Every finding on record at Sandstone Estates Rehab Centre

Based on resident and staff interviews, clinical record review, and facility policy, the facility failed to make prompt efforts to resolve a grievance and issue a written decision/ response, per regulation and per policy for one resident, #33. The deficient practice could compromise a resident's basic safety, psychosocial well-being and serve as a breach of trust between the resident and the facility.Findings include:Resident #33 was admitted on [DATE] with diagnosis including paranoid schizophrenia, essential hypertension, chronic obstructive pulmonary disease, and idiopathic progressive neuropathy.Review of the quarterly MDS (minimum data set) dated January 20, 2026 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident was cognitively intact. The MDS further revealed that there were no potential indicators of psychosis, verbal behaviors and other behavioral symptoms not directed toward others were noted to have occurred 1-3 days.A review of the care plan revealed a focus area noting that resident #33 and his representative had chosen to engage in a behavioral contract.A review of the facility grievances revealed a grievance form dated August 25, 2025 for resident #33. The form displayed numerous scribbles to the side of the document. The description of the concern was documented to refer to a staff member yelling at the resident, and noted that the staff member called the resident a liar. The form further noted that another staff member was bullying/ demanding of the resident, alleged desertion of post, staff member's alleged resident to be racist/ lazy, as well as accusing resident of assault. The form further noted 2 witnesses. The form had a check-mark denoting immediate corrective action was required and noted that certain staff be reprimanded and reassigned from the south hall.An interview was conducted with resident #33 on June 5, 2026 at 11:02 AM. The resident stated that the staff bend the rules to their advantage and that he is not heard. He stated that he had filed 3 grievances and had not heard back regarding an outcome.An interview was conducted on June 5, 2026 at 11:52 AM with the Social Services Director, staff #7. Staff #7 stated that he has been with the facility approximately 1.5 years. Staff #7 stated that he was in charge of the grievance forms. He stated that there is a standard grievance form and that he would generally take the form to the resident to complete, but stated that each hall/ unit also has grievance forms available for the residents. Staff #7 further stated that he is responsible for finding a resolution and ensuring that everyone is in agreement with the outcome. He stated that the form would need to be signed by everyone, including the resident. Staff #7 stated that resident #33 had recently expressed that he wanted to file a grievance and that generally he would meet with the resident the same day, but because he had already met with the resident on Monday, June 1, 2026 he did not have the meeting for the grievance with resident #33 scheduled until today, Friday, June 5, 2026. Staff #7 provided the previous grievance form dated August 25, 2025 for resident #33. When asked if this grievance had been investigated and what the outcome was, staff #7 stated that he would have forwarded the grievance to the DON (director of nursing) as it involved nursing staff. Staff #7 reviewed the electronic health record for resident #33 in PCC (point click care) and stated that he did not see any entries documenting giving the form to the DON or what the outcome was. Staff #7 explained that he had not received much training on the grievances process and was just told, here is the grievance form and this is what you have the residents fill out. Staff #7 stated that if a resident grievance was not investigated or the resident provided a resolution to their reported grievance, then the issue would remain unresolved, and there would be a risk to the facility as well as to his job.An interview was conducted on June 5, 2026 with the DON, staff #9. Staff #9 stated that any grievances are logged in the grievance log, given to the responsible department, resolved and that the outcome is reported back to the resident. Staff #9 stated that when there is a grievance, the Social Services Director would report it to her, unless the resident filed the grievance directly with her. She stated that she was not aware of any grievances from resident #33 in the past year. She stated that any grievance forms in the facility's possession would be investigated. She further stated that if she did not receive the form then she would not be in the 'loop' or able to conduct an investigation. Staff #9 stated that the risk of not investigating a grievance or reporting back to the person who filed the grievance could include angering either staff or residents, and making the filer of the grievance feel as if no one listens to them.A review of the facility policy titled Resident Rights-Grievances revealed that purpose of the policy was to support the residents' rights to voice grievances and receive follow-up related to those. The policy noted that grievances are received, tracked through their conclusion, and that any necessary investigations would be ensue. The policy further revealed that the facility would issue written grievance decisions and maintain confidentiality.

Based on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure 1 (#81) of 3 sampled residents received proper treatment and care to maintain mobility and good foot health by ensuring regular podiatry appointments were maintained. The deficient practice could lead to developing foot problems, infections, wounds or amputations. Findings include:Resident #81 was admitted on [DATE] with diagnosis including type 2 Diabetes Mellites with hyperglycemia, hypertensions, cerebral infarction due to unspecified occlusion or stenosis of middle cerebral artery, aphasia, hemiplegia and hemiparesis affecting right dominant side, hyperlipidemia, morbid obesity, cognitive social or emotional deficit, bipolar disorder, anxiety disorder and other seizures.A review of the quarterly MDS (minimum data set) dated February 10, 2026 revealed a BIMS (brief interview of mental status) score of 9, indicating that the resident was moderately cognitively impaired. The MDS further revealed that the resident was at risk for development of pressure ulcers.A review of the care plan revealed focus areas including that the resident was on anticoagulant therapy with a risk for abnormal bleeding, at risk for fluctuations in blood sugar and complications due to diabetes mellites. The care plan further revealed that the resident is to be referred for podiatry services, as needed, and that nails are to be cut by podiatry and or charge nurse, with an initiation date of November 1, 2024.A review of documents in the EHR (electronic health record) revealed that the last podiatry appointment was on September 30, 2025. The podiatry visit note dated September 30, 2025 noted that findings included decreased circulation. It was further documented that 2 nails were debrided (the medical process of removing dead, damaged or infected tissue from a wound) and 8 nails trimmed with nippers. The note revealed that a follow-up was to be scheduled in 2-3 months or more as needed for acute problems. Finally, the note indicated to contact the podiatry with any concerns.A further review of the EHR revealed no evidence of podiatry visits after September 30, 2025.Further documentation provided by the facility via email revealed an encounter note from podiatry dated December 05, 2025 indicating that the resident was working with therapy and could not be seen this date and a subsequent note dated February 27, 2026 indicating that the resident was at an activity and could not be seen this date. However, the EHR revealed no documentation that anyone was notified of the missed appointment or that attempts were made to reschedule the appointment.An interview was conducted on June 5, 2026 at 2:03 PM with staff #7, Social Services Director. Staff #7 stated that he ensures that residents are on the referral list and are available on the date for scheduled and necessary services including vision, hearing and podiatry and relays missed appointments to the DON (director of nursing). He stated that the facility previously had 3 different provider groups providing vision, hearing and podiatry services that rounded every 3 months. Staff #7 stated that they now have a new provider group starting next month that will be able to provide all 3 (vision, hearing and podiatry) services under one umbrella. He further stated that until the new group starts, the old provider group for podiatry will continue to provide services. Staff #7 stated that if a resident was seen in September of 2025 by podiatry with a 2-3 month noted follow-up, they should have had 2-3 follow-up visits by now. Staff #7 further stated that if a resident missed a visit or rounding by the podiatry team, he would inform the DON and see if an 'outside' provider could come in to see the resident. However, the DON was not notified for resident #81 nor was an 'outside' provider obtained. Staff #7 further stated that at times a resident may refuse a visit, but staff #7 reviewed the EHR for resident #81 and stated that he did not see a follow-up visit after September 30, 2026 nor did he see evidence of resident visit refusals after September 2025. He stated that the resident had refused visits in the past and stated that he thought she may have refused again, but no evidence of refusal was documented. Staff #7 stated that the resident #81 was on the referral list for podiatry with both the current provider and the new provider. He stated that the last time the current provider had rounded was on February 27, 2026 and that the resident was on the list but no evidence was present in the EHR that she was seen. Resident #7 stated that if a resident with diabetes needs to be seen by podiatry every 2-3 months and has not been seen by podiatry in 9 months, the risk could include infection, loss of a toe, foot or leg.An interview was conducted June 5, 2026 at 2:37 PM with staff 10, medical records. Staff #10 stated that she is responsible for scanning documentation from outside / contracted providers into the EHR as soon as she receives it. Staff #10 reviewed her documentation as stated that she had not received and podiatry visit notes after September 30, 2026 for resident #81.An interview was conducted on June 5, 20265 at 3:09 PM with staff #9, DON. Staff #9 stated that residents who needed to be seen for podiatry would be added to the referral list by social services. She further stated that any missed appointments should be documented by the physician group and uploaded by medical records. Staff #9 reviewed the records for resident #81 and stated that the last visit note from podiatry was observed to have been on September 30, 2026 with a documented follow-up advised within 2-3 months. Staff #9 stated that the risk for not having the required follow-up appointments could include a multitude of problems including cellulitis, pain, discomfort and the potential for losing a toe.A review of the facility policy / procedure titled Routine Procedures-Nail Care adopted May 1, 2024 revealed that the policy served to promote cleanliness, safety and neat appearances of the residents. The policy noted that only licensed staff can cut the nails of diabetic residents.A review of the facility policy titled Quality of Care-Foot Care with a revision date of May 4, 2023 revealed that the purpose of the policy is to provide residents with foot care, including treatment to prevent complications from diabetes, peripheral vascular disease or immobility, that is consistent with professional standards of practice. The policy further noted that the facility assists in making necessary medical appointments with qualified persons. The policy documented that residents with complicating disease process will be referred to qualified professionals for foot care and that the facility will assist with these making appointments.

