Every finding on record at Palm Valley Post Acute

Based on clinical record review, staff interviews, and facility documents and policy, the facility failed to ensure electronic medical records remained confidential for one resident (Resident #159). The universe was 163. The deficient practice could result in violations of patient privacy. Findings include:An observation during medication administration was conducted on January 28, 2026 at 8:12 a.m. with registered nurse (RN) Staff #169. Staff #169 gathered the medications to be administered to Resident #159. Staff #169 proceeded to turn around and walk into the resident's room at 8:23 a.m.An observation conducted on January 28, 2029 at 8:24 a.m. with Staff #169, revealed that upon returning to the medication cart, the electronic health records (EHR) for Resident #159 was still in view and open. Staff #169 confirmed that it Resident #159's EHR was visible at that time. Staff #169 revealed that the risks may be anybody could see that.An interview was conducted on January 28, 2026 at 2:00 p.m. with social services director Staff #34 who stated that leaving your computer screen unsecured would be a risk for HIPAA violation.An interview was conducted on January 29, 2026 at 9:22 a.m. with certified nursing assistant (CNA) Staff #130 who stated that charting conducted on the screens in certain areas may be visible to residents; and that, there is a way to lock the screen so residents can not see it. Staff #130 stated that the risk of leaving the screen open is a HIPAA violation.An interview was conducted on January 29, 2026 at 9:32 a.m. with licensed practical nurse (LPN) Staff #46 who stated that if a staff needs to leave their computer, staff need to secure it, because anyone could get in to the computer and read information about the residents.An interview was conducted on January 29, 2026 at 9:40 a.m. with director of nursing (DON) Staff #239 who stated that documentation is done in in the electronic health records. The DON stated that leaving a computer screen unsecured could allow somebody to see HIPAA information. A review of the Resident Rights policy version 1.2 (H5MAPL0768) revealed in section 3. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues.

Based on observation, staff interviews, and policy and procedures, the facility failed to ensure that refuse was disposed of appropriately. The deficient practice could result in an unsanitary condition and/or the harborage of pests.Findings include:During a kitchen inspection conducted on January 26, 2026, at 8:40 a.m. with Dietary Director (Staff #244), an observation revealed that the designated facility garbage receptacle area had an accumulation of refuse around and behind trash dumpsters to include a clear bag of trash, miscellaneous trash, yard waste, and a dead bird. Staff #244 stated that the bag of trash contained medical stuff, swabs, tissue, and that it looked clinical.An interview was conducted on January 28, 2026 at 10:14 a.m. with Maintenance Director (Staff #51) why stated that the protocol for maintaining the dumpster area was to inspect it every day. Additionally, Staff #51 stated that the responsibility for maintaining the cleanliness of the dumpster area is a team effort on the part of the maintenance team; and that, someone was designated every morning. Further, Staff #51 revealed that the condition of the dumpster area does not meet his expectations and it presents aninfection control risk.An interview was conducted on January 28, 2026 at 10:25 a.m. with Housekeeping Supervisor (Staff #101). Staff #101 revealed that the potential risk for refuse outside of the dumpster area was that there could be contamination; and, if the trash had something contagious and someone touched it, it could spread a lot of germs.An interview was conducted on January 28, 2026 at 10:38 a.m. with Facility Administrator (Staff #12). Staff #12 stated that the protocol, for maintaining the dumpster area clean, was that the lids should be closed; and that, it should be free from any rubbish or refuse. Additionally, Staff #12 stated that the facility maintenance team was responsible for the cleanliness of the dumpster area; and that, the expectation was that it should look better than that -- they would like it to be clean. Further, Staff #12 revealed that the potential risk for refuse outside of the dumpster was that it could bring pests, foul odors, make for a less than homelike environment, and present an infection control issue.Review of the undated policy, Refuse and Trash, revealed, Policy Interpretation and Implementation: Waste Segregation that waste should be disposed of immediately after use with general waste going into standard trash bins.

Based on the observations, clinical record review, interviews, and facility policy, the facility failed to ensure that urinary catheter bag for 1 of 2 sampled residents (Resident #6) was not resting on the floor. The universe was 22. The deficient practice could lead to catheter associated infection due to inappropriate urinary catheter bag placement. Findings Include:Resident #6 was admitted on [DATE], with diagnoses of sequelae of cerebral infarction, chronic respiratory failure, acute pulmonary edema, type 2 diabetes mellitus, and immunodeficiency. The care plan dated November 19, 2025, had a focused care area for Indwelling Catheter: Neurogenic Bladder. Interventions included providing a catheter every shift, ensuring a privacy cover is placed on the Foley bag, the resident has a position catheter bag and tubing below the level of the bladder and away from the entrance room door, monitoring signs and symptoms of discomfort on urination and frequency, monitor document for pain/discomfort due to the catheter. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 06, which indicated that the Resident #6 was severely cognitively impaired. The physician's order dated December 07, 2025, revealed orders for indwelling catheter: Indwelling Catheter care. An observation was conducted on January 28, 2026, at 09:20 AM. Resident #6 was awake, lying in the bed, and the catheter was set under the bed on the floor, along with the catheter tubing touching the full surface of the floor with a blue cover privacy bag. Another observation was conducted on January 28, 2026, at 09:36 AM with a Certified Nursing Assistant (Staff #103), Resident #6 was awake, still lying in the bed, and his Foley Catheter set under the bed on the floor along with the catheter tubing touching the full surface of the floor with blue a blue cover privacy bag. An interview was conducted on January 28, 2026, at 09:22 AM with CNA (Staff #103), who stated the facility's process for handling catheter care was to first wear appropriate PPE, such as gloves and gowns, before entering the room. She stated that staff changed the urine drainage bags, and cleaned the genitourinary area with 2-3 wipes. She stated that she must twist the cap to open the drainage bag and place the towel under the cup to avoid any spillage. Staff #103 stated she records the urine output at the end which gives that information to the nurse. Staff #103 stated that the catheter should never be on the floor because it could pose a risk of infection. An interview was conducted on January 29, 2026, at 09:50 AM with a Registered Nurse (RN/Staff #211), who stated that the facility's process for catheter care was to be performed every shift by a CNA or nurses. She stated that if the catheter needs to be changed, they would do that as well, however stated that the CNA does the majority of the catheter touching. She stated that the catheter should not be touching the floor; and that, the Catheter tubing hanging to the side of the bed, and covered with a dignity bag. She stated that if the Catheter is touching the floor, it would pose a risk of the catheter being pulled out, leakage on the floor, or infection. An interview was conducted on January 29, 2026, at 12:05 AM with the Director of Nursing (DON/staff #239), who stated that the facility's process for Cather care was that CNAs are responsible for cleaning the foley catheter, keeping it clean, emptying the foley catheter, and reporting to the nurse if the resident is urinating or not. DON stated that they place the privacy bag on the catheter and ensure that the catheter is hung up so it does not touch the floor. DON stated the catheter should not touch the floor, and should be protected with a barrier, such as a Foley catheter cover bag. She stated if the catheter is not protected by the barrier, then it can not touch the floor. DON stated that catheters should not be left on the floor because it pose risk of pain, someone running it over, causing infection. The facility policy titled, Palm Valley Post Acute Catheter Care, Urinary, revealed that the procedure is to prevent catheter-associated urinary tract infections. The facility policy titled, Infection Prevention and Control Program, revealed that the program is based on accepted national infection prevention and control standards. Review of the Centers for Disease Control and Prevention - Catheter-Associated Urinary Tract Infection Prevention. Proper Techniques for Urinary Catheter Maintenance for Catheter Care. (2009), revealed that the collecting bag should be below the level of the bladder at all times and should not rest the bag on the floor.

Based on the clinical record review, interviews, and facility policy, the facility failed to ensure that a Preadmission Screening and Resident Review Screening was completed for 1 of 4 residents (Resident #158). The universe was 163. The deficient practice could result in specialized services not being identified and provided to the residents. Findings include:Resident #158 was admitted to the facility on [DATE] with medical diagnoses that include personal history of traumatic brain injury, opioid use, schizophrenia unspecified, and cognitive communication deficit.A minimum data set (MDS) completed on July 23, 2025 revealed a brief interview of mental status (BIMS) score of 7 which indicated that Resident #158 had severe cognitive impairment.The care plan dated July 18, 2025, revealed a focus area for medication-antipsychotic related to schizophrenia as evidenced by auditory hallucinations, and delusions. Date of revision on September 25, 2025. Interventions included: administer antipsychotic medication as ordered. Will exhibit a therapeutic effect related to the use of the medication, will not have any adverse effects related to the use of antipsychotic medication, Haloperidol oral tablet black box warning.A review of Resident #158's PASRR level I completed on July 18 2025, revealed that a yes answer was submitted for Section A Exemptions and Categorical Determinations, i.e., convalescent care, respite, terminal illness/severe illness or primary diagnosis of dementia. However, Resident #158 remained in facility; and, PASRR level I or II was not found in the documents section when the change, from skilled nursing to long term occurred, and Resident #158 remained in the facility.An interview was conducted on January 28, 2026, at 2:00 p.m. with SSD Staff #34 who stated that a PASARR level 1 should be done if a resident is in the facility longer than 30 days, then a level II may proceed. The system will flag the PASARR if it needs to go on for a PAS level II. If a resident had diagnosis of schizophrenia and taking medications, then it would end up going for a level II. If the resident is admitted for skilled or a respite stay, then it would not trigger for a level II. If a level II was completed and accepted, it would be uploaded. If not accepted, an email would be sent to the facility. Resident #158 was not submitted for another level I PASARR evaluation when he went to long term. Both level I, and no level II were completed. The risk for not submitting would be that Resident #158 may not get proper behavior needs met, and facility would not be able to determine if a higher level of care is needed. Resident #158 not having a Preadmission Screening and Resident Review Level 1 or II would not meet facility expectation. There are currently audits in place for new admissions and for hospice, that will be added when residents go from skilled to long term care.An interview was conducted on January 29, 2026, at 9:40 a.m. with the Director of Nursing (DON/Staff #239) who revealed that the SSD is responsible for completing the PASARR. DON stated that she would ensure that Staff #34 completed Preadmission Screening and Resident Reviews for residents; and that, would discuss about how many Preadmission Screening and Resident Reviews are due in the next morning stand up meeting.An interview was conducted on January 29, 2026 at 9:47 a.m. with Executive Director (ED) Staff #12 who stated that he was aware of the findings regarding Preadmission Screening and Resident Review and planned on implementing audits through the medical records.A review of newly submitted Preadmission Screening and Resident Review for Resident #158 on January 29, 2026 at 6:56 a.m., revealed that in section A- Exemptions and Categorical Determinations -- there was no Dementia/Alzheimer's diagnosis.A review of the facility's policy titled PASRR (Pre-admission Screening & Resident Review), revealed that Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings.

Based on observations, staff interviews, record review, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for two of four residents (#139, #87). The deficient practice could result in adverse effects and further medication errors.Findings include:Eight medication administration errors were identified out of twenty-six opportunities during medication administration observation. The medication error rate was 30.77%.Regarding Resident #139Resident #139 was admitted to the facility on [DATE] with diagnoses that included hydronephrosis, type two diabetes mellitus, and immunodeficiency. A medication administration observation was conducted with a Registered Nurse (RN/Staff #26) on July 31, 2025 at 8:34AM for Resident #139. During this administration, the RN was observed to take out a bottle of Cholecalciferol (Vitamin D3) 2.5mcg/1000IU, and the RN placed one tablet into the medicine cup. After preparing the resident's other medications, Resident #139 was observed to swallow the medications, including the single tablet of Cholecalciferol. Upon reviewing the provider orders for Resident #139, the following order was found:- Cholecalciferol Tablet 1000 UNIT - Give 5 tablet by mouth one time a day for supplementRegarding Resident #87Resident #87 was admitted to the facility on [DATE] with diagnoses that included type two diabetes mellitus with ketoacidosis, need for assistance with personal care, and reduced mobility. Review of the provider orders for Resident #87 revealed the following medications to be administered at 08:00AM:- Allopurinol Oral Tablet 200 MG (Allopurinol) - Give 200 mg by mouth two times a day for GOUT- amLODIPine Besylate Oral Tablet 10 MG (Amlodipine Besylate) - Give 10 mg by mouth one time a day for HTN- Amoxicillin Oral Capsule 250 MG (Amoxicillin) - Give 1 capsule by mouth three times a day for Dental pain for 5 Days- Aspirin Tablet 81 MG- Give 1 tablet by mouth one time a day for CAD- Carvedilol Oral Tablet 12.5 MG (Carvedilol) -Give 12.5 mg by mouth two times a day for HTN- Gabapentin Oral Tablet 100 MG (Gabapentin)- Give 100 mg by mouth three times a day for Neuropathy- levETIRAcetam Oral Tablet 500 MG (Levetiracetam) - Give 500 mg by mouth two times a day for SeizuresA medication administration observation was conducted with a Registered Nurse (RN/Staff #244) on July 31, 2025 for Resident #87. The RN was observed preparing the medications for administration on July 31, 2025 at 09:06AM. While preparing the medications, the RN stated that the medication orders were all red, referring to the Electronic Health Record. At this time, it was observed that the medication orders on the EHR were mostly red, with only a couple orders being yellow. When asked what the red meant on the EHR, the RN stated that the red meant they were overdue, while yellow meant due. The RN explained that these medications were due at 08:00AM, and it was currently 09:06AM, therefore the medications were past due. When asked why the medications were being administered at this time, and if she felt she had enough help and resources to administer medications timely, the RN stated that she had to care for twenty-seven patients, and she had to work really fast. The RN finished preparing the medications and then proceeded to administer the medications to Resident #87. Interview was conducted on August 1, 2025 at 10:18AM with a Licensed Practical Nurse (LPN/Staff #14), who stated that medications should be administered per the orders, and that staff typically have one hour before and one after a medication is due to administer the medication. Interview was conducted on August 1, 2025 at 1:59PM with the Director of Nursing (DON/Staff #125), who stated she would expect that her nurses ensure they check the rights of medication administration, including that they ensure they have the right person, right medication, and right dose. She also stated she would expect the staff to call the doctor if they found any errors. The DON stated the staff typically have an hour before and after a medication's scheduled time to administer the medication, and she would expect the staff to call the doctor if they were not administering within this timeframe. When asked to review Resident #139's order for Cholecalciferol, the DON confirmed that she would read the order as to administer 5 tablets of 1000 units, for a total dose of 5000 units, so this is what she would expect to be administered. Review of the facility policy titled, Administering Medications, revealed that medications should be administered in a safe and timely manner, and as prescribed. This policy indicated that medications should be administered in accordance with prescriber orders, including any required time frame. Additionally, medications should be administered within one hour of their prescribed time, unless otherwise specified.

Based on observation, staff interviews, and review of facility policy, the facility failed to ensure that there were no expired supplies readily available for resident use and that medications available for resident use had visible expiration dates. The deficient practice could result in an increased risk for side effects or ineffective drug therapy. The census was 172 and the sample consisted of 34 residents.Findings include:Observation of a medication cart conducted on [DATE] at 12:58PM revealed several single-dose blister packets of Omeprazole within a small compartment in the top drawer of the medication cart. These medications were stored without the original box. Observation of the individual medication packets revealed that the packaging did not indicate an expiration date for the medication.Interview was conducted on [DATE] at 1:00PM with the Licensed Vocational Nurse (LVN/Staff #77) who was assigned to this medication cart. The LVN looked at the packets of Omeprazole and confirmed that she could not locate an expiration date. The LVN stated that the medications come from a big box, which may have the expiration date, but the box was not retained. The LVN left to ask her supervisor how to locate the expiration date. Upon return, the LVN stated that she could not verify the expiration dates of the medications or how long the medications had been in the cart in this state, so she would dispose of the medications. The LVN then proceeded to remove the Omeprazole packets from the medication cart for disposal.Observation was conducted on [DATE] at 1:26PM in one of the facility's medication storage rooms. Observation in this room revealed a pile of blood culture collection kits on a shelf containing supplies and medications. Closer inspection of one of the kits revealed an expiration date of [DATE]. The nursing staff in the medication room were asked what the date meant. The staff then called in the Executive Director (ED/Staff #4) for assistance. The ED confirmed that the blood culture collection kit was expired, stating that the hourglass symbol beside the date symbolized the expiration date. The ED explained that the kits are not being used by the staff, but stated that they should not be in the medication room if they are expired. The ED then removed the expired kits for disposal. Interview was conducted on [DATE] at 1:59PM with the Director of Nursing (DON/Staff #125), who stated that she would expect medications would have the correct expiration date and should be the correct medication for the patient.Review of the facility policy titled, Medication Labeling and Storage, revealed that medications and biologicals should be stored in the packaging, containers or other dispensing systems in which they are received. The policy also indicated that if the facility had discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy should be contacted for instructions regarding or destroying these items.

Based on clinical record reviews, staff interviews, review of facility documentation and policy, and observation of current practice, the facility failed to evaluate and implement effective care plan interventions related to falls for one of two sampled residents (#156). The deficient practice resulted in the resident experiencing multiple falls in the facility, and could result in other residents failing to receive effective fall-prevention measures. The census was 172.Findings include:Resident #156 was admitted to the behavioral unit of the facility on June 25, 2025, with diagnoses displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, unspecified symptoms and signs involving cognitive functions and awareness, other abnormalities of gait and mobility, fall on same level, pain in left hip, parkinsonism, unspecified, unspecified dementia.Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating mental status interview was not successfully completed.Review of the resident care plan initiated on June 26, 2025, revealed that the resident had a witnessed fall and was at risk for a history of ground-level fall with Left hip fracture status post arthroplasty, weakness, decreased mobility, Parkinson's Disease. Initial intervention initiated on June 26, 2025, indicated evaluation of medications for side effects that may increase fall risk. Another Initial intervention was initiated on June 27, 2025, which included placing fall mats against the wall with family agreement.Review of the admission progress notes dated June 25, 2025, revealed that Resident #156 had a history of Chronic Obstructive Pulmonary Disease, Diabetes Mellitus Type 2, Dementia, Parkinson's, and falls; and, the patient recently fell, resulting in a clavicle fracture and two rib fractures; and that, the daughter stated the patient is a fall risk and will try to get out of bed on her own.Review of the resident fall risk assessment dated [DATE], revealed that resident #156 is non-ambulatory, uses a wheelchair, and has a history of three or more falls for the last ninety days.Further review of the resident's progress notes dated July 3, 2025, revealed that the resident was transferred from the behavioral unit to the dementia unit, accompanied by her daughter. The resident is alert and oriented with generalized weakness, Dementia, hip fracture, Surgical incision to the left hip, multiple bruises to the bilateral arms, and LE high fall risk. Introduced to the room and call light the bed is placed in a low position call light.On July 29, 2025, at 9:16 AM, the surveyor observed Resident #156 on the floor next to her Geri chair, which was located by the bedroom door. At the time of the incident, there were no staff present. A Certified Nursing Assistant (CNA) emerged from one of the resident rooms and informed the nurses, who were at the nursing station at that time. The staff then assisted the resident in assisting her back into her Geri chair.Review of the progress note dated July 30, 2025, revealed that the Interdisciplinary Team (IDT) met and reviewed fall for July 29, 2025 the resident noted purposefully placing self onto the floor from wheelchair. The resident had a full spoon, one fell onto the floor, and the resident purposefully placed herself onto the floor to get the spoon. Range of motion at baseline, no complaints of pain or discomfort noted. Per family resident who used to hoard items at home states she has pictures of what she used to do at home. She used to put herself down onto the floor all the time and would scooch on the floor.Further review of the Interdisciplinary Team (IDT) progress notes, regarding the resident's fall on July 29, 2025, revealed that prior intervention(s) included a fall mat next to the resident's bed while the bed is occupied. Perimeter overlay, anticipate and meet needs, and call light within reach. Additionally, the Interdisciplinary Team (IDT) recommends current intervention(s) such as staff provides frequent safety reminders.Review of the resident's revised care plan dated July 29, 25, revealed that the resident had two falls on June 27, 2025, before the resident transferred to the dementia unit from the behavioral unit, and on July 29, 2025, the resident purposefully placed herself on the floor.Further review of the resident's care plan initiated July 30, 2025, revealed that on July 29, 2025, the staff were to provide frequent safety reminders.An interview was conducted on August 1, 2025, at 9:45 AM with the Certified Nursing Assistant (Staff #243), who stated that if a CNA witnesses a fall, they must stay with the resident for their safety and use the pager to call the nurse. The nurse will then conduct an assessment. She stated that she has not witnessed an incident where the resident (#156) slid from her wheelchair. She added that the resident can grab onto the bar in the bathroom, pivot, and sit on the toilet. The CNA indicated that she wouldn't classify the resident as needing maximum assistance; rather, the resident's level of assistance required depends on how tired she is. The resident may require extensive or minimal assistance, but not maximum assistance. She stated that if the resident slides from the chair or wheelchair, that would be considered a fall.An interview was conducted on August 1, 2025, at 10:00 AM with the Licensed Practical Nurse (Staff #108), who stated that if a Certified Nursing Assistant (CNA) discovers a resident on the floor, they are not allowed to assist the resident. Instead, the CNA must notify the nurse. The nurse will then conduct a risk management assessment. If, during the assessment, it is determined that the resident hit their head during the fall, neurological checks will be performed for seventy-two hours. However, if the assessment shows that the resident did not hit their head, neuro checks are not necessary unless specifically ordered by a doctor. The LPN (staff #108) stated that sliding from a wheelchair, it is considered a fall.An interview was conducted on August 1, 2025, at 10:11 AM, with the Unit Supervisor (staff #90), who stated that the nurse typically reports, if there's any fall incident, so he can guide the staff on what the next steps are to taken. Whenever there is a fall, an Interdisciplinary Team (IDT) note is usually completed by the next business day, and the care plan is updated with the necessary interventions. Additionally, if there are any changes in a resident's condition, a seventy-hour charting is conducted. He mentioned that resident #156 was transferred from another unit. The unit manager added that resident #156 had two falls in June 2025, while in the behavioral unit before being moved to the dementia unit on July 3, 2025. The unit supervisor (staff #90) added that slipping from a chair or wheelchair was considered a fall.An interview was conducted on August 1, 2025, at 10:45 AM, with the Director of Nursing (staff #125), who stated that residents are assessed for fall risks upon admission and each time they experience a fall. If a Certified Nursing Assistant (CNA) finds a resident on the floor, they should stay with the resident and immediately call the nurse using a radio. The nurse will then assess the resident for injuries, contact the rapid response team if necessary, and inform the healthcare provider. If there are injuries, especially to the head, the resident will be taken to the emergency department for further evaluation. Each fall, will be reviewed, and new interventions will be implemented as needed. Both nurses and CNAs are responsible for ensuring that fall prevention interventions are effectively in place.During the interview, the Director of Nursing (staff #125) reviewed the care plan for resident #156. She explained that there are no interventions listed in the care plan because sliding from her Geri chair is a part of the resident's behavior.Review of the facility policy titled Falls and Fall Risk Managing, (revised 2018) revealed, based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on interviews, review of records, and review of facility policy and procedure, the facility failed to protect the rights of one of five sampled residents (#1) to be free from abuse by another resident (#3). The deficient practice could lead to ongoing abuse leading to harm of other residents. -Findings include: Resident #1 was admitted to the facility with an original admission date of November 02, 2021, with diagnoses that included psychotic disorder with hallucinations due to known physiological condition, personality change, alcohol dependence with alcohol induced persisting dementia, vitamin deficiency, generalized anxiety disorder and type 2 diabetes mellitus. A review of the quarterly minimum data set (MDS) dated [DATE] for Resident #1 revealed a brief interview of mental status (BIMS) of 07, which indicated the resident was severely cognitively impaired. Review of the electronic medical records (EMR) progress note dated June 20, 2025, 22:30, revealed Resident #1 was questioned by the police department regarding the altercation with another resident (#3). Resident #1 stated that he hot punched in the stomach a couple of times and that it didn't hurt. Review of the electronic medical records (EMR) progress note dated June 20, 2025, revealed nursing - comprehensive skin evaluation assessment type change of condition, section skin assessment comments documented, Resident has skin discoloration to arms and upper body. Resident #3 was admitted on [DATE] with diagnoses that included schizoaffective disorder, essential primary hypertension and type 2 diabetes mellitus. A review of the minimum data set (MDS) dated [DATE] for Resident #3 revealed a brief interview of mental status (BIMS) of 09, which indicated the resident was moderately cognitively impaired. A care plan initiated on April 30, 2024 with a revision on December 23, 2024 revealed that Resident #3 had a behavior problem related to schizoaffective disorder as evidenced by verbal aggression to staff/peers, physical aggression to staff/peers. Interventions initiated on April 30, 2024 included to intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to an alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. A behavioral progress note dated June 20, 2025 at 7:39 pm, revealed that Resident #3 was in the hallway between rooms [ROOM NUMBERS] when he came into contact with another resident and started punching that resident. That resident was Resident #1. Staff intervened and separated the two residents. Resident #3 started to yell and use foul language and hit staff. An interview was conducted on June 24, 2025 at 2:44 p.m. with certified nursing assistant (CNA/Staff #3) who stated that staff would need to separate both parties and make sure they are okay, and report immediately when abuse happens. A telephonic interview was conducted on June 24, 2025 at 2:58 p.m. with Licensed Practical Nurse (LPN/Staff #5) who stated, regarding the incident, that she was at the nurse's station and heard noises in the hall. A certified nursing assistant (CNA) was there with the residents. First CNA Staff #7 was there then CNA Staff #4 came to assist. CNA Staff #4 then stayed with Resident #3. Staff #5 stated that the incident was reported by LPN Staff #8 to the Director of Nursing (DON/Staff #6), right away. A telephonic interview was conducted on June 24, 2025 at 3:04 p.m. with CNA Staff #4 who stated that he did not see how the situation initiated, but jumped in to help separate the two residents and took Resident #3 back to his room; and that, Resident #3 was yelling and cursing when he returned to his room. Staff #4 stated the incident was reported immediately to the Administrator. An interview was conducted on June 24, 2025 at 3:33 p.m. with DON/Staff #6 who stated that psychiatrist and the medical provider were notified and got involved. Staff members were in-serviced about abuse and what to do if abuse happens. The staff were educated on keeping the residents separated; and that, if residents abuse other residents, they can be harmed. Review of facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, last revision date of September 2022 revealed 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. Review of facility's policy titled, Resident Rights, last revised date of February 2021 revealed the resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation.

