to lack of her language use. The resident is not being communicated to in the language that she recognizes which causes the resident to forget and get stuck when she is communicating in ASL-tactile. Due to the lack of use of her language and isolation this is causing her not to understand and not be as responsive. She also indicated that it makes it hard for the resident when she is not familiar with the interpreter and it is important to have object that she can relate to the person in order for her to recognize and be familiar with an individual. Staff #8989 also indicated staff should communicate to resident via ASL-tactile to explain to her what is going on around her so she can understand and not be weary when she is being touched. In an e-mail communication with the Program Coordinator of a Non-Profit Interpretation Service/interpreter (staff#8989) dated June 12, 2024, she indicated taht resident #48's communication had declined over the year due to lack of communication access. She stated that the only time resident #48 has communication access is when she, resident's Mom, or another SSP (Statewide Support Service Provider) is sent to the facility. Review of the facility policy titled Personal Care: Sensory Impairments - Clinical Protocol in effect as of January 1, 2024 indicated that the staff and physician will identify risk factors for sensory deficits or complications of sensory deficits. Furthermore, the policy noted that the staff and physician will identify approaches to help the resident improve or compensate for sensory deficits. The policy also indicated that the physician and staff will adjust interventions based on the results of these interventions and on subsequent changes in the resident's condition, prognosis, and function. The facility policy titled Personal Care: Activities of Daily Living (ADL, Supporting in effect January 1, 2024, indicated that residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).

Based on observations, clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure assistance with meals was provided to one resident (#48). The sample size was 20. The deficient practice could result in resident not receiving adequate nutrition. Findings include: Resident #48 was admitted on [DATE] with diagnoses of aphasia, dysphagia, major depressive disorder-recurrent, schizophrenia, generalized anxiety disorder, deaf, and blindness-right eye. The minimum data set (MDS) dated [DATE] included a staff assessment for mental status score of 3 indicating the resident had a severe cognitive impairment. The care plan dated September 7, 2023 included that the resident had communication problem related to hearing deficit and impaired cognition. Interventions included anticipating and meet resident needs; and to communicate regarding resident's capabilities and needs. The care plan further revealed that the resident was at risk for functional self-care deficits, required assistance with meals, had a nutritional or potential nutritional problem requiring one on one assistance with dining. The resident's plan of care (POC) response history/ CNA (certified nursing assistant) tasks for April 2024 revealed the following information: -April 7 - No meal intake entry documented for lunch; -April 20 - No meal intake entry documented for breakfast; and, -April 28 - No meal intake entry documented for breakfast. Further review of the POC also revealed no documentation that the resident refused meals on April 7, 20 and 28, 2024. A review of facility's video recordings for the 2100 nurses' station was conducted on May 2, 2024 at 3:09 P.M. with assistant director of nursing (ADON/staff #6833). The video recording revealed the following: -An unknown staff member entered the resident's room with a lunch tray on April 7, 2024 at 12:44 p.m. and exited the room right away. The video recording further showed that no one entered the resident room again until 1:14 p.m. -On April 20, 2024, the facility video recording revealed that an unknown staff member delivered the breakfast tray to resident #48 at 7:29 a.m. and immediately exited the room. At 7:57 a.m., a certified nursing assistant (CNA/staff #7901) entered the room and exited the room approximately 30 minutes after. -On April 28, 2024 at 7:39 a.m., the CNA (staff #4901) dropped off the breakfast tray for resident #48 and then immediately exited the room. The video revealed that there was no one who entered the resident's room until 8:00 a.m. On the same date at 12:33 p.m., a lunch tray was delivered to resident #48 by staff the same CNA (#4901) who entered the room with the tray and immediately came back out of the room without the tray. The video recording did not show anyone else entering the resident's room again until 1:11 p.m. An interview was conducted on May 2, 2024 at 10:31 A.M. with CNA (staff #29010) who stated that resident #48 was blind and deaf; and, required assistance with eating. A telephone interview with licensed practical nurse (LPN/staff #7840) was conducted on May 2, 2024 at 9:41 A.M. The LPN stated that resident #48 required assistance with meals, tends to not eat much and needed encouragement. The LPN said that on April 30, 2024 she assisted the resident with eating for lunch; and that, the LPN documented that the resident only ate about 25% of her meal on April 30, 2024. An interview was conducted on May 5, 2024 at 8:41 A.M. with the Operations Manager (staff #2910) and the Acting Administrator (staff # 3911). The acting administrator stated that the expectations were for staff to deliver meal trays and provide assistance to residents at the time meal trays were delivered. The acting administrator also stated that meals should be provided to residents that were independently able to eat first and then to those residents requiring assistance next, to ensure that staff can take their time with those that needed help. Further, the acting administrator stated that the delay for meal assistance after meal delivery for resident #48 did not meet his expectations; and that, the risk could include that the food would be cold and not palatable and the resident's nutritional needs would not be met. The facility policy titled The Dining Experience, dated 2020, revealed that residents will have an exceptional dining experience that enhances their quality of life and provides attention to the individual resident's plan of care. Review of the policy on Food Services: Assistance with Meals with effective date of January 1, 2024 revealed that staff are to serve resident trays and help residents who require assistance with eating; however, meal assistance was not consistently rendered at the time of meal tray delivery, in spite of the resident requiring meal assistance as documented in the plan of care.

Based on clinical record review, resident and staff interviews, facility documentation and policy, the facility failed to ensure one resident (#1) was free from sexual abuse. The deficient practice could increase risk of harm to other residents. Findings include: Resident #1 had an initial admission on June 7, 2019 and readmitted to the facility in a private room on September 9, 2022 with diagnoses of tracheostomy status, epilepsy (intractable with status epilepticus), major depressive disorder, and anoxic brain damage. The MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) Score of 15 indicating the resident was cognitively intact. The MDS assessment revealed resident was coded as feeling down, depressed, or hopeless with symptom frequency of 7 to 11 days (half or more of the days); and that, the resident required two plus persons physical assist for bed mobility, transfers, and toilet use and one-person physical assist for locomotion on and of unit, dressing, eating and personal hygiene. The MDS revealed resident was not steady, was only able to stabilize with staff assistance with moving from seated to standing position and surface-to-surface transfer (transfer between bed and chair or wheelchair). The care plan for ADL self-care performance deficit related to traumatic brain injury revealed a goal that resident will accept assistance during ADLs without complications of immobility. Interventions included extensive to total assistance of two staff participation to reposition and turn in bed. A psychiatry visitation note dated March 20, 2023 revealed resident was seen for depression; and reported anxiety level of 9 out of a 10 scale, and depression of 9 out of 10. Per the documentation, the resident became tearful when talking and reported she cannot verbalize or explain why resident felt sad. Further, the note included that the resident liked to talk with females about her feelings. The psychiatry visitation note dated March 25, 2023 revealed resident was seen for depression; and, reported poor sleep and having a hard time staying asleep. Review of physician visitation note dated April 1, 2023 revealed resident had weakness of her extremities on physical examination. The psychiatry visitation note dated April 2, 2023 revealed resident reported to the psychiatry nurse practitioner that she always had anxiety and depression. The physician visitation note dated April 16, 2023 revealed resident was alert and oriented x 3 and had a history of seizure disorder anoxic encephalopathy secondary to multiple drug overdose. Review of a psychiatry visitation note dated April 17, 2023 revealed resident was alert and oriented x 3. The physician visitation note dated April 18, 2023 revealed resident had weakness on the extremities and had chronic muscle spasticity. Review of the facility's investigation report revealed that on April 22, 2023 at approximately 04:50 p.m. the licensed practical nurse (LPN/staff #25) walked into her private room and observed a man in bed with the resident. According to the report, the alleged aggressor was the husband of another resident in a nearby room. The facility investigation report included an interview conducted by the administrator on April 23, 2023 at 5:45 p.m. with staff #25 who reported that she was going to give resident #1's medication, in that process knocked and opened the door to the room and saw alleged perpetrator who was on top of resident #1. Staff #25 reported the alleged perpetrator's pants were down to his ankles with his butt bare; and that, the alleged perpetrator quickly got off of resident #1 and pulled his pants up while stating nothing happened repeatedly. Staff #25 went over to resident #1 and saw that her brief was undone and her vagina exposed. Staff #25 asked resident #1 if she was okay; and the resident responded that the alleged aggressor raped her. Staff #25 stated the resident denied letting the alleged aggressor in. Continued review of the facility investigation revealed an interview conducted by the administrator at 6:00 p.m. (no date noted) with a certified nurse assistant (CNA/staff #52) who reported that she was at the nurses' station when he heard the LPN (staff #25) yell for help. He stated that he rushed in to find alleged perpetrator doing up his pants and stated he did not do nothing. The State of Arizona Sexual Assault Medical Examination Report revealed that a history and physical examination was initiated on April 22, 2023 beginning at 08:20 p.m. The report stated that resident #1's description of the assault was that a man came in her room and was on top of her. The examiner's diagnoses included minor genital injury by exam described as erythema to labia minora (red) from 1-11 o'clock and an abrasion described as red 4.0 centimeter by 5.0-centimeter, oval with dried blood present to the right lower leg 2 centimeter below the