The facility failed to ensure RN coverage was provided 8 hours a day, 7 days a week.Number of residents sampled:Number of residents cited:Based on staff interviews, review of facility documentation, policy, and procedure, the facility failed to ensure there was a registered nurse (RN) on duty for 8 consecutive hours for 7 days a week. The deficient practice could have a substantial impact on the quality of care and outcomes for residents. Findings include: The staff posting from February 15, 2026, through March 17, 2026, revealed the sections on the number of RN's was blank for:-February 26, 2026, and the facility census on that day was 62.-March 1, 2026, and the facility census on that day was 64.-March 8, 2026, and the facility census on that day was 64.-March 15, 2026, and the facility census on that day was 51. The punch detail for RN's from February 15, 2026, through March 17, 2026, revealed no data for February 26, 2026, March 1, 2026, March 8, 2026, and March 15, 2026, for the following RN staff #89, #130, #68, #14, #71, and #51. The staff posting from February 15, 2026, through March 17, 2026, revealed the sections on the number of RN's from 6:00 AM to 6:30 PM was blank for:-February 28, 2026, and the facility census on that day was 65.-March 7, 2026, and the facility census on that day was 66. The punch detail for RN's from February 15, 2026, through March 17, 2026, revealed no data for February 24, 2026, February 27, 2026, February 28, 2026, and March 7, 2026 from 6:00 AM to 6:00 PM An interview was conducted on March 18, 2026, at 1:16 PM with the Director of Nursing (DON, staff #36). She stated it did not meet her expectations to have low RN staff. She stated the risks to not having an RN were a higher risk to intervene earlier to prevent rehospitalizations or emergency room visits. She stated she was actively recruiting RN's. An interview was conducted on March 18, 2026, at 2:27 PM with RN (staff #68). The RN stated the facility has had a decrease in RN's since May 2025 due to lower census. She stated there were times she experienced a large resident assignment that would be overwhelming. She stated RN's have been hired, however have resigned due to a decreased number of working hours.Review of the Nursing Administration Policy dated May 1, 2024, stated provides for the services of a registered nurse for at least eight (8) consecutive hours a day, seven (7) days a week.

Based on observations, staff interviews, and policy review, the facility failed to ensure that food was stored in accordance with professional standards for food safety. The deficient practice has the potential to place residents at risk for consumption of expired or unsafe food. The census was 51.Findings include:On March 17, 2026, an initial observation of the facility kitchen was conducted with the dietary director/maintenance director/environmental services director (Staff #112) and dietary cook (Staff #80). At 10:10 AM, a walk-through of the dry storage revealed an open original package of what Staff #112 identified as taco seasoning, which had no evidence of an opened date, and a binder clip sealed the package. It also revealed an open original package of what Staff #112 identified as brown gravy, which had no evidence of an opened date, and a binder clip sealed the package. It also revealed an open original package of what Staff #112 identified as chicken gravy, which had no evidence of an opened date, and a binder clip sealed the package. It also revealed an open original package of what Staff #112 identified as turkey gravy, which had no evidence of an opened date, and a binder clip sealed the package. It also revealed an open original package of what Staff #112 identified as breadcrumbs, which had no evidence of an opened date, and a binder clip sealed the package. Following the initial observation on March 17, 2026, an interview was conducted with Staff #112 and #80. Staff #112 stated that for items opened and then stored within the dry storage, they are expected to have a label of an open date, and, as applicable, a use-by date, in an accessible view to staff. Staff #112 further stated that the staff is expected to place the food item in a sealable container or package with the opened date and a use-by date, per facility policy. Staff #80 had also stated that dietary staff are expected to seal the original packaging of opened items in a Ziploc or a sealed container with the opened date. Staff #112 stated that the current open items are not within the facility's expectations and immediately discarded the items, per the policy, as the risk of maintaining the food items has the potential for inconsistency with the longevity, quality, or safety of food items.On March 19, 2026, at 9:15 AM, an interview was conducted with the dietary manager (Staff #62), who stated that unopened items are expected to be dated with the delivered date. Staff #62 further stated that if a food item package should be opened, staff are expected to put the opened date. Staff #62 further stated that staff are expected to put the opened food item in a Ziploc, and dated with the delivered date and the opened date. Staff #62 further stated that the facility had used binder clips for their opened packaged items as per previous guidance; however, Staff #62 stated that this process has been changed to ensure food items are rolled up and in a Ziploc with an opened date. Staff #62 stated that it is not within the facility's expectations that opened food packages are not dated for the risk of utilizing expired food items, and if not sealed appropriately, the risk for pests.A policy titled 'Food Receiving and Storage', adopted May 1, 2024, revealed that it is the policy of this facility that foods shall be received and stored in a manner that complies with safe food handling practices. A policy titled, 'Ontray Dietary Policies and Procedures: Storage Labeling and Dating', a 2025 edition, revealed that product inventory must be stored, labeled, dated, rotated, and discarded properly to ensure inventory is stored in a safe, sanitary manner to provide the best food quality and safety. The policy revealed that opened products stored in the dry storage area must be labeled with their received date and open date.

Based on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#25) was provided specialized rehab services to meet the needs of the resident and in order to reach the resident's highest practicable level of function. The deficient practice could result in a resident not attaining their highest practicable level of function, or result in a functional decline.-Findings include:Resident #25 was admitted to the facility January 7, 2026, with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, unsteadiness on feet, abnormality of gait and mobility, dementia, and history of falling.An insurance Approved Referral for Medical Care, dated January 7, 2026, revealed that the expiration date of the insurance authorization was April 17, 2026. The resident's chief complaint was adult failure to thrive. The referral included that per PT (physical therapy) consult, Resident #25 demonstrated ongoing ataxia of the right lower extremity with walking, decreased right lower extremity strength, right knee buckling, and decreased endurance. Additionally, Resident #25 would continue to benefit from skilled PT to improve functional outcomes. Regarding medical devices, the document included that the facility may recommend that medical devices, adapted equipment, or other items be provided for the treatment or rehabilitation of Resident #25's medical condition. In such instances, the facility must provide the resident with a prescription / physician order for the specific item or service.Physician orders dated January 7, 2026, included:-Admit Resident #25 to skilled services.-Physical therapy to evaluate and treat as indicated A care plan focus dated January 7, 2026, revealed the resident had an activities of daily living (ADL) self-care performance deficit, with a goal that the resident would participate in ADL tasks with therapy services as ordered to attain and maintain prior level of function. Interventions initiated on January 7, 2026, included to encourage the resident to participate to the fullest extent possible with each interaction. Another care plan focus dated January 7, 2026, included that the resident had limited/impaired physical mobility, with interventions that included to provide assistive devices for mobility if needed; i.e. wheelchair, walker, cane, etc., and to provide supportive care, assistance with mobility as needed, and to document assistance as needed. A Physical Therapy Evaluation and Plan of Treatment dated January 8, 2026, revealed Resident #25 presented with a decline in functional activity tolerance, mobility independence, and progressive lower extremity weakness leading to increased risk for falls. The evaluation included that the resident reported that his right lower extremity gives out without warning, and had a history of 4 falls within the past year. The evaluation included that the resident's prior level of function included that the resident used to be able to walk 250 feet with a cane with modified independence, and perform transfers with modified independence. The evaluation included that the resident's current level of function at the time of evaluation included the ability to walk 25 feet with a two-wheeled walker and with contact-guard assistance, and perform transfers with contact-guard assistance. The clinical impression included that the resident would benefit from therapy for strengthening, transfer and gait training, and safety awareness training to maximize independence with all functional mobility and return to prior level of function. The plan included for therapy frequency of 5 times a week for 60 days, until March 8, 2026. The evaluation was signed on January 8, 2026, by a physical therapist (Staff #136).An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #25 had a brief interview for mental status (BIMS) assessment score of 15, indicating intact cognition. Section GG - Functional Abilities revealed that Resident #25 had impaired range of motion of the lower extremity on both sides. Additionally, Section GG revealed that Resident #25's admission mobility performance (within the first 3 days of the stay) included that the resident required substantial / maximal assistance with sit to lying bed mobility, and partial / moderate assistance with toilet transfers and walking 10 feet. The assessment included that the resident did not walk 150 feet due to medical condition or safety concerns.A physician note dated January 21, 2026, revealed Resident #25 had chronic weakness and functional decline, status post C5-C6 Laminectomy, with persistent right lower extremity weakness and gait instability. The plan included that the resident was improving, and to continue inpatient physical therapy.A PT Progress Report dated January 8 through January 22, 2026, and signed by Staff #136 on January 28, 2026, revealed that Resident #25 required contact guard assistance for bed mobility, standby assistance for transfers, and standby assistance for walking 250 feet with a front-wheeled walker. The report revealed that although the resident was making progress in all goals, the resident had not yet met his long term goals of reaching independent to modified independent with his mobility. The report revealed that the resident had remaining impairments of balance deficits, decreased functional capacity, decreased safety awareness, gross motor coordination deficits, pain, and strength impairments. Additionally, the documentation included that skilled PT services were warranted to analyze gait pattern, assess functional abilities, facilitate discharge planning, increase coordination, increase functional activity tolerance, increase independence with gait, increase lower extremity strength and range of motion, and minimize falls. Also, the report revealed the resident was making consistent progress, was compliant with the plan of care, and that maximum improvement was yet to be attained. The report included that the resident demonstrated good rehab potential.A PT treatment encounter note dated January 27, 2026, revealed Resident #25 was instructed in gait training with a front-wheeled walker for two trials, and with stand-by assistance, and required minimal cueing to maintain upright posture, forward gaze, and heel-to-toe gait pattern, in order to decrease fall risk and increase the resident's independence with functional