Based on clinical record review, staff and resident interviews, facility documentation and policy review, the facility failed to confirm that an allegation of misappropriation was appropriately reported to the state agency (SA). Failing to report could lead to other residents property being misappropriated. Findings include: Upon review investigation of the allegation of misappropriation complaint, the source of complaint was found not to be from the facility but by another reporting source. A federally reported incident number was not located in the (SA) reporting portal or the Complaint system for federal complaints. A call was placed by the surveyor to the state agency (SA) on March 20, 2025 at 09:05 am to verify that the reportable from the facility was received via the reporting system. At 09:06 am, is was confirmed that no submission for the initial report was found submitted from the facility. An interview was conducted with resident #2 on March 20, 2025 at 12:11 pm who revealed that the resident originally reported the missing wallet in February, to a certified nursing assistant (CNA), a staff member that always helps the resident, but resident #2 could not think of her name. Nothing was done. Then resident #2 told social services director staff #6. An interview was conducted on March 20, 2025 at 1:05 pm with social services director staff #6 who confimed that she placed the initial report into the complaint portal for the state agency. Staff #6 stated a verification link appeared immediately when attempting to submit the complaint. When asked how long did you wait until clicking on the link to verify the email address? Staff #6 stated it was immediately then stated, maybe 2 to 3 minutes later and nothing happened. Staff #6 stated that you could be putting your residents in harms way, and not protecting your staff/families if not reporting abuse, neglect, misappropriation or any issues. Staff #6 confirmed that she did not call the SA to see if the report went through when asked if she followed up with the SA to see if it went through. Facility staff claimed to have reported the incident on March 11, 2025, however, review of the State Agency incident/complaint intake program did not document submission of the incident. The staff reported that they received an email requiring email verification in order to complete the incident/complaint submission process, however, the staff failed to verify their email address and then failed to follow up with the State Agency to ensure the incident was received. A copy of the email received from the Arizona Department of Health Services Licensing, to verify your email address was obtained from staff #6. The email revealed, Hi (Staff #6): Click below to verify your email address. Once your email address is verified, your complaint will be submitted to the Department for you review. This email was sent on Tuesday, March 11, 2025 at 2:53 PM within the time 2 to 3 minute time frame that Staff #6 claimed to have not received a response from the complaint submission. Further the 5-day facility investigation report, confirms documented by facility manager (Staff # 8) that at 2:52 PM the complaint was reported to the state agency. The link to verify was sent to staff #6 on March 11, 2025 2:53 pm. No other documentation available by facility that the complaint was submitted succesfully was received. An interview was conducted on March 20, 2025 at 2:13 pm with director of nursing (DON) staff #7 and revealed that not reporting abuse, neglect, misappropriation or any issues will leave residents at risk and the staff are mandated reporters. Review of the policy Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating has a policy statement that reads: 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. Reporting allegations to the administrator and authorities, section 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury b. states within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to implement adequate supervision to one resident (#3) which resulted in a fall with injury. The deficient practice could result in other injuries to residents. Findings include: Resident #3 was initially admitted on [DATE] and most recently on February 8, 2025, with diagnoses of Parkinson's disease, dementia, trans ischemic attack (TIA), fracture of nasal bones. A brief interview for mental status (BIMS) assessment dated [DATE], revealed resident #3 had a score of 6, indicating severe cognitive impairment. A minimum data set (MDS) assessment dated [DATE], revealed the resident had a fall history in the last month. A care plan dated January 13, 2025, revealed that resident #3 was at risk for falls, listing three falls after admission to the facility. January 14, 2025, January 18, 2025, January 24, 2025. Educate resident/family/caregivers/IDT as to causes date initiated: January 13, 2025. Fall interventions included: anticipate and meet needs with a revision on January 14, 2025, Psych eval, therapy screens date initiated: January 14, 2025. Floor mat next to bed while bed is occupied date initiated: January 15, 2025 with a revision on February 10, 2025. Follow facility fall protocol. Front wheeled walker next to bed, initiated January 21, 2025. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove potential causes if possible. Staff to intervene when ambulating without appropriate assistive devices, date initiated: January 27, 2025. A progress note dated January 20, 2025 at 12:52 pm revealed that the interdisciplinary team (IDT) met and reviewed the fall from January 18, 2025. The IDT recommended continuing with all current interventions at this time. A progress note dated January 27, 2025 at 7:18 pm revealed that the IDT met regarding the fall from January 24, 2025. Prior interventions, and anticipate needs. Current interventions, staff to intervene when ambulating without appropriate assistive device. Although careplan was reviewed and revised, progress notes revealed resident #3 required surgical care due to sustaining another fall. A progress note dated February 4, 2025 at 17:02:45 by registered nurse (RN) staff #2 revealed that resident #3 had, a skin tear on his right elbow today, patient got injured when rolling on the floor and certified nursing assistant (CNA) was attempting to assist him back on his floor mat. A progress note dated February 4, 2025 19:40 by RN staff #2 revealed resident #3 was sent to the emergency department (ED) for evaluation of right hip deformity. A progress note dated February 8, 2025 18:05 revealed that the resident returned to the facility with bruising to the left upper extremity (UE), bruising to left flank, left groin, right hip with three areas of staples (#10 to proximal, #10 to distal and #3 to medial), right lateral knee with #6 staples. Review of progress notes revealed s/p R ORIF hip fracture with IM rodding R femur (status post right open reduction internal fixation hip fracture with intramedullary rodding right femur). An interview was conducted on March 20, 2025 at 11:51 am with resident #3 family member who revealed was told that resident #3 fell out of bed, was on the floor, not walking anymore, and was sent to the hospital; and that the resident had a broken femur. An interview was conducted on March 20, 2025 at 1:10 pm with certified nursing assistant (CNA) staff #1 who revealed that she did not remember the resident falling, but would notify the nurse immediately and refrain from touching a resident until the nurse does an assessment. Then they will assist the resident up. An interview was conducted on March 20, 2025 at 1:12 pm with registered nurse (RN) staff #3 who revealed that if a resident falls you stay with them and ask if they hit their head, or if they have pain. Do not get them up. Get help and contact the provider, contact the unit manager, and contact the family. Lastly, fill out the risk management form. An interview was conducted on March 20, 2025 at 2:13 pm with director of nursing (DON) staff #7 who revealed that when a resident falls, the process is to ask the resident how it happened, call the provider, family if the provider wants to send to the hospital, look at the interventions, and review the fall event with the interdisciplinary team. Review of the policy titled, Falls and Fall Risk, Managing (revision date March, 2018) was reviewed revealed unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Section Monitoring Subsequent Falls and Fall Risk in the Falls and Fall Risk, Managing, revealed that if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.

Based on clinical record review, observation, interviews, and the facility policy and procedures, the facility failed to ensure that the physician and resident representative were notified of missed and rescheduled dialysis treatments for three of 10 sampled residents (#3, #9, #19); failed to ensure that pre and/or post dialysis assessment(s) were completed for resident (#18); and, failed to ensure dialysis policy contained the minimum requirements for the provision of dialysis services according to professional standards. The deficient practice could result in dialysis treatments and care not being met and not safely administered. Findings include: Regarding Incomplete pre and post dialysis assessments: -Resident #18 was admitted on [DATE] with diagnoses that included encephalopathy, dependence on renal dialysis, fluid overload, and unspecified kidney failure. A review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 15, which indicated the resident was cognitively intact. The physician order with start date December 10, 2024 revealed resident had scheduled transportation to receive dialysis every Tuesday, Thursday, Saturday located outside of facility. The care-plan initiated on December 19, 2024 revealed Resident #18 required hemodialysis due to end stage renal failure. The goal was for resident to be free of signs or symptoms of complications related to hemodialysis to extent possible. Interventions included obtain vital signs (pre- and post- dialysis). Review of the pre- and post- assessments for January 2025 revealed that pre- and/or post- dialysis assessment was not completed on January 2, 11 and 16, 2025. However, review of the clinical record revealed that the resident received dialysis treatment on January 2, 11 and 16, 2025. An interview was conducted on February 11, 2025 at 11:00 a.m. with Director of Nursing (DON/Staff #125) who stated that medication administration record (MAR) and treatment administration record (TAR) will have some information regarding dialysis; however, the pre- and post-dialysis assessments were required to be completed by nursing every time a resident have dialysis. She stated that TAR and MAR will have the same information, including the pre and post vitals which were signed off by the staff who provided the primary care. The DON stated that the providers should be aware that this information can also be found on other documents in the clinical record. The DON further stated that if there was a pre- and post-dialysis assessment, it was safe to assume that dialysis was provided to the resident. In a later interview with the DON (staff #125) conducted on February 11, 2025 at 12:54 p.m., the DON stated that Resident #18 received dialysis treatments at an outpatient dialysis center on Tuesdays, Thursdays, and Saturdays. During the interview, the DON reviewed the clinical record and stated that the facility had identified that night nurses had been charting assessments the day after the resident's dialysis. The DON said that she did have all the information regarding dialysis in one place or the other; but, the pre- and post dialysis assessments were marked as done in the MAR for resident #18. She said that there were days in the MAR which were incomplete and she was not sure why the information was missing. The DON also stated the progress notes in the clinical record were also missing information; but that, if there were vitals somewhere else in the clinical record, it indicated that the vitals were taken and it possibly was not entered in the right section in the clinical record. An interview was conducted on February 12, 2025 at 9:37 a.m. with a Licensed Practical Nurse (LPN/Staff #175) who stated that she assist residents to their dialysis appointments on time; and she evaluates resident before and after they have dialysis. The LPN said that she documents her assessment in the Nursing Pre- and Post-dialysis Communication Observation/Assessment form. She said that pre and post-assessment forms were done for every resident receiving dialysis and should be charted in the electronic medical system. The LPN stated that it was important that these forms were completed and to report the information to the provider; and that, if staff do not document or have inaccurate documentation it could be harmful and if there was something worrisome it will not be relayed to providers accurately. Regarding dialysis policy: Review of the facility's policy titled, End Stage Renal Disease, Care of a Resident with, revealed that residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. However, further review of the policy revealed that the policy did not include the following: -Procedures for the initiation, administration and discontinuation of HHD/PD treatments, type of monitoring required before, during and after the treatments, including documentation requirements; -Procedures for methods of communication between the nursing home and the dialysis facility including how it will occur, with whom, and where the communication and responses will be documented; -The development and implementation of a coordinated comprehensive care plan(s) that identifies nursing home and dialysis responsibilities and provides direction for nursing home staff; -The development and implementation of interventions, based upon current standards of practice including, but not limited to documentation and monitoring of complications, pre-and post-dialysis weights, access sites, nutrition and hydration, lab tests, vital signs including blood pressure and medications; -Management of dialysis emergencies including procedures for medical complications, and for equipment and supplies necessary; -The provision of medications on dialysis treatment days; -Procedures for monitoring and documenting nutrition/hydration needs, including the provision of meals on days that dialysis treatments are provided; -Responsibility for reporting adverse events, including who to report to, investigating the event and correcting identified problems; -Safe and sanitary care and storage of dialysis equipment and supplies; and, -Assessing, observing and documenting care of access sites, as applicable, such as: auscultation/palpation of the AV fistula (pulse, bruit and thrill) to assure adequate blood flow; significant changes in the extremity when compared to the opposite extremity (edema, pain, redness); steal Syndrome (pain, numbness, discoloration, or cold to touch in the fingers or hand indicating inadequate arterial flow); skin integrity (waxy skin, ulcerations, drainage from incisions); bruising/hematoma; collateral vein distension (veins in access arm close to AV fistula becoming larger); complaints of pain or numbness; or, evidence of infection at the surgical site, such as drainage, redness, tenderness at incision site, fever. In an interview with the Director of Nursing (DON/staff #125) conducted on February 11, 2025 at 11:39 a.m., the DON stated that the policy on ESRD that was provided to the survey team was the only policy the facility has regarding dialysis. An interview was conducted on February 12, 2025 at 9:34 a.m. with Director of Staff Development/Infection Preventionist (IP/Staff #101) who stated that she was not involved or have not contributed in the revision of the facility policy on dialysis. The IP stated that residents on dialysis automatically go on enhanced barrier precautions because these residents have a catheter; and that, the DON comes to her to review any infection sections, but that the DON has not come to her regarding dialysis infection control. Regarding notification of physician and resident representative: -Resident #3 was admitted into the facility on [DATE] with diagnoses of end stage renal disease, type 2 diabetes mellitus with other circulatory complications, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. The quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 13, which indicated the resident was cognitively intact. Review of a list of residents receiving dialysis at the in-house dialysis center revealed resident #3 received dialysis treatments in the facility. The physician order dated December 26, 2024 included for an in-house dialysis Monday, Wednesday, Friday one time a day for end stage renal disease. This order was transcribed onto the MAR (medication administration record) for January 2025. However, review of the MAR revealed dialysis was not marked as administered on January 1, 2025 (Wednesday) and was documented as 'See Nurses notes.' Review of progress notes dated January 1, 2025 revealed no documentation that the provider and the resident representative were informed of resident's missed dialysis appointment. The clinical medical record revealed no physician order to re-schedule the dialysis to January 2, 2025 or that the resident's representative was informed of the dialysis treatment being rescheduled to January 2, 2025. However, the post dialysis assessment revealed the resident had returned from dialysis on (Thursday) January 2, 2025 at 11:00 a.m. A progress note dated February 5, 2025 revealed that the resident did not have hemodialysis this day. The clinical record revealed no documentation thagt the provider and the resident representative was informed of the missed scheduled dialysis on February 5, 2025; and that, dialysis was rescheduled. Review of the post dialysis assessment dated [DATE] included that the resident had returned from dialysis on (Thursday) February 6, 2025 at 12:00 p.m. However, the clinical record revealed no evidence of physician order to re-schedule the dialysis to February 6, 2025. An interview was conducted on February 10, 2025 at 10:38 a.m. with Director of Nursing (DON/Staff #125) who stated that if residents do not refuse physician orders, it was the expectation that staff would follow the physician orders. She stated that whenever an order cannot be accomplished for any reason, the expectation was that it would be documented in the clinical records and the provider is notified. The DON stated that on January 1, 2025, New Years Day, in house dialysis treatment was not completed for resident #3; and that, the dialysis treatment was rescheduled to the following day January 2, 2025. The DON also stated that on February 5, 2025, in house dialysis treatment was not completed for resident #3 because of dialysis staffing shortage. She said that dialysis treatment for resident #3 was rescheduled to the following day February 6, 2025. A review of the clinical record was conducted with the DON who stated that the clinical record revealed no documentation that the provider was notified of the dialysis treatment not completed for resident #3 on January 1, 2025 because, it was a common knowledge that dialysis treatments are not provided on holidays. The DON also said that the clinical records did not have any documentation that the provider was notified of the dialysis treatment not completed for resident #3 on February 5, 2025 due to dialysis nurses calling off. Further, the DON stated that there were no changes to the physician order for in-house dialysis for resident #3 after the date the order had been initiated on December 26, 2024. 35111 -Resident #9 was admitted on [DATE] with diagnoses of acute on chronic systolic congestive heart failure, type II DM (diabetes mellitus), ESRD (end stage renal disease) and dependence on renal dialysis. The admission summary note dated November 27, 2024 included that the resident arrived at the facility, was alert and oriented x 2, and will be receiving in-house HD (hemodialysis) services provided by a contracted dialysis provider. Per the documentation the resident had HD catheter to the right upper chest. A physician order dated December 1, 2024 revealed to monitor HD access site on right chest port for redness, swelling, drainage and pain every shift and to notify physician if present. The care plan dated December 4, 2024 revealed the resident required hemodialysis due to ESRD, had a catheter located in the right chest and was at risk for complications. Interventions included to check the dialysis/catheter site dressing every shift and in-house dialysis every Monday, Wednesday and Friday. The clinical record revealed documentation that the resident received dialysis Monday-Wednesday-Friday except on January 1, 2025 (Wednesday). The MAR (medication administration record) for January 2025 revealed a transcribed order for in-house dialysis den Monday, Wednesday and Friday. The documentation in the MAR included that the resident was coded 9 which indicated to see nurses' note on January 1, 2024. The eMAR (electronic medication administration record) note dated January 1, 2025 revealed that the resident's dialysis was scheduled on January 2, 2025 (Thursday). However, the clinical record revealed no documentation that the resident refused to have dialysis on January 1, 2025; and, there was no documentation of a reason why dialysis was not provided to the resident on January 1, 2025. Further review of the clinical record revealed no evidence of physician order to re-schedule the dialysis to January 2, 2025. There was also no evidence found that the resident representative was informed of the missed schedule on January 1 and the rescheduled dialysis on January 2, 2025. The post dialysis assessment dated [DATE] revealed that the resident returned from dialysis on January 2, 2025 at 4:12 p.m. However, the MAR revealed that dialysis was documented/marked as X indicating dialysis was not administered on January 2, 2025. The pre- and post- dialysis assessment dated [DATE] revealed that the resident received dialysis treatment. There was no evidence found in the clinical record that the physician was notified that the resident received dialysis treatment for 2 consecutive days (January 2 and 3, 2025). -Resident #19 was admitted on [DATE] with diagnoses of ESRD, nutritional anemia and dependence on renal dialysis. The physician order dated August 29, 2024 included to monitor access site to the left chest for redness, swelling, draining and pain every shift; and, to notify the provider if present. The care plan dated August 29, 2024 revealed that the reside had an AVF (arteriovenous fistula) graft and central venous catheter and was at risk for clotting, impaired circulation, infection, narrowing and occlusion. Interventions included to follow physician orders for dialysis dressing care, observe access/shunt/catheter site for signs or symptoms of complication such as redness, pain, bleeding, unusual bruising, pus/drainage, absent thrill/bruit over graft site, complaints of coldness/numbness of hand/arm or chest pain and report abnormal findings to the physician. Another care plan dated August 29, 2024 revealed that resident required hemodiaysis due to ESRD and was risk for bleeding at access site, chest pain, deficient/excess fluid volume. Interventions included hemodialysis 3x a week every Monday, Wednesday and Friday, labs as ordered and report abnormal results to physician and to observe access/shunt/catheter site for signs or symptoms of complication (i.e., redness, pain, bleeding, unusual bruising, pus/drainage, absent thrill/bruit over graft site, complaints of coldness/numbness of hand/arm or chest pain) and report abnormal findings to the physician. A physician order dated August 30, 2024 revealed hemodialysis 3x/week every Monday, Wednesday and Friday. A physician order dated September 19, 2024 included for vital signs pre- and post-dialysis two times a day every Monday, Wednesday and Friday. The NP (nurse practitioner) note dated November 29, 2024 revealed the resident had diabetes mellitus, anemia, ESRD on HD. Intervention included to continue HD per nephrology. The dietary quarterly review note dated December 2, 2024 included that the resident was receiving HD treatment related to ESRD and weight fluctuations related to fluid shifts was anticipated. The NP note dated December 22, 2024 included that the provider was notified that the resident missed HD treatment due to transportation not showing up. Per the documentation, lab work was ordered and HD center to arrange any additional HD sessions. The nursing note dated December 23, 2024 (Monday) revealed that the resident returned from dialysis. The eMAR note dated December 25, 2024 (Wednesday) included that there was no dialysis appointment due to holiday. There was no evidence found that the physician and resident representative was informed of the missed dialysis schedule on December 25, 2024. There was also no evidence found in the clinical record that the missed dialysis for the resident was rescheduled. The nursing note dated January 1, 2025 included that the resident was picked up by transportation and retuned to facility due HD center being closed. The eMAR note dated January 1, 2025 (Wednesday) included that there was no dialysis appointment due to holiday. There was no evidence found that the physician and resident representative was informed of the missed dialysis schedule on January 1, 2025. There was also no evidence found that the missed dialysis treatment for resident #19 was rescheduled on a later date or time. An interview was conducted with the in-house dialysis tech (staff #283) on February 7, 2025 at 2:45 p.m. The dilaysis tech stated that only residents at the facility are provided with dialysis treatment in the in-house dialysis unit. He stated that the in-house dialysis unit were only open on Monday,Wednesday and Friday. During an interview with the in-house dialysis nurse (staff #280) conducted on February 7, 2025 at 2:50 p.m., the dialysis nurse stated that the in-house dialysis unit had been operational since August 2024; and, was only open Monday, Wednesday and Friday. The dialysis nurse said that the in-house dialysis unit was closed on February 5, 2025 because she did not have another staff to help her with the residents scheduled for dialysis. The dialysis nurse stated that dialysis treatment were not provided for residents scheduled on the 1st and 2nd shift of February 5; and that, she called the provider who agreed that dialysis can be done the following day. However, she stated that she did not have any documentation of the this. In an interview with a licensed practical nurse (LPN/staff #268) conducted on February 11, 2025 at 11:11 a.m., the LPN stated that the in-house dialysis gives the facility the weekly schedule for residents on dialysis; and that, all the residents at the facility that has dialysis go to the in-house dialysis unit. She stated that before and after dialysis, staff will take the resident's vitals, check the dialysis sites and conduct an pre- and post-dialysis assessment and document in the clinical record. She stated that if the resident refused or missed a dialysis treatment, she would inform the provider and talk with the resident if they wanted to go on a later schedule that same day. The LPN said that if the resident continued to refuse, she would call the provider to obtain an order for a laboratory work to check the resident's potassium level. She said that if the laboratory results were abnormal, she would then call the provider to send the resident to the hospital. An interview was conducted on February 11, 2025 at 11:39 a.m. with the director of nursing (DON/staff #125) who stated that the entries on the MAR (medication administration record)/TAR (treatment administration record) related to dialysis were not specific to whether or not the resident had dialysis or not. She stated that providers have access to the assessments in the clinical record if they want to know whether or not the residents had dialysis; and, if they had questions, they can also ask the staff. The DON also stated that the providers do not usually look at the MAR/TAR. She said that if there was a pre- and post-dialysis assessment, it was safe to assume that dialysis was provided to the resident. Regarding no dialysis on holidays, the DON stated that it was a common knowledge between dialysis and facility staff including providers that there is no dialysis on holidays; and, there was no sppecific order or policy regarding this because it is just known. Further, the DON stated that the provider is not going to create/change or sign each and every order just because there was no dialysis due to a holiday. The DON said that if it was a holiday, the dialysis unit is closed; and, if the resident really needed the dialysis, then the resident will be sent to the hospital for dialysis. Regarding the facility policy on ESRD, the DON stated that the policy provided to the survey team was the only policy for ESRD. An interview with a certified nurse assistant (CNA/staff #144) was conducted on February 12, 2025 at 8:38 a.m. The CNA stated that she takes the resident's vitals before and after dialysis; and if the results were abnormal, she will report it to the nurse. The CNA stated that if a resident refused to have dialysis, she will report it to the nurse who will then contact the dialysis center and, the dialysis nurse will instruct the facility nurse whether or not the resident was okay to miss their scheduled dialysis that day. During an interview with another LPN (staff #107) conducted on February 12, 2025 at 9:38 a.m., the LPN stated that before and after the resident goes to dialysis, she will conduct a pre-and post-dialysis assessment that include vital signs, checking of the bruits/thrills, any s/s of nausea, or that the resident was not feeling. She said that she will then document the assessment in the electronc record. She said that if everything was okay before dialysis, she would tell the CNA to take the resident to dialysis which usually about 3-4 hours. The LPN said that if there were recommendations/orders from the dialysis center, the dialysis nurse would usually call her but she would encourage them to document it in the electonic record. Further, the LPN stated that the residents on dialysis do not miss dialysis treatment because of holidays such as Christmas and New Year. She stated that the in-house dialysis at the facility runs on Monday-Wednesday-Friday; and, if a holiday falls on one of these days, the dialysis schedule will be changed to Tuesday-Thursday-Saturday; but this will be done or coordinated by the dialysis staff. She further stated that the physician and resident's responsible party will be notified of any changes in the residents medication/treatment such as missed dialysis, resident refusal of dialysis. The LPN further stated that if it was a missed dialysis, the responsible party usually would just ask what the provider ordered and usually would agree with what the provider said. An interview with the corporate resource (staff #284) was conducted on February 12, 2025 at 11:00 a.m. The corporate resource stated that when the scheduled dialysis falls on a holiday, the dialysis center run on a holiday schedule. She said that if the residents missed their dialysis, the provider will be notified and the provider will decide whether the resident will go to dialysis in the hospital or dialysis can be rescheduled. She stated that when dialysis is rescheduled for another day, there should be a physician order reflecting the change. The facility's policy titled, End Stage Renal Disease, Care of a Resident with, revealed that residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. The policy also included that if dialysis needs to be rescheduled for any reason including but not limited to holidays, emergency, illness, refusal, etc., a medical provider will be notified and resident is to be sent to hospital or another dialysis if deemed unsafe per physician order. It also included that the resident's comprehensive care plan will reflect the resident's needs to ESRD/dialysis care.

Based on clinical record review, observation, interviews, and the facility policy and procedures, the facility failed to protect the rights of one resident (#63) to be free from physical abuse by another resident (#48). The deficient practice could result in residents being physically injured. Findings include: -Resident #63 was admitted on [DATE] with diagnoses of Alzheimer's disease, depression, and history of falling. A review of the Quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 99, which indicated the resident was unable to complete the interview. The care-plan initiated on November 29, 2024 revealed that Resident #63 was resistive to care related to dementia, behaviors of refusing care, aimless wandering, exit seeking, intrusive at times. The goal was for resident to have decreased episodes of behavior. Interventions included to attempt to have 1:1 time when resident was having behaviors, allow wandering in safe areas within the facility, approach in calm, non-threatening manner, and provide redirection as needed. The nursing progress note dated February 9, 2025 revealed situation of change in condition on evaluation was reported as fall trauma. Per the documentation, the outcome of physical assessment functional status evaluation was a fall; and that, the skin initially noted with pinkness to right upper back. -Resident #48 was admitted on [DATE] with diagnoses that included dysphagia following cerebral infarction, cognitive communication deficit, agitation, and transient alteration of awareness. A review of the Quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 99, which indicated the resident was unable to complete the interview. The care-plan initiated on November 29, 2024 revealed that Resident #48 had a behavior problem related to dementia. The goal was for resident to have fewer episodes of refusing care and spitting on floor by review date. Interventions included to intervene as necessary to protect the rights and safety of others, approach/speak in calm manner, divert attention, remove from situation and take to alternate location as needed, monitor behavior episodes and attempt to determine underlysing cause, consider location, time of day, persons involved, and situations and to document behavior and potential causes. The nursing progress note dated February 9, 2025 revealed the resident had physical aggression and was a danger to self or others; and that, the facility was unable to report any of the occurrence to the local police department because the resident did not recall the alleged incident. Review of the facility investigation report dated February 10, 2025 revealed that a licensed practical nurse (LPN/Staff #205) reported that the LPN witnessed the alleged physical aggression after resident #48 swung at resident #63 who fell backwards and hit the wall. An interview was conducted on February 12, 2025 at 12:11 p.m. with family/resident representative (RR) for resident #63. The RR stated that he received a phone call the day the incident had occurred on the evening of February 10, 2025. The RR stated that he was not told whether resident #48 approached resident #63 or resident #63 approached resident #48, but that resident #48 had pushed resident #63 causing the resident to lose their balance and fall. An interview was conducted on February 12, 2025 at 12:16 p.m. with Certified Nursing Assistant (CNA/Staff #171) who stated that resident #48 hardly talked and recalled that when she was new at the facility resident #48 charged at her. The CNA stated that resident #63 was a pleasant little lady and a wanderer; and that could have been what happened because resident #63 liked to pick up stuff while wandering. An interview was conducted on February 12, 2025 at 12:39 p.m. with another Certified Nursing Assistant (CNA/Staff #137) who stated that he was currently on a 1:1 assigned supervision with resident #48 in order to make sure that others around him as well as the resident was safe. In an interview with administrator (Staff #278) conducted on February 12, 2025 at 12:48 p.m., the administrator stated that anytime there was an allegation of abuse, the expectation was that an investigation is started at the very least 2 hours after he was notified of the abuse. The administrator stated that following the allegation of abuse, the facility ensures that residents were properly assessed, and the interdisciplinary team will implement a 1:1 supervision. Regarding the incident between residents #48 and #63, the administrator said that the abuse incident was substantiated during facility's ongoing investigation because one staff witnessed resident #48 pushed resident #63. An interview was conducted on February 12, 2025 at 1:53 p.m. with Director of Nursing (DON/Staff #125) who stated that the risks of physical abuse, per the policy, were risks of injury that may lead to physical or psychosocial status changes; and has the potential to lead to further illness. The DON stated they were unsure how exactly the abuse occurred whether resident #48 hit or pushed resident #63, but, something happened so she would likely substantiate the incident. Further, the DON stated that any abuse in the facility did not meet the facility's expectations. The facility policy on Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating with revision date of September 2022 revealed that upon receiving any allegation of abuse, the administrator is responsible for determining what actions are needed for the protection of residents.

Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure the necessary treatment and services were provided for 3 of 32 sampled residents according to professional standards regarding following physician orders for two residents (#95 and #77) and behavior monitoring for one resident (#108). The deficient practice resulted in resident hospitalization and could result in residents not receiving the necessary treatment, services and monitoring they need. Findings include: -Resident #77 was readmitted on [DATE] with diagnoses of type 2 diabetes, end stage renal disease (ESRD), atherosclerosis of arteries, peripheral vascular disease and CHF (congestive heart failure). Re-admission progress notes dated April 22, 2024 and June 13, 2024, indicated that an amputation had been recommended but the resident declined at that time. The care plan dated December 13, 2021 revealed the resident needed cardiac monitoring related to diagnoses of CHF exacerbation, atrial fibrillation and CAD (coronary artery disease). Interventions included to administer medications as ordered, obtain and monitor lab/diagnostic work as needed and report results to physician and follow-up as indicated. The care plan dated April 29, 2024 included that the resident required ESP (enhanced standard precautions) related to wound, history of MRSA (methicillin-resistant staphylococcus aureus) and LAVF (left atrial vortex flow). The infection note dated July 8, 2024 revealed the resident had completed her IV (intravenous) antibiotic treatment for osteomyelitis and that the wound remained stable. Per the documentation, the resident was s/p (status post) debridement x 2, left lower extremity angiogram with revascularization. An NP (nurse practitioner) progress note dated July 21, 2024 included that the resident was seen and examined to monitor for s/p antibiotic therapy for left heel osteomyelitis secondary to MRSA infection. Assessments of bleeding, non-healing and stable left heel ulcer, worsening chronic stage IV bilateral heel ulcer and uncontrolled diabetes. Plan was to request second opinion on left foot wounds, recommend amputation and close monitoring of the wound. The skin/wound note dated July 23, 2024 revealed that the resident had osteomyelitis to the left heel; and that, on May 21, 2024 the wound team were re-consulted for the left heel deteriorating s/p skin grafting by podiatry. Per the documentation the skin graft failed and amputation was recommended but the resident declined. The NP progress note dated July 25, 2024 included an assessment of bleeding, non-healing and stable left heel ulcer, worsening chronic stage IV bilateral heel ulcer and uncontrolled diabetes. Plan was to request second opinion on left foot wounds and recommend amputation. An operative Report dated August 4, 2024, revealed that an angiogram was performed to improve the flow to the resident's wound as well as ensure adequate perfusion for any amputation she may need in the future. The 72-hour charting dated August 29, 2024 included that a doppler study performed and the results were pending; and that aspirin (nonsteroidal anti-inflammatory) remained on hold per vascular provider. The NP progress note dated August 30, 2024 revealed that the resident was seen and examined to follow-up on extremities arteries ultrasound results showed severe peripheral vascular disease with occlusion of mid-SFA (superficial femoral artery), distal SFA and popliteal, right lower extremity; and that, the bilateral lower extremities arterial US (ultrasound) results were sent to her vascular doctor office. Assessment included severe (PVD) peripheral vascular disease with occlusion of mid SFA, distal SFA and popliteal on the right lower extremity. Plan included US of the bilateral lower extremity arteries was completed on August 30, 2024. The 72-hour charting dated August 30, 2024 revealed that ultrasound to bilateral lower extremity arteries was faxed to a vascular center. The physician progress note dated September 2, 2024 included pending vascular surgery follow-up. Assessments included severe PVD with occlusion of mid SFA, distal SFA and popliteal, right lower extremity. Plan was for US of bilateral lower extremity arteries showed big severe PAD. The vascular outpatient progress note dated September 24, 2024 revealed that the resident's right toe wound was unchanged and the left heel wound was stable. The physician order included for right lower extremity angiogram. The 72-hour charting dated September 24, 2024 included that the resident returned from her vascular appointment; and that, orders were received for a right lower extremity angiogram. Per the documentation, there was no date and time for the right angiogram; and that, the unit secretary will reach out to the doctor's office the following day for the date and time of the angiogram. Further, the documentation included that the provider was aware. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The assessment also included the resident had one arterial ulcer-diabetic foot ulcer. The skin and wound evaluation dated October 2, 2024 included that the resident had new dehiscence surgical wound to the left heel, measuring 2.5 cm (centimeter) x 1.2 cm x 0.5 cm, with 100% of wound was filled with eschar, with light serous exudate, no odor, attached periwound edges, intact surrounding tissue and no induration. Treatment included normal saline, enzymatic debridement with dry dressing. The health status note dated October 10, 2024 revealed that the resident went for right lower extremity angiogram procedure. The 72-hour charting dated October 11, 2024 included that resident returned from angiogram appointment last night. Another 72-hour charting dated October 11, 2024 revealed resident returned from an angiogram appointment on October 10, 2024 at 9:00 p.m. Instructions included to follow-up with vascular surgeon in 2 weeks. The facility's appointment schedule included that the resident had a schedule to see the vascular clinic on October 22, 2024. The NP progress note dated October 22, 2024 included that the resident was scheduled to follow-up with vascular clinic today. A vascular outpatient progress note dated October 22, 2024 included physician orders for bilateral lower extremity ultrasound and bilateral antebrachial index (ABI) with toe pressures and to return to clinic in 2 weeks. Per the documentation, there were no concerns from a vascular post-op standpoint. The skin and wound evaluation dated October 23, 2024 included that the resident had new dehiscence surgical wound to the left heel, measuring 2.8 cm x 1.3 cm x 0.7 cm, with 100% of wound was filled with yellow/black eschar, with light serous exudate, no odor, attached periwound edges, intact surrounding tissue and no induration. Treatment included normal saline, enzymatic debridement with dry dressing. A nursing progress note dated October 23, 2024 revealed that progress note from the vascular clinic was received with new orders for bilateral lower extremity ultrasound, bilateral lower extremity ABI with toe pressures to be set up through the vascular provider and to return to clinic in 2 weeks. Per the documentation, vascular center will call the facility to inform when appointments have been made; and that, scheduling was aware to set up transport. The NP note dated October 24, 2024 included an assessment of severe PVD with occlusion of mid SFA, distal SFA and popliteal, right lower extremity. Plan was for Bilateral lower extremity ultrasound and bilateral lower extremity ABI with toe pressures in 2 weeks with vascular clinic. An appointment progress note dated October 28, 2024, included that a call to the vascular clinic to schedule a 2 week follow-up was made; and that, the facility was waiting for a response. Review of skin and wound evaluation dated October 30, 2024, revealed a left heel surgical dehiscence present on admission with 100% eschar present, slow to heal wound, stable and decreasing wound measurements, followed by wound clinic. The infection note dated November 4, 2024 included that the resident continued to be followed-up with the wound clinic and vascular surgery. Assessment included chronic osteomyelitis of the left foot. The NP note dated November 7, 2024 revealed that resident was seen and examined to follow-up on chronic conditions. Per the documentation, infectious disease follow-up was done related to osteomyelitis to the left heel and did not recommend any antibiotic therapy at this point. Assessment included severe peripheral vascular disease with occlusion of mid SFA, distal SFA and popliteal, right lower extremity. Plan was for a bilateral lower extremity ultrasound and Bilateral lower extremity ABI with toe pressures. Despite documentation of physician order for the bilateral lower extremity ultrasound and bilateral ABI with toe pressures, there was no evidence found that these orders were entered in the clinical record. Review of the clinical record revealed no evidence that the bilateral lower extremity ultrasound and bilateral ABI with toe pressures was scheduled or had been completed; the reason why it was not completed; and that, the provider was notified. There was also no evidence that the resident returned to the vascular clinic 2 weeks after the last visit in October 22, 2024. The skin and wound evaluation dated November 13, 2024 included that the resident had new dehiscence surgical wound to the left heel, measuring 2.3 cm x 1.0 cm x 0.5 cm, with 100% of wound was filled with yellow/black eschar, with light serous exudate, no odor, attached periwound edges, intact surrounding tissue and no induration. Treatment included normal saline, antimicrobial with dry dressing. The nursing note dated November 14, 2024 included that the facility received a call from the vascular clinic following up to see if the bilateral lower extremity ultrasound and bilateral lower extremity ABI with toe pressures had been completed. Per the documentation, the facility staff informed the vascular clinic that when the staff called the clinic on October 23, 2024, vascular clinic told staff that the clinic would be setting the procedure up and will call the facility when the appointment had been made. Further, the documentation included that the vascular clinic cancelled the follow-up visit because it was a follow-up after the procedures (i.e. bilateral lower extremity ultrasound and bilateral lower extremity ABI with toe pressures). The NP progress note dated November 17, 2024 revealed that vascular appointment was rescheduled because the resident was unable to get the bilateral lower extremity ultrasound and bilateral lower extremity ABI with toe pressures. The facility appointment records revealed that the resident was scheduled for a follow-up appointment with the vascular consultant on November 19, 2024. However, the 72-hour charting note dated November 19, 2024 revealed that the resident may go out of the facility with family despite having a vascular consultant appointment scheduled. There was no evidence found in the clinical record that the missed November 19, 2024 vascular consultant appointment was rescheduled. The skin and wound evaluation dated November 20, 2024 included that the resident had dehiscence surgical wound to the left heel, measuring 2.7 cm x 1.4 cm x 0.5 cm, with 80% of wound was filled with slough, 20% of wound was filled with yellow/black eschar, with moderate serosanguineous exudate, no odor, attached periwound edges, macerated surrounding tissue and no induration. Treatment included normal saline, enzymatic debridement with dry dressing. The NP progress note dated November 21, 2024 continued to have an assessment of severe peripheral vascular disease with occlusion of mid SFA, distal SFA and popliteal, right lower extremity; and continued to have a plan for bilateral lower extremity ultrasound and Bilateral lower extremity ABI with toe pressures. The skin and wound evaluation dated November 25, 2024 included that the resident had dehiscence surgical wound to the left heel, measuring 2.2 cm x 1.3 cm x 0.4 cm, with 100% of wound was filled with yellow/black eschar, with light serous exudate, no odor, attached periwound edges, intact surrounding tissue and no induration. Treatment included normal saline, enzymatic debridement with dry dressing. However, the clinical record revealed no evidence that the order for a bilateral lower extremity ultrasound or bilateral extremity ABI with toe pressures was completed since October 22, 2024; and that, the vascular provider was notified. There was also no documentation found of a reason why these procedures were not completed; why the vascular follow-up appointment was not rescheduled; and that, the resident refused the follow-up appointment and/or the completion of the bilateral arterial ultrasound or bilateral ABI with toe pressures as ordered. The late entry skin/wound note dated December 1, 2024 at 7:00 a.m. revealed that the night shift nurse notified the wound nurse that the resident had purple blisters to left lateral lower leg and left medial lower leg along with purple discoloration to left dorsum foot; and that, there was a faint pedal pulse to left foot. Per the documentation, the NP was notified and an order for a STAT venous/arterial ultrasound to the left lower extremity was received. The skin and wound evaluation dated December 1, 2024 at 9:18 a.m. included that the resident had dehiscence surgical wound to the left heel, measuring 3.0 cm x 1.3 cm with 50% of wound was filled with slough, 50% of wound filled with eschar, with light serosanguineous exudate, no odor, attached periwound edges, normal surrounding tissue and no induration. Treatment included normal saline, antibiotic and dry dressing. According to the documentation, the resident had faint pulse, NP was notified; and, the NP ordered for a STAT venous/arterial ultrasound. Another skin and wound evaluation dated December 1, 2024 included the resident had a new, inhouse acquired dark purple blisters to the front left lateral lower leg measuring 9.1 cm x 2.3 cm, with no signs of infection, no exudate, attached periwound edges, normal surrounding tissue, and no swelling. Treatment included normal saline and antimicrobial. Per the documentation, NP was notified; and, the NP ordered for a STAT venous/arterial ultrasound. The eINTERACT summary for provider note dated December 1, 2024 at 2:35 p.m. revealed that the resident had a change in condition related to skin wound or ulcer change in skin color or condition. Per the documentation, the resident had purple blisters to left lateral lower leg and left medial lower leg along with purple discoloration to left dorsum foot; and, faint pedal pulse to left foot. It also included that the NP ordered for STAT venous/arterial ultrasound to left lower extremity. The 72-hour charting dated December 1, 2024 included that the case manager of the resident's insurance was notified of the new blisters and bruising to the foot and the interventions at this time. However, there was no evidence found in the clinical record that the vascular surgeon/provider was notified of the resident's change in condition. The physician order dated December 1, 2024 included for STAT verbal orders for venous and arterial ultrasound to the left lower extremity; and that the reason for the procedure included faint pulse, new blisters, purple bruising to the foot. Despite the order being STAT, the unilateral lower ultrasound on the resident's left lower leg was completed only on December 2, 2024; and the results revealed diffusely abnormal monophasic waveforms, suggestive of peripheral atherosclerotic vascular disease (PAD). The skin/wound note dated December 2, 2024 included that the resident had an altered mental status, was slightly confused and complained of increase pain to the left foot. Per the documentation, the left lower extremity blisters and dark discoloration to left dorsum foot was worsening and the pedal pulses was diminished. It also included that the NP was notified and an order for STAT CBC (complete blood count)/BMP (basic metabolic panel) and 3 view X-rays of the left foot and ankle. Per the documentation, the infectious disease provider was also notified and consulted; and that the infectious disease provider evaluated the resident's left lower extremity. The documentation also included that the infectious disease provider requested to send the resident to the ER (emergency room ) for evaluation of wet gangrene to the left dorsum foot/toes and diminished pulses; and that, the resident was transferred to the hospital. The physician order dated December 2, 2024 included for STAT X-rays of the left foot/ankle 3 views for left ankle bruising/swelling/trauma. The infection note dated December 2, 2024 revealed that infectious disease was consulted for new onset black discoloration of her left foot and blisters on the left lower extremity. Assessment included wet gangrene of the left foot, diminished pulses and cool to touch. Recommendation included for sending the resident out to the ER for evaluation of acute left lower extremity ischemia. The 72-hour charting dated December 2, 2024 revealed that the case manager was notified that the resident was sent to the hospital. An eINTERACT transfer form dated December 2, 2024, revealed the resident had an unplanned transfer was transferred to the hospital due to having no left foot pedal pulse. The nursing note dated December 3, 2024 revealed that the resident was admitted to the hospital and that according to the hospital nurse, the resident will have an amputation of the lower left limb. The 72-hour charting dated December 13, 2024 included that the resident returned to the facility; and that, a treatment order was discontinued at this time because the resident had an amputation and new wound care orders were received. An interview was conducted on February 5, 2025 at 8:28 a.m. with a licensed practical nurse (LPN/staff #4) who stated that nursing reviews the provider consultation evaluation/follow-up packet that residents bring back to the facility after an off-site provider appointment. She stated that she reviews the packet for any new or changed orders and follow-up appointment schedules. She also stated that nursing then enters any orders written on the paperwork into the electronic medical record (EMR), the facility provider is notified of new/changed orders, and then the records/packet is given to medical records for scanning in to the EMR. The LPN further stated that follow-up instructions are then entered as an order, including labs diagnostics date/times and follow-up appointment date/time, so the care is coordinated with all staff/providers. She stated that scheduling staff was responsible to ensure that all follow-up testing was scheduled, and the scheduling staff will then enter the order on the medication administration record (MAR) for nursing staff to see, including all follow-up appointments and testing. The LPN stated that the providers were good at notifying the facility if something needs to be done immediately, and it would be written in the paperwork. Further, the LPN stated that she was not sure how soon testing should be completed when ordered and the answer to this would come from the Medical Director. In an interview with the Medical Records Director (MRD/staff #160) conducted on February 5, 2025 at 10:19 a.m., the MRD stated that all provider evaluations/referrals are placed in the EMR. She said that when residents return from an offsite evaluation/specialist visit, the resident would give a packet from the clinic to the nurse who then would enter any orders including diagnostic testing and follow-up appointments. She further stated that if diagnostic testing was ordered for an arterial doppler it would be performed in-house, at an outpatient testing facility or the hospital. She also stated that all appointments for follow-up or diagnostic testing would be placed in the appointment section of the EMR. A review of the clinical record was conducted during the interview with the MRD who stated that there was no evidence that the vascular testing (bilateral arterial ultrasound or bilateral ABI with toe pressures) was scheduled or completed from October 22, 2024 through November 30, 2024; and, she was not sure why they were not completed. She also stated that there was no evidence in the clinical record that the resident went to the vascular appointment scheduled on November 19, 2024 or this appointment was rescheduled for a later date. She said that when a scheduled appointment was missed, the unit managers would inform medical records staff so they can follow-up on it. The MRD stated that she was not sure how this fell through the cracks; and, the resident's clinical record showed that the resident did not go to the follow-up appointment nor was the appointment rescheduled. She further stated that there was no evidence in the clinical record that the vascular consultant office called back with a date/time for the bilateral arterial doppler and bilateral ABI with toe pressures; and that, the facility staff followed up on the schedule. The MRD stated the risk of not completing vascular testing timely as ordered could result in the development of other issues. A phone interview was conducted February 5, 2025 at 10:19 a.m. with a vascular provider's office staff (Vascular/staff #301) with the facility's MRD (staff #160) present. The vascular office staff stated that the resident's last vascular appointment was on October 22, 2024, and the November 19, 2024 appointment was cancelled. The vascular office staff stated that the only vascular test results they had were completed on August 30, 2024 and January 8, 2025. Vascular staff #130, also stated that they did not have any appointments scheduled for vascular testing between October 22, 2024 and January 1, 2025. During an interview with the Director of Nursing (DON/staff #157) conducted on February 6, 2025 at 2:42 p.m., the DON stated that the facility policy was to follow physician orders as written, including any orders from outside providers. The DON reviewed the clinical record of resident #77 and stated that the vascular provider note dated October 22, 2024 indicated that the vascular provider recommended a bilateral extremity arterial doppler, ABI with toe pressures and to follow-up on 2 weeks. However, she stated she was not sure if the tests were completed at the appointment or were it was to be ordered/completed by the facility. She also said that the she did not see any vascular testing after October 22, 2024 or before December 2, 2024 found in the resident's clinical record; and that, the October 22, 2024 order should have been clarified by nursing, to find out if the testing had been completed at the office, or needed to be scheduled. The DON also stated that there was also no evidence that the order was clarified with the vascular provider; and that, the nursing progress note dated October 23, 2024 stated that the tests were to be set up with the vascular provider. However, the DON said there was no evidence in the clinical record that the appointments had been made, or of any follow-up with vascular on the status of appointments for the tests. Further, the DON stated that the resident had refused amputation for a long time and it was a lot to expect that facility would follow-up on the appointment status, especially when the resident was alert and oriented. The facility policy on Social Services Referrals, revealed that social services personnel shall coordinate most resident referrals with outside agencies. Referrals for medical services must be based on physician evaluation of resident need and a related physician's orders. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. Social services will document the referral in the resident's medical record. Social services will help arrange transportation to outside agencies, clinic appointments. 46606 -Resident #108 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, major depressive disorder, and mental disorder. A cognition care plan initiated on June 17, 2024 revealed that resident had impaired cognitive function/impaired thought process related to impaired decision making. Interventions included to administer medications as ordered, monitor/document/report to physician any changes in cognitive function, and review medications and record possible causes of cognitive deficit. Review of a behavioral care plan initiated on June 19, 2024 revealed the resident had behavior problem related to history of substance abuse with anoxic brain damage; behaviors of psychosis, refusing care/medication/showers, sexual behaviors/sexual talks to female staff, verbal aggression towards staff/angry outbursts, exposing self to female staff, physical aggression to staff, taps on staff shoulders to say what's up. Interventions included to administer medications as ordered; follow behavior treatment plan approaches; intervene as necessary to protect the rights and safety of others; monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved, and situations; and, to document behavior and potential causes. The behavior note dated December 1, 2024 included that the resident had physical and verbal aggression towards staff and resident. Per the documentation, the resident was removed from the environment, was redirected and was placed on 1:1. The behavior note dated December 2, 2024 revealed that the resident was yelling out in the dayroom not directed at any particular resident. A behavior note dated December 10, 2024 revealed that resident went out of his room with no pants on, was assisted back to his room and was instructed to put his pants back on. Per the documentation, the resident went out in the hallway and was sexually inappropriate and was redirected back to his room. The eINTERACT summary dated December 12, 2024 revealed that the resident was coming out of his room and another resident was walking towards his room. A certified nurse assistant (CNA) stepped behind the other resident to let resident #108 who then swung his arm in the direction of other resident's chest area. Per the documentation, both residents were separated and resident #108 denied hitting the other resident. The behavior note dated December 12, 2024 included that the resident was verbally and physically aggressive; and that, the psych provider was notified. Per the documentation, the provider ordered for an antianxiety medication to be re-instated. The physician progress note dated December 16, 2024 revealed that the resident was seen and evaluated. Assessments included anoxic brain injury, major neurocognitive disorder and major depressive disorder. Plan included to admit the resident to the locked unit. The 72-hour charting dated December 16, 2024 included the resident wandered to and from his room several times, had verbal outbursts and was able to be redirected. The 72-hour charting dated December 17, 2024 revealed that the resident grabbed a supplement drink from the nurse's cart when he was walking in the hallway; and, was verbally aggressive when asked to put it back. A physician order dated December 20, 2024 included to monitor for physical/verbal aggression, delusions and inappropriate sexual behavior, record the number of episodes every shift, and, to use 0 for none. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 indicating that the resident had severe cognitive impairment. The MDS also said that the resident exhibited wandering behavior which occurred 1-3 days during the assessment period; and, had no indicators of psychosis, behavioral symptoms, and rejection of care at the time of the assessment period. The behavior note dated December 26, 2024 revealed the resident wandered around the unit and had restlessness. The eMAR (electronic medication administration record) note dated December 27, 2024 revealed that the reside had restlessness, was sexually inappropriate towards female staff and was redirected. The behavior note dated December 27, 2024 included the resident was sexually inappropriate towards female staff and was redirected as needed. The behavior note dated December 30, 2024 revealed the resident was ambulating to and from room several times and was redirected without difficulty. The behavior note dated January 4, 2025 included that the resident was awake throughout the night and came out of his room [ROOM NUMBER] times. Another behavior note dated January 4, 2025 revealed the resident wandered around the unit, talked to self and answered questions, and was verbally aggressive towards staff. A behavior note dated January 5, 2025 revealed that the resident was coming out of his room and was sexually inappropriate towards a female CNA. Per the documentation, the resident was showing the CNA his penis, told the CNA that he wanted to have sex with her, and followed the CNA around until the CNA got to the nurse's station. The documentation also included that the resident was redirected back to his room. Another behavior note dated January 5, 2025 included that the resident had verbal aggression, made sexually inappropriate comments towards female staff and was redirected as needed. The behavior note dated January 6, 2025 revealed that the resident was verbally and physically aggressive to staff. The late entry NP (nurse practitioner) note dated January 10, 2025 revealed that the resident was alert and oriented x 3, was delusional, paranoid, disheveled, mumbling, unable to complete sentences, was making unintelligible sentences, elevated, somatic with flight of ideas, clearly lacked insight and exhibited poor judgment. Per the documentation, staff reported that the resident was verbally and physically aggressive to staff, refused to take his shower and was interacting with staff inappropriately at times. The behavior note dated January 11, 2025 included that the resident was walking down the hallway on the unit and was redirected away from the red boundary lines. The documentation included that the resident was resistive to the redirection. The behavior note dated January 18, 2025 revealed the resident was over by another room and told staff he was looking for the bathroom. Per the documentation, the resident was redirected to his room on the other side of the hallway and the resident was resistive to redirection and put his hand up to staff members. The documentation included that after informing the resident that his room had a bathroom and he was free to use it, the resident went willingly back to his room. A late entry NP note dated January 21, 2025 revealed that the resident was verbally aggressive towards staff sexually; and that, staff reported that the resident was interacting with staff inappropriately. Psychiatric diagnosis included Schizoaffective disorder bipolar type. Per the documentation, the diagnosis was updated on January 10, 2025 due to mood swings/shifts, trouble concentrating, several notes that describe ongoing psychosis, bizarre and aggressive behaviors noted by staff and was responding to internal stimuli. The physician order dated January 21, 2025 revealed an order to monitor for verbal aggression, and record number of episodes every shift. The 72-hour charting note dated January 28, 2025 included that the resident was administered with his as needed anti-anxiety after dinner because he was pursuing another resident with aggressio[TRUNCATED]