patella. The facility documentation and records revealed that on April 22, 2023 (the day of the alleged incident) the spouse of the alleged perpetrator (AP) was a resident (#10) at the facility whose private room was adjacent to the room of resident #1. The visitation log from April 1, 2023 through April 22, 2023 revealed the AP checked into the facility 17 times with no records of ever checking out. The AP checked in twice on April 22, 2023, once at 5:37 a.m. and again at 3:02 p.m. Of the 16 times the AP checked in, he used his first and last name; on April 22, 2023 at 3:02 p.m. he checked in using only his first name. During an observation conducted on April 25, 2023 it revealed that the room of resident #1 room was the first room on the unit, followed by resident #10, on the same side of the hallway. The nurses' station was located across the hall from the rooms next to resident #10's room. An individual must pass resident #1's room when entering and or leaving the unit from the elevator. Multiple random observations conducted from April 25 through 27, 2023, there were no staff at the nurse station or in the hallway on multiple occasions. Multiple visitors were observed entering and exiting resident #1's room. An interview was conducted on April 25, 2023 at 3:24 p.m. with resident #1 who stated that she told staff to keep someone away from her room; however, the resident was unable to state when she told staff and the name of the staff. Resident #1 stated she was sleeping, had a feeling of waking up and was scared; and that, she had a feeling that someone was looking at her and that he was by the door. She stated that he touched her below her body and she told him to get away from her. The resident began to explain similar incidents from her childhood. She described a feeling that she could not be herself anymore and that it made her feel the same as that of her childhood. She stated that she was falling asleep and did not know exactly what the AP did. She reported that she knew AP had a wife and two children; and that the AP should not have been doing that. She explained that the AP spoke in Spanish; and, the AP tried to do something inappropriate and that he was on her bed once. Resident #1 said she told him to go away and did not want to get into trouble and then he left her room. She said she did not know if he took his pants off but stated he touched her and she did not like that. The resident said she did not think there was any witnesses. She further explained that she thought she saw him the next day and asked if he was here or if he was in jail. The resident said that the AP he touched her sexually the first time. She described that she told him to stop when he pulled down her pants and stated he finally stopped after she told him that he was going to get him and her in trouble. She said that he was creeping around the corner and that she knew that he came in her room two times. When asked if he raped her, resident #1 shook her head and became tearful and said she was tired. An interview was conducted on April 26, 2023 at 9:39 a.m. with the director of nursing (DON, staff #161) who stated the video cameras in the facility were not functioning; and that, there would be no recordings available for review. During a follow-up interview with resident #1 conducted on April 26, 2023 at 1:53 p.m., resident #1 stated the facility never put her on physical restraints and her arms were never tied or wrapped up. An interview was conducted a unit coordinator (staff #10) on April 26, 2023 at 02:03 p.m. The unit coordinator stated that she sat at that nurses' station (across the elevators) Monday through Friday from 8:00 a.m. to 4:30 p.m.; and, no one replaces her after she leaves at 4:30 p.m. and on the weekends because the other hallways on that floor were closed. She said visitors do not have to check in with her when they get to the floor; however, if they appeared lost then she would direct them to the unit. An interview was conducted on April 26, 2023 at approximately 12:10 p.m. with the LPN (staff #25) who stated that on April 22, 2023 at approximately 4:50 p.m. resident #1 was the last person she was assigned to administer medications to because the unit on the other side of the elevator is closed down for reconstruction. The LPN said that she saw that the resident's room door was closed. Staff #25 stated that the resident #1's door was always kept open; and that, when a door was closed it usually meant that a CNA was in the room with the resident performing care. The LPN said that there was no response to her knock so she opened the door and saw the AP on top of resident #1 with his pants down. Staff #25 said the AP immediately jumped off the bed and said it was okay and attempted to leave. The LPN said that the AP spoke broken English and that he was Spanish speaking. The LPN said she yelled for the CNA (staff #52) who immediately came; and that, resident #1 reported the AP touched and raped her while her legs were open, diaper down to her knees, and vagina exposed. An interview was conducted on April 26, 2023 at 3:48 p.m. with another CNA (staff #64) who stated that at the time of the incident she was at the nurses' station; and, she saw the nurse (staff #25) pulling up close to resident #1. She said that the nurse yelled and called for CNA (staff #52). The CNA said that she then ran towards the room because her first thought was that resident #1 could be falling off the bed. When she arrived to the room, she said the AP who was a family member for another resident was trying to pull up his pants. She stated the AP was right by and standing by the resident #1's bed. An interview was conducted on April 27, 2023 at 11:24 a.m. with restorative nursing assistant (RNA, staff #44) who stated that he was working on the day of the incident on the same unit it occurred and did not see the AP. He stated that the AP started visiting daily and more often when the AP's daughter had surgery, within the last couple of weeks. Staff #44 stated that he saw the AP in his wife's room or saw him wandering the halls, walking back and forth the hall, or looking out the window in the dining room. He said that sometimes he is in the dining room with another family member or sometimes alone. He added, visitors are allowed to be unattended, especially if they are close to the family member's room but never saw him in the back halls. He stated that the AP glances in rooms when he is walking down the halls but never walked in. He stated that it is natural to look in rooms and never gave it any thought when others looked in room as they walked by. He stated that the nurse or the staff monitored the visitors. He said that the staffs are familiar with the visitors that visit regularly. If the visitor is not familiar to them then staff would ask who they are here to see. On April 22, 2023, he stated that there were two CNAs, a nurse, an RT (Respiratory Therapist) and himself who were on the unit at the time of the incident. An interview was conducted on April 27 at 12:00 p.m. with CNA (staff #96) who reported that she had interactions with AP because she had provided care for resident #10. She had directed him to the restroom or had gotten the nurse for him. She said she had seen him walking back and forth, pacing down the hall. She reported while AP is in spouse's room he would peek out and look in the direction of the nurses' station. She said the AP would not say anything, would just look, walk out of resident #10's room and walk down the hall. She stated she did not know what he did after that. An interview was conducted on April 28, 2023 at 7:57 a.m. with the administrator (staff #151) who stated that he did not know what regulations they did not follow and stated that bad things happen. He added that the AP was not someone that was not permitted to come to the facility and was not a random person off the street. He stated that the only thing they have changed since the incident is the visitor sticker with the room number written on it so that if they are on a different floor staff would know. He stated that this change would not have made a difference on the day of the incident because the AP was on the right floor and his spouse was next door. He added that resident #1's room is a highly traffic room; she was not in a corner. He stated the sticker program would not have prevented the incident but stated it will help identify the visitor are in the right floor. However, he stated the AP was in the right area. Staff #151 stated that they have provided resident #1 with psychiatry to see her. He reported that she had never been restrained. When asked how are visitors monitored, staff #151 questioned how are other visitors in other places monitored? He stated that they do not follow them and that they have nurses and aids on the floor who keep an eye on who is going in and out of rooms. He said the nurses and aids ask questions and keep an eye on residents. He reported that they do not have the cameras turned on and the police and detectives have already asked about it. An interview was conducted on April 28, 2023 at 10:23 a.m. with a CNA (staff #86) who stated that the AP came to visit his wife and that he was familiar. She stated that she had seen him walking down the hallway and that maybe go out to get food. She stated that when she changed his spouse, the AP went to the dining room. She stated that visitors can be in the dining room without staff there. When asked if that is safe, she said that usually visitor go straight to their family's room but sometimes they can go get coffee. She stated the visitors can go anywhere and are free to go anywhere. When asked if she knew who are the visitors currently on the unit she said she cannot say who was there. She stated she knew who the residents are that go to therapy but she did not have information on who had visitors at that moment (resident #3 had a visitor as of 10:16 a.m.). She stated there was no way of knowing which resident had a visitor at that moment. She also stated that visitors had no restrictions on how long they can stay with the residents and stated they can come visit at 04:00 a.m. She stated that visitors go up the elevator and go straight to the rooms. She stated that she thought the facility should have more control with the visitors and informed the nurses. She said she had suggested that visitors come with a badge with the resident's room number and come to the nurses' station once on the unit so staff can follow them to the room for privacy and security of the patients. She added currently it was not what they were doing. When asked if the incident could have been prevented she commented that the AP was intelligent because he saw when CNAs do rounds because they were done at 4:00 p.m. - 4:30 p.m. and that is when they changed, repositioned, and get residents clean and ready for dinner; it is when staff prepare them for the next shift. She stated that the AP may have calculated the time. The next shift started at 6:00 p.m. and dinner came between 5:00 p.m. and 5:30 p.m. Staff #86 stated that to know when visitors have left the building is when they are no longer in the room; would ask the resident where thee visitor has gone to; or ask the visitors how long they planned to stay. She said the only to know visitors are still in the facility is when they are in the room with the resident. However, she stated that the AP's spouse did not talk. Staff #86 stated that once the AP arrived the facility, the other visitors for resident #10 would leave. Staff #86 also stated that she had seen the AP in resident #10's