activities. The note also included the resident received training in bed mobility and transfers, which required minimal verbal cues and supervision. The note included Resident #25 tolerated the interventions fairly well.A physician note dated January 27, 2026, revealed the resident continued to have weakness with both lower extremities, that the resident was improving, and the plan included to continue inpatient physical therapy.A PT treatment encounter note dated January 28, 2026, revealed Resident #25 was greeted for PT discharge, and that the resident reported that he should not be getting discharged from therapy at this time. The note included that the physical therapist consulted with the social worker and relayed back the message to Resident #25 that he was awaiting a room at another facility but would be staying at this facility until then. The note included that the physical therapist educated the resident that discharge from PT was due to meeting most functional goals and reaching maximal functional benefit at this time, and included a recommendation for the resident to continue with daily activity including using the bike at the therapy gym to maintain his current level of function. The note included that the resident completed bed mobility with modified independence, completed transfers with modified independence from his wheelchair using a front-wheeled walker, and able to walk to the bathroom with a front-wheeled walker and with supervision. The note included that the resident was compliant with adaptations, skilled interventions, and trained techniques. There was no evidence of education or recommendation for a restorative nursing program or a functional maintenance program or staff training for a walking program to maintain the resident's current level of function or for a knee orthotic for the right lower extremity.A PT Discharge summary dated [DATE], and signed by Staff #136 on January 28, 2026, revealed that Resident #25 had not yet met his short-term goal for improving lower extremity strength. Additionally, the resident had met his long term goals of reaching modified independent in bed mobility and transfers, however the resident had not yet met his long term goal for walking with modified independence with a walker, or ascending/descending 1 stair with modified independence. The discharge assessment revealed that the resident's current level of function for walking at the time of discharge was requiring supervision for 250 feet with a walker, and with occasional verbal cues. The record revealed that Resident #25 made consistent progress throughout plan of care, however also revealed that the resident reached maximum potential. The documentation revealed that the resident was discharged due to highest practical level achieved. The discharge recommendations included daily activity including ambulation (walking) with staff, riding bike in therapy gym. Despite the recommendation for Resident #25 to continue walking with staff, and the documentation that Resident #25 needed supervision for safety with walking 250 feet, there was no evidence of a care plan, physician order, or task log indicating for a plan for nursing staff to assist Resident #25 with a walking program.A Late Entry physician note dated February 13, 2026, revealed Resident #25 stated he was off therapy services per the insurance provider. The note included that the resident continued to have chronic weakness and functional decline, and that the resident improved but was now off therapies as per the insurance provider.A Late Entry physician note dated February 16, 2026, revealed the provider confirmed with case manager that the resident was off therapy services, and that the resident could not go home with the resident's wife, as the spouse could not take care of him. The note revealed the resident had chronic weakness and functional decline, and that the resident had improved, but was now off therapies as per the insurance provider. The plan included to maintain fall precautions.The resident's care plan focus for ADL self-care performance deficit revealed a revision dated February 19, 2026, with added interventions that included Resident #25 required partial assistance of 1 staff for transfers, toilet use, and bathing/showering. The care plan revealed no evidence regarding the resident's walking.A Late Entry physician note dated March 6, 2026, revealed Resident #25 wanted to get back on physical therapy (PT). The note revealed the resident had chronic weakness and functional decline, and the plan included that a physician order was placed for therapy.Despite the documentation that an order was placed for therapy, review of the clinical record revealed no evidence of a physician order for therapy on March 6, 2026 until March 16, 2026.A physician order dated March 16, 2026, included for physical therapy to evaluate and treat as indicated.A PT Evaluation and Plan of Treatment dated March 17, 2026, and signed by Staff #136, revealed it was an evaluation only, with no further treatment recommended. The evaluation revealed that the resident's reason for referral included that the resident presented for evaluation and assessment of a decline in functional mobility, and that the resident was requesting physical therapy assessment at that time. The documentation revealed the resident was pleasant and cooperative, and that Resident #25 had a fall risk, and right lower extremity weakness and pain. The resident's mobility assessment revealed that the resident had a decline in functional mobility since the resident's discharge from PT on January 28, 2026, and now required verbal cueing for bed mobility, supervision for transfers, and standby assistance for walking 20 feet with a front-wheeled walker. The clinical impression included that the resident presented with minimal decrease in function since last PT discharge summary was completed, and that it was attributed to the resident demonstrating lack of motivation to ambulate/complete functional mobility without assistance from nursing staff (despite the discharge summary recommending that Resident #25 walk with staff). Also, despite the statement that the resident had been noncompliant with the previous discharge recommendations, the note included that Resident #25 had been consistently coming to the therapy gym to complete daily weight lifting and biking. The documentation included that Resident #25 was limited in walking tolerance due to right lower extremity pain and discomfort, and that PT recommended for the resident to reach out to the insurance provider to obtain a right lower extremity brace /orthotic to facilitate increased tolerance to walking. The plan included for the resident to pick up on PT when he obtains brace for functional mobility training and further assessment at that time. The note included that the PT informed certified nursing assistants (CNAs) that the resident was agreeable to walk with his walker to the bathroom to increase walking throughout the day, and would benefit from supervision during mobility due to occasional lower extremity weakness and buckling. Additionally, the documentation revealed that the resident had been somewhat limited in maintaining his prior level of function due to noncompliance with prior discharge recommendations. The note included that the resident would benefit from a functional maintenance program or restorative nursing program to maximize independence with walking.Despite the recommendation for a right lower extremity orthotic for Resident #25, the clinical record revealed no evidence of communication of that recommendation to the physician or evidence of a physician order for a right lower extremity orthotic or knee brace.The clinical record revealed no evidence of staff communication with the insurance provider, regarding recommendations for the orthotic/knee brace.Additionally, the clinical record revealed no evidence of a restorative nursing program or a functional maintenance program, as recommended by PT.An interview was conducted with a physical therapist (Staff #136) on March 19, 2026, at 10:16 a.m., who stated she received a referral to evaluate Resident #25 earlier that week on March 17, 2026, because the resident wanted to walk more. Staff #136 stated that previously, the resident had been seen by physical therapy in January 2026, and the resident received a good amount of gait (walking) training at that time. Staff #136 stated at the time physical therapy discharged the resident (January 28, 2026), the resident was able walk and perform transfers and required staff supervision due to pain and instability in the resident's right knee. Staff #136 stated that the resident had a decline in mobility since the last therapy on January 28, 2026, because the resident was not compliant with what she asked him to do. Staff #136 stated that when she evaluated the resident on March 17, 2026, that Resident #25 wanted to be able to walk more, and that she had recommended for the Resident to get a knee brace from the insurance provider, and then Staff #136 planned to re-evaluate the resident again once he had obtained the knee brace. Staff #136 stated that the resident needed supervision with walking, and that she developed a plan with the CNAs to walk with Resident #25 two times a day, to help with the resident's goal of walking. Staff #136 stated that the facility did not have a designated staff responsible for restorative nursing or functional maintenance programs, and that the facility relied on the floor CNAs to perform that role.An interview was conducted with the Director of Rehab (DOR / Staff #40) on March 19, 2026, at 10:50 a.m., who stated that if a resident were discharged from therapy and remained in the facility, that the therapists would communicate to the CNAs to encourage participation and offer whatever mobility task was recommended by therapy to prevent a resident from having a functional decline. Staff #40 stated that the restorative nursing or functional maintenance program would sometimes be documented under a CNA task log. Staff #40 stated that if a resident was recommended to have an orthotic or brace either by a therapist or physician, then a physician order would be obtained and then sent to an orthotic company along with the resident's face sheet with insurance information. Staff #40 stated that then the orthotic company would come to the facility promptly and assess the resident and communicate with the DOR whether the orthotic/brace would be covered by insurance or not. Staff #40 stated that if the resident's insurance would not cover the brace, then the facility would then cover the cost. Regarding Resident #25, Staff #40 stated that she was notified by the physical therapist (Staff #136) of the recommendation for a knee brace for Resident #25. Staff #40 stated the reason Resident #25 was discharged from therapy in January 2026 was because the resident was walking 300 feet at a modified independent level. Additionally, Staff #40 stated that the resident was not discharged from therapy services in January due to loss of insurance coverage, because the resident was still within the pre-approved coverage, and could still receive skilled therapy services. Staff #40 stated that she was aware that Staff #136 informed Resident #25 that he needed a knee brace for his right leg, and Staff #40 also stated that the resident would have to contact the insurance provider, and make an appointment outside the facility himself, in order to get the knee brace.An interview was conducted with Resident #25 on March 20, 2026 at 8:55 a.m., who stated that he was told he was not getting therapy because he could get in and out of bed, and in and out of the restroom, and that the therapist did not think he needed therapy. Resident #25 stated that he believed he did need therapy, and that he was weak, and not able walk without staff assisting him. Resident #25 stated that after he was discharged from physical therapy at the end of January 2026, that he had tried to ask CNA staff to help him walk, and when he did, the CNAs told him they did not have time. Resident #25 stated that he believed the facility was understaffed. Additionally, Resident #25 stated that because he was weak and at risk for falls, that when he was in therapy, the therapists had placed a gait belt around his waist and followed him with a wheelchair when helping him to walk, and that Resident #25 was afraid that the CNAs did not know what he needed to safely walk or if the CNAs were properly trained by therapy to help him