Based on observations, interviews, clinical record review, and review of facility policy, the facility failed to ensure pressure ulcer was assessed, monitored and treatment was provided for one sampled resident (#95). The deficient practice could result in development and/or worsening pressure ulcers. Findings include: Resident #95 was admitted on [DATE], with diagnoses of chronic respiratory failure, quadriplegia, tracheostomy status, dependence on respirator (ventilator) status, cerebellar stroke syndrome, history of sudden cardiac arrest, and chronic pain. The care plan dated November 29, 2023 revealed the resident was at risk for skin breakdown related to quadriplegia and hypoxia. Interventions included to administer medications/treatments/diet/supplements as ordered, air mattress as ordered, apply barrier cream as indicated, assist to turn and reposition as indicated/tolerated, check skin during daily care provisions, monitor skin with use of device(s) (i.e., brace, cast, splint etc.) for skin breakdown and notify the physician of abnormal findings and non-compliance with treatment. The skin/wound note dated October 15, 2024 included that the resident acquired new stage III pressure ulcer to the right buttocks, measuring 3.3 cm (centimeters) x 2 cm x 0.2 cm depth, with moderate amount of serosanguineous drainage and wound bed with 76%-100% pink granulation. Wound orders included for normal saline, calcium alginate (non-occlusive dressing) and dry dressing daily, offloading, repositioning per facility policy, ROHO to chair if available and offloading mattress. A physician order dated October 23, 2024 included to clean the right buttock with normal saline, apply calcium alginate, cover with dry protective dressing daily and as needed. The skin/wound note dated October 29, 2024 included that the resident stage III pressure ulcer to the right buttocks, measuring 1.45 cm x 1.1 cm x 0.2 cm depth, with moderate amount of serosanguineous drainage and wound bed with 76%-100% pink granulation. Wound orders included for normal saline, calcium alginate and dry dressing daily, offloading, repositioning per facility policy, ROHO to chair if available and offloading mattress. The comprehensive skin evaluation dated November 5, 2024 revealed that the resident had no identified or existing wounds or skin integrity concerns. However, the skin/wound note dated November 5, 2024 included that the resident unhealed stage III pressure ulcer to the right buttocks, measuring 1.1 cm x 0.8 cm x 0.2 cm depth, with moderate amount of serosanguineous drainage and wound bed with 76%-100% pink granulation. Wound orders included for normal saline, calcium alginate and dry dressing daily, offloading, repositioning per facility policy, ROHO to chair if available and offloading mattress. The wound treatment order continued to be transcribed onto the TAR (treatment administration record) for November 2024 and revealed that treatment was documented as administered as ordered except for November 2, 2024. The clinical record revealed no documentation of why the treatment was not provided on November 2, 2024; and that, the provider was notified. The skin/wound not dated November 19, 2024 revealed that the stage III pressure ulcer to the right buttock was resolved. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident did not complete the Brief Interview for Mental Status (BIMS) assessment due to being rarely or never understood. The assessment also included that the resident was dependent on caregivers for toileting, hygiene, clothing management, bed mobility, and transfers from bed to chair. A late entry skin/wound note dated December 3, 2024 revealed that the resident had a re-opened stage III pressure ulcer to the right buttock, measuring 0.9 cm x 0.6 cm x 0.1 cm, with small amount of sero-sanguineous drainage, wound bed with 26-50%, pink, granulation and 26-50%epithelialization. Treatment recommendation included for cleaning the wound with normal saline, barrier cream (Triad) every shift and PRN (as needed), offloading, reposition per facility protocol and offloading mattress. However, the comprehensive skin evaluation dated December 3, 2024 revealed that had no one or more newly identified or existing wound or skin integrity concerns. A physician order dated December 4, 2024 included to apply Triad to buttocks every shift and as needed for episodes of soiling. The skin/wound note dated December 10, 2024 included that the stage III pressure ulcer to the right buttocks had received an outcome of resolved. The weekly comprehensive skin assessment dated [DATE] revealed the resident had an open area to sacrum with wound team following the wound and treatment/skin interventions in place. The assessment did not include the type and description of the wound. The weekly comprehensive skin evaluation dated December 24, 2024 included that the skin was intact; and, the resident had no one or more newly identified or existing wounds or skin integrity concerns. The treatment order for Triad was transcribed onto the TAR for December 2024 and revealed that the Triad was not documented as administered on the night shift of December 6 and December 24, 2024. The clinical record revealed no documentation of why the treatment was not provided on December 6 and 24, 2024; and that, the provider was notified. The weekly comprehensive skin evaluation dated December 30, 2024 included that the resident had no one or more newly identified or existing wounds or skin integrity concerns. The skin/wound note dated December 31, 2024 revealed that the resident had a stage 3 pressure ulcer to the right buttocks. However, the documentation did not include whether this was a new or reopened wound; and, the documentation did not include the description of the wound. It also did not include any open or resolved wound to the sacral area. The NP (nurse practitioner) note dated January 5, 2025 revealed skin was warm and dry and to see the wound assessment. Plan included for wound care as needed and preventative skin care per nursing/facility protocol. The weekly comprehensive skin evaluation dated January 7, 2025 included that the skin was cyanotic and the resident had no one or more newly identified or existing wounds or skin integrity concerns. The skin/wound note dated January 7, 2025 revealed resident had an abdominal wound on the left upper quadrant. The documentation did not indicate any open or resolved wound to the buttocks/sacral area. The NP note dated January 10, 2025 included that the resident had a rash to the left flank and back. The documentation did not include any open or resolved wound to the buttocks/sacral area. The weekly comprehensive skin evaluation dated January 13, 2025 included that the skin was dry and intact; and, the resident had no one or more newly identified or existing wounds or skin integrity concerns. The documentation did not indicate any open or resolved wound to the buttocks/sacral area. The skin/wound note dated January 15, 2025 revealed resident had an abdominal wound on the left upper quadrant. The documentation did not indicate any open or resolved wound to the buttocks/sacral area. A physician progress note dated January 15, 2025 included skin was warm and dry and to see wound assessment. Assessment included atypical rash. Plan included wound care and preventive skin care per nursing/facility protocols. The documentation did not indicate any open or resolved wound to the buttocks/sacral area. The weekly comprehensive skin evaluation dated January 20, 2025 included that the skin was dry, intact, warm and moist. It also included that the wound to the left 1st digit of the foot; and that, the resident had no one or more newly identified or existing wounds or skin integrity concerns. The documentation did not include any open or resolved wound to the buttocks/sacral area. The weekly comprehensive skin evaluation dated January 27, 2025 included that the skin was warm, oily and moist. It also included an open area to left ischial, red raised bumps from upper back to back of thighs; and that, wound care was daily and as needed. The skin/wound note dated January 27, 2025 revealed that the resident was started on an antibiotic therapy for a new wound to the left ischium. The treatment order for Triad to buttocks continued to be transcribed onto the TAR for January 2025 and was documented as administered. Review of the clinical record revealed no evidence that the open area to the sacrum was assessed and monitored after it was identified on December 18, 2024. There was also no documentation whether or not these wounds have healed/resolved from December 19, 2024 through January 27, 2025. There was also no evidence that the stage 3 pressure ulcer to the right buttocks was assessed and monitored after it was identified on December 30, 2024. There was also no documentation whether or not these wounds have healed/resolved from December 30, 2024 through January 27, 2025. Despite being care planned, there was no evidence that the use of pressure-relieving cushion was implemented. A review of the Certified Nurse Assistant (CNA) task log from January 6 to February 3, 2025, indicated that the resident was turned and repositioned three or more times on each date, except for January 7, 8, 15, 18, 20, 22, 31, and February 3, 2025, when the documentation showed the resident was turned and repositioned only twice on these specific dates. A skin/wound note dated January 28, 2025 revealed stage III pressure ulcer to the left ischial, measuring 0.8 cm x 0.4 cm x 0.1 cm, with small amount of serous drainage, and wound bed had 51-75% pink granulation and 1-25% epithelialization. Treatment included to cleanse the wound with normal saline or wound cleanser, barrier cream (Triad) twice daily, every shift and as needed. The documentation did not include any wound to the right buttocks. A physician order dated January 28, 2025 included to clean the left ischial wound with normal saline or wound cleanser and apply barrier cream every shift and as needed. The 72-hour charting note dated January 30, 2025 included that wound was assessed by the wound nurse, the provider was notified and treatment was ordered and was in place. The care plan dated January 30, 2025 revealed the resident had a pressure ulcer to the sacrum and was at risk for further breakdown and/or slow, delayed healing related to impaired mobility and incontinence. Interventions included to administer medication/treatment/vitamins/nutritional supplements as ordered, apply barrier cream as indicated, air mattress/pressure reducing mattress, pressure reducing cushion for chair, turning/positioning as tolerated. The skin/wound note dated February 4, 2025 revealed the resident had three pressure wounds: -Stage III pressure ulcer to left ischial, measuring 0.6 cm x 0.5 cm x 0.1 cm depth, with small amount of serous drainage, and wound bed with 51-75% pink granulation and 1-25% epithelialization; -Stage III pressure ulcer to right ischial tuberosity, measuring 2 cm x 1 cm x 0.1 cm, with small amount of sero-sanguineous drainage, and wound bed with 51-75% pink granulation and 1-25% epithelialization; and, -Deep Tissue Pressure Injury to the sacrum, non-blanchable, with deep red, maroon, or purple discoloration, measuring 2.9 cm x 1.4 cm, with scant amount of serous drainage and wound bed with 76-100% epithelialization. A wound care observation conducted on February 5, 2025, at 9:45 a.m. with a wound nurse (staff #40). The resident had open wounds to both the left and right ischial tuberosities and had an opened deep tissue injury to the sacrum that had a purple discoloration. An interview was conducted on February 5, 2025, at 10:03 a.m. with the wound nurse (staff #40) who stated that the resident's left ischial wound was first noticed by staff on January 27, 2025, the sacral wound was first noticed on January 30, 2025, and the right ischial wound was first noticed on February 3, 2025. The wound nurse stated that these wounds were pressure-related, and it likely occurred because of a combination of factors such as bowel incontinence, loose stools, history of previous pressure wounds and the resident's family sometimes wants the resident up in a wheelchair. The wound nurse said that the resident should have a Roho cushion (seating solution for preventing and treating pressure ulcers) for the wheelchair and confirmed that there was an order in place for a Roho cushion; and that, the resident should not be in the wheelchair for more than 2 hours at a time. An observation was conducted on February 5, 2025, at 10:15 a.m. of the resident's room. The resident was sitting in a plain cushion in his tilting and reclining wheelchair. The resident was not sitting on a Roho cushion. An interview was conducted with the director of rehab (DOR/staff #266) on February 5, 2025, at 10:24 a.m. The DOR stated that the facility manages the pressure-relieving wheelchair cushions by communicating back and forth between the wound team and the therapy team to provide the resident with whatever cushion that was recommended. The DOR stated that a Roho cushion was an air cushion that has pillars filled with air that distributes the resident's weight evenly to reduce pressure points. The DOR also said that other cushions do not relieve pressure; and that, a Roho cushion would be indicated for a resident who has wounds, has difficulty relieving their pressure, has difficulty repositioning or if the resident were paralyzed or quadriplegic. An observation with the DOR was conducted immediately following the interview. The DOR stated that resident #95 was unable to reposition himself; and that, the wheelchair could be tilted back to relieve some of the pressure on the resident's bottom. However, when the DOR demonstrated the tilt-back function, the DOR reached for the handle which was behind the resident's back to release the tilt function. The DOR further stated that the resident's tilt-back wheelchair had a cushion on it, but it was not a Roho cushion or a specialized air cushion. In an interview with a certified nurse assistant (CNA/staff #400) conducted on February 6, 2025, at 12:37 p.m., the CNA stated that residents who were unable to reposition themselves get turned and repositioned by staff every two hours; and there were 3 shifts for CNAs per day. The CNA stated that staff was not required to document every time a resident was turned or repositioned; however, it was required that staff document to be documented at least once per shift. The CNA also stated that, and that there are 3 shifts for CNAs per day. The further stated that there should be at least 3 documented entries on the task log for turning and repositioning; and that was once per shift. An interview was conducted with the Director of Nursing (DON/staff #157) on February 6, 2025, at 1:33 p.m. The DON stated that the facility's process for preventing pressure ulcers included completing a Braden risk assessment, the wound nurses putting interventions in place, and residents were offered to be repositioned every 2 hours while awake. The DON stated that other interventions such as low air loss mattress, offloading devices, specialized wheelchair cushions, and customize wheelchairs were also put in place as indicated. She said that she believed that a pressure ulcer was a disease process and not related to an event; and that, it would be important for the facility to provide all interventions necessary to prevent pressure ulcers. The DON further stated that if a resident did not receive the recommended intervention/s, it could result in an increased risk of skin breakdown. Regarding resident #95, the DON stated that the order for the Roho cushion was dated and just placed on February 5, 2025; and, turning and repositioning of the resident was documented on the MAR. Review of the facility's policy on Pressure Injury Risk Assessment revealed a purpose to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PIs). Risk factors that increase a resident's susceptibility to develop or to not heal PIs include impaired/decreased mobility, the presence of previously healed or existing PIs, exposure of skin to urinary or fecal incontinence, impaired sensory perception, and cognitive impairment. Once risk factors are identified, a resident-centered care plan can be created to address modifiable risks for pressure injuries. Conduct a comprehensive skin assessment with every risk assessment. Interventions must be based on current, recognized standards of care, and the effects of the interventions must be evaluated. Review of the facility's policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised March 2014, revealed the nursing staff and physician will assess and document a resident's significant risk factors for developing pressure sores. The nurse shall describe and document and report the full assessment of pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue; and current treatments. Additionally, the physician will help identify factors contributing or predisposing residents to skin breakdown. The physician will authorize pertinent orders related to wound treatment, and identify medical interventions related to wound management. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive or non-healing wounds. The facility policy on Repositioning, revised May 2013, revealed that repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief, and is critical for a resident who is immobile or dependent on staff for repositioning.

Based on observation, clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure that interventions regarding activities for resident #69, skin issues for one resident (#95) was implemented as care planned; and failed to ensure a care plan was developed with interventions implemented related to oxygen use for one resident (#153). Sample size was 3. The deficient practice could result in residents needs not being met according to their assessed needs. Findings include: -Resident #69 was admitted on [DATE] with diagnoses of anoxic brain damage, hydrocephalus, altered mental status, seizures, quadriplegia, deformity of head, psychosis, depression, and anxiety disorder. A physician order dated May 10, 2024 revealed that the resident may participate in activities not in conflict with treatment plan. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognitive skills were severely impaired. An activity care plan revised on April 16, 2024, revealed the resident was dependent on staff for activities and was unable to physically participate due to poor mobility, one-on-one activities for cognitive stimulation, social interaction related to cognitive deficits, immobility and physical limitations. Interventions included keeping the television on during the day per family request, and that the resident enjoys watching [NAME], football, soccer, comedy and sci-fi; 1:1 (one on one) room visits 3-4 times per week for sensory stimulation; and, reading aloud for sensory stimulation 2 times weekly for 20 minutes i.e., current events, daily chronicles and sports articles, story books, per family request. Review of a 1:1 activity task report for the past 30 days revealed the resident received 1:1 visit from activities on 8 out of 30 days. There was no evidence that the resident received 1:1 visit 3-4 times a week as care planned. Despite documentation that the resident preferred [NAME], sci-fi, soccer, football and comedy show, an observation was conducted on February 3, 2025 and revealed the resident was watching the news channel in his room. An observation was conducted on February 4, 2025 and revealed that the resident's television in the room was on a news channel. A CNA (certified nursing assistant) entered the resident's room. However, the CNA did not interact nor speak to the resident. An interview was conducted on February 5, 2025 at 11:20 a.m. with a CNA (staff #76) who stated that the resident liked the sports channel. An observation with the CNA (staff #76) immediately following the interview. The CNA stated that turned to a soap opera; but it should on a sports channel. An interview with a licensed practical nurse (LPN/staff #209) was conducted on February 5, 2025 at 11:43 a.m. The LPN stated that the interventions in the resident's care plan included keeping the television on at all times; and that, the resident enjoys football, soccer, comedy and sci-fi. She also stated that the resident's television tuned to a soap opera does not meet the activity interventions as care planned. The LPN further stated that it was their policy to follow the interventions as care planned for the resident. An interview was conducted on February 6, 2025 at 8:08 AM with the Activity Director (staff # 86), who stated that they provide 1:1 visits and sensory stimulation for patients that have cognitive impairment and cannot leave their rooms, and the visits are documented in tasks. He also stated that other activities for room-bound patients include television and radio. He further stated that it is the facility policy to follow the activity interventions as care planned. He reviewed the resident's care plan and stated the interventions included 1:1 room visits 3 - 4 times a week for sensory stimulation, television preferences included football, soccer, comedy and sci-fi. The Activities Director reviewed the January 2024 1:1 task in the resident's clinical record for the past 30 days and stated that there were just a couple of 1:1 visit provided, and there was no evidence that the resident had declined any 1:1 visit for the past 30 days. Staff # 86 explained that when resident's refuse 1:1 visit it would be documented in the activity task. The Activity Director also stated that the he knew that not enough 1:1 visit were being provided to the resident, but he did not know that it was this bad. He further stated that that it also would not be meeting the activity interventions for the resident's television to be on a soap opera channel. He stated that this did not meet the care planned interventions for 1:1 visits or television. He stated the risks of not following the activity care plan's interventions could result in not meeting the resident's activity needs. He stated that they could do better regarding 1:1 room visits and following the interventions as care planned. An interview was conducted on February 6, 2025 at 02:42 PM with the Director of Nursing (DON/staff # 157), who reviewed the resident's activity care plan and stated that interventions included 1:1 visit 3-4 times/week, and that the resident enjoyed TV including football, soccer and sci fi. The DON stated that there was no evidence that the resident received 1:1 visit 3-4 times a week as care planned in the past 30 days. She stated that the expectation would be that the resident's television would be on a show that included the areas that the resident enjoyed and were noted in the resident's activity care plan. The DON stated that the risk of not receiving the care planned activities could result in decreased socialization/stimulation. Further, the DON stated that she expected staff to follow the interventions on the care plan. 50887 -Resident #153 was admitted on [DATE] with diagnoses of encephalopathy, type II diabetes mellitus, and acute pulmonary edema. A respiratory note dated December 9, 2024 revealed that resident was on 2 liters per minute of oxygen via nasal cannula. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. The MDS assessment also coded that the resident was receiving oxygen therapy. A nurse practitioner (NP) note dated January 24, 2025 revealed the resident was on oxygen via nasal cannula. An observation was conducted on February 3, 2025 at 11:30 a.m. showing that resident #153 lying in bed wearing an oxygen nasal cannula that was connected to an oxygen concentrator by the bedside. The oxygen concentrator was on and set to 3 liters of oxygen. In another observation conducted on February 5, 2025 at 11:34 a.m., resident #153 was sitting up in bed wearing an oxygen nasal cannula that was connected to an oxygen concentrator by the bedside; and the oxygen concentrator was on and was set to 3 liters of oxygen. Despite documentation and observations that the resident was on oxygen, there was no evidence found in the clinical record that a care plan was developed with interventions implemented for the use of oxygen. An interview was conducted on February 5, 2025 at 8:47 a.m. with a certified nursing assistant (CNA/staff #30) who stated that resident #153 was on oxygen all the time. An interview conducted on February 5, 2025 at 10:28 a.m. with a licensed practical nurse (LPN/staff #221) who stated that resident #153 use oxygen; and that, oxygen therapy/use for resident #153 should be care planned. During the interview, the LPN reviewed the clinical record and stated that she could not find a care plan for oxygen use for resident #153. The LPN stated the risk of not having oxygen care planned with interventions could result in staff not knowing how much oxygen the resident should be receiving or what interventions would be needed for that resident. Further, the LPN stated oxygen use not care planned with intervention did not meet facility expectations. In an interview with a unit manager (staff #131) conducted on February 5, 2025 at 11:13 a.m., the unit manager stated that staff add to the resident's care plan with interventions as things/issues present/happen. The unit manager stated that the respiratory director was responsible in developing the care plan with interventions for residents who receive oxygen therapy. An interview with the respiratory therapy director (RT director/staff #55) was conducted on February 5, 2025 at 11:22 a.m. The RT director stated that care plan would be completed by a staff who does the resident's admitting orders. She stated that she would complete the care plan with interventions for residents who were on ventilators, have a tracheostomy, or receiving breathing treatments. However, the RT director stated that the nursing staff was responsible in developing a care plan with interventions for residents who were only on oxygen via nasal cannula. During an interview with the Director of Nursing (DON/staff #157) conducted on February 5, 2025 at 11:54 a.m., the DON stated that multiple departments either respiratory or nursing would be responsible for completing the care plan with interventions for residents who were receiving oxygen therapy. The DON stated that the clinical record of resident #153 revealed no documentation that a care plan with interventions was developed for oxygen use. She stated that if all of the staff were aware that resident #153 was on oxygen, she could not think of a risk to the resident related to oxygen not be documented in the care plan. However, the DON stated that it was her expectation that oxygen use would be in the resident's care plan. Review of the facility's policy on Care Plans, Comprehensive Person-Centered, revised March 2022, revealed that the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The policy revealed that the comprehensive person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy also indicated that assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change.

Based on observation, clinical record review, facility documentation and staff interviews, the facility failed to ensure medications/treatment for two residents (#316 and #93) were not left at bedside. The facility census was 161 and the sample size was 32. The deficient practice could result in resident injury, medication over-dose or contraindications. Findings include: -Resident #316 was admitted on [DATE] with diagnoses of cerebral infarction, unspecified symptoms and signs involving cognitive functions and awareness, need for assistance with personal care, pressure ulcer of the sacral region and altered mental status. An observation was conducted on February 3, 2025 at 8:17 a.m. and revealed that there was a hydrophilic wound dressing containing petroleum, zinc oxide and dimethicone on the resident's bedside table. Resident #316 stated that the staff were aware that the cream was on her bedside table. In another observation was conducted on February 4, 2025 at 8:47 a.m., the hydrophilic wound dressing containing petroleum, zinc oxide and dimethicone was on the resident's bedside table. The care plan dated [DATE] revealed the resident had impaired visual function, had actual risk for ADL (activities of daily living)/mobility decline and required assistance related to impaired mobility and visual impairment. The care plan dated [DATE] revealed the resident required skilled speech therapy for speech and swallowing deficit. The physician order dated [DATE] included to cleanse the right groin with normal saline, pat dry, apply Xeroform and cover with dry dressing. A review of the MDS (minimum data set) dated [DATE] revealed a BIMS (brief interview of mental status) score of 9 the resident has moderate cognitive impairment. The 72-hour charting dated [DATE] revealed the resident was alert and oriented x 2. Review of the clinical record revealed no evidence that the resident was assessed and determined to be able to self-administer medications/treatment. -Resident #93 was admitted on [DATE] with diagnoses of chronic inflammatory demyelinating polyneuritis, fibromyalgia, opioid dependence, schizoaffective disorder, unspecified psychosis and asthma. An observation was conducted on February 3, 2025 at 8:38 a.m. and revealed that there were OTC (over the counter) cough drops and immune system gummies (multivitamins/supplement) were found in an open bedside drawer. Resident #93 stated that she had the cough drops and gummies for a while; and that, the staff were aware. In another observation conducted on February 4, 2025 at 8:53 a.m., the OTC cough drops and gummies continued to be found in opened bedside drawer. The care plan revised on [DATE] revealed that the resident required an antipsychotic medication for mood swings and was at risk for adverse reaction. A review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. The care plan revised on [DATE] revealed that resident had ADL self-care performance deficit. Intervention included to assist with ADLs. A review of the electronic health record revealed no evidence the resident was assessed and determined to be able to self-administer medications/treatment. Further review of the clinical record revealed that there was no physician order found for the OTC cough drop and immune system gummies. An interview was conducted on February 2, 2025 at 8:55 a.m. with a certified nursing assistant (CNA/staff #76) who stated that a medication can include any creams, pills and over the counter medications; and that, to her knowledge, A & D cream (topical medicated cream) can be left in the resident's room as long as it was in the resident's drawer. She stated that it cannot be left on the resident's bedside table. She also said that cough drops and vitamin gummies cannot be left in the resident's room unless ordered by the doctor and the resident had been assessed to self-administer medication. She stated that if she observed medication at bed-side she would remove it and alert the nurse. She further stated that the risk for medications present at bedside and not authorized for self-administration could include expired medication and potential risk for overdose. An interview was conducted on February 4, 2025 at 9:01 A.M. with licensed practical nurse (LPN/staff #249) who stated that a medication was anything that is used to treat the resident. The LPN said that medication would be specific to a resident, to include name, dose and route of administration.; and that, this include OTC medications. She stated that medications can be left at bedside, if there was a specific order in place and if the resident requested it. The LPN said that there are some residents who receive medications that they order via the mail. She stated that staff educate the residents and if medications are observed at bedside, staff would remove them. In an interview with another LPN (staff #238) conducted on February 4, 2025 at 9:08 a.m., the LPN stated that medications were not permitted at bedside unless there was an order and the resident had been assessed. The LPN stated that if medications including vitamins and pain cream were observed at bedside, staff were to remove them from bedside and notify the physician. The LPN stated that the clinical record of both residents #316 and #93 revealed that there was no order or assessment for the residents #316 and #93 to self-administer medication; and that, these two residents should not have any medications at bedside. An observation was conducted with the LPN immediately following the interview. The LPN went into the room of resident #316, found the wound cream on the bedside table then proceeded to remove the wound cream and stated that the wound cream should not have been there. The LPN then proceeded to the room of resident #93, found the cough drops and gummies in the bedside drawer, removed them from the drawer and stated that the cough drops and gummies should have not been in the resident's room. The LPN further stated that the risk of having medications at bedside could result in over-medication, residents taking the medication without the physician knowing and could also result in drug interacting with the resident's existing medications. During an interview with the director of nursing (DON/staff #157) conducted on February 4, 2025 at 9:25 a.m., the DON stated that medications at a resident's bedside required physician orders and an assessment; and that, medications include anything medicated, creams, prescription and over the counter medications, vitamins, cough drops and medicated wound creams. The DON reviewed the ingredients of the wound cream found in the room of resident #316 and stated that she would consider the wound cream to be a medication, since it contained zinc oxide. She stated that the wound cream, cough drops and immune system gummies should not have been at bedside of residents #316 and #93 without an assessment and a physician order. Further, the DON stated that the risk of having medication at bedside could include accessibility to other residents, potential medication interaction and contraindications. A review of the facility policy on Administering Medications with a revision date of [DATE] revealed that medications are administered in a safe and timely manner and as prescribed. Only persons licensed or permitted to prepare, administer and document the administration of medications may do so. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined they that they have the decision-making capacity to do so safely.