room or walking towards the elevator but did not know where he would go. She added resident #1 can use the rails to help herself get up but stated she is weak and is unable to walk. She also stated that resident #1 had no control of her legs. She said she had helped put her pants on in the past and resident #1 had no control of her legs. She said that during the day resident #1 can be sleepy because she is awake all night but when staff knocks on the door she would open her eyes. She stated that resident #1 would not be able to defend herself because she cannot move and that she is not strong. She said that it is very unsafe that visitors have no identification and have told the nurse that. Staff #86 stated that the day after the incident, resident #1 told her that she did not want to talk much and that she was very quiet, which was not normal for her. Staff #86 added that resident used to cry but have not seen her cry in the last days. Staff #86 stated that on the day after the incident resident #1 told her that had happened very soon and she could see him. Staff #86 said she asked resident #1 what she was talking about and said resident #1 fell back to sleep. Staff #86 said she asked resident #1 if she was having a bad dream and resident #1 shook her head and said no and fell back to sleep. Staff #86 said that she felt that resident #1 was talking about the AP. An interview was conducted on April 28, 2023 at 12:19 p.m. with the DON (staff #161) who stated that the only way to know who is currently in the building is to check the kiosk. She said the facility has a list of current residents and staff but to check who the visitors are currently in the building she would check the kiosk. However, only in the event of an emergency the kiosk is checked of current visitors and stated she never had to do that in the past. Further, she (staff #161) said the kiosk is not accurate because they do not require everyone to sign-out and that it is not part of the facility policy. When asked if that was a problem, she said in the event of an evacuation she would want an accurate headcount. She said even prior to the COVID pandemic it was never required for visitors to sign-out. Staff #161 said she had received feedback from staff that the process be changed to require checking in and out and print out who is exactly in the building; however, she said it is more accurate to check every room for headcount instead of the kiosk. Currently, she had no record of visitors currently in the building. The process, she said, is that visitors check in through the kiosk, staff ask who they are visiting or what their business is and ask whether they know where they are going and staff direct them. She said they are directed by giving step by step direction. She reported there were no rules given to visitors and they were not required to check in with staff once they get to the unit/floor. She reported that visitors (family members), with the exception of vendors, and contracted agencies, are not required to provide identification when visiting. She confirmed, visitors are not escorted to their designated rooms. When asked if it is a problem that visitors do not check out, she said no scenario came to mind that it would be a problem. She said checking out would not have prevented the incident that occurred on April 22, 2023. Staff #161 stated that her expectation is that during resident care, to provide dignity, visitors are to step out of the room and hangout in either the dining room or in the hallway. Staff #161 reported that the facility had a security guard to replace the receptionist at night, and monitored the video cameras when they were functioning. The security guard only went to the units if called but not necessarily tasked to round on the units. She said that the plan is to have a key pad on the front door and visitors would need to buzz in but currently, it is the security guard that monitor the front desk. The security guard and the receptionist report to each other residents who are going out for appointments or who are out on appointments. She does not think they report on the number of visitors currently in the building. Upon exit on April 28, 2023 at 03:09 p.m. with facility staff (staff #151, #161 and #175), and the Administrator (staff #151) was asked what would he do differently to prevent this incident from happening again in the future, he stated nothing. Review of the facility policy titled, Resident Rights and Abuse with no revision date, revealed, our facility is a place of employment for many, but more importantly, it is a home for many others. As any home should be, our facility is a safe haven and it is our job to make sure each resident is safe, and treated with respect and dignity. Residents rights include: 1) quality of life: provide a safe environment 2) freedom from abuse, mistreatment, and neglect. Review of the facility's policy titled, Visitation revised on February 2014 revealed, Our facility permits residents to receive visitors subject to the resident's wishes and the protection of the rights of other residents in the facility.

Based on clinical record review, interviews, and review of facility documentation and policies, the facility failed to ensure that one resident (#1) received adequate supervision to prevent the removal of the resident's [CONDITION(S)] ([CONDITION(S)]) tube. The facility census was 79 residents. The deficient practice could result in residents not receiving the supervision they require to remain safe. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included acute [CONDITION(S)], [CONDITION(S)], and acute kidney failure. Review of the resident's respiratory care plan dated [DATE], revealed that the resident had a [CONDITION(S)] related to impaired gas exchange, ineffective airway clearance, and respiratory insufficiency. The goal was that the resident's airway and the [CONDITION(S)] tube will be maintained through the next review. Review of the progress notes revealed the following entries: -[DATE] (late entry), the resident was noted to be calm and was wearing soft hand mitts. -[DATE], the resident had soft hand mitts to both hands to prevent pulling on equipment. -[DATE], a respiratory note indicated that staff went into the room to assist with transfer to [CONDITION(S)]. Upon entry, the resident was unresponsive and his [CONDITION(S)] was out. The resident had no pulse. Cardiopulmonary Resuscitation (CPR) was initiated and the Respiratory Therapist (RT) reinserted the resident's [CONDITION(S)] successfully. The resident was bagged (given air manually) and his oxygen saturation was 100%. Paramedics arrived and took over care. -[DATE], the resident coded at 1:45 p.m. The resident's [CONDITION(S)] was out, but it was able to be reinserted. Six cycles of CPR was performed and a defibrillator was placed on the resident and he received one shock at 1:59 p.m. CPR continued and at 2:01 p.m., the paramedics arrived and took the resident to the emergency room (ER). The note included that the resident did not pull at the [CONDITION(S)] in the past, but had been seen taking the mitts off numerous times. The note also included that prior to the incident, the resident was last seen by a Certified Nursing Assistant (CNA) when she performed care and that the resident was stable when she left the room. Review of the physician's orders revealed no order for the bilateral soft hand mitts. Also, there were no orders for monitoring of the mitts. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for [DATE], revealed no evidence of monitoring for the use of the hand mitts. Review of a facility investigation dated [DATE] revealed that the resident was confused and required bilateral soft hand mitts to prevent him from pulling on medical equipment. On [DATE] at 1:45 p.m., a RT (staff #162) entered the resident's room with a CNA (staff #17) to assist with transportation to [CONDITION(S)] and the resident was unresponsive and had no pulse. It was noticed that one of the resident's mitts was hanging from his left wrist and his [CONDITION(S)] tube was in his hand. CPR was initiated and a backup [CONDITION(S)] was successfully inserted. The paramedics arrived and the resident was transported to the hospital where he expired. The investigation found that the staff had acted appropriately. The investigation did not include information regarding the resident removing his hand mitts prior to the incident on [DATE]. Review of the clinical record revealed no documentation that the resident was monitored for the use of the bilateral hand mitts including whether the resident's restraints were checked at regular intervals, if the resident's skin under the mitts was checked regularly, or if the mitts were removed periodically. An interview was conducted with a Licensed Practical Nurse (LPN/staff #145) on [DATE] at 11:43 a.m. She stated that she was assigned to the resident on the day he was found unresponsive with his [CONDITION(S)] out. She said that she did not receive training on how to use the hand mitts, but she knew how to use them because she had used them at a previous place of work. She said that the mitts are put in place to prevent a resident from self-harm such as scratching or pulling at tubes. She said that if a behavior occurred, she would document this in a progress note, but she did not remember if she had documented a note about the resident removing his mitts on the day of the incident. She said that one of the CNAs had told her that the resident's mitts were off, but she could not recall which CNA told her this. The CNA had put them back on and then she went in to make sure they were secure. She said that she had reported to the charge nurse that the mitts were off via her radio about 15 minutes after it happened. She said that the nurses and the CNAs did more checks on the resident that day, but they did not document them. She stated that she had heard another staff saying that the resident had removed the mitts before, but she wasn't sure which staff member said this. She said that at the time she did not think he was at risk for harming himself because he did not seem anxious and for the most part, he was sleeping that day. She stated that looking back, she would have addressed the safety concern differently as she would see if there was anything else they could do for safety precautions. An interview was conducted on [DATE] at 1:27 p.m. with a Charge Nurse/LPN (staff #130), who stated that mitts are a form of restraint and a nursing assessment is done if a resident is pulling on equipment and/or exhibiting self-harm. She said that a physician's order is needed to use restraints. She said nursing staff makes sure the mitts are properly put on and secured by Velcro by the wrist. She said the hands are checked every shift by the nurse or CNA. She stated that if the resident is found with the mitts off, the supervisor should know as they will contact the physician to get an order for a sitter to ensure the resident is safe. She said this should also be documented in the progress notes. She said that it has to be documented because the intervention did not work so something new would have to be attempted. She stated that one on one would be needed in this case. A interview was conducted on [DATE] at 1:38 p.m. with another Charge Nurse/LPN (staff # 22). He stated that he was working on the day that the resident was found unresponsive. He said he was not contacted by staff regarding the resident removing his mitts. He stated that if he knew that the resident's mitts had been removed, he would have done an observation and could not have walked