walk. Resident #25 stated that a therapist had recommended a knee brace for him, and told him that he needed to call the insurance provider himself to get the knee brace. Resident #25 stated that he did call the insurance provider, and the insurance provider informed Resident #25 that it was the therapists or physician who had to communicate the recommendation and order the knee brace to the insurance provider. Resident #25 stated that he communicated this to the facility staff 2 days ago. Resident #25 stated that he had experienced a functional decline since he had not been on therapy services, that he was weaker, and could not walk as far. Resident #25 stated that he had been using the bike in the therapy gym, but it was not doing enough.An interview was conducted on March 20, 2026, at 9:11 a.m., with a CNA (Staff #92), who stated that she was familiar with Resident #25 and had been assigned to work with the resident multiple times, and that Resident #25 was motivated to improve himself. Staff #92 stated that as far as she knew, the resident had not gotten clearance from PT to be able to walk with the CNA staff.An interview was conducted with the Director of Human Resources and business office manager (Staff #69) on March 20, 2026, at 9:28 a.m., who stated that Resident #25 was covered by the insurance provider for skilled therapy services under a renewable contract, and was still within that timeframe, until April 17, 2026.An interview was conducted on March 20, 2026, at 9:44 a.m., with the Director of Nursing (DON / Staff #36), who stated that if a resident were to communicate to staff that they wanted to improve their mobility, then that message would be relayed to therapy, and the facility would determine if the resident had insurance coverage for therapy services. Additionally, Staff #36 stated that nursing staff would communicate with the therapy staff to make sure the resident met their goals, or were at the same functional level and had not had a decline. Staff #36 stated that the facility did not have a designated staff responsible for restorative nursing or functional maintenance programs. Additionally, Staff #36 stated that she had informed therapy staff, that if there is any hand-off of tasks from therapy to nursing staff that the CNAs need to be educated and trained in that program, and that the program would be documented on a CNA task log and should be in the care plan too. Staff #36 stated that the impact on a resident, if there was not proper hand-off or communication from therapy to nursing would be that the resident could have a decline in functional mobility. Regarding braces and orthotics, Staff #36 stated that if a resident were recommended by therapy to have an orthotic/brace, then the DOR (Staff #40) would obtain a physician order, and the facility staff would assist the resident with reaching out to the insurance provider to determine if the brace would be covered. Staff #36 stated that if the insurance provider did not cover the brace, then the facility would cover the expense and order the brace. Regarding Resident #25, Staff #36 stated that she believed Resident #25 had reached modified independent level with therapy in January 2026 and was able to walk and do things by himself, and that the resident chooses to have staff to do things for him. Staff #36 stated that nobody had informed her that the resident needed a knee brace. The clinical record was reviewed, and Staff #36 stated she could find no evidence of communication regarding the knee brace or a physician order for the knee brace for Resident #25.Review of the facility policy titled Specialized Rehabilitation Services, revised May 4, 2023, revealed each resident receives the specialized rehabilitative services as determined by their comprehensive plan of care to assist them to attain, maintain, or restore their highest practicable level of physical, mental, functional and psycho-social well-being. The facility will provide specialized rehabilitative services such as, but not limited to physical therapy (PT), speech-language pathology (SLP), occupational therapy (OT), respiratory therapy and rehabilitative services for mental illness and intellectual disability, or services of a lesser intensity as are required in the resident's comprehensive plan of care. The facility will provide specialized rehabilitation services or will obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in federal or state health care programs. The facility will employ directly or contract with an outside resource to engage the qualified personnel and support staff.Review of the facility policy titled Care Planning, dated May 1, 2024, revealed it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. A comprehensive care plan is developed within seven (7) days of completion of the comprehensive assessment. To the extent possible, the resident, the resident's family and/or responsible party should participate in the development of the care plan. The Care Plan will be reviewed and revised by the IDT after each assessment and as the resident's care needs change.

Based on a review of facility documentation, staff interviews and facility policies and procedures, the facility failed to ensure the provision and implementation of necessary behavioral health services for one resident (#5) with identified mental health needs. The deficient practice has the potential to worsen the residents symptoms and reduce quality of life. The sample was 1. The universe was 19 and the census was 51.Findings include:Resident #5 was admitted on [DATE], with the diagnoses that included major depressive disorder, adult failure to thrive; cognitive communication deficit; and need for assistance with personal care.An order dated February 12, 2026, revealed Resident #5 had been ordered to take one 2 mg aripiprazole tablet for mood stabilization.An order dated February 12, 2026, revealed Resident #5 had been ordered to take one 15 mg mirtazapine tablet for depression, as evidenced by tearfulness.An order dated February 16, 2026, revealed that a referral for behavioral health services for psychiatric and psychological evaluation and treatment as indicated for Resident #5.A care plan focus was initiated on February 17, 2026, which revealed Resident #5 used antidepressant medication related to depression. A care plan focus was initiated on February 17, 2026, which revealed Resident #5 used psychotropic medication related to depression, and that Resident #5 would receive counseling by a mental health professional. An admission MDS (minimum data set) assessment dated [DATE], revealed a BIMS (brief interview for mental status) score of 15 indicating intact cognition. The assessment also revealed that within the 14 days before the completion of the assessment, Resident #5 was experiencing symptoms of feeling down, depressed, or hopeless 2 - 6 days out of the 14. The assessment also revealed that Resident #5 had depression and had taken antipsychotics and antidepressants during the 7 days before the assessment completion.There was no additional evidence in the electronic health record of Resident #5 receiving behavioral health services.On March 17, 2026, at 11:23 AM, an interview was conducted with Resident #5. Resident #5 stated that she had been admitted to the facility in February, and when she was admitted to the facility, she had not been in a good place mentally. Resident #5 stated that she had been told by the social services director that she should have received therapy services with a therapist, and that she should have been told of any updates regarding that process. Still, she has not received any updates regarding the services. Resident #5 further stated that the transition from having her family with her 24/7 to the facility with restrictions on overnight visits had been difficult. Resident #5 stated she relied heavily on the support of her family and required 24/7 assistance with her difficulty completing day-to-day tasks. Resident #5 also stated that upon admittance to the facility, she had been completely out of it and described it as a mental setback due to waking up in a foreign place, the hospital, and didn't know what to expect as it came to her recovery. Resident #5 stated that she had been waiting for an update on therapy services following her initial conversation with the social services director and felt that having therapy during that transition would have benefited her overall mental health during the first couple of weeks of her stay.On March 19, 2026, at 12:23 PM, an interview was conducted with a CNA (certified nursing assistant/Staff #106). Staff #106 stated that she was unaware whether Resident #5 had received mental health services.On March 19, 2026, at 12:33 PM, an interview was conducted with an LPN (licensed practical nurse/Staff #73). Staff #73 stated that she was unaware whether Resident #5 had received mental health services.On March 20, 2026, at 9:27 AM, an interview was conducted with a social services director (Staff #86). Staff #86 stated that should mental health concerns arise, he would report the concern to the DON (director of nursing) to submit a referral to talk therapy or psychotherapy, and then follow up with the process to ensure the services requested are completed. Staff #86 stated that once a consultation is completed, interventions can be tailored for a resident's care plan, and nursing floor staff would be made aware of the changes to their care, medications, and any orders to monitor behaviors. Regarding Resident #5, Staff #86 reviewed her diagnoses and her care plan and stated that Resident #5 had the diagnosis of major depressive disorder, and a care plan intervention that she should have seen a counselor for behavioral health concerns. Staff #86 also stated that Resident #5 had an order for a referral for counseling services, and that any updates regarding the process would be documented in the progress notes. Staff #86 reviewed the progress notes of Resident #5 and stated that there had been no evidence in the progress notes regarding counseling services. Staff #86 further stated that since the DON submits the referrals for counseling services, she would also have access to reviewing the status of the process. Staff #86 further stated that the risk of not receiving ordered counseling services has the potential to be detrimental to a resident, and if services are not received, can lead to the decline of overall well-being and the increased severity due to the lack of interventions.On March 20, 2026, at 10:02 AM, an interview was conducted with the DON (Staff #36), who stated that orders for behavioral services are made and handled by her as the DON, as well as the ADON (assistant director of nursing). Staff #36 further stated that the staff who can follow up on an order can be the DON, the ADON, or the social services director. Regarding Resident #5, Staff #36 stated that an order was obtained on February 16, 2026, for a referral for behavioral health services for psychiatric and psychological evaluation and treatment as indicated. Staff #36 also stated that after hearing an interview on March 19, 2026, regarding Resident #5, there was a review of her records, and it was determined that there was no evidence that Resident #5 had received the ordered behavioral health services, no evidence that a consent for treatment with a signature of Resident #5, and no evidence of a follow-up for the initial order. Staff #36 stated that her order fell through the cracks and that Resident #5 could have benefited from the behavioral health services, such as therapy and psychotherapy, for her transition into the facility. Staff #36 stated that the risk could have resulted in her mood and well-being worsening, and with continued issues with her mental health, and her goal to be discharged home. Staff #36 further stated that Resident #5 went through a rough transition when she was first admitted from the facility and experienced what Resident #5 described as ICU PTSD (intensive care unit post-traumatic stress disorder).A policy titled 'Physician Orders', adopted May 1, 2024, revealed that it is the policy of the facility to ensure that all resident/patient medications, treatment, and plan of care must be in accordance with the licensed physician's orders, and to ensure that the physician orders are input into the medical chart.A policy titled 'Care Planning', adopted May 1, 2024, revealed that it is the policy of this facility that the interdisciplinary team shall develop a comprehensive care plan for each resident.