Based on observations, clinical record reviews, resident and staff interviews and policy review, the facility failed to ensure respiratory care related to BiPAP (Bi-level positive airway pressure)/CPAP (Continuous positive airway pressure) devices for one of 3 sampled residents (#98) and oxygen administration for one of 3 sampled residents (#153) consistent with professional standards was provided as ordered by the physician. The deficient practice could result in residents not receiving the necessary respiratory care and services to meet their needs. Findings include: -Resident #98 was admitted on [DATE] with diagnoses of Parkinson's disease, mentation fluctuations, obstructive sleep apnea, dependence on other enabling machines and devices, and need for assist with personal care. The admission summary note dated January 20, 2025 revealed that that the resident admitted to the facility for 8-week respite. A physician order dated January 20, 2025 included for Respiratory Therapy (RT) evaluation and treatment as indicated. However, there was no evidence found in the clinical record that an RT evaluation and treatment was completed for resident #98 as ordered by the physician. There was also no documentation as to why the RT evaluation and treatment was not completed as ordered; and that, the physician was notified. A physician order dated January 21, 2025 revealed an order written for RT BiPAP/CPAP 2 - CPAP settings: 5-20cm at night and as needed for respiratory distress. The NP (nurse practitioner) initial comprehensive note dated January 22, 2025 revealed that the resident was admitted to the facility for inpatient respite for approximately 8 weeks from January 20 through March 17, 2025. Assessments included essential hypertension and Parkinson's Disease. The documentation did not include whether or not the resident used a BiPAP/CPAP machine at night. Review of Medicare 5-day MDS assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating the resident had moderate cognitive impairment. Active diagnoses included Parkinson's Disease, obstructive sleep apnea and dependence on other enabling machines and devices. Further, the assessment coded that the resident did not have shortness of breath; and that, the resident did not have a BiPAP /CPAP upon admission. The physician progress note dated February 3, 2025 included that the resident had assessments of Parkinson's Disease vs Movement Disorder, chronic pain and hypertension. Plan was to continue current treatment plan. The documentation did not include whether or not the resident had or used BiPAP/CPAP. Despite the physician order, the respiratory therapy (RT) care plan was only initiated on February 5, 2025 (approximately 15 days after resident's admission and the physician order). The care plan revealed that the resident had an alteration in the respiratory system; and that, the resident was not dependent on oxygen with a high risk for potential development of cardio-pulmonary symptoms, respiratory distress and ADL (activities of daily living) functional decline related to dyspnea, hypoxemia and shortness of breath. Interventions included to administer medications, oxygen therapy and CPAP as ordered and to implement respiratory care interventions as ordered e.g., pulse oximetry checks, airway treatment, chest wall percussion and incentive spirometry) The orders for the BiPAP/CPAP were not transcribed onto the MAR (medication administration record) and TAR (treatment administration record) for January and February 2025. Despite documentation that the resident had BiPAP/CPAP machine/devices, there was no evidence found in the clinical record that the resident was assessed and monitored for the use the BiPAP/CPAP device; care related to the use of BiPAP/CPAP was provided; and, the CPAP settings ordered by the physician was checked, monitored and followed. Further review of the clinical record revealed no documentation that RT saw the resident and provided care/treatment related to the use of a BiPAP/CPAP device, or any upcoming schedule of respiratory care/treatment. An observation was conducted on February 3, 2025 at 12:22 p.m. and revealed that the resident's BiPAP/CPAP machine/device was on the table next to the resident's bed. Resident #98 stated that the BiPAP/CPAP machine/device on the table was his and he had been using the BiPAP/CPAP machine since admission. He further stated that he fills the device with water, but he was not sure who cleans the tubing. In an interview a Certified Nursing Assistant (CNA/staff #76) conducted on February 5, 2025, the CNA stated that the RT was responsible for the treatment and care of any BiPAP/CPAP devices. An interview was conducted on February 5, 2025 at 11:43 a.m. with a Licensed Practical Nurse (LPN/staff #209), who reviewed the clinical record and stated that there was a physician order written on January 21, 2025 for the use of BiPAP/CPAP with settings for resident #98; and that, the RT was responsible for BiPAP/CPAP care/treatment. The LPN also stated that if the BIPAP/CPAP was being used by the resident, it should be documented on the respiratory MAR. However, the LPN stated that respiratory MAR for January and February 2025 for resident #98 revealed no evidence that respiratory care/treatment related to the resident's BiPAP/CPAP use was provided to resident #98. An interview was conducted on February 5, 2025 at 12:00 p.m. with a Respiratory Therapist (RT/staff #224), who stated that the physician would write an order for the use of a BiPAP/CPAP device. During the interview, the RT reviewed the clinical record and stated that there was an order dated January 21, 2025 for resident #98 to use the BiPAP/CPAP at night and as needed. She also stated that the night shift RT was responsible for ensuring that all residents with orders for BiPAP/CPAP devices have correctly applied the masks prior to going to bed, that the masks fit appropriately, and the device was turned on with the oxygen switched over to the device. The RT said that this process was then documented on the RT MAR. The RT further stated that she was not aware that resident #98 was using a BIPAP/CPAP; and that, resident #98 was not on the RT resident list. An observation with the RT was conducted immediately following the interview. The RT stated that resident #98 had a BiPAP/CPAP device sitting on the resident's bedside table. In an interview with the RT supervisor (RTS/staff #55) conducted on February 5, 2025 at 12:15 p.m., the RT supervisor stated that there was a physician order for the use of the BiPAP/CPAP machine at night and as needed found in the clinical record of resident #98. The RT supervisor also stated that if an RT was following the resident's care/treatment of the BiPAP/CPAP device, the RT should maintain and check the BiPAP/CPAP device twice a day. However, the RT supervisor stated that the clinical record for resident #98 revealed no evidence this was being followed. She also stated that she would expect a daily airway evaluation to be completed and documented in the clinical record, but there was no evidence that this had been completed. The RT supervisor also stated that there was no evidence in progress notes that the BiPAP/CPAP device had been monitored/followed by RT. She stated that they follow all CPAP/BIPAP use, even if the resident brings their own device. During this interview, the RT supervisor interviewed resident #98 who told the RT that the resident brought the device from home and had been using it since he was admitted to the facility. The RT supervisor further stated that the order for the resident's BiPAP/CPAP was not entered correctly and therefore, was not placed on the schedule for monitoring; and, there was no documentation related to the care/treatment of the BiPAP/CPAP device since the resident's admission. The RT supervisor stated the risk of not monitoring treatment and care of a BiPAP/CPAP device could result in not assessing the resident's skin and mask fit nightly, and the mask and tubing not being changed every Monday night. Regarding resident #98, the RT supervisor said that unfortunately this resident fell through the cracks. During an interview with the Director of Nursing (DON/staff #157) conducted on February 6, 2025 at 2:42 p.m., the DON stated that her expectation was that the care plan included the use of a BiPAP/CPAP device. The DON stated that she would refer to RT for the care/treatment of a BiPAP/CPAP device; and that, the RT supervisor (staff #55) informed her that respiratory had not signed off on this resident's BiPAP/CPAP device use/care/treatment. However, the DON stated that there was no risk, as the resident was able to use the BiPAP/CPAP without assistance. The DON further stated that risk of not monitoring the BiPAP/CPAP device use could result in the device not being maintained according to policy. Review of the facility policy titled, Non-Invasive Ventilation with revision date of December 2024 revealed that BiPAP or CPAP therapy requires a specific physician order to use each mode. To initiate therapy, the unit must be set up by RT, physician orders verified, check equipment, check that all connections on unit are secured, check for proper fit and seal of mask, check that the unit connects to an oxygen source if indicated, adjust tubing/connections and/or mask as needed, assess the resident for adverse reaction and re-assessing vitals and breath sounds. 50887 -Resident #153 was admitted to the facility on [DATE], with diagnoses of encephalopathy, type II diabetes mellitus, and acute pulmonary edema. A respiratory note dated December 9, 2024 revealed that the RT assessed the resident who was awake, alert and sluggish to respond. Per the documentation oxygen saturation at the time of assessment was floating between 85%-90%; and that, the resident was repositioned and worked with some breathing exercises. It also included that oxygen did not improve and the RT immediately applied 2L/M (liters per minute) of oxygen via nasal cannula; and that, this was discussed with nursing and the physician. The nursing note dated December 9, 2024 included that the resident was very drowsy and complained of shortness of breath and wheezing; and that a respiratory therapist (RT) was notified and had check on the resident. A late entry physician progress note dated December 9, 2024 revealed that the resident was alert and oriented x 4 and had clear breath sounds. The documentation did not include the resident was on oxygen or used oxygen. The NP (nurse practitioner) initial visit note dated December 10, 2024 revealed the resident was on oxygen via nasal cannula without shortness of breath and had no audible wheezes. The late entry eINTERACT note dated December 10, 2024 included the resident had a change in condition for shortness of breath; and, had oxygen via nasal cannula. Per the documentation, resident complained of shortness of breath and was given 2 liters of oxygen; and, that the provider ordered to do stat lab. New intervention orders included oxygen use. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. The MDS assessment also coded that the resident was receiving oxygen therapy. An NP note dated January 24, 2025 revealed the resident was on oxygen via nasal cannula. Despite documentation that the resident was using oxygen, there was no evidence of a physician order for the use of oxygen from December 9, 2024 through February 4, 2025. There was also no evidence that care related to oxygen use such as change of the tubing, checking for kinks was provided to the resident from December 9, 2024 through February 4, 2025. A physician order dated February 5, 2025 included for oxygen therapy to titrate oxygen 1-5 LPM (liters per minute) to maintain oxygen saturation of >92%. An observation was conducted on February 3, 2025 at 11:30 a.m. Resident #153 was lying in bed wearing an oxygen nasal cannula that was connected to an oxygen concentrator by the bedside. The oxygen concentrator was on and was set to 3 liters of oxygen. In another observation conducted on February 5, 2025 at 11:34 a.m., resident #153 was sitting up in bed wearing an oxygen nasal cannula that was connected to an oxygen concentrator by the bedside; and the oxygen concentrator was on and was set to 3 liters of oxygen. An interview was conducted with a Certified Nursing Assistant (CNA/staff #30) on February 5, 2025 at 8:47 a.m. The CNA stated that resident #153 was on oxygen all the time. In an interview with a Licensed Practical Nurse (LPN/staff #221) conducted on February 5, 2025 at 10:28 a.m., the LPN stated that there should be an order for oxygen use for resident #153. However, the LPN stated that she did not find any physician order for the use of oxygen for resident #153 in the clinical record. The LPN stated that the risk of not having a physician order for the use of oxygen could be that staff would not know how much oxygen resident #153 needed. She further stated that not having a physician order for oxygen did not meet facility expectations. An interview was conducted on February 5, 2025 at 11:15 a.m. with a unit manager LPN (staff #131) who stated that oxygen would require a physician order. During the interview the unit manager reviewed the clinical record of resident #153 and stated that there was no physician order for oxygen use; and, she was not sure what the risks would be if there was no physician order for oxygen use. However, she stated that this did not meet facility expectations. During an interview with the Director of Nursing (DON/Staff #157) conducted on February 5, 2025 at 11:54 a.m., the DON stated that according to their policy on Respiratory Clinical Services Policy and Procedure: Oxygen Administration, issued and revised on December 2024, a physician order was not required if the resident was not over 4 liters of oxygen. The DON further stated that she did not find a physician order for the use of oxygen in the clinical record of resident #153. An interview was conducted on February 6, 2025 at 11:22 AM with the respiratory therapy director (staff #55) who stated that in a rapid response, the respiratory therapist can administer oxygen to the residents and then communicate with the MD. She also stated that there was no policy on how long the resident was on oxygen before there needs to be a physician order in place. The respiratory therapy director stated that as long as the physician was notified that the resident was on oxygen, then it was okay. However, she also said that oxygen is a medication and a physician order would need to be in place for a medication. Regarding resident #153, the respiratory therapy director said that oxygen therapy order for resident #153 was created on February 5, 2025 as an order clarification since the resident was originally on 2 liters of oxygen but was currently on 3 liters of oxygen; and that, and she wanted to ensure that the physician was aware. The respiratory therapy director further stated that if a resident needed a rapid response or was experiencing a change in condition that required the resident to need more oxygen, they could administer the oxygen but would then need to communicate with the physician and then obtain an order. The facility policy on Oxygen Administration, revised October 2010, included a purpose to provide guidelines for safe oxygen administration. Preparation for oxygen administration included to verify that there is a physician's order for the procedure, and to review the physician's orders or facility protocol for oxygen administration. Review of the facility policy on Respiratory Clinical Services Policy and Procedure: Oxygen Administration, issued and revised in December 2024 revealed that oxygen administration must be reported to the physician. The policy also revealed that no more than a nasal cannula running at 4 liters per minute should be started without contacting the physician for physician order or to notify the change for room air saturation.

Based on review of resident council minutes, resident and staff interviews, a food test tray, and policy review, the facility failed to ensure food was palatable; and, failed to ensure food was at an appetizing temperature for resident consumption. The facility census was 161 and the sample size was 32. The deficient practice has the potential for residents who disliked a meal to experience nutritional problems or dissatisfaction with their meals. Findings include: The resident council minutes dated September 24, 2024 included an issue was brought up in the meeting that food was cold at times. The resident council minutes dated October 29, 2024 revealed a concern that rice served to resident was not fully cooked at times. The resident council minutes dated November 26, 2024 revealed issues reported that fish served was always dry. The resident council minutes dated December 31, 2024 revealed concerns that meals served were cold. During an interview conducted with a random an alert and oriented resident conducted on February 2, 2025 at 8:17 a.m., the resident stated that food served at the facility was cold and not served hot. A resident council meeting was conducted on February 4, 2025 at 1:55 p.m. and was attended by 5 alert and oriented residents. 3 of the 5 residents reported receiving cold food numerous times, and that, they had informed staff. Further, these 3 residents stated that the issue was still ongoing; and one resident stated that the concerns brought up during the resident council meetings were not acted upon or reported back on. In an interview with the cook (staff #134) conducted on February 6, 2025 at 8:17 a.m., the cook stated that the applesauce should be at 31 degrees Fahrenheit or below, oatmeal between 160-170 degrees Fahrenheit, breakfast sausage 168 degrees Fahrenheit and pancakes 150-160 degrees Fahrenheit. In a later interview with the with the facility cook (staff #134) conducted on February 6, 2025 at 8:58 a.m., the cook stated that he was aware of complaints from the residents regarding food temperature; and that, he had heard from some residents that it may be the delay in the tray delivery to the rooms versus kitchen service temperature. The cook further stated that the risk of food just sitting on the delivery cart and not served right away depended on the type of foods, but could include bacterial build-up. An interview was conducted on February 6, 2025 at 9:40 A.M. with the dietary director (staff #178) who stated that his expectation was that food was at a safe temperature when served to the residents. The dietary director further stated that if food was not at a safe temperature, the risk could include development of food borne illness. During an interview with the director of nursing (DON/staff #157) conducted on February 6, 2025 at 10:58 a.m., the DON stated that her expectation was that food was served at an appropriate temperature and stated that the risk for not serving food at the correct temperature could include resident dissatisfaction and the potential for illness related to food temperature. She also stated the issue of food being cold was identified last week; and that, she was also aware that this issue was discussed during the resident council from September 2024 through December 2024. The DON further stated that food pass/delivery was not efficient; and that, the facility was monitoring it and trying to figure it out. 46606 -During the initial pool screening conducted on February 3, 2025 multiple residents complained of food served was not hot, and not appetizing. A test tray was obtained on February 6, 2025 at 8:12 a.m. following the last meal tray delivered was at 8:11 a.m. The test tray contained apple sauce, oatmeal, breakfast sausage and pancakes. The dietary manager (staff #178) used his food thermometer to take the temperatures of the food and were recorded as follows: -Apple sauce was at 71 degrees Fahrenheit; -Oatmeal was at 106.4 degrees Fahrenheit; -Breakfast sausage was at 128.5 degrees Fahrenheit; and, -Pancakes was 135.9 degrees Fahrenheit. The apple sauce was warm; the oatmeal was dry which made it look like it was not fully cooked and not appealing to eat; the breakfast sausage was chewy and had a lot of gristle; and, the pancakes were really thin, dry, tasteless and had a sponge like texture. During an interview with the dietary director (staff #178) conducted on February 5, 2025 at approximately 11:04 a.m., the dietary director stated that during Resident Council Meetings, the residents complained that food was cold. The dietary director noted that they use plate warmer and metal plate to keep the food warm; however, the problem was that they do not know how long it takes for unit staff to deliver the food to the residents in the unit. Further the dietary director stated that the unit staff had been told to deliver the trays right away when the food cart arrives to the unit. An interview was conducted with the cook (staff #134) on February 6, 2025 at 8:58 a.m. The cook stated that the risk of not maintaining appropriate food temperature was that bacteria can set in the food making it unsafe for residents to eat. The cook said that the kitchen had been informed that meals served were not hot when residents receive them; however, the cook said that this was due to the CNAs (certified nursing assistants) not delivering the meals right away to the residents. Further, the cook stated that when food was not served at an appropriate temperature, the food becomes unsatisfying and contamination can start. The cook indicated the following as the safe temperature range for the breakfast that was served to the residents today: -Oatmeal should be between 160-170 degrees Fahrenheit; -Breakfast sausage should be 168 degrees Fahrenheit; -Pancakes should be 150-160 degrees Fahrenheit; and, -Apple sauce should be 31 degrees Fahrenheit and below. In another interview with the dietary director (staff #178) conducted on February 6, 2025 at 9:20 a.m., the dietary director stated that it was important to ensure that food items served to the residents were within the appropriate temperature range so that the residents do not get sick and do not complain about food being cold. He further stated that there was a risk that the residents can get sick if food items not being within the appropriate temperature. The facility policy on Food Preparation and Service included that food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. It also identified 'danger zone' as food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit; and, 'potentially hazardous foods' or 'time/temperature control for safety (TCS) food' as food that required time/temperature control for food safety to limit the growth of pathogens (i.e., bacterial or viral organisms) capable of causing disease a disease or toxin formation. It is further noted that potentially hazardous foods include meats.

Based on review of resident council minutes, resident and staff interviews, and facility policy and procedures, the facility was failed to ensure concerns from the resident council meeting were considered or acted upon by facility staff. The facility census was 161 and the sample size was 32. The deficient practice could result in the residents' concerns, views, grievances or recommendations that affect their care, treatment and quality of life are not valued and considered. Findings include: The resident council minutes dated August 27, 2024 revealed that a resident brought up a concern of being served the same food for 2 days, not enough coffee brought down for meals, not having enough snacks and one resident's bed was making noise. The resident council minutes dated September 24, 2024 included the following issues were brought up in the meeting: -CNAs (certified nurse assistants) needed to help residents with simple tasks like opening blinds and getting the things residents asked for; -Food was cold at times; -Food portions seemed to get smaller; and, -One resident would like therapy for his left hand. The resident council minutes dated October 29, 2024 included the following concerns: -CNAs should get the residents up and out of bed before doing showers; -Rice served to resident was not fully cooked at times; -Outlet in a resident's room was out; and, -Remote on one of the resident's bed does not always work. The resident council minutes dated November 26, 2024 revealed issues reported such as fish served was always dry, the heater was not working and the room of one resident does not get cleaned the way the resident preferred. The resident council minutes dated December 31, 2024 revealed concerns such as meals were cold, missing pair of blue shorts and the weekend receptionist could use customer service training. The resident council department follow-up form dated January 16, 2025 included that the issues food being cold was resolved. However, there was no evidence found that all the other issues/concerns voiced by residents during the resident council meetings August through December 2024 were addressed or acted upon. A resident council meeting was conducted on February 4, 2025 at 1:55 p.m. and was attended by 5 alert and oriented residents. 3 of the 5 residents reported receiving cold food numerous times, and that, they had informed staff. Further, these 3 residents stated that the issue had also been discussed during the previous resident council meetings; but, the issue still had not been resolved. One resident stated that there were concerns from the resident council that the issues/concerns reported during these meetings were not acted upon by the facility or the facility had not reported back the resolution to their concerns. An interview was conducted on February 5, 2025 at 8:01 a.m. with the activity director (staff #86) who stated that he was in charge of resident council; and, the resident council meeting minutes for the past 6 months did have any documented follow-up for the issues/concern resident brought up in the resident council minutes. The activities director stated that there was a form that was filled out for each department to complete if the issue was resolved. However, he stated that he only had the form (dated January 16, 2025) that addressed the meeting from December 2024. He further stated that he did not have any documentation of resident council follow-up for the previous 6 months as this process had just been integrated by the corporate team in January of 2025; and, he could not recall the exact date of the implementation. In an interview with the business office manager (BOM/staff #94) conducted on February 2, 2025 at 9:18 a.m., the BOM stated that he had been made aware of the customer service concern that was documented in the resident council meeting minutes from December 2024. He stated that he had met with the staff member to address the concern; and that, he was presented with a written form documenting the concern. However, the BOM stated that he not able to locate a copy of the documentation. A telephone interview was conducted on February 5, 2025 at 10:25 a.m. with the executive director (ED/staff #300) who stated that his expectation was that concerns brought forward from the resident council were addressed and that the outcome/resolution was relayed back to the residents. He further stated that feedback throughout the months may not be immediate, but unless resident was specific, it should be reported back to the residents during subsequent resident council meetings. Further, the ED stated that it would not meet his expectations if there was no documentation of a follow-up conducted/completed the issue/concern. He stated that the risk could include poor communication between the facility and residents; and that, residents would feel as if they were not heard. A review of the facility's Resident Council policy with a revision date of February 2021 revealed a policy that supports residents' rights to organize and participate in resident council. It also included a purpose to provide a resident council a forum for discussion of concerns and suggestions for improvement, consensus building and communication between residents and facility staff as well as disseminating information and gathering feedback from interested residents.

Based on clinical record review, staff interview, and policy and procedure, the facility failed to ensure that two of three sampled residents (#38, #66) with diagnoses of a serious mental illness and mental disorders were referred to the appropriate State-designated authority for Level II PASRR (Pre-Admission Screening and Resident Review) evaluation. The deficient practice could result in residents not receiving the necessary specialized services that they need. Findings include: -Resident #66 was admitted on [DATE], with diagnoses of post-traumatic stress disorder (PTSD), major depressive disorder, schizoaffective disorder, and dementia. A care plan revised on initiated on September 7, 2023 revealed the resident required an antipsychotic medication related to schizoaffective disorder as evidenced by paranoia. Interventions included to administer antipsychotic medication as ordered and psychiatrist consult as indicated. A physician order dated March 25, 2024 included for Quetiapine Fumarate (antipsychotic) 100 mg (milligrams) by mouth at bedtime for schizoaffective disorder as evidenced by paranoia. The behavior care plan dated June 18, 2024 revealed the resident exhibited or was at risk for behavioral symptoms due to cluster personality disorder, PTSD and anxiety. Interventions included for activity assessment for diversional activities, medication as ordered and obtain psych consult as indicated. An NP (nurse practitioner) note dated September 19, 2024 included psychiatric diagnoses that included adjustment disorder, other specific personality disorder, PTSD, major depressive disorder and schizoaffective disorder, bipolar type. A level I PASRR screening dated September 27, 2024 revealed the resident had a serious mental illness (SMI) that included schizoaffective disorder and major depression; and, a mental disorder (MD) of PTSD. Per the documentation the resident had a recent psychiatric evaluation on September 19, 2024; and, was taking antipsychotic medication for schizoaffective disorder. Despite documentation of SMI and MD, the screening indicated that no referral was necessary for any Level II. There was no evidence found that another Level I PASRR screening was completed for resident #66 prior to and after September 27, 2024. Review of the clinical record revealed that the resident's SMI and MD diagnoses were present since September 2023. Further review of the clinical record revealed no evidence that resident #66 was referred to appropriate State-designated agency for Level II PASRR evaluation. There was also no documentation found why the resident was not referred to Level II PASRR evaluation. An interview was conducted on February 6, 2025 at 8:28 with the social services director (SSD/staff #172) who stated that it was her responsibility to complete PASRR Level I and PASRR Level II evaluations. She stated that on admission she ensures that the PASRR 1 was completed and accurate; and, if the resident had any mental illness (MI); and, a Level II PASRR assessment should be completed and submitted for any resident with a MI diagnosis or an intellectual disability (ID) and if dementia was not the resident's primary diagnosis. She stated that there were some Level II PASRR assessments that were not submitted to the appropriate State-designated authority; and that, she was currently going through a full house audit and submitting PASRR Level II if required. During the interview, a review of the clinical record was conducted with the SSD who stated that resident #66 had SMI diagnoses and did not have a primary diagnosis of dementia; therefore, a Level II PASRR should have been submitted. However, the SSD stated that there was no Level II PASRR submitted for resident #66. The SSD stated that the risk of not sending a Level II PASRR for residents with SMI and ID could result in residents not receiving and not being placed in the appropriate level of care. In an interview with the Director of Nursing (DON/staff #157) conducted on February 6, 2025 at 2:42 p.m., the DON stated that her expectation was that the Level II PASRR would be sent to the appropriate State Agency when a resident has MI or MD and had no primary diagnosis of dementia. She stated the risk could result in not implementing the appropriate level of care to a resident. 47911 -Resident #38 was admitted on [DATE] with diagnoses of major depressive disorder-single episode, anxiety disorder and schizoaffective disorder. The care plan dated December 14, 2021 included that the resident used an antidepressant medication related to depression and an antipsychotic medication related to schizoaffective disorder bipolar type. Interventions included to administer medications as ordered and psych follow-up as needed. The Level I PASRR (Pre-Admission Screening and Resident Review) dated December 19, 2023 revealed that the resident had SMI (serious mental illness) diagnoses that included major depression and bipolar disorder; had mental disorder (MD) diagnoses of anxiety disorder.; and had no primary diagnosis of dementia. Per the documentation the resident had a recent psychiatric/behavioral evaluation on November 28, 2023 and was prescribed with psychotropic medications within the last 6 months. Further, the documentation included that a referral for Level II determination was determined. The psychosocial care plan revised on March 19, 2024 revealed that the resident exhibited or was at risk for behavioral symptoms. Interventions included activity assessment for diversional activities and obtain psych consult as indicated. The annual MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 13 indicating the resident had intact cognition. The assessment also included that no behaviors and had no potential indicators of psychosis. Active diagnoses included anxiety disorder, depression and bipolar disorder. A review of the current and active physician order summary revealed active orders for antipsychotic and antidepressant medications. Review of an email correspondence from the facility's social services director addressed to the State-designated authority dated February 4, 2025 at 6:22 p.m., revealed that the facility made a follow-up inquiry to an PASRR Level II referral submitted to the State-designated authority in 2023. The State-designated authority responded to the facility on [DATE] at 7:41 a.m. that the State-designated authority was unable to find a PASRR Level II referral submitted for resident #38 for 2023. Further review of the clinical record revealed no evidence that resident #38 was referred to the State-designated authority for PASRR Level II evaluation. An interview and review of the clinical record was conducted on February 4, 2025 at 4:27 p.m. with the social services director (SSD/staff #172) and the director of nursing (DON/staff #157). The SSD stated that based on the completed Level I PASRR for resident #38 on December 19, 2023, the resident should have been referred for a Level II PASRR evaluation. However, the SSD said that she was not able to find any documentation that the completed Level II PASRR for resident #38 was referred or submitted the State PASRR representative. The SSD also stated that on January 8, 2025, a new tracking mechanism was put in place and it involved an access portal that would make submissions easier and facility has an ability to track the outcome. The SSD said that prior to this change, there was no a tracking system process in place to confirm receipt of the referral or response thereof. The DON stated that they were in the process of conducting a full-house 'sweep'/audit that was implemented on January 8, 2025 to identify residents that should have been sent for a Level II PASRR evaluation but were not. The DON also stated that her expectation was that Level I PASRR screening and Level II PASRR referrals were conducted timely as required and were tracked. The DON said that the risk of not referring the resident to the State PASRR representative for a level II PASRR screening could result in residents not receiving proper support or specialized or higher level of care that they needed. In another interview with the SSD (staff #172) conducted on February 5, 2025 at 12:43 p.m., the SSD stated that she reached out to the State PASRR representative who told her that the State did not have a record of the Level II PASRR referral for resident #38 in 2023. P.M. with staff #172. Staff #172 stated that she had conducted an email outreach to the state PASRR representative and that the representative stated they had no record of the 2023 referral. The SSD stated that Level I PASRR screening was conducted for resident #38 in 2023 as a result of the audit the facility conducted; and that based on the Level I PASRR screening, the resident that should have been referred to Level II PASRR; but, the resident was not. A facility policy titled, PASRR, revised on March 2019, revealed that the facility admits only residents who's medical and nursing care needs can be met. All new admissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASRR) program. A Level I PASRR screen is conducted for all potential admissions to determine if the individual meets the criteria for a MD, ID or RD. If the Level I screen indicates that the individual may meet the criteria, he or she is referred to the state PASRR representative for the Level II (evaluation and determination) screening process. The policy also included that the state PASRR representative provides a copy of the report to the facility and the interdisciplinary team then determines whether the facility is capable of meeting the needs and services of the resident as outlined in the evaluation.