away in good faith until he determined if the resident was able to take them off. He said the reason for mitts is safety and typically reserved when other methods are not working. He said that he would document the concern in the progress notes. It is his expectation that staff make sure the resident is safe and that no equipment is removed and that the mitts are secured properly. He said that if a resident is removing their mitts, they should notify him and he would then collect data and call the physician. He further said he would notify the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). He said the incident would be discussed with the Interdisciplinary Team (IDT) and another intervention should be implemented such as a new type of mitt, or a one-on-one sitter for the resident. An interview was conducted with the DON (staff #2) on [DATE] at 8:33 a.m. She stated that on [DATE], during the night shift, a LPN (staff #176) reported that the resident was pulling on his [CONDITION(S)] to a charge nurse (staff #47) who contacted the provider and received an order for the mitts. At this time, the ADON (staff #63) joined the interview. She stated that it is the responsibility of the floor nurse to contact the physician when a resident exhibits behaviors and to document this in the progress notes. She said they should also report the behaviors to the charge nurse. She said that once the charge nurse is aware of the behavior, it is their responsibility to ensure the behaviors were documented and that the physician was notified. She said that the floor nurse did not follow the above process when she did not report the resident's removal of the mitts and that she would reeducate the staff. The DON stated that there is a sitter policy for when a resident has the potential to harm themselves. She said that once staff contact the physician about safety concerns or behaviors, the physician will give the order for the one-on-one sitter. The DON reviewed the progress note dated [DATE] which noted that the resident was seen removing the mitts numerous time. She said that the staff member (staff #145) did not follow the protocol and notify the physician, so the physician was not aware that the resident needed a sitter. The DON said that if she had known that the resident was removing the mitts, she would have contacted the physician to get an order for a sitter. Review of the facility's safety and supervision of residents policy, revised [DATE], revealed a policy statement that the facility strives to make the environment as free from accident hazards as possible. The policy interpretation and implementation included that safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and the reporting process. The policy included that employees will be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents which could result in injury. Further, the policy noted that the IDT team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision. Review of the facility's sitter policy, revised [DATE], revealed a policy statement that residents with potential for self harm shall be taken seriously and addressed appropriately. The policy included interpretation and implementation. This included the following steps: 1. Staff shall intervene and report any potential harm to self immediately to the Nurse Supervisor/Charge Nurse. Staff will remain in room starting at the time of threats or behavior potentially causing harm to self (i.e., pulling out [CONDITION(S)]). 2. The Nurse Supervisor/Charge Nurse shall immediately access the situation and notify the Charge Nurse/Supervisor and/or DON of such threats. 3. A staff member shall remain with the resident until the Nurse Supervisor/Charge Nurse arrives to evaluate the resident. 4. After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's physician and responsible party, and shall seek further direction from the physician. 5. All nursing personnel and other staff involved in care of the resident shall be informed of the potential self harm and instructed to report changes in the resident's behavior immediately. 6. As indicated, a psychiatric consult or transfer may be initiated. 7. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly until the physician has determined that the self harm risk does not appear to be present. 8. Staff shall document details of the situation objectively in the resident's medical record. 9. Plan of care will be written for the resident's safety. 10. Sitter will not leave resident unattended until relieved by on coming staff member in the room. 11. In the event of resident confusion, potentially pulling out life saving equipment i.e., [CONDITION(S)], a sitter will be utilized until resident condition no longer requires.

Based on clinical record review, staff interviews, and review of facility documentation, policies, and a personnel file, the facility failed to ensure one resident (#1) was free from neglect. The deficient practice could result in residents being neglected by staff. The census was 84 residents. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per an admission functional assessment dated [DATE], the resident was dependent on staff for incontinence care and rolling in the bed from right to left side. In a review of a skilled/look back documentation dated April 24, 2021, the resident was assessed to be totally dependent on staff for bed mobility with a 2 person plus physical assist. A physical therapy note dated April 24, 2021 documented the resident was totally dependent on two staff for bed mobility, including rolling from side to side and provision of incontinence care. A care plan dated April 27, 2021 identified a problem for the resident's risk for falls due to paralysis and incontinence. The goal was for the resident to be free of falls and not sustain a fall with injury. An intervention included to anticipate and meet needs as required. A review of a nursing note dated April 29, 2021 revealed a Licensed Practical Nurse (LPN/staff #12) had been alerted by a Certified Nursing Assistant (CNA/staff #73) that the resident had slid out of bed and upon entering the resident's room, the LPN found the resident lying supine on the floor. The resident was immediately assessed by a Respiratory Therapist (RT/staff #39) to make sure his [CONDITION(S)] was stable and connected to the vent. The resident was assessed for injuries and none were noted and the resident did not appear to be in acute distress. Documentation included the fall was witnessed by staff #73 who denied the resident hit his head. Per an admission Minimum Data Set (MDS) assessment dated [DATE], the resident was assessed to be totally dependent in the areas of bed mobility, dressing, eating, toilet use, and personal hygiene. In addition, the resident required 2 person plus physical assist in the areas of bed mobility, transfer and toilet use. The resident was assessed to have memory problems and moderate cognitive impairment. The assessment included that the resident had a vent and a [CONDITION(S)] in use at the facility. In a review of a facility investigation dated April 30, 2021, there was documentation that on April 29, 2021, the resident fell out of bed during resident care and the ventilator alarm was alarming. A RT (staff #39) and a LPN (staff #12) were standing at the nurses station and heard screaming from the resident's room and they proceeded down the hall. Upon entering the resident's room they noticed the resident lying on the floor opposite the side of the ventilator. A CNA (staff #73) was kneeling on the floor with the resident lying on his back and staff #39 noticed the circuit on the ventilator to be incorrectly attached to the resident. She quickly removed the circuit and began to bag the resident. Staff #39 then made an immediate radio call to have all available staff to come to the room and help. Staff #12 assessed the resident for observable injuries and noted none at the time. The resident showed no signs or symptoms of distress and had full range of motion to all extremities. The resident was lifted to the bed from the floor by 7 staff and the provider was notified who ordered bilateral x-rays of the hips and ribs. Continued review of the facility investigation included written interviews from the involved staff: 1) The LPN (staff #12) stated on the afternoon of April 29, 2021, she heard a scream for help and entered the resident's room and noticed him lying on the floor opposite the side of the bed near the window. RT (staff #39) was in the room looking at the resident and the CNA (staff #73) was kneeling on the floor next to the resident. Staff #39 asked for an Ambu bag (a manual resuscitation used when a vent is not available or functional) and removed a piece of the ventilator tubing and threw it on the floor. Staff #12 then began to assess the resident to determine if there were visible signs of injuries. Vital signs were within normal limits and the resident's range of motion was unchanged. Staff #12 then notified the charge nurse to come and assess the resident. The resident was then lifted back into the bed. 2) The CNA (staff #73) stated she cared for the resident during the day shift and around 5:20 p.m. she noticed that he was soiled. She planned on changing the resident and left the room to collect supplies and asked several staff to help her. The staff members told her they needed to complete some other things first. Staff #73 then entered the resident's room and stated she wanted the resident to get the best care and be cleaned for the next shift. Staff #73 rolled the resident over toward her on the opposite of the bed from the ventilator. When she rolled the resident over he rolled off the bed and onto the floor. She then immediately began to call out for assistance in the room. The resident's RT and nurse entered the room to assist her and the RT came over next to the resident and removed the tubing from the tracheotomy. The RT then asked the CNA to give her the Ambu bag immediately. The LPN began to check the resident for any major injuries and check that all extremities could move. Other staff came and she said they lifted the resident to the bed. Staff #73 documented that the resident accidentally fell or rolled out of bed .It was a horrible mistake and I want to say I am truly sorry and apologize for letting that happen. 3) The RT (staff #39) stated that on April 29, 2021 around 5:30 p.m., she heard a scream by the CNA (staff #73) in the resident's room. Upon entering the room, the resident was seen lying on the floor on the opposite side of the ventilator. She said she noticed the ventilator was alarming continuously even though he was connected to the ventilator tubing. After getting closer to observe the tubing, it was noted that the circuit was incorrectly attached to the resident. She removed the circuit and asked for the Ambu bag and began bagging the resident. She made a stat (immediate) call for assistance to the resident's room and the resident was placed back in bed on the ventilator. Continued review of the facility report included that on April 30, 2021 the results of the residents x-rays showed no fractures to the hips, one rib fracture on the left side and two rib fractures on the right side. The conclusion of the facility investigation included the CNA (staff #73) failed to follow the facility policy and procedure for safely moving residents. In addition, she incorrectly placed the ventilator tubing back on the resident which was out of her scope of practice. Also, staff #73 did not have her radio in her possession to make any contact with other staff members to obtain assistance. On April 30, 2021 at 4:19 p.m. staff #73 was terminated from employment at the facility due to her failure to follow supervisory instructions and the facility's policies and procedures. Staff #73 was also reported to the Arizona Board of Nursing (AZBN). A review of the personnel file for the CNA (staff #73) included the following: 1) Date of hire: January 7, 2021. 