Based on review of the facility documentation, staff interviews, and review of facility policy and procedures, the facility failed to ensure that the Level I PASRR (Pre-admission Screening and Resident Review) screening was accurately completed and updated for two residents (#13 and #63). The deficient practice could result in failure to identify residents with mental illness and/or intellectual disabilities, leading to unmet care needs. The census was 51.Findings Include:-Regarding Resident #13Resident #13 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, Schizoaffective Disorder, and Anxiety Disorder.The Level I PASRR (Pre-admission Screening and Resident Review) dated May 6, 2024, indicated that a referral for a level II PASRR was not necessary. However, further review of the level I PASRR revealed that the box asking if the resident had a diagnosis of Schizoaffective disorder was not checked to reflect her diagnosis. It was also noted that Resident #13 was taking the following psychotropic medications: Bupropion 75mg, Trazadone 50mg, and Depakote 125mg.The care plan was revised on November 16, 2025 to include a focus related to Resident #13's psychosocial well-being related to her Schizophrenia. Interventions included assisting the resident to set realistic goals, support family communication, monitoring her response to internal and external issues, and to redirect the resident when conflict arises.The quarterly MDS (Minimum Data Set) dated January 13, 2026, revealed a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognition.An interview was conducted with the Social Services Director (Staff #86) on March 12, 2026 at 1:12 P.M. He confirmed that Resident #13 had a PASRR I, dated May 6, 2024, in her clinical record. After reviewing the PASRR I, he indicated that the Schizophrenia diagnosis was not listed on the PASRR I. He further indicated that he was not sure why the Schizophrenia diagnosis was not listed on the form. He shared that he expected the Schizophrenia diagnosis to be identified on the PASRR I if Resident #13 was diagnosed with it.Regarding Resident #63:Resident #63 was initially admitted to the facility on [DATE], and then re-admitted to the facility on [DATE], with the diagnosis that included anxiety disorder, unspecified; bipolar disorder, unspecified; depression, unspecified; generalized anxiety disorder; bipolar disorder, current episode manic severe with psychotic features.A Level I PASRR dated December 14, 2023, revealed no evidence of any mental illness answered; no evidence of symptoms answered; no history of psychiatric treatment answered; and no psychotropic medications answered.An admission MDS dated [DATE], revealed that Resident #63 had a BIMS score of 05, indicating that Resident #63 experienced severe cognitive impairment at the time of the assessment. The assessment also revealed that within the last 14 days before the completion of the assessment, Resident #63 experienced 2 - 6 days where she had trouble concentrating and had thoughts that she would be better off dead or hurting themselves; and experienced 7 - 11 days of feeling down or depressed, trouble falling asleep, feeling tired or having little energy, poor appetite or overeating, and moving or speaking so slowly, or the opposite, being fidgety or restless, moving around a lot more than usual, for a severity score of 12, indicating moderate depression, experiencing significant symptoms if depression and required consultation with a healthcare provider to discuss treatment options such as therapy or medication. The assessment stated that Resident #63 exhibited social isolation. The assessment also revealed the diagnosis of anxiety disorder, depression, and bipolar disorder; she had been taking antianxiety medications during the last 7 days before the assessment. A care plan focus initiated on January 10, 2024, revealed that Resident #63 had been at risk for adverse reactions due to the use of psychotropic medications related to bipolar disorder, anxiety, depression, and hallucinations. A care plan focus initiated on January 10, 2024, revealed that Resident #63 had a mood problem related to depression, bipolar disorder, and anxiety; with the intervention to receive a behavioral health consult as needed.A discontinued order with an initial order date of January 28, 2024, revealed that Resident #63 had been ordered one 5 mg buspirone tablet three times a day for anxiety.A discontinued order with an initial order date of February 9, 2024, revealed that Resident #63 had been ordered one 50 mg trazodone tablet at bedtime for depression, as evidenced by insomnia. A completed order with an initial order date of March 8, 2024, revealed that Resident #63 had been ordered one 0.5 mg lorazepam tablet every 6 hours as needed for tactile hallucinations for 3 days. A completed order with an initial order date of April 24, 2024, revealed that Resident #63 had been ordered one 1 mg lorazepam tablet every 12 hours as needed for anxiety, as evidenced by agitation for 14 days. A care plan focus initiated on September 25, 2024, revealed that Resident #63 used psychotropic medications related to bipolar disorder.A discontinued order with an initial order date of November 26, 2024, revealed that Resident #63 had been ordered one 10 mg suvorexant tablet at bedtime for depression, as evidenced by insomnia. A completed order with an initial order date of January 15, 2025, revealed that Resident #63 had been ordered one 20 mg suvorexant tablet at bedtime for depression, as evidenced by insomnia for 30 days. A care plan focus initiated on June 26, 2025, revealed that Resident #63 used anti-anxiety medications related to anxiety disorder.A care plan focus initiated on June 26, 2025, revealed that Resident #63 used antidepressant medications related to depression.An active order with an initial order date of July 17, 2025, revealed that Resident #63 had been ordered one 15 mg buspirone tablet every 8 hours for anxiety, as evidenced by restlessness.An active order with an initial order date of October 7, 2025, revealed that Resident #63 had been ordered two 100 mg trazodone tablets at bedtime for depression, as evidenced by the inability to sleep.A care plan focus initiated on December 2, 2025, revealed that Resident #63 had little or no activity involvement related to anxiety, depression, will state when they would not like to participate in activities.An active order with an initial order date of December 19, 2025, revealed that Resident #63 had been ordered one 6 mg doxepin tablet for depression, as evidenced by the inability to sleep.An active order with an initial order date of March 17, 2026, revealed that Resident #63 had been ordered one 450 mg bupropion tablet of 15 mg every morning for depression, as evidenced by anhedonia. On March 19, 2026, at 1:12 PM, an interview was conducted with the social services director (Staff #86). Staff #86 stated that the PASRR is a form that's filled out for each patient before their admittance to the facility. Staff #86 stated that there is a point of contact in Las Vegas, Nevada, with their corporate leadership who completes forms if not completed accurately at the time of admission, and had been unsure if they had been trained in Arizona regulations, but had assumed so due to conversations between himself and the point of contact. Staff #86 further stated that residents with a serious mental illness or intellectual disability would qualify for a level II form completion. Staff #86 further stated that he had never been formally trained on the PASRR process and had not been privy to what a completed PASRR form would look like. Staff #86 further stated that he had not been able to successfully utilize the website that he had been aware of as the main form of submission for PASRR forms. Regarding Resident #63, Staff #86 reviewed her orders and her active medications and identified medications for anxiety, depression, and bipolar disorder with psychosis and hallucinations would have been triggers for a level II PASRR submission. Staff #86 reviewed the PASRR form for Resident #63 and stated that there had been no evidence of any diagnosis or medications, and had been unsure what the process would be should a PASRR form state inaccurate information. Staff #86 stated that the purpose of the PASRR form is to protect residents and ensure that the facility maintains documentation of any interventions in place to provide the best possible care. Staff #86 then provided clarity on the website, which they understood as the PASRR submission website, stating that they had not been able to successfully utilize, however, there had been no evidence of a PASRR portal on the observed website, and Staff #86 had started refreshing the website without pressing any additional features.On March 19, 2026, at 10:02 AM, an interview was conducted with the DON (director of nursing/ Staff #36), who stated that the PASRR process included receiving a form from the hospital to ensure appropriate placement and appropriate treatment, and should a resident exceed 30 days of stay, and had the appropriate diagnosis, a level II form is expected to be sent to the appropriate state agency for determination a need for level II PASRR interventions. Staff #36 further stated that there is no in-house training regarding the PASRR process and that additional training can be requested on behalf of the social services director if it is determined to be required. Staff #36 further stated that she had found out the same day of the interview that there is a point of contact within their corporate leadership, located in Las Vegas, Nevada, who had handled the facility's PASARR process, and had been unsure if this individual had been privy to the regulations for the state of Arizona. Staff #36 also stated that she had not gone over the PASRR process with the current social services director and what a completed PASRR form would look like. Regarding Resident #63, Staff #36 stated that her diagnosis of anxiety, depression, bipolar disorder, and bipolar disorder with psychotic features would have been appropriate for a PASRR level II submission. Staff #36 further stated that on a PASRR form dated December 14, 2023, it revealed an inaccurate completion of Section A that required information on exemptions and categorical determination; an inaccurate completion of Section B that required information on mental illness diagnosis, symptoms, history of psychiatric treatment, and medications. Staff #36 stated that there was no evidence of a PASRR level II, and that it would have been expected to have a PASRR level II for Resident #63 for state agency determination. Staff #36 stated that the risk of not submitting a PASRR level II form for a resident who could benefit from a state agency review could leave a resident at a disadvantage in receiving appropriate review of behavioral health interventions that can hinder their environment and psychological health.A facility policy titled, Resident Assessment - Preadmission Screening and Resident Review (PASRR ) for MD (mental disorder) and ID (intellectual disability), last reviewed May 4, 2023, revealed that the facility is to validate each resident in a nursing facility is screened for a MD or ID before admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs. The policy also revealed that residents are offered the most appropriate setting for their needs and receive the services for their needs in those settings, and that specialized services will be offered to individuals with MD or ID in accordance with the determination of the appropriate state-designated authority. The policy also revealed that any resident with newly evident or possible MD, ID, or related condition will be referred by the facility to the appropriate state-designated mental health or intellectual disability authority for review. The policy also stated that for residents with a level II determination and recommendations, the facility would incorporate the determination and recommendation into the resident's assessment and care plan.