Based on observations, clinical record reviews, resident and staff interviews, and facility documentation, policy and procedures, the facility failed to ensure that allegations of sexual abuse for one resident (#38) were reported immediately to the State Agency (SA) as required. The deficient practice resulted in resident subjected to further sexual abuse and could result in protection of other residents being compromised and increased risks for serious injury and harm. As a result, the Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. Findings include: On November 17, 2023 at 6:53 p.m., the condition of IJ was identified. The administrator (staff #38), the director of nursing (DON/staff #52) and the regional director of clinical services (staff #92) were informed of the facility's failure to ensure residents were free from sexual abuse by staff was found. The administrator (staff #38) presented the Plan of Correction (POC) on November 20, 2023 at 9:39 a.m. The administrator was informed that the POC was not acceptable and failed to include the following: action plan for the alleged perpetrator (AP/staff #17); how in-service training will be provided for staff who were not on shift or were on leave at the time of the IJ; projected completion date for the in-service training; what will be discussed in their in-service training on workplace conduct and professionalism. A revised POC was received on November 20, 2023 at 11:40 a.m. The administrator was informed that the POC failed to include in-service regarding abuse of their contract staff and/or volunteers. Another POC was received at 12:41 p.m., and was accepted at 12:56 p.m. The accepted POC included the facility investigating the allegation of sexual abuse for resident #38, reporting of the allegation of sexual abuse, termination of the alleged perpetrator (AP/staff #17), interviewing of all residents regarding abuse, auditing of resident grievances, in-service training provided to all staff, monitoring of resident council notes and grievances, and conducting random resident and staff interviews for 3 months or until substantial compliance. Multiple observations were conducted of the facility implementing their POC which included resident and staff interviews, in-service training and review of documentation provided by the facility. On November 22, 2023 at 3:45 p.m., the condition of IJ was abated after the following: the facility provided documentation that more than 50% of their staff were in-serviced on abuse and the AP was terminated from the facility. -Resident #38 was admitted on [DATE] with a diagnosis of unspecified sequelae of cerebral infarction, post-concussion syndrome, anxiety disorder and unspecified injury of head. Resident #38 was the alleged victim (AV). -Resident #17 was admitted on [DATE] with diagnoses of pain in the right lower leg, pulmonary hypertension, chest pain, and acute embolism. Resident #17 was the roommate of resident #38 (AV). A nursing note dated September 28, 2023 at 7:57 p.m. revealed that resident #17 arrived at the facility via stretcher from the hospital. However, the AMA (against medical advice) note dated September 28, 2023 at 9:57 p.m. included that the certified nursing assistant (CNA) reported to the nurse that the resident (#17) was leaving the facility with her family against medical advice; and that, resident #17 was already out in the truck with her family. According to the documentation, resident #17 was visibly upset and reported that she had a problem with a CNA but would not reveal what happened. Per the documentation, a case manager (CM) spoke with the AV (resident #38) who reported that she overheard resident #17 tell her family that the facility was a ghetto and did not want to stay at the facility. Review of the AMA release form revealed that resident #17 had signed and dated the form on September 28, 2023. A letter from a law firm (A) dated October 17, 2023 included that the law firm had been retained by the AV to investigate the circumstances surrounding the care, treatment, and alleged sexual assault at the facility in September and October 2023. The letter from another law firm (B) dated November 3, 2023 revealed that the AV retained their services as it pertained to multiple incidents of sexual assault by alleged perpetrator (AP/staff #17) while the AV was under the facility's care between September 21, 2023 and October 5, 2023. An email correspondence from the administrator dated November 13, 2023 addressed to payroll/HR (human resources) and other management staff revealed that the facility needed to put the AP on unpaid leave effective immediately per their legal team; and, to do a DNA sample from the AP. Another email correspondence from the administrator dated November 13, 2023 addressed to payroll/HR (human resources) and other management staff included to contact the AP, do a DNA sample; and that, the facility will contact and let the AP know what he needed to do. Despite knowledge of allegations of sexual abuse on September 28, October 17, November 3 and November 13, 2023, there was no evidence found in the clinical record and facility documentation that the allegation of sexual abuse was reported to the SA until November 18, 2023. The undated and unsigned facility investigative report revealed that the date of discovery of the alleged sexual assault was November 18, 2023. The report included documentation that a CNA (staff #22) reported that one night a resident who was just admitted to the facility told her that resident wanted to leave because her neighbor was having sex with a CNA .; and, that staff #22 reported the allegation to the nurse manager (staff #7). Further, the report included that the incident was reported to the SA, APS (Adult Protective Services), Ombudsman and local police on November 18, 2023. An interview was conducted on November 17, 2023 at 5:11 p.m. with AV (resident #38) who stated that she woke up to the AP (staff #17) kissing her; and that; the AP put his penis in her mouth then removed her clothes, lifted her leg and had sex with her. She stated that this was the 3rd or 4th time that the AP had raped her. The AV stated that shortly after she got a roommate, she texted and told her sister that God was looking out for her now that she had a roommate; and that, maybe the AP would not rape her anymore. The AV stated that on the night that the AP had sex with her, the AP pulled the privacy curtain closed and took her underwear. She stated that her roommate (resident #17) started screaming and staff showed up and then told me not to talk about it. The AV stated that the AP came in the next day at 5:00 a.m. and apologized and told her that it would not happen again. However, the AV said that the AP came in later that day and did it again; and that, another CNA (#48) caught the AP on her. The AV stated that one time after the AP raped her, the AP carried her over his shoulder into the shower to clean her up; and that, after this, the AP was off for a few days. The AV continued to say that when the AP returned to work, he brought her a soda; and when she was going to drink it, the AP stopped her and told her that he will put it on ice for her. The AV said that she does not usually drink her soda with ice; and that, after the AP brought the soda back and she drank it she could not move. Further, she said that she was awake but she could not move. The resident stated that the AP raped her and put his penis in her vagina, mouth and anus. The AV stated that the AP would come in to rape her after she took her medications because the medications would make her tired. Further, the AV stated that she tried to speak to the operations director who told her that she needs to follow the chain of command and refused to talk to her; and that, the administrator and the nurse director were both aware of what was going on. An interview with a nurse manager (staff #7) was conducted on November 20, 2023 at 9:47 a.m. The nurse manager stated that at the end of the shift on September 28, 2023, a CNA (staff #22) came to her and informed her that the resident #17 (roommate of the AV) was leaving AMA due to an alleged sexual contact. Further, the nurse manager said that because it was an allegation of sexual contact she reported it to the Administrator (staff #38) immediately and followed the facility protocol regarding reporting of abuse allegations. She stated that the administrator asked her to interview the AV who said that she was not sure why her roommate (resident #17) left. The nurse manager further stated that upon interviewing multiple staff members and the AV, she went home as her shift ended; and, she was not aware if the allegation was reported to the SA as she did not follow-up on the situation. An interview was conducted with the administrator (staff #38) on November 20, 2023 at 10:27 a.m. The administrator stated he received a call around 10:30 p.m. to 11:30 p.m. on September 28, 2023 regarding the resident #17's discharging AMA related to an alleged sexual contact concern. The administrator stated he instructed the nurse manager (staff #7) to interview the AV, other residents and other staff; and to follow-up the alleged incident of sexual contact. The administrator said that the incident was never reported to the SA; and that, he should have done a better job completing a thorough investigation and reporting. In an interview conducted on November 20, 2023 at 10:48 a.m. with a CNA (staff #22 who reported sexual assault on September 28, 2023), the CNA stated that on September 28, 2023 the family of resident #17 told her that resident #17 wanted to leave the facility because there was a male CNA (AP/staff #17) having sex with the AV. Staff #22 stated she reported this to the nurse manager (staff #7) before she left that day for the night; however, she was not aware if this incident was reported to the SA. In an interview with the APS investigator conducted on November 21, 2023 at 9:32 a.m., the investigator stated the facility reported sexual abuse to APS on October 24, 2023. Further, on November 20, 2023, she met with the AV who reported allegations of rape by the AP. However, review of the SA complaint tracking system revealed there was no allegation of sexual abuse reported by the facility on October 24, 2023. An interview was conducted with male resident on November 21, 2023 at 11:32 a.m. The male resident was the one that the AV confided on regarding the incident. He stated that one day, the AV came up to him distraught, scared and did not know what to do. He said that resident #38 told him that AP raped her. The male resident stated that the AP was creepy; and that, the AP would go in the AV's room for long periods of time; and that, the AP did it to the AV more than once. He stated that he was the one who brought the AV to the police department; and they brought her underwear with the DNA of the AP in it. The male resident stated that he was with the AVwhen she tried to report the incident to the administrator who told the AV to follow the chain of command and refused to talk to the AV. An interview with the nurse unit manager (staff #107) was conducted on November 21, 2023 at 12:10 p.m. Staff #107 stated that he was the unit manager in the unit the AV was admitted to. He stated that he was made aware of the sexual allegation regarding the AP when the facility received a letter from a law firm; however, he could not recall the date/day. Staff #107 said that an employee would be sent home and an investigation would be conducted if there was ever an abuse allegation; however, he does not know if the AP was sent home after the allegation of sexual abuse was received by the facility. Later during the interview, he said that the AP was suspended but did not know when. He stated that he was considered a mandated reporter; and, the AP would have known to report the incident and he was under the impression that the AP had reported the incident. Staff #107 said that the negative outcome for not reporting abuse was that he loses his license, get sued, go to jail, fined, lose his job; and, the resident would be at harm as well. Further, staff #107 stated that he would not be doing his duty as a nurse if he did not report and allegation of abuse. An interview was conducted on November 21, 2023 at 12:49 p.m. with the Director of Nursing (DON/staff #52) who stated that she received a letter from the law firm on October 17, 2023 regarding investigation of circumstances surrounding the care, treatment, and alleged sexual assaults for the AV (resident #38) at the facility in September and October of 2023. The DON said that she did not put the letter and the September 28, 2023 allegation/incident together. The DON stated that when she received the first letter from the law firm, the facility did not initiate an investigation because she did not know what to investigate. The DON stated the facility received a second letter from another law firm that mentioned some sort of sexual assaults by the AP (staff #17) which prompted the suspension of the AP. However, the DON said that the facility did not initiate an investigation. Further, the DON stated that she did not report the allegation of sexual assault to the SA. During an interview conducted with the Administrator on November 21, 2023 at 2:03 p.m., the administrator stated that he was the abuse coordinator but he expected the DON to do the reporting for an allegation of abuse. The administrator also said that he was informed of an alleged sexual contact report and considered the initial investigation on September 28, 2023 a thorough investigation. However, he stated that prior to November 18, 2023 the AP (staff #17) was not interviewed about the incident/allegation; and that, the facility could have done a better job and could have dug deeper on the incident. Further, he stated that he never reported the incident/allegation to the state agency and the facility policies were not implemented. Review of the facility policy titled, Accidents and Incidents - Investigating and Reporting revealed that all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring in the facility's premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The policy included that the following data shall be included on the Report of Incident/Accident form that should include: -Date and time the accident or incident took place; -Nature of the injury/illness -Circumstances surrounding the accident or incident; -Name(s) of witnesses and their accounts of the accident or incident; -Injured person's account of the accident or incident; -Any corrective action; -Follow-up information; and -Signature and title of the person completing the report. The facility policy on Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating 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 policy included that the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: state licensing/certification agency responsible for surveying/licensing the facility; local/state ombudsman; adult protective services; and, law enforcement officials.

Based on observations, clinical record reviews, resident and staff interviews, and facility documentation, policy and procedures, the facility failed to ensure that allegations of sexual abuse for one resident (#38) was thoroughly investigated. The deficient practice could result in protection of residents being compromised, residents are placed at increased risks for serious injury/harm and further abuse and appropriate corrective action not taken. As a result, the Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. Findings include: On November 17, 2023 at 6:53 p.m., the condition of IJ was identified. The administrator (staff #38), the director of nursing (DON/staff #52) and the regional director of clinical services (Staff #92) were informed of the facility's failure to ensure residents were free from sexual abuse by staff was found. The administrator (staff #38) presented the POC (Plan of Correction) on November 20, 2023 at 9:39 a.m. The administrator was informed that the POC was not acceptable and failed to include the following: action plan for the alleged perpetrator; how in-service training will be provided for staff who were not on shift or were on leave at the time of the IJ; projected completion date for the in-service training; what will be discussed in their in-service training on workplace conduct and professionalism. A revised POC was received on November 20, 2023 at 11:40 a.m. The administrator was informed that the POC failed to include in-service regarding abuse of their contract staff and/or volunteers. At 12:41 p.m., another POC was received and was accepted at 12:56 p.m. The accepted POC included the facility investigating the allegation of sexual abuse for resident #38, reporting of the allegation of sexual abuse, termination of the alleged perpetrator (AP/staff #17), interviewing of all residents regarding abuse, auditing of resident grievances, in-service training provided to all staff, monitoring of resident council notes and grievances, and conducting random resident and staff interviews for 3 months or until substantial compliance. Multiple observations were conducted of the facility implementing their POC which included resident and staff interviews, in-service training and review of documentation provided by the facility. On November 22, 2023 at 3:45 p.m., the condition of IJ was abated after the following: the facility provided documentation that more than 50% of their staff were in-serviced on abuse and the AP (staff #17) was terminated from the facility. -Resident #38 was admitted on [DATE] with a diagnosis of unspecified sequelae of cerebral infarction, post-concussion syndrome, anxiety disorder and unspecified injury of head. Resident #38 was the alleged victim (AV). -Resident #17 was admitted on [DATE] with diagnoses of pain in the right lower leg, pulmonary hypertension, chest pain, and acute embolism. Resident #17 was the roommate of resident #38 (AV). A nursing note dated September 28, 2023 at 7:57 p.m. revealed that resident #17 arrived at the facility via stretcher from the hospital. However, the AMA (against medical advice) note dated September 28, 2023 at 9:57 p.m. included that the certified nursing assistant (CNA) reported to the nurse that the resident (#17) was leaving the facility with her family against medical advice; and that, resident #17 was already out in the truck with her family. According to the documentation, resident #17 was visibly upset and reported that she had a problem with a CNA but would not reveal what happened. Per the documentation, a case manager (CM) spoke with the AV (resident #38) who reported that she overheard resident #17 tell her family that the facility was a ghetto and did not want to stay at the facility. Review of the AMA release form revealed that resident #17 had signed and dated the form on September 28, 2023. The undated, unsigned and unlabeled facility documentation provided to the survey team at the time of the survey revealed an undated and unsigned written statement from the nurse manager (staff #7) who wrote that she interviewed resident #17 and the AV on September 28, 2023. It also included that two CNAs notified her that resident #17 reported sexual contact and was leaving the facility AMA. The statement also included that the nurse manager spoke with resident #17 and her family who reported that the facility was not safe. It also included that resident #17 told the nurse manager that she was not happy at the facility; and that, the facility will be on the news and will be paying resident #17 for the rest of her life. Further, the statement included that the nurse manager spoke with the AV who told the nurse manager that the AP came in the room, answered the AV's call light and attended to her needs. Per the documentation, when the AP left the room, resident #17 asked the AV why the AP was not spending time with resident #17. Further, the statement included that the AV told the nurse manager she was fine and had no concerns or complaints. Continued review of the undated, unsigned and unlabeled facility documentation revealed that the nurse manager conducted interviews with CNA/staff #22 who was the CNA who reported to the nurse manager (staff #7) that resident #17 was leaving AMA due to sexual contact between the AV and the AP; and two other staff who reported not hearing or seeing anything. However, the undated, unsigned and unlabeled facility documentation did not include the following: -Interview or attempts to interview with the AP; -Review of all the events leading up to the alleged incident; -Interviews of other residents to whom the accused employee provided care or services; -Corrective actions taken; -Notification of the alleged violation to the SA; and, -Notification of the alleged violation to other agencies or law enforcement authorities. A letter from a law firm (A) dated October 17, 2023 included that the law firm had been retained by the AV to investigate the circumstances surrounding the care, treatment, and alleged sexual assault at the facility in September and October 2023. The letter from another law firm (B) dated November 3, 2023 revealed that the AV retained their services as it pertained to multiple incidents of sexual assault by alleged perpetrator (AP/staff #17) while the AV was under the facility's care between September 21, 2023 and October 5, 2023. An email correspondence from the administrator dated November 13, 2023 addressed to payroll/HR (human resources) and other management staff revealed that the facility needed to put the AP on unpaid leave effective immediately per their legal team; and, to do a DNA sample from the AP. Another email correspondence from the administrator dated November 13, 2023 addressed to payroll/HR (human resources) and other management staff included to contact the AP, do a DNA sample; and that, the facility will contact and let the AP know what he needed to do. Despite knowledge of allegations of sexual abuse on multiple dates, there was no evidence found in the clinical record and facility documentation that the allegation of sexual abuse was investigated until November 18, 2023. Another undated and unsigned facility investigative report revealed that the date of discovery of the alleged sexual assault was November 18, 2023. The report included documentation that a CNA (staff #22) reported that one night a resident who was just admitted to the facility told her that resident wanted to leave because her neighbor was having sex with a CNA .; and, that staff #22 reported the allegation to the nurse manager (staff #7). The facility investigation included interviews conducted with the AP (staff #17), the CNA (staff #22) who reported the alleged sexual assault on September 28, 2023, the nurse manager and the roommate of AV. Continued review of the facility's investigative report did not include the following: -Interview or attempts to interview with the AV; -Identification of any injuries as appropriate; -Review of all the events leading up to the alleged incident; and, -Interviews of other residents to whom the accused employee provided care or services. Further, the report included that the AV did not make any allegations of sexual abuse towards the AP or any other staff; and that, this was a consensual relationship between resident #38 and the AP; and that, no sexual abuse had occurred in the facility. An interview with a nurse manager (staff #7) was conducted on November 20, 2023 at 9:47 a.m. The nurse manager stated that at the end of the shift on September 28, 2023, a CNA (staff #22) came to her and informed her that the resident #17 (roommate of the AV) was leaving AMA due to an alleged sexual contact. Further, the nurse manager said that because it was an allegation of sexual contact she reported it to the Administrator (staff #38) immediately and followed the facility protocol regarding reporting of abuse allegations. She stated that the administrator asked her to interview the AV who said that she was not sure why her roommate (resident #17) left. The nurse manager further stated that upon interviewing multiple staff members and the AV, she went home as her shift ended; and, she was not aware if the allegation was reported to the SA as she did not follow-up on the situation. An interview was conducted with the administrator (staff #38) on November 20, 2023 at 10:27 a.m. The administrator stated he received a call around 10:30 p.m. to 11:30 p.m. on September 28, 2023 regarding the resident #17's discharging AMA related to an alleged sexual contact concern. The administrator stated he instructed the nurse manager (staff #7) to interview the AV, other residents and other staff; and to follow-up the alleged incident of sexual contact. The administrator said that the incident was never reported to the SA; and, there was no follow-up done with the AP (staff #17); and that, his expectation was that the clinical staff will conduct the investigation and employee follow up. Further, he stated that he should have done a better job completing a thorough investigation and reporting. In an interview conducted on November 20, 2023 at 10:48 a.m. with a CNA (staff #22) who reported sexual assault on September 28, 2023), the CNA stated that on September 28, 2023 the family of resident #17 told her that resident #17 wanted to leave the facility because there was a male CNA (AP/staff #17) having sex with the AV. Staff #22 stated she reported this to the nurse manager (staff #7) before she left that day for the night; however, she was not aware if this incident was reported to the SA. In an interview with the APS investigator conducted on November 21, 2023 at 9:32 a.m., the investigator stated the facility reported sexual abuse to APS on October 24, 2023. Further, on November 20, 2023, she met with the AV who reported allegations of rape by the AP. However, there was no evidence found that allegation of sexual abuse reported by the facility on October 24, 2023 was thoroughly investigated. An interview with the nurse unit manager (staff #107) was conducted on November 21, 2023 at 12:10 p.m. Staff #107 stated that he was the unit manager in the unit the AV was admitted to. He stated that he was made aware of the sexual allegation regarding the AP when the facility received a letter from a law firm; however, he could not recall the date/day. Staff #107 said that an employee would be sent home and an investigation would be conducted if there was ever an abuse allegation; however, he does not know if the AP was sent home after the allegation of sexual abuse was received by the facility. Later during the interview, he said that the AP was suspended but did not know when. He stated that he was considered a mandated reporter; and, the AP would have known to report the incident and he was under the impression that the AP had reported the incident. Staff #107 said that the negative outcome for not reporting abuse was that he loses his license, get sued, go to jail, fined, lose his job; and, the resident would be at harm as well. Further, staff #107 stated that he would not be doing his duty as a nurse if he did not report and allegation of abuse. An interview was conducted on November 21, 2023 at 12:49 p.m. with the Director of Nursing (DON/staff #52) who stated that she received a letter from the law firm on October 17, 2023 regarding investigation of circumstances surrounding the care, treatment, and alleged sexual assaults for the AV (resident #38) at the facility in September and October of 2023. The DON said that she did not put the letter and the September 28, 2023 allegation/incident together. The DON stated that when she received the first letter from the law firm, the facility did not initiate an investigation because she did not know what to investigate. The DON stated the facility received a second letter from another law firm that mentioned some sort of sexual assaults by the AP (staff #17) which prompted the suspension of the AP. However, the DON said that the facility did not initiate an investigation. Further, the DON stated that she did not report the allegation of sexual assault to the SA. During an interview conducted with the Administrator on November 21, 2023 at 2:03 p.m., the administrator stated he was the abuse coordinator but he expected the DON to do the reporting for an allegation of abuse. The administrator stated that the report provided to the survey team was regarding the alleged sexual assault incident on September 28, 2023. He stated that prior to November 18, 2023 the AP (staff #17) was not interviewed about the incident/allegation; and that, the facility could have done a better job and could have dug deeper on the incident. Further, he stated that he never reportedthe incident/allegation to the state agency and the facility policies were not implemented. Review of the facility policy titled, Accidents and Incidents - Investigating and Reporting revealed that all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring in the facility's premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The policy included that the following data shall be included on the Report of Incident/Accident form that should include: -Date and time the accident or incident took place; -Nature of the injury/illness -Circumstances surrounding the accident or incident; -Name(s) of witnesses and their accounts of the accident or incident; -Injured person's account of the accident or incident; -Any corrective action; -Follow-up information; and -Signature and title of the person completing the report. The facility policy on Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating 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 policy included that the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: state licensing/certification agency responsible for surveying/licensing the facility; local/state ombudsman; adult protective services; and, law enforcement officials.