2) CNA certification was active and in good standing. 3) Documentation of attendance for policies related to neglect and compliance. 4) Documentation of compliance/code of conduct/employee understanding agreement that included statements of rules and respect resident rights and provide good care. Further review of the personnel file revealed a corrective action form dated April 16, 2021 signed by staff #73 and the Director of Nursing (DON/staff #44). Documentation revealed there was a violation of policy and procedure and unsatisfactory performance by staff #73. Staff #73 repeatedly silenced the vent alarm while in a resident's room and did not notify the RT. When the RT entered the room they found the resident hooked up wrong and in respiratory distress. An employee statement documented, I (staff #73) was not the person to put the tubing back together .At that time didn't realize we had to have walkies otherwise we could have called RT. The solution/objective included to alert the RT staff immediately using the radio. The corrective action form indicated that if there were further issues for staff #73, these may result in disciplinary action up to termination. Continued review of the personnel file for staff #73 included a corrective action memo dated April 29, 2021 identified as a final warning. Documented was that staff #73 rolled the resident out of bed, injuries were sustained, and the resident was disconnected from the vent. Staff #73 gave care solo when the resident was a maximum assist. An additional corrective action memo dated April 29, 2021 documented the resident was disconnected from the vent and then reconnected by staff #73, who was not licensed to do this. Review of the resident's clinical record revealed the resident passed away in the facility on May 9, 2021. An interview was conducted with a RT (staff #39) on May 13, 2021 at 3:25 p.m. She stated that there should be two CNAs caring for a resident with a [CONDITION(S)] or vent and believes that is the standard in the facility. She stated that if there was an issue with any vent or [CONDITION(S)], the CNAs are expected to contact her or someone else in the RT department using a radio which is considered to be part of the CNA uniform. She stated that all of the residents who require vents also have trachs and that they depend on this equipment to breathe. She stated that a resident would be connected from their [CONDITION(S)] tube by a ballard and an omniflex device which allows the tube to have more movement. She stated that during care a CNA should not touch any part of the [CONDITION(S)] tubing and if the vent alarms at any time, a CNA should always notify RT at once. The alarm on a vent is an apnea alarm and can be very serious. She stated that the alarm indicates that the pressure is low and that the resident may be struggling to breathe. She stated the resident needed full support and had not ever come off the vent and to the best of her knowledge there were no orders to wean him off the vent, indicating that the resident required the vent to sustain his life. On the day of the incident, she recalled that she was standing at the center nurses station with a nurse discussing another resident when she heard a call for help from the resident's room and heard the vent alarm sounding. She quickly went to the room and upon walking in she noticed that the resident was not in his bed and the vent tubing was laying across the bed. She then walked around the bed and saw the resident laying on the floor. She stated she noted that the [CONDITION(S)] was connected but since the alarm was sounding she looked closely at the circuit. She realized that the exhalation bacteria filter was placed on the inhalation side of the circuit instead of the exhalation side. She stated the purpose of the filter is to filter bacteria from entering the environment. She then stated she immediately asked the CNA (staff #73) for the Ambu bag and began bagging the resident. The CNA (staff #73) then began calling for help on the radio. She said that the radio was hers as the CNA did not have her radio on her. She stated that a [NAME] of staff began arriving at the room and assessing the resident for injuries and taking vitals. The RT ensured that the resident's airway was intact. The staff then worked together to place the resident back in his bed. She observed that the CNA (staff #73) was crying. She concluded by saying that the CNA should not have tried to provide care on her own and should have asked for assistance. A telephonic interview was conducted on May 14, 2021 at 8:56 a.m. with the CNA (staff #73). She stated she could recall the incident with the resident that occurred on April 29, 2021 and stated it was an unfortunate accident. She also stated she had asked two other staff to help her and they told her they would meet her in the room. She stated when no staff came into the room to help her, she felt she had to clean the resident and not leave him soiled for the next shift. She stated she followed the facility protocol for what needed to be done when the resident fell and further stated she had not been told to have a radio on her so she could call for immediate help. She stated she thought other staff had been at fault for this incident and she was the only one who got terminated. She stated she would not answer any further questions about this incident and ended the telephone call. An interview was conducted with the corporate nurse (staff #50) on May 14, 2021 at 9:27 a.m. She stated the facility does not have a specific policy regarding the necessity of having two CNAs to provide any care for a resident with a [CONDITION(S)] and vent. She further stated it is a standard of practice for two CNAs to give the care and follow the care plan for a resident with a [CONDITION(S)] and vent. An interview was conducted with a LPN (staff #12) on May 14, 2021 at 11:20 a.m. She stated the normal procedure was for staff to get a radio at the beginning of the shift and carry them during their assigned shift. The staff stated this was especially important when dealing with residents on vents so staff can immediately call RT if there is a problem with a resident. She stated a CNA should never work on their own and should work in pairs for a resident who has a vent and [CONDITION(S)] so that one can immediately call for help if needed. She stated CNAs are not qualified to do any care with a vent, [CONDITION(S)], tubing, or [CONDITION(S)] site and should consult a nurse or RT if there are any problems or concerns with a vent or [CONDITION(S)]. She stated she could recall the resident and stated he needed two staff for assistance with incontinence care. She stated that on April 29, 2021, she heard yelling in the hallway from the CNA (staff #73). She then stated she and the RT (staff #39) entered the resident's room and noticed the resident on the floor on the other side of the bed and there was concern he had decannulated ([CONDITION(S)] tube was not in place). She stated the RT (staff #39) began doing rescue breaths on the resident with the Ambu bag and a staff called for additional help on the radio and additional staff then entered the room. An interview was conducted with an Assistant Director of Nursing (ADON/staff #14) on May 14, 2021 at 1:27 p.m. She stated there was a system in place to allow the CNAs to know what kind of care a resident needs and how many staff are needed to give that care. She stated there was a section in the electronic clinical record, and a Kardex, that was accessible for the CNAs to view so they would know the assigned care. When requested, she stated that the CNA Kardex could not be printed for the resident. An interview was conducted with the DON (staff #44) on May 14, 2021 at 1:31 p.m. She stated if a resident is on a [CONDITION(S)] and vent then all care must be provided by two staff and this included incontinence care. She stated no CNA should ever touch the [CONDITION(S)], vent, or the associated tubing. She stated that on April 29, 2021, the CNA (staff #73) did not wait for additional staff to help her and she needed to have two staff to provide the incontinence care and then when she provided this care alone, the resident fell from the bed to the floor. She said that the CNA then touched the vent tubing and reconnected it but did so incorrectly. She stated that doing this was outside her scope of practice as a CNA and was not the right thing to do. Further, she stated that the CNA had done something similar earlier in April 2021 when in a room with a resident on a [CONDITION(S)] and vent and had been counseled and disciplined. She also stated that the CNA needed to have her radio with her and she did not when the resident fell . She said that the CNA had been counseled in the past for this. She concluded the interview with a statement that the CNA had been terminated for not following supervisory directions, failure to perform her job appropriately, and practicing outside her scope of practice as a CNA. An interview was conducted with a LPN (staff #54) on May 14, 2021 at 1:50 p.m. He stated he had been asked to perform an inservice/training after the incident on April 29, 2021 with the resident. He stated the topic for the training had been that two staff were needed to perform all activities of daily living for a resident with a [CONDITION(S)] and vent. He stated the CNA had been impatient and did not wait for assistance before she provided care to the resident by herself and the resident fell . An interview was conducted with the administrator (staff #51) on May 14, 2021 at 2:56 p.m. She stated the facility is specialized for care of residents with vents and trachs so there is specialized staff, such as RT. She further stated nursing staff may need specialized training and that would include operating the computerized clinical record system so all staff know what type of care the resident needed and how many staff are required to provide the care. She stated the resident required two CNAs for provision of care and this was because the resident was totally dependent on staff for all care. She stated she was informed of the incident on April 29, 2021 with the CNA and resident and was told that the CNA did not wait for additional staff to come and help change the resident. She stated that once they realized that the resident had multiple fractures, she knew that the CNA had to be terminated. Review of facility policies regarding abuse and neglect revealed a statement that the resident has the right to be free from neglect. The policy also included that neglect is defined as failure to provide goods and services necessary to avoid physical harm. According to a facility policy regarding in house communication, the following was included: Purpose: The facility initiated the use of hand held radios to be utilized to speak with other staff members for safety and wellness of residents in need. The facility is equipped with hand held radios for the purpose of relaying emergency information and relaying urgent information to staff. Hand held radios are distributed to every staff member at the beginning of their shifts. Radios are to be utilized between staff members for the purpose of communication and required to be worn at all times.