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#3) was provided with adequate supervision. Findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, encephalopathy, other stimulant abuse with intoxication and schizophrenia. An admission minimum data set (MDS) dated [DATE] included the resident's BIMS (Brief Interview of Mental Status) score of 3 that show that the resident #3 has severely impaired cognition and also included that the resident was exhibiting physical behaviors, rejection of care and wandering. A care plan dated March 30, 2025 included that this resident was an elopement risk/wanderer and included a goal that the resident would not leave the facility unattended. A wander risk scale dated March 30, 2025 included that this resident was at risk for wandering/elopement. A behavior notes dated April 1, 2025 included that resident frequently gets agitated screaming out and forgetting she has a left clavicle fracture, and resident was wandering around room frequently and coming into the hallway. A behavior note dated April 5, 2025 included resident frequently walking down the hallway without walker and yelling out for staff and that the resident was frequently wandering. This note included that the resident was unsteady on her feet and was educated to use walker while she is walking. A behavior note dated April 12, 2025 included that the resident was noted to have anxiety behaviors including attempting to leave the room exposed and wandering the hall attempting to open each door including the medication cart. Resident expressed frustration as evidenced by foul language and throwing/slamming walker towards wall. A progress note dated April 17, 2025 included that the resident went out for the afternoon with family and that when she got back she was upset that she was not being discharged and that the resident eloped trying to go outside. An activity note dated April 23, 2025 at 9:46 included that the resident was highly agitated and yelling about discharge and stated that she would walk out. This note includes that staff were able to deescalate the resident. A social services note dated April 23, 2025 at 10:13 included that the resident was screaming No I can't stay here anymore! and I cant take it anymore! This note also included that staff were able to deescalate the resident. A nurse's note dated April 24, 2025 included the activity director noticed this resident's wheelchair sitting outside front doors to the facility and resident was not around. This note included that a search was performed and that this resident was found at a bus stop. A communication with family note dated April 24, 2025 included that staff contacted family to obtain consent to place the resident on the secured unit following the elopement and included that since this resident had found out about NOMNOC (Notice Of Medicare Non-Coverage), she has been trying to leave facility and was in a very agitated mood. An interview was conducted on May 8, 2025 at 3:27 P.M. with a Certified Nursing Assistant (CNA/staff #87) who said that this staff had not personally lost a resident because this staff keeps an eye on the residents who have mentioned it. This staff said that this resident would scream and say she just wanted to go. This staff said that staff would make sure that this resident did not get on the elevator and that when she did that they would follow her and she would say, I just have to get out of here. This staff said that this resident attempted to get out of the second floor window but that it would not open enough for her to get out. This staff said that the day the resident eloped, she was very agitated and saying she was going to leave. This staff said that it was suggested to move this resident to the behavioral unit due to the wandering but that it did not happen. An interview was conducted on May 8, 2025 at 3:15 P.M. with a Certified Nursing Assistant (CNA/staff #17) who said that this resident did not want to be in the facility. This staff said that this resident was unstable on her feet and that staff knew that she was a runner and would watch her closely. This staff said that the facility gets residents who want to elope every now and then, but that normally management will catch on and move them to the behavioral unit but this was not done for this resident. An interview was conducted on May 9, 2025 at 11:30 A.M. with a Licensed Practical Nurse (LPN/staff #26) who said that if they have residents who are attempting to wander, they try to redirect them back to their room, try to keep an extra eye to make sure they don't go downstairs or in someone's room. This nurse said that if a resident told her that she wanted to leave, she would talk to them to find out why, notify the ADON and the DON, put it in a progress notes and let the nurse on the next shift know and if the resident seems adamant that she would let the receptionist know. This nurse said that resident #3 did not want to keep her sling on and just wanted to get out of here. This nurse said that the resident would wander all day long, passing her repeatedly while she was passing medications in the hall. This nurse said that she heard that this resident walked out the front. An interview was conducted on May 9, 2025 at 10:26 with the Assistant Director of Nursing (LPN/staff #22) who said that the management received the call that resident #3 was not in her room, noticed her wheelchair at the front and initiated the code [NAME] for elopement. This staff said that this resident would often scoot around the facility in a manual wheelchair, so when they found it, the management called the code green, had floor staff do an interior search and had the department heads do a search in a radius around the community. This staff said that resident #3 was found at a bus stop near a hospital which was on the other side behind a whoesale grocery store. This staff said that she was a little warm and thirsty but not in distress, and that she came back willingly. This staff said I believe she was looking for a cigarette. An interview was conducted on May 9, 2025 at 10:35 with the Receptionist (staff #74) who said that her responsibilities included to greet people, make sure they sign in and out and watch the front door, direct people where they need to go and the front paperwork. This staff said that there should always be someone watching the front door and that the facility locks to door at 8 P.M. when there is no one to watch it. This staff said that if she needed to step away from the door, she would call somebody to watch the door for her. This staff said that if she sees someone leaving who is a resident, that she will redirect them, and if that does not work she will call in the nurse chat and put Urgent and if the resident is still trying to leave that she will follow them out. This staff said that it's for safety in the roads and parking lot and also because we are in the desert and they can dehydrate so quickly. An interview was conducted on May 9, 2025 at 11:32 A.M. with the prior Director of Nursing (DON/staff #31) who said that prior to coming to the facility, resident #3 was homeless and using illicit substances and was found on the ground before before she was admitted to the facility and that the resident's behaviors were worse at night and included aggression and wandering. This staff said that the resident wandered normally but was not attempting to leave but that when she was given the Notice of Medical Non Coverage (NOMNC), that she became agitated. This DON said that not long afterward the staff were looking for her to follow up on some information they had discussed with family, the resident was not in the facility. This DON said that the resident's wheelchair was found by the front door, so a search was performed and that the resident was found unharmed but that she wanted extra water. This DON said that the receptionist did not see this resident leave. This DON said that after this resident #3 was really antsy and wanted to go and that the family approved the secured unit and over the weekend the family picked her up. This staff said that they did not want to initially put her in the secure unit because they were trying to do the least restrictive thing and maintain her dignity and rights. An interview was conducted on May 9, 2025 at 12:00 P.M. with the current Director of Nursing (DON/staff #9) who said that her expectations were that residents did not elope and are kept safe and secure by using the elopement assessment and making sure to utilize the tools at their disposal. A policy adopted May 1, 2024 titled Elopement revealed that all residents who are at risk for possible elopement/wandering shall be accompanied by staff or responsible party when leaving the facility grounds.

Based on observation, interviews, review of documentation, and review of facility policies, the facility failed to ensure that all allegations of abuse were reported to the state agency and other mandated entities within the required timeframe for two of two sampled residents (#11 and #13). The deficient practice could lead to a failure of the facility to report allegations of abuse timely, and could lead to continued abuse for a resident. -Regarding Resident #11: Resident #11 was admitted to the facility on [DATE], with diagnoses that included dementia, psychotic disorder, major depressive disorder, anxiety, chronic obstructive pulmonary disease, and adult failure to thrive. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. Review of the facility's Visitor Sign In log revealed that a male and female visitor had signed into the facility on [DATE] at 6:07 to visit room [ROOM NUMBER], with no sign out time. A nursing progress note dated September 04, 2024, revealed that at approximately 7:05 PM, certified nursing assistants (CNAs) made the writer aware that two CNAs had knocked on Resident #11's room door a couple of times with no answer. The two CNAs then entered the room, and stated that they saw a completely naked male in the room. The naked male then ran into the restroom. The licensed practical nurse (LPN) then knocked and opened the patient's room. The male had no shirt on, but had put on his pants, and his belt was still unbuckled. An additional female visitor was sitting at the foot of the bed, while the resident laid in the bed. The nurse asked what the situation was. The male visitor made a terrible joke while holding money in his hand that he was paying for sexual intercourse, but then said it was a joke. He then stated that he was just trying to take a shower. The nurse noted that at that time there was no shower water running and there was no scent of soap. The nurse notified the visitor that showers are for residents only. Resident #11 stated that she was not aware of this, and the male visitor kept blaming the resident for the situation. The note indicated that the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were made aware. The resident's daughter/ power of attorney (POA) was called and made aware of the situation. The resident's daughter stated that the resident used to live with the visitors but the daughter does not know them well, and that she would like the visitors listed as (Do Not Return) for the current time and would like to speak to her mother about the incident. Review of the state agency reporting system revealed no evidence that the facility submitted a Self-Report form for an allegation of sexual abuse for Resident #11. A nursing Alert Note dated September 5, 2024 revealed that at 1:20 AM, an LPN (Staff #621) received a message from the DON and night ADON to have both visitors (the male and female) leave the facility. The LPN entered the patient's room and observed the male sitting in the resident's wheelchair and the female sitting at the foot of the bed. The writer informed the visitors that they needed to leave the facility. The LPN observed he male visitor grabbing items from the bathroom, and that the bathroom and shower floor were wet. A Communication with Resident note dated September 05, 2024 at 9:25 AM, revealed that the DON (Staff # 618) spoke to resident regarding events from last night, that the resident denies any wrong doings and that the resident instructed the male visitor to take a shower because he was filthy. The resident denied any physical contact, and has no concerns with visitors. Review of the facility's Internal Investigation dated September 05, 2024 indicated that the allegation was of a male visitor naked in resident room on September 04, 2024 at 7:05 PM. The portion of the investigation indicating notification to the state department, notification to adult protective services, and notification to police was crossed out manually, with N/A (not applicable) handwritten across the section. A formal request was made to the facility on [DATE] at 10:45 AM for a log of all facility Self-Reports, all incidents and accidents, and all reportable and non-reportable investigations for the timeframe of August through October 2024. Upon review of facility provided documents, there was no evidence that the facility completed the mandated self-reporting of the incident of alleged sexual abuse for Resident #11. A follow-up formal request dated October 22, 2024 at 2:22 PM for the facility to specify if the incident regarding Resident #11 was reported, in which the facility indicated that the incident was only investigated internally. A telephonic interview was conducted on October 22, 2024 at 10:57 AM with Resident #11's daughter and POA. The daughter recalled the incident events and stated that she got conflicting stories from her mother and from the facility staff. The daughter stated that she was told by facility staff that the male visitor was in her mother's room and did not have any clothes on, and that he was taking a shower, and that he made some remarks that he was giving out sexual favors to the ladies. She stated that her mother said the male visitor did not take a shower. The daughter stated that her mother would not have asked the male visitor to get undressed. The daughter stated that she instructed the facility that she did not want the male visitor back until she could talk to her mother about the incident. An Interview was conducted with the ADON (Staff #640) on October 2, 2024 at 7:27 AM. The ADON stated that it was the facility's policy that staff are to report any allegation of abuse, including sexual abuse, to the abuse coordinator immediately, and that the abuse coordinator has 2 hours to report the allegation to the state department, and then an internal investigation is completed by the facility. An interview was conducted with the DON (Staff #618) on October 24, 2024 at 10:00 AM. Regarding Resident #11's incident on September 04, 2024, the DON stated that I did the investigation. The