Based on observations, clinical record review, resident and staff interviews, review of facility documentation, policy and procedures the facility failed to ensure one resident (#38) was free from sexual abuse from staff. The deficient practice resulted in psychosocial harm to resident #38 and had placed residents at increased risk for further abuse, serious injury, harm and psychosocial harm. As a result, the condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SOC) were identified. The census was 164. Findings include: On November 17, 2023 at 6:53 p.m., the condition of IJ was identified. The administrator (staff #38), the director of nursing (DON/staff #52) and the regional director of clinical services (Staff #92) were informed of the facility's failure to ensure residents were free from sexual abuse by staff was found. The administrator (staff #38) presented the POC (Plan of Correction) on November 20, 2023 at 9:39 a.m. The administrator was informed that the POC was not acceptable and failed to include the following: action plan for the alleged perpetrator; how in-service training will be provided for staff who were not on shift or were on leave at the time of the IJ; projected completion date for the in-service training; what will be discussed in their in-service training on workplace conduct and professionalism. A revised POC was received on November 20, 2023 at 11:40 a.m. The administrator was informed that the POC failed to include in-service regarding abuse of their contract staff and/or volunteers. At 12:41 p.m., another POC was received and was accepted at 12:56 p.m. The accepted POC included the facility investigating the allegation of sexual abuse for resident #38, reporting of the allegation of sexual abuse, termination of the alleged perpetrator (AP/staff #17), interviewing of all residents regarding abuse, auditing of resident grievances, in-service training provided to all staff, monitoring of resident council notes and grievances, and conducting random resident and staff interviews for 3 months or until substantial compliance. Multiple observations were conducted of the facility implementing their POC which included resident and staff interviews, in-service training and review of documentation provided by the facility. On November 22, 2023 at 3:45 p.m., the condition of IJ was abated after the following: the facility provided documentation that more than 50% of their staff were in-serviced on abuse and the alleged perpetrator (AP/staff #17) was terminated from the facility. -Resident #38 was admitted on [DATE] with a diagnosis of unspecified sequelae of cerebral infarction, post-concussion syndrome, anxiety disorder and unspecified injury of head. The admission MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident had intact cognition. The MDS also included the resident had no hallucinations or delusions and have not exhibited physical and/or verbal behaviors such as hitting, kicking and abusing others sexually, threatening others or screaming at others, screaming at others, hitting or scratching self. The MDS also included that the resident required limited assistance with one-person physical assist for bed mobility, transfers, dressing, toilet use and personal hygiene. The NP (nurse practitioner) progress note dated September 30, 2023 revealed that resident #38 denied all signs/symptoms of mania and psychosis including delusions, paranoia, hallucinations, and catatonia. According to the documentation, the resident was alert and oriented x 3 with proper responses, had intact memory, concentration, cognition thought process/content and judgement and had denied any anxiety and depression. A physician progress note dated September 30, 2023 included the resident was alert and oriented x 3. Assessment included post-concussion syndrome. Review of the clinical record revealed the resident was on as needed anti-anxiety and muscle spasm medications. The discharge summary dated October 5, 2023 included the resident was discharged to home with her family. The discharge MDS assessment dated [DATE] revealed the resident had a planned discharge on October 5, 2023 to home/community with return not anticipated. A letter from a law firm (A) dated October 17, 2023 included that the law firm had been retained by resident #38 to investigate the circumstances surrounding the care, treatment, and alleged sexual assault at the facility in September and October 2023. Despite documentation that the resident was discharged from the facility on October 5, 2023, the resident's comprehensive care plan was revised on October 19, 2023 and, revealed the resident had a behavior problem of false accusations and exaggeration of events related to attention-seeking behaviors. The care plan also included a special instruction for cares in pairs. The letter from another law firm (B) dated November 3, 2023 revealed that resident #38 retained their services as it pertained to multiple incidents of sexual assault by alleged perpetrator (AP/staff #17) while resident #38 was under the facility's care between September 21, 2023 and October 5, 2023. Review of staff schedule for September and October 2023 revealed that the AP was scheduled to work the 2:00 p.m.-10:00 p.m. shift. The record of actual hours worked for the AP from September 17 through November 10, 2023 revealed documentation that the AP worked on the following dates: September 21, 22, 23, 25, 26, 27, 28, 29, 30, October 3, 4, 5, 6 and 7, 2023. Despite the facility receipt of documentation of an allegation of sexual abuse by the AP on November 3, 2023, there was no evidence that the AP was suspended until November 13, 2023. An email correspondence from the administrator dated November 13, 2023 addressed to payroll/HR (human resources) and other management staff revealed that the facility needed to put the AP (staff #17) on unpaid leave effective immediately per their legal team; and, to obtain a DNA sample from the AP. Another email correspondence from the administrator dated November 13, 2023 addressed to payroll/HR (human resources) and other management staff included to contact the AP for a DNA sample; and that, the facility will contact and let the AP know what he needs to do. The personnel file of the AP revealed a hire date of May 12, 2023 as a hospitality aide and received orientation on resident rights, and abuse, abuse prevention and reporting. The file also included a personnel change notice dated July 4, 2023 indicating that the AP had a position of a CNA (certified nursing assistant); and that, on September 28, 2023, the AP signed the job description as a CNA. The undated and unsigned facility investigative report revealed that the date of discovery of the alleged sexual assault was November 18, 2023. The report included documentation that a CNA (staff #22) reported that one night a resident who was just admitted to the facility told her that resident wanted to leave because her neighbor was having sex with a CNA .; and, that she reported the allegation to the nurse manager (staff #7). The report also included documentation of an interview conducted with the nurse manager (staff #7) who reported that she interviewed resident #38 and roommate on the evening of September 28, 2023 because the CNA (staff #22) reported an alleged sexual contact. Per the documentation, staff #7 spoke with the resident #38's roommate who went AMA; and that, the roommate's family stated that the facility was not safe. Further review of the facility's investigative report revealed that the AP was interviewed and stated that he was in the room of resident #38 few days after the resident's admission. Per the documentation, the AP stated he lifted the resident's shirt to her belly button, lifted the waistband of the resident's pants and found the resident was not wearing a brief. It also included that resident #38 started discussing her sex life with the AP then touched his genital/groin area; and that, resident #38 kissed him on the cheeks and lips. The documentation included that the AP stated that on approximately September 25 through 27, 2023, he was making his last rounds for the evening shift and was checking on resident #38 who reached out for a hug and kissed him; and then, proceeded to an intercourse. Further, the AP reported that during the intercourse, he and resident #38 were both attempting to be discreet as roommate was present in the room with the privacy curtain pulled. Further, the facility investigation included that the AP reported that this was an isolated event; and, that he felt the relationship was consensual as resident #38 pursued him with sexual conversations and made the first physical contact. The facility investigation concluded that this was a consensual relationship between resident #38 and the AP; and that, no sexual abuse had occurred in the facility. Despite the special instruction in the care plan of having cares in pairs, there was no evidence found in the facility documentation and investigation that another staff was present in the room when the AP entered the room of resident #38. An interview was conducted on November 17, 2023 at 5:11 p.m. with resident #38 who stated that she woke up to the AP (staff #17) kissing her; and that; the AP put his penis in her mouth then removed her clothes, lifted her leg and had sex with her. She stated that this was the 3rd or 4th time that the AP had raped her. Resident #38 stated that shortly after she got a roommate, she thought that maybe the AP would not rape her anymore. Resident #38 stated that on the night that the AP raped her, the AP pulled the privacy curtain closed and took her underwear. She stated that her roommate (resident #17) started screaming and staff showed up and then told me not to talk about it. Resident #38 stated that the AP came in the next day at 5:00 a.m. and apologized and told her that it would not happen again. However, resident #38 stated that the AP came in later that day and did it again; and that, another CNA (#48) caught the AP on her. Resident #38 stated that one time after the AP raped her, the AP carried her over his shoulder into the shower to clean her up; and that, after this, the AP was off for a few days. Resident #38 continued to say that when the AP returned to work, he brought her a soda; and when she was going to drink it, the AP stopped her and told her that he will put it on ice for her. Resident #38 stated that she does not usually drink her soda with ice; and that, after the AP brought the soda back and she drank it she could not move. Further, she said that she was awake but she could not move. The resident stated that the AP raped her and put his penis in her vagina, mouth and anus. Resident #38 stated that the AP would come in to rape her after she took her medications because the medications would make her tired. Resident #38 stated that the AP would bring in home cooked food for her but she would not eat it. Resident #38 stated that it kept happening and that the AP would come in and move the call light away from her reach and would rape her. Resident #38 stated that a friend told her to go to the police department about it; and that, the police came to get information about the AP. She further stated the detective told her that the information the facility has on the AP was fake; and that, the police had a hard time getting the AP's contact information. The resident continued to say she was pregnant and the police had her an obstetrician at the rape crises center. Regarding her roommate, resident #38 stated she had two roommates (#17 and #4) during her admission. She said that resident #17 left AMA (against medical advice) and resident #4 was moved to another room. Resident #38 stated that the AP raped her approximately 15-20 times; and that, another staff member told her to watch what she says because the facility was going to discharge residents that she talks to. Resident #38 stated she tried to speak to the operations director who told her that she needs to follow the chain of command and refused to talk to her. Resident #38 stated that another male resident witnessed this attempt and was discharged soon after that interaction. Resident #38 said that the AP worked all shifts; and that, the administrator and the nurse director were both aware of what was going on. Further, resident #38 stated that the incident replays in her head over and over; and that, she had bruising around her vagina still. She stated that she came at the facility with about 15 pairs of underwear and was discharged with only about 2-4 pair; and that, the AP took her underwear after he raped her. An interview with a nurse manager (staff #7) was conducted on November 20, 2023 at 9:47 a.m. The nurse manager stated that at the end of the shift on September 28, 2023, a CNA (staff #22) came to her and informed her that the resident #17 (roommate of the AV) was leaving AMA due to an alleged sexual contact. Staff #7 stated that as a manager, she followed up immediately and when she arrived on the unit, the family of the roommate was at the nurse station filling out the AMA form; and, the roommate had already exited the facility and was in a red truck that was parked outside. Staff #7 stated she went out to the vehicle to have the roommate sign the AMA documentation and asked the roommate why she was leaving. Staff #7 stated that the roommate replied you (referring to the facility) guys are going to pay me for the rest of my life. Staff #7 stated she tried to get the resident to elaborate; however, the roommate stated that she needed to speak with someone higher up. Further, the nurse manager said that because it was an allegation of sexual contact she reported it to the Administrator (staff #38) immediately and followed the facility protocol regarding reporting of abuse allegations. She stated that the administrator asked her to interview the AV who said that she was not sure why her roommate (resident #17) left. The nurse manager further stated that upon interviewing multiple staff members and the AV, she went home as her shift ended; and, she was not aware if the allegation was reported to the SA as she did not follow-up on the situation. An interview was conducted with the administrator (staff #38) on November 20, 2023 at 10:27 a.m. The administrator stated that he received a call around 10:30 p.m. to 11:30 p.m. on September 28, 2023 regarding the resident #38's roommate discharging AMA related to an alleged sexual contact concern. The administrator stated he instructed the nurse manager (staff #7) to interview the resident #38 and the other staff regarding the incident. The administrator stated there was no follow-up done with the AP (staff #17); and that, his expectation was that the clinical staff will conduct the investigation and employee follow up. The administrator said that on November 13, 2023, the facility received a letter from a law firm regarding possible sexual abuse and it was only at that point that the AP (staff #17) was suspended. In an interview conducted on November 20, 2023 at 10:48 a.m. with a CNA (staff #22) who reported sexual assault on September 28, 2023, the CNA stated that on September 28, 2023 the family reported that the roommate wanted to leave the facility because there was a male CNA having sex with resident #38; and that, she reported this to the nurse manager (staff #7). Further, the staff #22 stated that the family said that the roommate did not see anything because the curtains were closed; but the roommate could hear them (referring to the male CNA and resident #38). An interview was conducted on November 20, 2023 at 11:06 a.m. with another CNA (staff #41) who stated that he was not aware of a relationship or had never observed anything between the AP (staff #17) and resident #38. However, the CNA said that he had heard rumors about it. An interview was conducted on November 20, 2023 at 1:36 p.m. with resident #4 (whom the AP admitted to being during his intercourse with resident #38). Resident #4 stated she was a former roommate of resident #38; and that, resident #38 was a sweet lady and would stick up for her. Resident #4 stated that she was familiar with the AP; and that, the AP would also bring her food. In an interview with another female resident conducted on November 20, 2023 at 2:20 p.m., the resident stated she overheard a staff talking about a sexual relationship between a resident and a staff member; however, she had no further details. In an interview with the APS (Adult Protective Services) investigator conducted on November 21, 2023 at 9:32 a.m., the investigator stated the facility reported sexual abuse to APS on October 24, 2023. Further, on November 20, 2023 resident #38 reported allegations of rape by the AP (staff #17). An interview was conducted with male resident on November 21, 2023 at 11:32 a.m. The male resident was the one that the AV confided on regarding the incident. He stated that one day, the AV came up to him distraught, scared and did not know what to do. He said that resident #38 told him that AP raped her. The male resident stated that the AP was creepy; and that, the AP would go in the AV's room for long periods of time; and that, the AP did it to the AV more than once. He stated that he was the one who brought the AV to the police department; and they brought her underwear with the DNA of the AP in it. The male resident stated that he was with the AVwhen she tried to report the incident to the administrator who told the AV to follow the chain of command and refused to talk to the AV. The male resident stated that a CNA (staff #48) caught the AP on the AV and may have reported the incident. Further, the male resident stated that the AV told him not to report the incident as she was afraid that the AP would hurt her. An interview with the nurse unit manager (staff #107) was conducted on November 21, 2023 at 12:10 p.m. Staff #107 stated that he was the unit manager in the unit that resident #38 was admitted to. He stated that he was made aware of the sexual allegation regarding the AP when the facility received a letter from a law firm; however, he could not recall the date/day. Staff #107 said that an employee would be sent home and an investigation would be conducted if there was ever an abuse allegation; however, he does not know if the AP (staff #17) was sent home after the allegation of sexual abuse was received by the facility. Later during the interview, he said that the AP was suspended but did not know when. In an interview with the director of nursing (DON/staff #52) conducted on November 21, 2023 at 12:49 p.m., the DON stated that she was not involved in the allegation of sexual contact on September 28, 2023; and that, it was only her third week at the facility. The DON stated that the allegation was handled and she was not sure of all of the details. She stated that she heard it was something sexual and it was reported to nurse supervisor (staff #7). The DON also said that when the facility received a letter from resident #38's law firm, she did not put the letter and the September 28, 2023 allegation/incident together. Regarding resident #38, the DON stated the facility knew the resident's demeanor, history and what type of person the resident was; and that, maybe the resident was out to get money. The DON said that the suspension of the AP (staff #17) was related to the facility receiving the second letter from the law firm with the AP's name. Further, the DON stated that when she was made aware of the allegation that the resident was pregnant, she did not report the incident as she felt it was a continuation of the initial complaint on September 28, 2023. During an interview with the administrator conducted on November 21, 2023 at 2:03 p.m., the administrator stated that he was the abuse coordinator but he expected the DON to do the reporting for an allegation of abuse. He stated that prior to November 18, 2023 the AP (staff #17) was not interviewed about the incident/allegation; and that, the facility could have done a better job and could have dug deeper on the incident. The administrator stated that negative outcome of not suspending an employee with an allegation of sexual assault to a resident could be that it could happen again. Further, the administrator stated that he was informed of an alleged sexual contact and considered the initial investigation on September 28, 2023 a thorough investigation. An interview was conducted with Payroll/Human Resources (HR/staff #77) on November 22, 2023 at 8:41 a.m. HR stated the AP (staff #17) was scheduled to work at 2:00 p.m. on November 13, 2023; and, at approximately 1:00 p.m. on November 13, she called the AP to suspend him as instructed by the administrator. Further, HR said that she also informed the AP that the facility will be in contact with the him to obtain a DNA test. A review of the facility policy on Resident Rights revised on December 2016 included that federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to be free from abuse, neglect, misappropriation of property, and exploitation.

Based on clinical record reviews, staff interviews, facility documentation and review of policies and procedures, the facility failed to implement their policy regarding protection of resident, reporting and investigating an allegation of sexual abuse for one resident (#38). The deficient practice resulted in appropriate corrective action not taken, further sexual abuse for resident #38, compromised protection of other residents, abuse not reported and thoroughly investigated. Findings include: -Resident #38 was admitted on [DATE] with a diagnosis of unspecified sequelae of cerebral infarction, post-concussion syndrome, anxiety disorder and unspecified injury of head. Resident #38 was the alleged victim (AV). -Resident #17 was admitted on [DATE] with diagnoses of pain in the right lower leg, pulmonary hypertension, chest pain, and acute embolism. Resident #17 was the roommate of resident #38 (AV). A nursing note dated September 28, 2023 at 7:57 p.m. revealed that resident #17 arrived at the facility via stretcher from the hospital. However, the AMA (against medical advice) note dated September 28, 2023 at 9:57 p.m. included that the certified nursing assistant (CNA) reported to the nurse that the resident (#17) was leaving the facility with her family against medical advice; and that, resident #17 was already out in the truck with her family. According to the documentation, resident #17 was visibly upset and reported that she had a problem with a CNA but would not reveal what happened. Per the documentation, a case manager (CM) spoke with the AV (resident #38) who reported that she overheard resident #17 tell her family that the facility was a ghetto and did not want to stay at the facility. Review of the AMA release form revealed that resident #17 had signed and dated the form on September 28, 2023. The undated, unsigned and unlabeled facility documentation provided to the survey team at the time of the survey revealed an undated and unsigned written statement from the nurse manager (staff #7) who wrote that she interviewed resident #17 and the AV on September 28, 2023. It also included that two CNAs notified her that resident #17 reported sexual contact and was leaving the facility AMA. The statement also included that the nurse manager spoke with resident #17 and her family who reported that the facility was not safe. It also included that resident #17 told the nurse manager that she was not happy at the facility; and that, the facility will be on the news and will be paying resident #17 for the rest of her life. Further, the statement included that the nurse manager spoke with the AV who told the nurse manager that the AP came in the room, answered the AV's call light and attended to her needs. Per the documentation, when the AP left the room, resident #17 asked the AV why the AP was not spending time with resident #17. Further, the statement included that the AV told the nurse manager she was fine and had no concerns or complaints. Continued review of the undated, unsigned and unlabeled facility documentation revealed that the nurse manager conducted interviews with CNA/staff #22 who was the CNA who reported to the nurse manager (staff #7) that resident #17 was leaving AMA due to sexual contact between the AV and the AP; and, two other staff who reported not hearing or seeing anything. However, the undated, unsigned and unlabeled facility documentation did not include the following: -Interview or attempts to interview with the AP; -Review of all the events leading up to the alleged incident; -Interviews of other residents to whom the accused employee provided care or services; -Corrective actions taken; -Notification of the alleged violation to the SA; and, -Notification of the alleged violation to other agencies or law enforcement authorities. A letter from a law firm (A) dated October 17, 2023 included that the law firm had been retained by the AV to investigate the circumstances surrounding the care, treatment, and alleged sexual assault at the facility in September and October 2023. The letter from another law firm (B) dated November 3, 2023 revealed that the AV retained their services as it pertained to multiple incidents of sexual assault by alleged perpetrator (AP/staff #17) while the AV was under the facility's care between September 21, 2023 and October 5, 2023. Review of staff schedule for September and October 2023 revealed that the AP was scheduled to work the 2:00 p.m.-10:00 p.m. shift. The record of actual hours worked for the AP from September 17 through November 10, 2023 revealed documentation that the AP worked on multiple dates: September 21, 22, 23, 25, 26, 27, 28, 29, 30, October 3, 4, 5, 6 and 7, 2023. Despite the facility receipt of documentation of an allegation of sexual abuse by the AP on October 17 and November 3, 2023, facility documentation revealed evidence that the AP was not suspended until November 13, 2023. An email correspondence from the administrator dated November 13, 2023 addressed to payroll/HR (human resources) and other management staff revealed that the facility needed to put the AP on unpaid leave effective immediately per their legal team; and, to do a DNA sample from the AP. Another email correspondence from the administrator dated November 13, 2023 addressed to payroll/HR (human resources) and other management staff included to contact the AP, do a DNA sample; and that, the facility will contact and let the AP know what he needed to do. Despite knowledge of allegations of sexual abuse on September 28, October 17, November 3 and November 13, 2023, there was no evidence found in the clinical record and facility documentation that the allegation of sexual abuse was reported to the SA until November 18, 2023. There was also no evidence found in the clinical record and facility documentation that the allegations of sexual abuse were investigated until November 18, 2023. Another undated and unsigned facility investigative report revealed that the date of discovery of the alleged sexual assault was November 18, 2023. The report included documentation that a CNA (staff #22) reported that one night a resident who was just admitted to the facility told her that resident wanted to leave because her neighbor was having sex with a CNA .; and, that staff #22 reported the allegation to the nurse manager (staff #7). Further, the report included that the incident was reported to the SA, APS (Adult Protective Services), Ombudsman and local police on November 18, 2023. The facility investigation included interviews conducted with the AP (staff #17), the CNA (staff #22) who reported the alleged sexual assault on September 28, 2023, the nurse manager and the roommate of AV. However, continued review of the facility's investigative report did not include the following: -Interview or attempts to interview with the AV; -Identification of any injuries as appropriate; -Review of all the events leading up to the alleged incident; and, -Interviews of other residents to whom the accused employee provided care or services. An interview was conducted on November 17, 2023 at 5:11 p.m. with AV (resident #38) who stated that she woke up to the AP (staff #17) kissing her; and that; the AP put his penis in her mouth then removed her clothes, lifted her leg and had sex with her. She stated that this was the 3rd or 4th time that the AP had raped her. The AV stated that shortly after she got a roommate, she texted and told her sister that God was looking out for her now that she had a roommate; and that, maybe the AP would not rape her anymore. The AV stated that on the night that the AP had sex with her, the AP pulled the privacy curtain closed and took her underwear. She stated that her roommate (resident #17) started screaming and staff showed up and then told me not to talk about it. The AV stated that the AP came in the next day at 5:00 a.m. and apologized and told her that it would not happen again. However, the AV said that the AP came in later that day and did it again; and that, another CNA (#48) caught the AP on her. The AV stated that one time after the AP raped her, the AP carried her over his shoulder into the shower to clean her up; and that, after this, the AP was off for a few days. The AV continued to say that when the AP returned to work, he brought her a soda; and when she was going to drink it, the AP stopped her and told her that he will put it on ice for her. The AV said that she does not usually drink her soda with ice; and that, after the AP brought the soda back and she drank it she could not move. Further, she said that she was awake but she could not move. The resident stated that the AP raped her and put his penis in her vagina, mouth and anus. The AV stated that the AP would come in to rape her after she took her medications because the medications would make her tired. The AV stated that it kept happening and that the AP would come in and move the call light away from her reach and would rape her. The AV stated that the AP raped her approximately 15-20 times; and that, the incident replays in her head over and over; and that, she had bruising around her vagina still. The AV stated that she tried to speak to the operations director who told her that she needs to follow the chain of command and refused to talk to her; and that, the administrator and the nurse director were both aware of what was going on. An interview with a nurse manager (staff #7) was conducted on November 20, 2023 at 9:47 a.m. The nurse manager stated that at the end of the shift on September 28, 2023, a CNA (staff #22) came to her and informed her that the resident #17 (roommate of the AV) was leaving AMA due to an alleged sexual contact. Further, the nurse manager said that because it was an allegation of sexual contact she reported it to the Administrator (staff #38) immediately and followed the facility protocol regarding reporting of abuse allegations. She stated that the administrator asked her to interview the AV who said that she was not sure why her roommate (resident #17) left. The nurse manager further stated that upon interviewing multiple staff members and the AV, she went home as her shift ended; and, she was not aware if the allegation was reported to the SA as she did not follow-up on the situation. An interview was conducted with the administrator (staff #38) on November 20, 2023 at 10:27 a.m. The administrator stated he received a call around 10:30 p.m. to 11:30 p.m. on September 28, 2023 regarding the resident #17's discharging AMA related to an alleged sexual contact concern. The administrator stated he instructed the nurse manager (staff #7) to interview the AV, other residents and other staff; and to follow-up the alleged incident of sexual contact. The administrator said that on November 13, 2023, the facility received a letter from a law firm regarding possible sexual abuse and it was only at that point that the AP (staff #17) was suspended. Further, the administrator stated that the incident was never reported to the SA; and that, he should have done a better job completing a thorough investigation and reporting. In an interview with the APS investigator conducted on November 21, 2023 at 9:32 a.m., the investigator stated the facility reported sexual abuse to APS on October 24, 2023. Further, on November 20, 2023, she met with the AV who reported allegations of rape by the AP. However, review of the SA complaint tracking system revealed there was no allegation of sexual abuse reported by the facility on October 24, 2023. There was no evidence found in the clinical record and facility documentation that the allegation of rape by the AP was reported to the SA and investigated on October 24, 2023. An interview was conducted with male resident on November 21, 2023 at 11:32 a.m. The male resident was the one that the AV confided on regarding the incident. He stated that one day, the AV came up to him distraught, scared and did not know what to do. He said that resident #38 told him that AP raped her. The male resident stated that the AP was creepy; and that, the AP would go in the AV's room for long periods of time; and that, the AP did it to the AV more than once. He stated that he was the one who brought the AV to the police department; and they brought her underwear with the DNA of the AP in it. The male resident stated that he was with the AV when she tried to report the incident to the administrator who told the AV to follow the chain of command and refused to talk to the AV. An interview was conducted on November 21, 2023 at 12:49 p.m. with the Director of Nursing (DON/staff #52) who stated that she received a letter from the law firm on October 17, 2023 regarding investigation of circumstances surrounding the care, treatment, and alleged sexual assaults for the AV (resident #38) at the facility in September and October of 2023. The DON said that she did not put the letter and the September 28, 2023 allegation/incident together. The DON stated that when she received the first letter from the law firm, the facility did not initiate an investigation because she did not know what to investigate. The DON stated the facility received a second letter from another law firm that mentioned some sort of sexual assaults by the AP (staff #17) which prompted the suspension of the AP. However, the DON said that the facility did not initiate an investigation. Further, the DON stated that she did not report the allegation of sexual assault to the SA. In another interview with the Administrator on November 21, 2023 at 2:03 p.m., the administrator stated that he was the abuse coordinator but he expected the DON to do the reporting for an allegation of abuse. The administrator also said that he was informed of an alleged sexual contact report and considered the initial investigation on September 28, 2023 a thorough investigation. He stated that prior to November 18, 2023 the AP (staff #17) was not interviewed about the incident/allegation; and that, the negative outcome of not suspending an employee with an allegation of sexual assault to a resident could be that it could happen again. He stated that the facility could have done a better job and could have dug deeper on the incident. Further, the administrator said that he never reported the incident/allegation to the state agency and the facility policies were not implemented. An interview was conducted with Payroll/Human Resources (HR/staff #77) on November 22, 2023 at 8:41 a.m. HR stated the AP (staff #17) was scheduled to work at 2:00 p.m. on November 13, 2023; and, at approximately 1:00 p.m. on November 13, she called the AP to suspend him as instructed by the administrator. Further, HR said that she also informed the AP that the facility will be in contact with the him to obtain a DNA test. A review of the facility policy on Resident Rights revised on December 2016 included that federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to be free from abuse, neglect, misappropriation of property, and exploitation. Review of the facility policy titled, Accidents and Incidents - Investigating and Reporting revealed that all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring in the facility's premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The policy included that the following data shall be included on the Report of Incident/Accident form that should include: -Date and time the accident or incident took place; -Nature of the injury/illness -Circumstances surrounding the accident or incident; -Name(s) of witnesses and their accounts of the accident or incident; -Injured person's account of the accident or incident; -Any corrective action; -Follow-up information; and -Signature and title of the person completing the report. The facility policy on Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating 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 policy included that the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: state licensing/certification agency responsible for surveying/licensing the facility; local/state ombudsman; adult protective services; and, law enforcement officials.

Based on staff interviews, review of records and review of policies and procedures, the facility failed to ensure that one resident (#1) was provided with adequate behavioral supervision. The deficient practice resulted in the resident pulling out his [MEDICAL CONDITION] which caused the resident to asphyxiate and expire. Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician's progress note dated [DATE] at 8:18 p.m. included that the resident had a medical history that included [MEDICAL CONDITION], was non-verbal, and had chronic [MEDICAL CONDITION] dependent on [MEDICAL CONDITION]. A health status note dated [DATE] at 8:30 p.m. included that the resident had pulled [MEDICAL CONDITION] out and [MEDICAL CONDITION] been placed back in and the resident had stopped breathing. The note included that the resident had been bagged (artificial breaths administered with an ambu-bag) until he began breathing again. A [MEDICAL CONDITION] progress note dated [DATE] at 8:23 a.m. included that the resident had acute/chronic [MEDICAL CONDITION], and a [MEDICAL CONDITION]. The note included that the resident had a sitter at the bedside, and that on the previous day the resident had removed [MEDICAL CONDITION], and had to be bagged, and that the nurse had been almost unable to put [MEDICAL CONDITION] in after the second time that the resident had removed it. The note included that at the time of the assessment, the resident was calm, but still reaching up towards his trach. The note also included that the resident was alert, but did not follow commands. A health status note dated [DATE] at 8:50 a.m. included that the resident was very anxious and continuously pulling on his trach, and a 1:1 sitter was with the resident. A physician's progress note dated [DATE] at 12:21 p.m. included that resident #1 had pulled [MEDICAL CONDITION] overnight and continued to reach up and pull even though he had a sitter at the bedside, and that he did not follow commands. Review of health status notes dated [DATE], and [DATE] included the following: -A note dated [DATE] at 6:51 p.m. included that the resident currently had a sitter due to pulling his [MEDICAL CONDITION]. -A note dated [DATE] at 7:30 a.m. included that a sitter was at the resident's bedside, as the resident was pulling at [MEDICAL CONDITION] that assistance was needed to suction the resident. An Admission MDS (Minimum Data Set) assessment dated [DATE] included that resident #1 had severely impaired cognition, was totally dependent on staff for cares and had [MEDICAL CONDITION]. The assessment also included that resident #1 received oxygen therapy, suctioning and [MEDICAL CONDITION] care. Review of physician's progress notes dated [DATE], and [DATE] included the following: -A note dated [DATE] at 2:53 p.m. included that resident #1 was pulling a blanket over his head and attempting to pull his trach. The note included that the resident was not very redirectable even with a sitter, and included a plan to continue with the 1:1 sitter. -A note dated [DATE] at 11:04 a.m. included that the resident was continually grabbing at [MEDICAL CONDITION] hard, was difficult to redirect and remained with a 1:1 sitter. A health status note dated [DATE] at 7:42 a.m. included that the resident had a sitter around the clock at the bedside as he continued to pull at [MEDICAL CONDITION] and remove his oxygen, as well as pull on the trach. The note included that the resident had been redirected but goes right back to it. Review of physician's progress notes dated [DATE], and 7, 2019 included the following: -A note dated [DATE] at 10:30 p.m. included that the resident continued to have a 1:1 sitter and had been pulling on his ventilator and lines like usual. -A note dated [DATE] at 12:11 p.m. included that the physician had examined the resident and as soon as he moved away, the resident grabbed [MEDICAL CONDITION] had the collar of [MEDICAL CONDITION] on his head trying to take it off. The note included a plan to continue with the 1:1 sitter. -A note dated [DATE] at 7:37 p.m. included that the resident continued to have a 1:1 sitter and continued to pull at [MEDICAL CONDITION]. A health status note dated [DATE] included that the resident had a sitter around the clock at the bedside and continued to pull at the trach. Review of physician's progress notes dated [DATE], and [DATE] included the following: -A note dated [DATE] at 11:36 a.m. included that the resident had a sitter at the bedside, and continued to grab at his trach. A note dated [DATE] at 7:33 p.m. included that there was a sitter at the resident's bedside, the resident appeared agitated, was pulling at sheets, and lines Review of health status notes dated [DATE] included the following entries: -At 1:01 a.m. an RT (Respiratory Therapist/staff #139) documented that at 12:15 a.m. he had been called to the resident's room, the resident was cold, his eyes were fixed and dilated, and [MEDICAL CONDITION] out. The note included that after 30 minutes of CPR (Cardiopulmonary Resuscitation) the resident had no signs of life. -At 1:10 a.m. a note by staff #139 included that at the time of arrival EMS checked the resident's body temperature, it was 94 F (Fahrenheit) and stated that the resident had been like that for a while, and the resident's body was cold and stiff. -At 3:45 a.m. a note by an LVN (Licensed Vocational Nurse/staff #52) included that a CNA (Certified Nursing Assistant) had notified her that the resident was not breathing. The note included that the resident had no pulse and respirations, CPR was initiated, 911 was notified and the fire department started CPR when they arrived. The note included that the resident was unable to be revived, and the time of death was 12:51 a.m. Review of an investigative report dated [DATE] revealed that on [DATE] at 12:15 a.m. resident #1 had pulled/dislodged [MEDICAL CONDITION] oxygen mask causing him to be unresponsive. The report included that nursing and respiratory staff immediately started CPR and notified 911. The report included that emergency responders took over CPR, and that resident #1 expired despite their immediate interventions. The report included that the resident had behaviors of pulling at his life sustaining device ([MEDICAL CONDITION]) and had a 1:1 sitter prior to CPR being initiated. The report included that a CNA (staff #40) had stated that she was at the resident's bedside and at 12:10 a.m. another CNA entered the room, staff #40 and the other CNA had a short conversation and when staff #40 turned to look at the resident, he had pulled [MEDICAL CONDITION] over his face, she immediately placed [MEDICAL CONDITION] over the resident's neck and noticed that he was cold, and that while she checked the resident for a pulse, the another CNA left to get the nurse. The report included a statement from another CNA (staff #37) who stated in the report, that at 12:15 a.m. when she entered the resident's room to ask staff #40 a question, she noticed that the resident had [MEDICAL CONDITION] over his head, she told staff #40 to check on the resident, and started calling for help after turning on the light. The report included that an investigation had been conducted, and that staff #40 had been found negligent in monitoring resident #1 from the hours of 11:30 p.m. until 12:15 a.m. and employment was terminated. During an interview conducted on February 11, 2020 at 8:50 a.m. with a Behavioral Clinical Liaison/staff #227, she stated that when a staff is doing a 1:1 sit with a resident for behavioral issues the staff is supposed to sit within 2 arm lengths away from the resident to be able to redirect the resident and is supposed to monitor the resident continuously. Staff #227 stated that the sitter is supposed to only focus on the resident and is not allowed to sleep, or use a cell phone, or any electronic devices while providing 1:1 supervision to a resident. During an interview conducted on February 11, 2020 at 9:42 a.m. with a Regional Clinical Director (staff #89) she stated the resident had a 1:1 sitter at the time that he removed his trach. During an interview conducted on February 11, 2020 at 10:24 a.m. with the former DON (Director of Nursing/staff #65) he stated that he interviewed staff #40 during the investigation and she stated to him that she wasn't paying attention to resident #1 and admitted to not being careful when she was the resident's 1:1 sitter at the time that the resident removed his trach. During an interview conducted on February 11, 2020 at 12:40 p.m. with a CNA (staff #185), the CNA stated that she had sat 1:1 with resident #1 and that the sitter had to sit at the bedside because resident #1 would try to take out [MEDICAL CONDITION] and that she had to sit right next to him and watch him to make sure he didn't pull it out. During an interview conducted on February 12, 2020 at 11:55 a.m. with an RT (staff #124) she stated that on [DATE] at 11:30 p.m. when she entered the room of resident #1 to provide a breathing treatment a CNA (staff #40) was seated in a chair, 2 ,[DATE] to 3 feet away from the resident's bed, and positioned sideways to the resident, who was lying on the bed. The staff #124 stated that the CNA had ear buds in her ears and was watching something on a handheld electronic device. Staff #124 stated that while she was providing a breathing treatment to the resident, she asked the CNA some questions and when the CNA didn't answer her, she turned around and noticed that the CNA was watching the electronic device and listening to it with ear buds. Staff #124 stated that when she repeated her questions, the CNA removed the ear buds prior to answering her questions. Staff #124 stated that when she left the resident's room, the CNA was still seated in the chair, in the same location in the room, and continued to watch the electronic device and listen to it with ear buds, and was not observing the resident. During an interview conducted on February 12, 2020 at 9:03 a.m. with an RT/staff #139, he stated that on the night shift [DATE] at 12:15 a.m. a CNA asked him to come into the room of resident #1. Staff #139 stated that upon entering the room he saw that the resident was dead and [MEDICAL CONDITION] pulled out of his neck. Staff #139 stated that the resident's color was bad and that a pulse-oximeter reading he took read zero. Staff #139 stated that he sealed the resident's stoma, started to bag the resident (with an ambu-bag) and when a nurse arrived moments later, they initiated CPR until the EMS arrived (within 10 minutes) and that EMS checked the resident's temperature, which was 94 degrees, and the resident was stiff. A policy and procedure titled Behavior Management included a statement that it is the policy of the facility to attempt to manage and reduce or eliminate dysfunctional resident behavior through the provision of behavioral interventions. The policy included that its purpose is to assure that dysfunctional behaviors are managed, reduced or eliminated in order to maintain a safe environment and to promote quality of life. The policy included that behavioral interventions include 1:1 monitoring, redirection, visual supervision and distraction. A policy titled Resident Supervision and Monitoring included a statement that residents are provided with intense supervision when they present with conditions that may place other residents and/or themselves at risk for harm. The policy included that 1:1 supervision includes that staff stay within close proximity (no more than 2 arm's length) of the resident at all times. The policy included that the assigned staff member has no other assigned duties and 1:1 supervision requires a physician's orders [REDACTED].>