Based on clinical record review, staff interviews, facility policy review, hospital records, Infusion Nurses Society- Infusion Therapy Standards of Practice and the Arizona State Board of Nursing Scope of Practice, the facility failed to ensure medication administration for one resident (#4) met professional standards. The deficient practice could result in significant adverse medication side effects. Findings include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record indicated that the resident was admitted with a Peripherally Inserted Central Catheter (PICC) that was used for Total [MEDICATION NAME] Nutrition (TPN) and was a pediatric resident. The resident was also assessed to be totally dependent on staff for all Activities of Daily Living (ADL). Review of the September 2019 physician's orders [REDACTED]. -September 17: Nothing by Mouth (NPO) -September 17: Review & verify with a second licensed nurse [MEDICATION NAME] nutrition prescription, admixture of additives and compare bag label with chart order. -September 18: Use electronic infusion device to administer TPN. -September 18: TPN macro formula for Amino Acids (AA) and [MEDICATION NAME] (Dex): 672 milliliter (mL) per day, 28 mL per hour for 24 hours. Dex 16%, 107 grams, AA 2.5 grams per kilogram per day (15 g/day) one time a day for nutrition. -September 18: TPN lipids: 60 mL per day. Intralipids 2 gram per kilogram per day. 2.5 mL per hour for 24 hours one time a day for nutrition. The September 2019 Medication Administration Record [REDACTED]. There was no entry for the lipids. There was no entry on the MAR indicated [REDACTED]. Review of the baseline care plan revealed the following areas of focus: -Nutrition and dehydration risk related to the resident's diagnoses. The goal of this area was to have the resident maintain adequate nutritional intake via TPN. An intervention included providing TPN as ordered. -TPN required for the resident related to needed gut rest. An intervention included to monitor the PICC site for signs and symptoms of infiltration. -ADLs with a goal that the resident's ADL needs be met daily. Interventions included that the resident needed assist with toileting, and required assistance of 1-2 staff during transfers. -Activities noting that the resident is dependent on staff for activities, social stimulation and social interaction related to physical limitations. An intervention included that the resident needs assistance with ADLs during activities. Review of the clinical record revealed no evidence that lipids were documented to be administered from September 19 through 28, 2019. Review of the Medication Administration Record [REDACTED]. This included three different LPNs (#282, #1, and #284). Review of the clinical record from September 18 through September 28 revealed the following: -On the dates that LPNs documented the administration of the TPN, there was no evidence that RNs had administered the TPN. -On several occasions, there was no documentation that 2 clinicians had verified the TPN or lipids including on September 18, 22, 23, and the 24. -On several occasions, there was no evidence that nurses monitored the TPN or lipids including on the 19, 20, 21, 25, 26, 27 and 28. The administrator confirmed that there were RNs working on the days that LPNs documented the administration of the TPN (19, 20, 21, 27, and 28). Review of the MAR for September 29, 2019, revealed initials to indicate that a LPN (staff #1) administered the TPN at 9:00 p.m. On September 30, 2019, a nursing note was entered at 8:32 a.m. by a RN (staff #196). The note indicated that the RN was the one who administered the TPN and lipids to the resident at 9:00 p.m. on September 29 (the LPN had signed off on this administration in the MAR) She noted that she mixed up the tubing which caused the TPN to infuse at the rate of the lipids and the lipids to infuse at the rate of the TPN. A nursing note, entered at 1:05 p.m. on September 30, 2019 by a LPN (staff #1) indicated that the resident had received the TPN and lipids from the RN at 9:00 p.m. on September 29, 2019. He documented that he heard the resident's IV pump alarming at around 6:00 a.m. which caused him to check on the resident. The resident looked pale, had an elevated temperature (103.0 degrees Fahrenheit) and oxygen saturation levels that were dropping. At that time, a nurse called the provider and left a text message about the elevated temperature. The resident's family was notified and requested the resident be sent to the hospital. A physician note dated October 1, 2019, written by staff #281 revealed that the resident was transferred at the representative's request. The note indicated that the physician had been notified regarding the resident's fever. The physician had responded to see if the staff had tried Tylenol or [MEDICATION NAME]. The physician did not get a response. The note indicated that an hour later, the nurse called to notify him that the resident's lipids had been given at an accelerated rate and a medication error was documented. He noted that he discussed the risks of that error and ordered labs to examine the resident's liver function and cause of the fever. The note indicated that an hour later, the resident was transferred out of the facility. The physician was not notified of this transfer. Review of the hospital records revealed that the resident was initially admitted in relation to the accelerated infusion of the lipids and noted that she received the full 24 hour lipid dose in 2 hours. She was admitted with a fever of 105.4 degrees Fahrenheit. While in the hospital, she was monitored for the accelerated lipid infusion. The hospital records indicated that the resident had a low serum sodium level on admission which could have been in relation to the lipid administration. The hospital records also indicated that the resident's fever could have been caused by the accelerated infusion of lipids, but also noted that the resident was found to [MEDICAL CONDITION] in her PICC line which may have caused the fever as well. An interview was conducted with a RN (staff #133) on June 29, 2020 at 12:40 p.m. She stated that RNs have to administer the TPN and lipids. She stated that when the medication is administered, two nurses have to check the medication and the settings on the pump. She stated she will check the IV pump multiple times during her shift. Staff #133 stated if she administers a medication, she is the one to chart it in the MAR. An interview was conducted with a RN (staff #196) on June 29, 2020 at 1:00 p.m. She stated she checked the TPN and lipids for the resident twice during the shift. She stated that it is policy for two nurses to verify the TPN and lipid orders before starting the IV; however, she did not do that. She stated in the morning she was asked to come back upstairs to assess the resident. She stated the resident was lethargic. She stated she did not do an assessment at that time because the ambulance was already in route. She stated that another nurse contacted the provider before she got there. In an interview with the Director of Nursing (DON/staff #98) on June 29, 2020 at 3:00 p.m., she stated that high risk medications, like TPN and lipids should be monitored every two to three hours. She said that a medication error involving a PICC line would be serious and would be investigated. She stated that because of the age of the resident, there would be increased monitoring. She stated staff should follow standards of practice, state regulations, and facility policies. She stated that medications should be documented by the person who administered the medication. The DON stated that LPNs cannot administer TPN or lipids. She stated that all LPNs can do is flush PICC lines but only if they have received additional training. An interview was conducted with a LPN (staff #1) on June 29, 2020 at 3:38 p.m. He stated that the RN actually hung the TPN and lipids for the resident on September 29 even though he charted it. He stated he monitored the resident's vital signs during administration of the TPN and lipids but did not look at the pump. Staff #1 was unable to remember exactly when and how often the RN checked the IV pump. He stated that a lot of times, the charge nurse would come around and do the TPN and he would just chart it for the charge nurse. He stated he would speak to the nurse on the phone and if the RN was busy he would set up the TPN and lipids so they could just change it out. In an interview with an RN (staff #290) on June 30, 2020 at 11:15 a.m., he stated that if he is the one who administered the TPN or lipids, he would document this in the MAR. He stated that he would monitor the PICC line at least twice per shift and document this assessment in the nursing notes. An interview was conducted with a RN (staff #4) on June 30, 2020 at 11:20 a.m. She stated RNs have to hang (administer) TPN and lipids. She stated two nurses verify the medication is correct using the physician orders [REDACTED]. An interview was conducted with a RN (staff #148) on June 30, 2020 at 12:49 p.m. She stated that a LPN cannot administer TPN and lipids. She stated if she administered a medication, she is the one that charts it in the MAR. She stated when she administers PICC medications she checks the infusion every 15 minutes for the first hour, then every 30 minutes for an hour. She stated after that she checks every hour or couple of hours. An interview was conducted with a RN (staff #57) on June 30, 2020 at 1:00 p.m. She stated LPNs can remove the TPN and lipids out of the refrigerator to get them to room temperature. She stated the RN has to be the one to administer the TPN and lipids. She stated that when she administers a medication, she is the one that charts it in the MAR. She stated she would check the infusion rate every time she would enter the resident's room. She stated she would do that every two hours or six times a shift. Review of employee records revealed no evidence that competency assessments had been completed for PICC lines for RNs and LPNS. Also, no documentation was revealed for IV training for pediatric residents. The facility policy titled Administration of Drugs included it is the policy of this facility that medications shall be administered as prescribed by the attending physician. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer and record the administration of medications. Medications must be administered in accordance with the written orders of the attending physician. All current drugs and dosage schedules must be recorded on the resident's MAR. The medications are administered according to the dose prescribed. In the 2016 Journal of Infusion Nursing under the section for medication verification, the standard stated medications and infusion solutions are identified, compared against the medication order, and verified by reviewing the label for the name (brand and generic), dosage and concentration, beyond-use date, expiration date, sterility state, route of administration, frequency, rate of administration, and any other special instructions. Perform an independent double check by 2 clinicians for the organization's selected high-alert medications that pose the greatest risk of harm. The document indicated to develop a standard process and educate staff in how to perform the double check. Review of the Arizona State Board of Nursing Infusion Therapy/Venipuncture: The Role of the LPN included it is within the scope of practice for a LPN to provide infusion therapy within their scope and training if they are delegated to do so by an RN or licensed independent practitioner and the following requirements are met. The facility must have written policies and procedures which include but are not limited to, which medication classes the LPN can and cannot administer either by intravenous (IV), intraosseous (IO) or subcutaneous (Subq) routes are maintained by the employer. LPNs are considered to have basic training when the only training received is education contained in their core curriculum or in an organized course of instruction which meets the core curriculum standards. LPNs are considered to have advanced training if they have documentation of the successful completion of an instructional program that meets the criteria established. The documentation of competency validation appropriate to the training level, including venipuncture and safe medication/ infusion practice is on file with the employer. Each facility should determine frequency of re-evaluation of competency. The LPN cannot administer medications which require close RN monitoring, assessment, or interpretation of data, or titration for example TPN and lipids.