DON stated that the facility's policy on reporting allegations of abuse is that it is supposed to be reported to the abuse officer, who was the interim administrator at the time (Staff #72), and that he was notified of the incident when he read the investigation report on either September 05 or September 06, 2024, and that she was not sure exactly when he was notified. She stated that she did not know if he reported it to anyone. When asked if the DON reported the allegation to any of the state agencies or the police, the DON stated that It's up to the abuse coordinator. She also stated that she was not sure on the mandated reporting time requirement, and that she would have to look at the policy. Further, the DON stated that if there is a potential for abuse for a resident, and the facility does not protect the resident, that there could be continued abuse or harm to that resident. -Regarding Resident #13: Resident #13 was admitted to the facility on [DATE] with diagnoses that included hemiplegia affecting the left side, dementia, traumatic brain injury, and major depressive disorder. A physician order for Resident #13 dated August 16, 2024, indicated for behavior tracking for physical aggression every shift. Review of the progress notes revealed a Behavior Note dated September 11, 2024, indicating that Resident #13 was wheeling down the hallway, as she passed by another resident, he stuck his foot out. Resident #13 yelled at the other resident Hey dipshit, don't do that. I don't like you and I had a way to hurt you, I would. The note revealed that staff redirected Resident #13 back to her room. A Behavior Note dated September 13, 2024 at 5:13 PM, indicated that another resident touched Resident #13's wheelchair. The resident then stated if you put your hand on my wheelchair again, I am going to pop you one. The note indicated that staff redirected Resident #13 into her room and away from the situation. A Behavior Note dated September 16, 2024 at 11:55 AM, indicated Resident #13 was coming out of her room, that she made a fist with her right hand, and punched another resident. The note indicated that the resident stated the other resident had it coming. The note indicated that the staff told Resident #13 that her behavior was unacceptable and not to do it again. Review of the clinical record and facility-provided documents revealed no evidence that the facility investigated or reported the incident of alleged abuse on September 16, 2024. Review of Resident #13's clinical record revealed no evidence of notes of an additional resident-to-resident incident on October 04, 2024. Review of the facility's Internal Investigation file dated October 04, 2024 indicated that at 9:27 AM, staff alerted the DON and ADON to a potential resident to resident incident. Resident #13 made an accusation against a male peer (Resident #33) that he grabbed her arm and twisted, that she yelled help and he let go. The investigation revealed that both residents were interviewed, and that Resident #13 was assessed with no physical findings and denies feeling unsafe. The investigation indicates that Resident #33 reports he did not touch Resident #13. The file also revealed that the alleged interaction was not witnessed by staff or peers, however a separate document in the investigation file labeled Incident Witness Interviews with the DON's name listed underneath, dated October 04, 2024, revealed a discrepancy that the writer went to the dining room and spoke to residents (included three resident names). When questioned on what had occurred, they collectively stated that when Resident #33 walked into the mileu, Resident #13 let out a scream, but did not make physical contact with her. Additionally, the portion of the Internal Investigation for notification of family or POA was revealed to be left blank, despite having two family members listed in Resident #3's emergency contact file. The portion of the investigation indicating notification to the state department, notification to adult protective services, and notification to police was crossed out manually, with N/A (not applicable) handwritten across the section. Additionally, the portion of the Internal Investigation indicating notification to the state department, notification to adult protective services, and notification to police was crossed out manually, with N/A (not applicable) handwritten across the section. A formal request was made to the facility on [DATE] at 10:45 AM, for a log of all facility Self-Reports, all incidents and accidents, and all reportable and non-reportable investigations for the timeframe of August through October 2024. Upon review of facility provided documents, there was no evidence that the facility completed an Internal Investigation for the incident of Resident #13 punching another resident on September 16, 2024, or that the facility completed the mandated self-reporting for an allegation of physical abuse. Further, there was no evidence that the facility completed the mandated self-reporting of the incident on October 04, 2024 of alleged resident-to-resident physical abuse for Resident #33 against Resident #13. A follow-up formal request was made October 22, 2024 at 2:22 PM, for the facility to specify if the October 04, 2024 incident regarding Resident #33 and Resident #13 was reported, in which the facility indicated that the incident was only investigated internally. -Regarding Resident #33: Resident #33 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, dementia, depression, and anxiety. An IDT Note dated September 3, 2024 at 3:40 PM, indicated that in the past week, Resident #33 continued to have inappropriate grabbing episodes, where resident attempted to grab a female staff inappropriately as she was passing by the resident. A Behavior Note dated September 11, 2024 at 11:59 AM indicated that Resident #33 was sitting in hallway with other residents, and as another resident was wheeling down the hall in her wheelchair, Resident #33 stuck his foot out in front of her. The intervention and outcome section of the note indicated that the staff asked patient not to do that. A Nurses Note dated September 16, 2024 at 6:31 PM, revealed that Resident #33 waits for staff to walk out of room and then will grab the breast of female residents. This happened 3 different times throughout the day today. Patient was redirected and told not to touch other people each time it happened. Review of the clinical record and facility-provided documents revealed no evidence that the facility investigated or reported the incident of alleged sexual abuse on September 16, 2024. A Psychiatry/Mental Health note dated September 17, 2024 at 5:15 PM revealed that the provider met with Resident #33 for follow up to report of his inappropriate behaviors. The note revealed that Resident #33 states he touched a female resident because I think she wanted me to. I think it's in her character. The note revealed that we discussed that he cannot touch other people or go into other's rooms. A progress note dated October 04, 2024 by the LPN (Staff #648) revealed that according to another resident, the patient twisted resident's arm in the dining room. The intervention and outcome section of the note indicated that the patients were separated in the dining room. A formal request was made to the facility on [DATE] at 10:45 AM, for a log of all facility Self-Reports, all incidents and accidents, and all reportable and non-reportable investigations for the timeframe of August through October 2024. Upon review of facility provided documents, there was no evidence that the facility completed an Internal Investigation for the incident of Resident #33 repeatedly grabbing the breasts of a female resident on September 16, 2024, or that the facility completed the mandated self-reporting for an allegation of sexual abuse. Further, there was no evidence that the facility completed the mandated self-reporting of the incident on October 04, 2024 of alleged resident-to-resident physical abuse for Resident #33 against Resident #13. An interview was conducted with a certified nursing assistant (CNA/Staff #642) on October 23, 2024 at 10:02 AM. Regarding the incident on October 04, 2024, the CNA stated that she did not witness it, that she was in another resident's room and she heard Resident #13 yelling Help, Help. The CNA confirmed that she was the first staff to respond, and that she went into the dining room and Resident #13 said that Resident #33 twisted her arm. The CNA stated that Resident #33 was seated in the dining room when she entered. She also stated that, at that time, it was only those two residents in the dining room, that no other residents were present. She stated that she then separated the residents. She stated that then the DON came down and did a report of the incident, that the staff were instructed to provide extra supervision, and that the residents were to sit at separate tables. She further stated that her understanding of the facility's abuse policy was to report any allegation of abuse to the supervisor or to the Administrator immediately. An interview was conducted with the ADON (Staff #640) on October 24, 2024 at 9:24 AM. The ADON stated that regarding the incident on October 04, 2024, that there was an allegation that Resident #33 twisted Resident #13's arm, that the facility did an investigation and made sure there was no injury, and that staff and residents were interviewed. When asked if the incident was witnessed by anybody, the ADON stated I don't believe so And when asked to clarify if he facility could determine with certainty that this alleged event happened or did not happen, the ADON confirmed that the facility would not be able to determine with certainty because it was an unwitnessed event. When asked if this allegation of physical abuse was reported to the state agency as required by the facility's policy, the ADON stated I would have to believe it was. An interview was conducted with the DON (Staff #618) on October 24, 2024 at 10:14 AM. The DON stated that she was made aware of the accusation and was there in the dining room to assess the incident within 5 to 10 minutes. She stated that nobody in the dining room saw what happened. She further stated that she discussed the incident with the Administrator (Staff #629) within the hour. She stated to her knowledge, the Administrator did not complete the mandated reporting of the allegation of abuse. When asked what the facility's policy requires regarding mandated reporting, the DON stated that she notified the abuse officer (Staff #629) immediately, and that the facility has 2 hours to complete the mandated reporting if there is serious injury. When asked what the policy states if there is no apparent injury, the DON stated that she would have to look at the policy. The DON stated that if the abuse policy is not followed, that there is potential for harm to a resident. An interview was conducted with the Administrator (Staff #629) on October 24, 2024 at 10:23 AM. The Administrator stated that his role in cases of alleged abuse is to help the DON investigate, and to report to the state department if the allegation is substantiated. He then stated that the facility has 2 hours to report any allegations of abuse. He stated that he knew the incident on October 04, 2024 was not reported to the state. When questioned why it is important for the facility to report to the required entities any allegation of abuse, the Administrator stated that sometimes the facilities unsubstantiate an allegation, but the state department may still be more experienced in investigating. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation revised May 04, 2023 revealed that the facility will provide a safe resident environment and protect residents from abuse, including verbal, mental, sexual, and physical abuse. The policy defines abuse as the willful infliction of injury or intimidation, with resulting physical harm, pain, or mental anguish. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. When the facility has identified abuse, the facility should take appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. This includes: take steps to prevent further abuse, report the allegation to the appropriate authorities within the required timeframes, conduct a thorough investigation of the allegation, document and report the result of the investigation of the allegation, take appropriate corrective action, and revise the resident care plan if indicated. The policy further defines types of abuse. Physical abuse includes but is not limited to hitting, slapping, punching, biting, and kicking. Sexual abuse includes non-consensual sexual contact of any type with a resident who appears to want the contact to occur but lacks the cognitive ability to consent, or a resident who does not want the contact to occur. Review of the facility's policy titled Freedom from Abuse, Neglect, and Exploitation: Abuse Reporting and Responsibilities of Covered Individuals, revised May 04, 2023, revealed that the facility will report to the State Agency and law enforcement any reasonable suspicion of a crime against any resident within the time frames required by federal and state law. Further, for allegations of abuse, the facility will report immediately, but not later than 2 hours, all alleged violations involving abuse and alleged violations in which the result was serious injury.