Based on closed clinical record review, hospital documentation, staff interviews, review of the Journal of the American Medical Association documentation and policy review, the facility failed to provide the necessary care and services to one resident (#348) following a change in condition. Findings include: Resident #348 was admitted at the facility on June 22, 2015, with [DIAGNOSES REDACTED]. An Advance Directive for Health Care form dated June 22, 2015 included that the resident want to be transferred to the hospital if her medical status changed. The advance directives care plan dated June 22, 2015 included that the resident had chosen a full code status. Interventions included honoring the resident's wish for a hospital transfer. The Activities of Daily Living (ADL) care plan dated June 23, 2015 included that the resident had self-care performance deficits and had limited physical mobility. Interventions included the resident was able to ambulate using a walker with one person assistance and was able to feed self. An admission MDS (Minimum Data Set) assessment dated [DATE] included a BIMS (Brief Interview for Mental Status) score of 9, which indicated that the resident had moderate cognitive impairment and had no problems with speech clarity. The MDS also included that the resident required extensive assistance of two person physical assistance with bed transfers and bed mobility. The resident also had functional limitation in range of motion of both lower extremities. A nurse practitioner's note dated August 3, 2015 documented that the resident was alert and oriented to time, place, person and situation and was negative for muscle weakness. The note further included the resident was independent with eating. A physician's order summary report for September 2015, revealed the resident was a full code. A nursing note dated September 7, 2015 revealed that at 3:00 p.m., the resident had trouble speaking, had right sided weakness with a weak grip on the right, and was unable to answer questions appropriately without difficulty. Called after hours provider and received no return call. Called a second time after one hour and spoke to the NP (nurse practitioner). An SBAR (Situation Backgroun Assessment Request) form dated September 7, 2015 revealed the resident had a sudden change in the level of consciousness or responsiveness, had weakness to the right arm with no grip, and had abnormal or slurred speech, which were signs and symptoms that had not occurred before and were described as an abrupt onset or change. The assessment further included that the resident appeared weak with no strength to the right side, speech was garbled, and was unable to answer as usual and that the NP was notified. The NP orders dated September 7, 2015 included STAT chest x-ray for [MEDICAL CONDITION], CBC (complete blood count), BMP (Basic metabolic panel), BNP (brain natriuretic peptide-measures the amount of BNP hormone in the blood, BNP shows how well the heart is working, used to check for heart failure) and a UA & C&S for change of condition. Review of the chest x-ray report dated September 7, 2015 revealed the resident had modest cardiomegaly with clear lungs. Additional orders following the lab results dated September 7, 2015 included for a potassium level to be done on September 9, due to an elevated potassium level and an antibiotic. A nursing note dated September 8, 2015 included that on September 7, the resident presented with weakness, increased confusion and required more help with activities of daily living (ADLs). Per the documentation, a urine sample was collected and resident was started on antibiotic for leukocytosis. A nursing note dated September 9, 2015 11:52 a.m., included the resident was lethargic, awake and required assistance with meals and continued on an antibiotic for elevated white blood cells. Another nursing note dated September 9, 2015 at 6:12 p.m., revealed the resident seems to have difficulty with eating and had right-sided weakness. A physician's note dated September 10, 2015 included that the resident had a urinary tract infection [MEDICAL CONDITION] and was treated with an antibiotic, which was discontinued after the resident developed a rash. Neurological examination included that the resident was weak. There was no additional neurological assessment documentation regarding the resident's right-sided weakness, slurred speech, or mental status. The plan included supportive care and to continue with current medications. Further review of the clinical record revealed there was no thorough ongoing assessments from September 8 through September 15, regarding the resident's neurological changes, including the right-sided weakness, slurred speech and the inability to answer questions as before. A nursing note dated September 16, 2015 at 1:23 p.m., included the resident was unable to feed herself at lunch today, unable to follow verbal cues and was pale in color. The NP was at the bedside and orders were received. The NP's orders dated September 16, 2015 included STAT x-ray, CBC, BMP, and BNP one time only for a change in condition. An additional nursing note dated September 16, 2015 at 1:40 p.m. included the resident was alert, but was not able to follow simple commands. Follows staff with eyes, but not verbalizing. Family requesting resident be sent to hospital. Diagnostic orders canceled due to hospital transfer. An NP order dated September 16, 2015 now included for the resident to be transferred to the hospital for a change in level of consciousness, abnormal neurological assessment and irregular heart rate. Another nursing note dated September 16, 2015 included that the ambulance service was called and estimated time of arrival was 30-45 minutes. A note at 2:29 p.m. included the resident was transferred to the hospital via ambulance. Review of the SBAR form dated September 16, 2015 revealed the resident had altered mental status with a decrease in level of consciousness or responsiveness, had general weakness and needs more assistance with ADLs, had an abrupt change in speech and speech was impaired and abnormal, and the resident was not following commands. Assessment included TIA ([MEDICAL CONDITION]) or [MEDICAL CONDITION]. Review of the hospital records dated September 16, 2015 revealed an admission time of approximately 2:40 p.m. The documentation included that the patient mumbles incomprehensible words and is not moving the right leg and does not withdraw to pain. The CAT (Computerized Axial Tomography) scan of the head revealed extensive small vessel change in the left cerebral hemispheres. [DIAGNOSES REDACTED]. An interview with a licensed practical nurse (LPN/staff #140) was conducted on December 7, 2016 at 11:40 a.m. She stated that when she observes a resident manifesting sudden onset of right-sided weakness, slurred speech and lack of grip on the right side, she would call the physician and follow orders prescribed. She further stated that if the resident continued to show these symptoms, she would send the resident to the hospital, as sending a resident with these symptoms to the ER is a standard of practice. An interview with the nurse manager (staff #26) was conducted December 7, 2016 at 1:54 p.m. She stated that when a resident presents with an acute onset of right-sided weakness, slurred speech and lack of grip on the right side, she would call the physician and would send the resident to the ER. During an interview with a registered nurse (RN/staff #123) on December 7, 2016 at 2:28 p.m., she stated that when a resident manifest symptoms of weakness and slurred speech, she would call 911 and send the resident to the ER. She stated that she would then inform the physician that the resident was sent to the ER, because of these symptoms. She further stated that she would not wait for the physician's order to send the resident to the hospital. An interview with the Director of Nursing (DON/staff #3) was conducted on December 8, 2016 at 8:58 a.m. She stated that when a resident suddenly develops right-sided weakness, slurred speech and lack of grip on the right side, the floor nurses are expected to call the physician and transfer the resident to the hospital. She stated that if the floor nurses did not receive any orders to transfer the resident to the hospital, she would call the physician and inform the physician of the need to transfer the resident to the hospital. The regional clinical director (staff #263) who was present during this interview agreed with the statement of staff #3. In a later interview with staff #263 conducted on December 8, 2016 at 12:38 p.m., she stated that the resident had a lot going on at the time the resident developed symptoms of right-sided weakness, slurred speech and lack of grip on the right. She stated she does not know why the resident was not sent to the hospital by the physician and/or the nurse. Further, she stated that if she had called regarding the resident's symptoms and received no orders for transfer, she would clarify the order and follow up with the physician. Review of the facility policy regarding Resident Change in Condition revealed that it is the facility's policy to identify, inform the physician and resident (or designated agent) and intervene to provide medical or nursing care for a resident experiencing an acute medical change in condition in a timely and effective manner. Upon noting or receiving report of a change in a resident's physical, emotional or mental status, the nurse will assess the resident's condition. This assessment may include, but is not limited to, vital signs, complaints or symptoms of pain .changes in cognitive status or orientation, changes in mobility or skeletal alignment .The policy further included that in the event of a life-threatening situation, serious injury ., when a physician cannot be contacted timely, the charge nurse may elect to contact emergency personnel services to assist with care and possible transport to an acute hospital. The policy also included to document all assessments and interventions in the clinical record and continue to monitor and document the resident's condition at a minimum of every shift for 72 hrs or more frequently or longer as needed, until the acute episode has subsided and the resident is stable. The Director of Nursing will review new telephone orders and daily change of condition reports to monitor for any further actions needed. According to a study published in the Journal of the American Medical Association, treating stroke victims quickly is of high importance. If you suffer a stroke, for every 15 minutes that pass before doctors address your condition, the likelihood of death jumps 4%, you are 4% less likely to be able to walk when you leave the hospital, 4% more likely to suffer debilitating brain hemorrhages and 3% less likely to return home. Acute ischemic stroke is treatable if addressed within 4.5 hours. Symptoms include facial drooping, arm weakness, and speech difficulty. When a stroke strikes, each passing minute could mean the difference between life and death or whether you leave the hospital standing and thinking like your old self.

Based on closed clinical record review, staff interviews and hospital documentation, the facility failed to ensure the resident environment was free from accident hazards for one resident (#349). Finding include: Resident #349 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long term membory problems and had severe cognitive impairment with decision making skills. The resident was also assessed as requiring extensive assistance of two staff members for transfers. The fall risk assessment dated [DATE] revealed the resident was at moderate risk for falls. A falls care plan included the resident was at risk for falls. An intervention included to keep all hallways and room free of clutter. Review of the closed clinical record revealed that on March 10, 2016, a LPN (licensed practical nurse/staff #223) was called to the resident's room by a CNA (Certified Nursing Assistanct/staff #260). The resident was lying face down and had a hematoma to the middle of her forehead, and she was bleeding from her nose. The resident was complaining of pain. Neurological checks were done and the resident was sent to the hospital at 9:20 a.m. Review of the facility's investigative report revealed that on March 10, 2016 the resident was being pushed into her room by a CNA (staff #260) and got her right foot caught in the air mattress cord of her roommates bed. The CNA was unaware of this and continued to push the resident, and the resident fell out of the wheelchair. Corrective action included that staff #260 was in-serviced and that zip ties were applied to the cords on the roommates bed. Review of the hospital emergency room report dated March 10, 2016 revealed the resident had a cervical spine fracture and a cervical collar was applied. The resident was released from the hospital and was sent back to the facility on [DATE]. An interview was conducted on December 7, 2016 at 10:11 a.m. with staff #260, who was the CNA that was pushing the wheelchair at the time of the incident. She stated she was wheeling the resident into her room and the resident's foot was sticking out and got stuck on some wires or something, which caused her to fall. She stated she did not see that her foot was stuck, as she was behind her pushing the wheelchair. She stated that after she fell the nurse came in and assessed her and 911 was called. She said the resident came back from the hospital later that same day, with a neck brace and she had some bruises. An interview was conducted on December 7, 2016 at 10:30 a.m. with LPN (staff #223). She stated that she assessed the resident and suspected a possible injury, so 911 was called. An interview was conducted on December 8, 2016 at 1:05 p.m. with the regional clinical director (staff #263). She stated the cables for the air mattresses on the beds are usually at the foot of the beds, because that's where the pumps are located. She stated that when a resident suddenly moves in a wheelchair they can get their foot caught in the cables. She stated that falls are reviewed the next business day and the situation is looked at and interventions might be put into place to prevent it from happening again.

Based on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that one resident (#247) was free from a significant medication error. Findings include: Resident #247 was admitted on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of a care plan revealed the resident was at risk for pain and verbalizes complaints of pain. One of the interventions included to administer pain medications as ordered. The admission orders [REDACTED]. The orders also included for [MEDICATION NAME] 5 mg (milligrams) by mouth every six hours PRN (as needed) for pain. A review of the [DATE] MAR (Medication Administration Record) reflected that on [DATE], the resident was administered a [MEDICATION NAME] at 8:45 p.m. to the chest. The dose initialed as being applied was 25 mcg/hr. However, a form titled Controlled Substance Countdown Sheet, revealed that a [MEDICATION NAME] 50 mcg/hr was signed out on [DATE] at 8:45 p.m., by the same nurse who initialed the administration of the 25 mcg/hr [MEDICATION NAME] on the MAR. Review of the clinical record revealed there was no physician's order for [MEDICATION NAME] 50 mcg/hr, after readmission on [DATE]. Prior to the [DATE] readmission, the resident had a physician's order for [MEDICATION NAME] 50 mcg/hr. In addition, the resident also received [MEDICATION NAME] as follows: [DATE] at 9:30 p.m., and [DATE] at 10:32 a.m., 4:34 p.m. and at 11:10 p.m. Per the Controlled Substance Sheet, the documentation showed that for the 10:32 a.m. dose on [DATE], the resident received 2 tablets (a total of 10 mg) instead of 1 tablet (5mg) as ordered. Further review of the clinical record revealed an order change dated [DATE] for [MEDICATION NAME] 5 mg one tablet by mouth every 6 hours PRN for a pain scale of ,[DATE] and [MEDICATION NAME] 5 mg two tablets by mouth PRN for a pain scale of ,[DATE]. On the MAR for [DATE], the resident received one tablet of [MEDICATION NAME] at 5:26 a.m. and two tablets at 6:44 p.m. According to the [DATE] MAR and the Controlled Substance Sheet, the resident received [MEDICATION NAME] 5 mg two tablets at 5:22 a.m. and 1:00 p.m. on [DATE]. Continued review of the [DATE] MAR revealed that a 25 mcg [MEDICATION NAME] was applied to the resident's chest on [DATE] at 11:09 p.m. There was no corresponding Controlled Substance Sheet for the 25 mcg [MEDICATION NAME] for [DATE]. In addition, the clinical record did not reflect that the 50 mcg [MEDICATION NAME] which had been applied on [DATE] was ever removed. Further review of the [DATE] MAR and the Controlled Substance Sheet revealed that [MEDICATION NAME] 5 mg, two tablets were administered on [DATE] at 12:30 a.m., 8:47 a.m., and 11:52 p.m., on [DATE] at 6:37 a.m., 12:37 a.m., and 8:44 p.m., and on [DATE] at 4:40 a.m. and 10:30 a.m. Another order change regarding the [MEDICATION NAME] dose occurred on [DATE] as follows: [MEDICATION NAME] 10 mg every four hours PRN for pain of ,[DATE] and 20 mg for pain of ,[DATE]. A review of the [DATE] MAR revealed that on [DATE], the resident received 20 mg of [MEDICATION NAME] at 12:00 p.m. and 4:00 p.m., for a pain scale of nine. Review of a nursing note dated [DATE] at 6:29 p.m. revealed that at 4:40 p.m., a nurse entered the resident's room to provide wound care and found the resident unresponsive. The resident had no heart rate and was not breathing and CPR (cardiopulmonary resuscitation) was initiated. Paramedics arrived and took over the CPR and the resident was transferred to the hospital. Review of the hospital admission history and physical dated [DATE], revealed the resident was found to be unresponsive and was coded by the facility nursing staff. The resident was transported to the hospital and admitted with altered mental status. The documentation also included that the resident was found with three [MEDICATION NAME]es on, which were removed and the resident was [MEDICAL CONDITION] in the ER. Review of an Infectious Disease consultation report dated [DATE], reflected a [DIAGNOSES REDACTED]. Altered mental status/[MEDICAL CONDITION], which appears more of toxic metabolic type, likely medication-related, resolving. Further review of the hospital records revealed a Consultation report dated [DATE], which included the resident had been overly sedated from narcotics and received CPR, which resulted in broken ribs on the left side. The report also included that three [MEDICATION NAME]es (strength unknown) had been removed from her chest upon admission. The resident was admitted to ICU, then transferred to telemetry when stable. During an interview with a RN (Registered Nurse) on [DATE] at 2:58 p.m., the RN stated that with any [MEDICATION NAME] such as [MEDICATION NAME], nurses were to document the site/location of application and also the removal of the patch on the MAR. The RN said that the nurses were to review the orders to ensure they included for the patch to be removed, so when the order is transcribed into the eMAR (electronic MAR), it would ensure that nurses initiated an area to document the removal of the patches. On [DATE] at 12:04 p.m., the DON (Director of Nursing) stated that when a [MEDICATION NAME] is applied the location is documented on the MAR and that prior to applying the next patch, nurses were to remove the old patch, fold it in half and discard it in the sharps container. The DON stated that the nurses were to document the removal of the patches and that the order should include removal of the patches. However, after reviewing the resident's clinical record, the DON stated that she could not locate documentation that the [MEDICATION NAME] applied on [DATE] had been removed, prior to the application of the next scheduled [MEDICATION NAME] dose on [DATE]. She stated that she would not know if it was removed, as it was not documented. A phone interview with the RN who applied the [MEDICATION NAME] on [DATE], was conducted on [DATE] at 3:38 p.m. The RN stated that she had placed two [MEDICATION NAME]es on the resident, each 25 mcg in strength, on the resident's left chest. She stated that she had placed two patches on because there was an order change from 25 mcg to 50 mcg and there were only 25 mcg patches on hand (however, there was no physician's order for [MEDICATION NAME] 50 mcg/hr in the clinical record at this time). During the interview, the MAR documentation was read to the nurse regarding that she had initialed that she had applied 25 mcg only. Despite this, the nurse stated that she had applied two patches because this was what she had seen on the resident's orders, when administering the medications. The nurse further stated that she did not see another patch in place and did not recall removing a patch from the resident. The nurse could not recall where she obtained the [MEDICATION NAME]es from, stating it was either from the resident's previous stock prior to the last discharge or from medications received when she was readmitted . She further stated that she did not obtain it from the emergency narcotic kit. During an interview with a pharmacist on [DATE] at 11:20 a.m., the pharmacist explained that if a [MEDICATION NAME] 25 mcg every 72 hours was applied and was not removed prior to another [MEDICATION NAME] application, it could cause increased effects of the medication, even though the medication loses some of its effects after three days. She stated that if more than what was prescribed was applied and a patch was not removed, then the resident could overdose, have increased side effects, and the severity would depend on the resident's size, weight, and if other narcotic medications were administered, such as [MEDICATION NAME]. The pharmacist stated that anytime you combine these drugs, it increases the risk of overdose and side effects of the narcotic medication. Interviews with the ADON (Assistant Director of Nursing) were conducted on [DATE] and revealed that the Controlled Substance Sheet for the 25 mcg [MEDICATION NAME]es used on [DATE] by the RN could not be located. The ADON stated that after speaking with the facility's pharmacy, the 25 mcg [MEDICATION NAME] order was processed, but could not provide records that the medication was delivered to the facility. The ADON also stated that there were no records that the [MEDICATION NAME]es were removed from the narcotic emergency kit and used for the resident during the time period from [DATE] to [DATE]. An interview with the LPN (Licensed Practical Nurse) who performed CPR on the resident was conducted on [DATE] at 1:06 p.m. The nurse stated that when giving medications, such as narcotic medication, she would verify the correct dose of the medication by comparing it against the physician's order, as well as with the Controlled Substance Sheet. During another interview with the DON on [DATE] at 1:07 p.m., the DON stated that nurses should check the right route, right patient, right medication, right dose, and that when administering narcotic medications, the nurses should verify that the narcotic sheet reflects the physician's order. Review of the facility policy on Preparation and General Guidelines for Medication Administration revealed that Medications are administered as prescribed in accordance with good nursing principles and practices. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. The policy also included that the individual who administers the medication dose, records the administration on the resident's MAR directly after the medication is given. A review of another facility policy, titled [MEDICATION NAME] Drug Delivery System (Patch) Application, dated as effective in [DATE] documented to 3) Remove old patch from body. Fold in half and discard per facility policy .8) Apply new patch firmly against skin.

Based on clinical record review, observations, facility documentation, review of hospital records, staff and resident interviews, the facility failed to ensure that one resident (#3) received adequate supervision to prevent a fall that resulted in actual harm. The sample size was five. Findings include: Resident #3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A nurse's note dated March 12, documented that the resident displayed exit seeking wandering behaviors. This entry also included that the unit manager was notified. There were no entries identified in the care plan that addressed this new behavior nor were there further wandering assessments identified. The comprehensive MDS (Minimum Data Set) assessment dated [DATE], documented that the resident had severe cognitive impairment for decision making. The resident was further assessed as dependent upon staff for most activities of daily living, unable to ambulate and she required assistance of one staff member for locomotion in her wheelchair. The resident was not assessed to wander. The care area assessment summary dated April 27, documented that the resident was at a high risk for falls. A care plan was created on May 5, 2011, and had identified that the resident was at risk for falls due to a [DIAGNOSES REDACTED]. There was nothing noted on the care plan that had identified that the resident required supervision and monitoring by staff. The focus of the care plan was related to bed safety and that the resident required the use of a Sara lift for transfers. Review of the clinical record revealed no further documentation of exit seeking or wandering behaviors. The nurse's note dated July 10 at 3:30 p.m., documented that the resident was transported to the hospital following a fall from her wheelchair. The nurse documented that another resident stated that he was outside when an unknown boy pushed resident #3 in her wheelchair outdoors and left her next to him within arms reach for 10 minutes. According to this entry, resident #3 then she rolled to the curb for a little bit and the left front wheel of her wheelchair went off the curb and she then fell out of the wheelchair and landed on her left side on the asphalt. The nurse's note dated July 10 at 7 p.m., documented that the emergency room nurse called to give report that the resident sustained [REDACTED]. The nurse's note dated July 10 at 7:15 p.m. documented that the resident returned to the facility. The resident was assessed to have reddened areas to the bilateral knees, bruises to the right forearm and wrist, 8 centimeters (cm) by 3 cm abrasion to the left side of the forehead, left eyelid was bruised and swollen shut, and there was a reddened area to the left breast. The witness statement from the receptionist dated July 10, documented, that resident #5 came in from outside through the front doors and reported that someone needed help. The receptionist documented that she looked outside and saw resident #3 on the ground and that she then came back into the building and used the pager system to call nursing; however, "no one heard me." The receptionist stated that she saw a staff member in the hall and told her to get help. The receptionist then went outside and a visitor reported that she had called 911. The hospital record dated July 10, documented that the resident was found by the police department face down on the sidewalk with an altered level of consciousness and transported to the emergency room for evaluation. The resident complained of headache with a left forehead contusion and multiple areas of contact burns from pavement on hands and legs. The resident was assessed to have subdural hematomas times two and first degree burns to the left side of the face. The elopement risk assessment dated [DATE], documented that the resident wandered out front of the building. The assessment further documented that the resident had no previous elopement wandering behaviors which was contrary to the nursing notes from March 12, 2011. The nurse practitioner monthly note dated July 14, documented that the resident was seen for follow-up after a fall with a closed head injury and facial burns. The burn care plan documented that the resident received Lidocaine each shift and as needed to the wound on her face for pain and she also received treatments of Silvadene twice a day to the burn on the left side of her face. During this investigation the resident was unable to be interviewed secondary to her severe cognitive deficits. She was able to state that she fell , but was unable to provide any details. The resident was observed to have a 6 centimeters (cm) by 2 cm reddened area with areas of crusting on the left temporal area going down toward her cheek. The left eye and periorbital area was swollen and there was yellowish discoloration above the left eye. Resident #5, an alert and oriented, resident stated during an interview conducted on August 10, that he was sitting outside and he observed a boy that was approximately [AGE] years old push resident #3 out the front door then leave. He stated that the boy parked the resident about three feet from him. Resident #3 remained stationary for approximately ten minutes and then she moved herself diagonally toward the curb. Per the resident after another three minutes the left front wheel of the chair went off the curb and resident #3 fell . He stated that a lady in a red dress ran out and pulled the wheelchair off the resident and that the lady next door (the receptionist) came out and called for help. During an interview conducted on August 10, the CNA (certified nursing assistant) assigned to the resident on the day of her fall stated that at approximately 1:45 p.m. on July 10, she brought the resident to the activity room for Bingo. She stated that she was on a smoke break when she heard what happened and when she ran out the lead CNA and nurses were with the resident so she went back in to care for the other residents. She was unsure how the resident got out of the building and the last time that she had seen the resident was when she was in Bingo. The CNA further stated that the CNAs did not monitor the front area. She stated that the receptionist was there. The lead CNA was interviewed on August 10, and she stated that she was outside on a 15 minute break on July 10 at 3:30 p.m. when a CNA coming on duty came to her and asked if it was okay for resident #3 to be outside by herself because the resident was sitting in front of the building without supervision. The lead CNA stated that she walked around the building and that when she got out front the resident was on the ground face down. She stated that she called on her personal cell phone to the nurse who came out to assess the resident. She further stated that a police officer, that happen to be patrolling the parking, lot also came over and that he called the paramedics. During an interview conducted on August 10, the Director of Nurses (DON) stated that residents were pretty much free to go around the outside perimeter of the building and that they did not have to sign out unless they leave the building. She stated that the facility did not have a Wander-guard system. She further stated that the resident was not assessed as a risk for elopement so there was no restriction that she could not go outdoors. "We knew that she could not push herself that long distance." She stated that it was suspected that a visitor's child pushed the resident outdoors although the child was not identified. Per the DON, the receptionist monitors the front desk; however, there were "a lot of visitors on the weekend." The routine resident checks policy documented that routine resident checks shall be made to ensure that the resident's safety and well-being are maintained. A resident check was to be made at least every (2) hours.