Based on clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to provide adequate supervision to one resident (#2) and the facility failed to document and implement interventions to reduce risk for one resident (#3). The deficient practice could result in life-threatening injuries. Findings include: -Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record revealed that the resident was a pediatric resident who was admitted with a [MEDICAL CONDITION] and required mechanical ventilation to survive. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was rarely or never understood. The resident was totally dependent on staff for Activities of Daily Living (ADL) and had no functional limitations in range of motion for upper and lower extremities. An active [DIAGNOSES REDACTED]. Specialty treatments included oxygen therapy, suctioning,[MEDICAL CONDITION], and ventilator. The resident was coded to have no restraints or alarms in use. A respiratory care plan initiated October 10, 2019 noted the use of the resident'[MEDICAL CONDITION] related to impaired gas exchange, impaired mobility, ineffective airway clearance, and respiratory insufficiency. Goals for this care plan included to treat the resident following respiratory therapy policies and procedures and to maintain the resident's airway [MEDICAL CONDITION] the next review. The care plan did not include information regarding supervision of the resident's trach. Review of the clinical record from November 11, 2019 to January 12, 2020 revealed the resident had dislodged or de-cannulated [MEDICAL CONDITION] several times including on November 11 and 26 and on December 8 and 21, and on January 12. There was no documentation to show that the resident's care plan had been updated to prevent dislodgement or de-cannulation or that any interventions had been implemented to prevent this from occurring. There was no evidence to show that the interdisciplinary team had met to discuss the frequent dislodgement or to determine why the tube continued to dislodge. A physician's orders [REDACTED]. The order included that family must be at bedside. A nursing note was entered on March 4, 2020 at 11:27 p.m. by a Licensed Practical Nurse (LPN/staff #214). The note indicated that the nurse was providing care to a resident (not resident #2) when she heard a vent alarming in another room. The nurse went down the hall to locate the alarming vent. She entered resident #2's room and observed the resident on her left side and not moving. The vent was alarming. The resident's pulse oximeter machine was showing no sensor. The nurse put the resident on her back. The resident was observed to be grey/blue in color and unresponsive. The nurse could not detect a pulse. The nurse called for immediate Respiratory Therapist (RT) assistance. The nurse observed that the resident'[MEDICAL CONDITION] out and she placed [MEDICAL CONDITION] into the resident. An RT (staff #155) entered the room and began providing air to the resident by using a manual resuscitator. The nurse indicated that at 10:27 p.m. the catheter passed with patent airway and a scant amount of blood was suctioned. The nurse indicated the resident still did not have a pulse and she could not obtain an oxygen reading. The RT started to perform chest compressions and during the chest compressions, the pulse oximetry read 17% oxygen saturation and the resident's Heart Rate (HR) was 36 beats per minute (bpm). The nurse called a code blue over the radio at 10:29 p.m. The resident's HR was 90 bpm and her oxygen saturation was 63%. The resident's color began to return to pale pink. A second code blue was called by a security guard at 10:31 p.m. When additional staff arrived for the code, the resident's HR was 133 bpm and her oxygen saturation was 100%. At this point, the resident's color was pink and warm to the touch. No other staff assistance or the code cart equipment was required. The nurse indicated that staff had informed her that the first code blue call was not heard by staff over the radio and that is why there was a second code blue. The nurse indicated that the resident was transferred to the hospital for evaluation. The note indicated that it was the resident's family who requested the transfer to the hospital and when help arrived at the facility to transport the resident, they were unable to take her and stated they did not have the ability to transport a vent dependent resident. At this point, a second transport was notified and a second team came to take the resident to the hospital. The resident was transported to the hospital at 11:55 p.m., an hour and 28 minutes after the resident coded. The resident's HR was 137 bpm and her oxygen saturation was 98% when she was transported. She was pink, warm, and crying intermittent lethargy. Review of an incident report for the code blue revealed that the RT (staff #155) had provided a statement regarding the incident. The statement included that the RT was providing care for another resident when a call for help was heard from down the hall. The RT responded and the call came from the resident's room. The RT was notified that the resident'[MEDICAL CONDITION] was out. The resident was dusky gray/blue and non-responsive. The pulse oximeter was alarming and showing no sensor. The nurse was able to put [MEDICAL CONDITION] back in while the RT got an oxygen tank and a manual resuscitator known as an ambu bag. The RT began to use the ambu bag while the nurse checked for a pulse. The nurse could not obtain a pulse. Catheter was passed to ensure patent airway and a scant amount of blood was suctioned. The RT noted that a code blue was called via radio at 10:29 p.m. by the nurse. The RT performed chest compressions and the pulse oximeter began detecting oxygen at 17% and the HR was 36 bpm. The resident's color began to return to pale pink. A second code blue was called at 10:31 p.m. by the security guard as no staff had shown up. Several staff arrived. At this point, the resident's HR was 133 bpm and the oxygen saturation was 100%. The resident's color was pink and warm to touch. No code care equipment required. The resident was placed back on the vent at 10:37 p.m. The resident was to be transferred to the hospital for further evaluation. When transport arrived, they were not able to take the resident due to her being on a ventilator. The resident's HR was between 130-190 bpm and the resident was lethargic and her level of consciousness was in and out. The resident was sent to the emergency room (ER) via stretcher at 11:55 p.m. The RT accompanied the resident to the hospital. Upon departure from the facility, the resident's HR was 137 bpm, the oxygen saturation was 98% and the resident's skin was pink and warm. The resident was crying with intermittent lethargy. An interview was conducted on June 29, 2020 at 12:23 p.m. with a RT (staff #65). He stated the resident would have to be monitored constantly. He stated she would pull and grab at her trach. He stated that when she was awake, the nursing staff would have the resident in the nursing area so they could monitor her. An interview was conducted with a LPN (staff #2) on June 29, 2020 at 1:00 p.m. She stated the staff would tie [MEDICAL CONDITION] a little tighter to help keep the resident's cannula in place. She stated the staff would keep the resident at the nurse's station often to keep an eye on her. She stated that she was often told in report that the resident would take out the cannula or cough it out. An interview was conducted on July 2, 2020 at 10:25 a.m. with the Director of RT (staff #245). She stated the resident was very active with her arms. She stated the resident would take [MEDICAL CONDITION] out often. She stated that the resident would de-saturate very quickly. She stated the resident had [MEDICAL CONDITION] an inflatable cuff to keep it in place. She stated this cuff should be checked every 2 hours. Staff #245 stated that from a respiratory standpoint the resident was assessed and monitored per the facility protocol. She stated that every time the resident dislodged or de-cannulated herself, we were able to bring her back every time. An interview was conducted with the Director of Nursing (DON/staff #98) on June 29, 2020 at 3:00 p.m. She stated that if a resident has an episode where they decannulate, this would be serious and would require that the incident be investigated. -Resident #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On May 16, 2020, a care plan was initiated for falls related to a [DIAGNOSES REDACTED]. Interventions included to anticipate and meet the resident's needs, follow the facility fall protocol, supply the appropriate adaptive equipment or devices as needed, and to re-evaluate the resident every shift and as needed for continued appropriateness to ensure the least restrictive device or restraint is in use. The care plan did not include specific interventions regarding adaptive equipment or restrictive devices that were to be in use. The plan did not include information about use of a low bed or fall mats. An admission MDS assessment dated [DATE] indicated the resident had severely impaired cognitive skills with short and long term memory problems. The resident did not have any behaviors. The resident required total assistance for ADL. The resident, according to the MDS, had an indwelling and external condom catheter and was always incontinent of bowel. The resident had active [DIAGNOSES REDACTED]. The resident had no history of falls. The resident was on a ventilator and no restraints were used. Review of a fall risk assessment dated [DATE] revealed the resident was coded as a moderate fall risk. The assessment included that the resident was receiving [MEDICAL CONDITION]/antiepileptic medications. No fall interventions were noted on the fall risk assessment. On October 22, 2019, a nurse's note was entered at 11:18 p.m. by a Registered Nurse (RN). The note indicated that the resident was experiencing tremors. The bed was noted to be in a low position. The nurse documented that the resident was unable to make his needs known. A nursing note dated October 23, 2019 at 7:43 a.m. was entered by a LPN (staff #279). The note indicated that the resident was found on the floor with his upper torso and head on the floor. The lower part of the resident's body was in bed. Review of the resident's fall care plan revealed that it was not revised to reflect the resident's fall and did not include any further interventions. The care plan did not include information regarding the use of fall mats by the bed or that a low bed was to be in use. The care plan did not address the resident's tremors. An interview was conducted on June 29, 2020 at 11:33 a.m. with a Certified Nursing Assistant (CNA/staff #271). She stated the resident required total assistance for turning and repositioning. She stated the resident had a fall mat on the floor and his bed was up against one wall. She stated this was to prevent him from falling. An interview was conducted on June 30, 2020 at 11:40 a.m. with staff #279. She stated that the resident had spasms and he would jerk from time to time. She stated the resident had the spasms and jerking motions from the start of his admission. She stated the resident had fall mats on both sides of his bed. She stated the resident's bed was out from the wall and that is why there were mats on both sides. The facility policy titled Fall Management System included that this facility is committed to promoting resident autonomy by providing an environment that remains free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function though providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents. It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented. A review of the fall incident will include an investigation to determine probable causal factors considering environmental factors, resident medical condition, resident behavioral manifestations, and medical or assistive devices that may be implicated in the fall. The investigation will be reviewed by the Inter Disciplinary Team and results of the investigation will be documented. Residents will be reassessed for fall risk with any significant change in the resident's condition or the development of behavioral symptoms that increase the resident's risk for falls.

Based on clinical record review, staff interviews, facility policy, hospital records, and Infusion Nurses Society- Infusion Therapy Standards of Practice, the facility failed to ensure Total [MEDICATION NAME] Nutrition (TPN) and lipids were administered as ordered for one resident (#4) resulting in a significant medication error. The deficient practice could result in adverse side effects. Findings include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record indicated that the resident was admitted with a Peripherally Inserted Central Catheter (PICC) that was used for TPN and was a pediatric resident. The resident was also assessed to be totally dependent on staff for all Activities of Daily Living (ADL). Review of the September 2019 physician's orders [REDACTED]. -September 17: Nothing by Mouth (NPO) -September 17: Review & verify with a second licensed nurse [MEDICATION NAME] nutrition prescription, admixture of additives and compare bag label with chart order. -September 18: Use electronic infusion device to administer TPN. -September 18: TPN macro formula for Amino Acids (AA) and [MEDICATION NAME] (Dex): 672 milliliter (mL) per day, 28 mL per hour for 24 hours. Dex 16%, 107 grams, AA 2.5 grams per kilogram per day (15 g/day) one time a day for nutrition. -September 18: TPN lipids: 60 mL per day. Intralipids 2 gram per kilogram per day. 2.5 mL per hour for 24 hours one time a day for nutrition. The September 2019 Medication Administration Record [REDACTED]. There was no entry on the MAR indicated [REDACTED]. There was no entry for the lipids. Review of the baseline care plan revealed the following areas of focus: -Nutrition and dehydration risk related to the resident's diagnoses. The goal of this area was to have the resident maintain adequate nutritional intake via TPN. An intervention included providing TPN as ordered. -TPN required for the resident related to needed gut rest. An intervention included to monitor the PICC site for signs and symptoms of infiltration. -ADLs with a goal that the resident's ADL needs be met daily. Interventions included that the resident needed assist with toileting, and required assistance of 1-2 staff during transfers. -Activities noting that the resident is dependent on staff for activities, social stimulation and social interaction related to physical limitations. An intervention included that the resident needs assistance with ADLs during activities. Review of the MAR for September 29, 2019, revealed initials to indicate that a LPN (staff #1) administered the TPN at 9:00 p.m. Review of the clinical record revealed no evidence that two licensed nurses verified the TPN and lipid administration on September 29, 2019. A respiratory treatment note entered at 8:00 a.m. on September 30, 2019 indicated that the resident's oxygen saturation was 82% and the resident's breath sounds were diminished. The nurse was notified and the resident was placed on four liters per minute of oxygen via nasal cannula. The resident's oxygen saturation increased to 100% and the resident's breath sounds were documented as being course. The resident's heart rate was 167 beats per minute. The resident was sent out via ambulance to the hospital at 8:15 a.m. On September 30, 2019. a nursing note was entered at 8:32 a.m. by a RN (staff #196). The note indicated that the RN was the one who administered the TPN and lipids to the resident on September 29 (the LPN had signed off on this administration in the MAR) She noted that she mixed up the tubing which caused the TPN to infuse at the rate of the lipids and the lipids to infuse at the rate of the TPN. A nursing note, entered at 1:05 p.m. on September 30, 2019 by a LPN (staff #1) indicated that the resident had received the TPN and lipids from the RN on September 29, 2019. He documented that he heard the resident's IV pump alarming at around 6:00 a.m. which caused him to check on the resident. The resident looked pale, had an elevated temperature (103.0 degrees Fahrenheit) and oxygen saturation levels that were dropping. At that time, a nurse called the provider and left a text message about the elevated temperature. The resident's family was notified and requested the resident be sent to the hospital. A physician note dated October 1, 2019, written by staff #281 revealed that the resident was transferred at the representative's request. The note indicated that the physician had been notified regarding the resident's fever. The physician had responded to see if the staff had tried Tylenol or [MEDICATION NAME]. The physician did not get a response. The note indicated that an hour later, the nurse called to notify him that the resident's lipids had been given at an accelerated rate and a medication error was documented. He noted that he discussed the risks of that error and ordered labs to examine the resident's liver function and cause of the fever. The note indicated that an hour later, the resident was transferred out of the facility. The physician was not notified of this transfer. Review of the hospital records revealed that the resident was initially admitted in relation to the accelerated infusion of the lipids and notes that she received the full 24 hour lipid dose in 2 hours. She was admitted with a fever of 105.4 degrees Fahrenheit. While in the hospital, she was monitored for the accelerated lipid infusion. The hospital records indicated that the resident had a low serum sodium level on admission which could have been in relation to the lipid administration. The hospital records also indicated that the resident's fever could have been caused by the accelerated infusion of lipids, but also noted that the resident was found to [MEDICAL CONDITION] in her PICC line which may have caused the fever as well. An interview was conducted with a RN (staff #196) on June 29, 2020 at 1:00 p.m. She stated she checked the TPN and lipids for the resident twice during the shift. She stated that it is policy for two nurses to verify the TPN and lipid orders before starting the IV; however, she did not do that. She stated in the morning she was asked to come back upstairs to assess the resident. She stated the resident was lethargic. She stated she did not do an assessment at that time because the ambulance was already in route. She stated that another nurse contacted the provider before she got there. In an interview with the Director of Nursing (DON/staff #98) on June 29, 2020 at 3:00 p.m., she stated that high risk medications, like TPN and lipids should be monitored every two to three hours. She said that a medication error involving a PICC line would be serious and would be investigated. She stated that because of the age of the resident, there would be increased monitoring. She stated staff should follow standards of practice, state regulations, and facility policies. She stated that medications should be documented by the person who administered the medication. The DON stated that LPNs cannot administer TPN or lipids. She stated that all LPNs can do is flush PICC lines but only if they have received additional training. An interview was conducted with a LPN (staff #1) on June 29, 2020 at 3:38 p.m. He stated that the RN actually hung the TPN and lipids for the resident on September 29 even though he charted it. He stated he monitored the resident's vital signs during administration of the TPN and lipids but did not look at the pump. Staff #1 was unable to remember exactly when and how often the RN checked the IV pump. He stated that a lot of times, the charge nurse would come around and do the TPN and he would just chart it for the charge nurse. He stated he would speak to the nurse on the phone and if the RN was busy he would set up the TPN and lipids so the RN could easily change the TPN out. In an interview with an RN (staff #290) on June 30, 2020 at 11:15 a.m., he stated that if he is the one who administered the TPN or lipids, he would document this in the MAR. He stated that he would monitor the PICC line at least twice per shift and document this assessment in the nursing notes. The facility policy titled Administration of Drugs included it is the policy of this facility that medications shall be administered as prescribed by the attending physician. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer and record the administration of medications. Medications must be administered in accordance with the written orders of the attending physician. All current drugs and dosage schedules must be recorded on the resident's MAR. The medications are administered according to the dose prescribed. In the 2016 Journal of Infusion Nursing under the section for medication verification, the standard stated medications and infusion solutions are identified, compared against the medication order, and verified by reviewing the label for the name (brand and generic), dosage and concentration, beyond-use date, expiration date, sterility state, route of administration, frequency, rate of administration, and any other special instructions. Perform an independent double check by 2 clinicians for the organization's selected high-alert medications that pose the greatest risk of harm. The document indicated to develop a standard process and educate staff in how to perform the double check.