Based on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure a thorough investigation for allegations of abuse were completed for two of two sampled residents (#11 and #13) and that the residents were protected from further abuse during an investigation. The deficient practice could result in residents not protected from further abuse and appropriate corrective action not taken. -Regarding Resident #11: Resident #11 was admitted to the facility on [DATE], with diagnoses that included dementia, psychotic disorder, major depressive disorder, anxiety, chronic obstructive pulmonary disease, and adult failure to thrive. The resident's admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. Review of the facility's Visitor Sign In log revealed that a male and a female visitor had signed into the facility on [DATE] at 6:07 to visit room [ROOM NUMBER], with no sign out time. A nursing progress note dated September 04, 2024, revealed that at approximately 7:05 PM, certified nursing assistants (CNAs) made the writer aware that two CNAs had knocked on Resident #11's room door a couple of times with no answer. The two CNAs then entered the room, and stated that they saw a completely naked male in the room. The naked male then ran into the restroom. The licensed practical nurse (LPN) then knocked and opened the patient's room. The male had no shirt on, but had put on his pants, and his belt was still unbuckled. An additional female visitor was sitting at the foot of the bed, while the resident laid in the bed. The nurse asked what the situation was. The male visitor made a terrible joke while holding money in his hand that he was paying for sexual intercourse, but then said it was a joke. He then stated that he was just trying to take a shower. The nurse noted that at that time there was no shower water running and there was no scent of soap. The nurse notified the visitor that showers are for residents only. Resident #11 stated that she was not aware of this, and the male visitor kept blaming the resident for the situation. The note indicated that the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were made aware. The resident's daughter/ power of attorney (POA) was called and made aware of the situation. The resident's daughter stated that the resident used to live with the visitors but the daughter does not know them well, and that she would like the visitors listed as (Do Not Return) for the current time and would like to speak to her mother about the incident. Review of the resident's clinical record revealed no evidence of communication from the facility to the provider regarding the incident involving the naked male visitor in Resident #11's room on September 04, 2024. A nursing Alert Note dated September 5, 2024 revealed that at 1:20 AM, an LPN (Staff #621) received a message from the DON and night ADON to have both visitors (the male and female) leave the facility. The LPN entered the patient's room and observed the male sitting in the resident's wheelchair and the female sitting at the foot of the bed. The writer informed the visitors that they needed to leave the facility. The LPN observed he male visitor grabbing items from the bathroom, and that the bathroom and shower floor were wet. A Communication with Resident note dated September 05, 2024 at 9:25 AM, revealed that the DON (Staff # 618) spoke to resident regarding events from last night, that the resident denies any wrong doings and that the resident instructed the male visitor to take a shower because he was filthy. The resident denied any physical contact, and has no concerns with visitors. Review of the facility's Internal Investigation dated September 05, 2024 indicated that the allegation was of a male visitor naked in resident room on September 04, 2024 at 7:05 PM. The portion of the investigation indicating notification to the state department, notification to adult protective services, and notification to police was crossed out manually, with N/A (not applicable) handwritten across the section. The internal investigation revealed no evidence of notes of staff interviews. The investigation revealed no evidence of which two CNA's initially entered the resident's room. The investigation also revealed no evidence of interviews of residents surrounding Resident #11's room. Review of the facility's Visitor Sign In log revealed that the male visitor had also signed in to visit the resident on the following dates after the incident: -September 11, 2024 -September 18, 2024 -October 04, 2024 -October 14, 2024. Review of the clinical record revealed no evidence of communication follow-up from the facility to the resident's daughter regarding whether the male visitor was permitted back to the facility between the timeframe of September 04, 2024, and when the male visitor signed in on the facility's Visitor Sign in log on September 11, 2024 to visit Resident #11. Review of the resident's electronic medical record on October 23, 2024 at 2:12 PM, revealed no evidence that the Special Instructions banner at the top of the resident's chart had any information regarding visitation instructions for the male and female visitors. However, on October 24, 2024, the DON provided a copy of the Special Instructions banner that was now updated to indicate (the male and female visitors) CANNOT visit per POA. A telephonic interview was conducted on October 22, 2024 at 10:57 AM with Resident #11's daughter and POA. The daughter recalled the incident events and stated that she got conflicting stories from her mother and from the facility staff. The daughter stated that she was told by facility staff that the male visitor was in her mother's room and did not have any clothes on, and that he was taking a shower, and that he made some remarks that he was giving out sexual favors to the ladies. She stated that her mother said the male visitor did not take a shower. The daughter stated that her mother would not have asked the male visitor to get undressed. The daughter stated that she instructed the facility that she did not want the male visitor back until she could talk to her mother about the incident. An interview was conducted on October 24, 2024 at 8:28 AM with Social Services Director (SS Director / Staff #672). The SS Director stated I have no knowledge of this incident. She stated that she is part of the daily stand-up meeting with facility leadership, and that she did not recall the incident being discussed. She stated that if she had been made aware of the incident, that she would have had started the grievance process for it. An interview was conducted with the DON (Staff #618) on October 24, 2024 at 10:00 AM. Regarding Resident #11's incident on September 04, 2024, the DON stated that I did the investigation. The DON stated that staff monitored the resident the rest of the evening, and that the next morning (September 05, 2024) the DON came into the facility and did the investigation. The interview with the DON continued, and she described her investigation process. She stated she interviewed Resident #11 on September 05, 2024, that she interviewed the staff, but could not remember who the CNA staff was who initially entered the resident's room and saw the naked male visitor. She also stated that she interviewed the residents across the hall from Resident #11, despite no evidence of staff or resident interviews within the Internal Investigation. The DON stated that the resident was kept safe, as the facility notified the front desk staff that the male visitor was not allowed back. She further stated that the male visitor has not been back to the facility since the incident, and that he still is not allowed back, despite contradicting evidence of multiple entries on the facility's Visitor Sign In log for the male visitor after the incident. Further, the DON stated that if there is a potential for abuse for a resident, and the facility does not protect the resident, that there could be continued abuse or harm to that resident. -Regarding Resident #13: Resident #13 was admitted to the facility on [DATE] with diagnoses that included hemiplegia affecting the left side, dementia, traumatic brain injury, and major depressive disorder. The resident's admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident was unable to complete the interview for cognitive assessment. Review of the progress notes revealed a Behavior Note dated September 11, 2024 at 11:58 AM, indicating that Resident #13 was wheeling down the hallway, as she passed by another resident, he stuck his foot out. Resident #13 yelled at the other resident Hey dipshit, don't do that. I don't like you and I had a way to hurt you, I would. The note revealed that staff redirected Resident #13 back to her room. A Behavior Note dated September 13, 2024, indicated that another resident touched Resident #13's wheelchair. The resident then stated if you put your hand on my wheelchair again, I am going to pop you one. The note indicated that staff redirected Resident #13 into her room and away from the situation. A Behavior Note dated September 16, 2024, indicated Resident #13 was coming out of her room, that she made a fist with her right hand, and punched another resident. The note indicated that the resident stated the other resident had it coming. The note indicated that the staff told Resident #13 that her behavior was unacceptable and not to do it again. Review of the clinical record and facility-provided documents revealed no evidence that the facility investigated or reported the incident of alleged abuse on September 16, 2024. An Interdisciplinary Team (IDT) Note dated September 18, 2024 at 12:52 PM indicated that in the past week, Resident #13 had one incident of aggression toward another resident. The note indicated that No other behavioral episodes reported. The note further indicated that in attendance of the IDT review was the ADON (Staff #640), the behavioral therapist, the psychiatrist, the SS Director (Staff #672), and the interim administrator (Staff #72). Review of the facility's Internal Investigation file dated October 04, 2024 indicated that at 9:27 AM staff alerted the DON and ADON to a potential resident to resident incident. Resident #13 made an accusation against a male peer (Resident #33) that he grabbed her arm and twisted, that she yelled help and he let go. The investigation revealed that both residents were interviewed, and that Resident #13 was assessed with no physical findings and denies feeling unsafe. The investigation indicated that Resident #33 reports he did not touch Resident #13. The file also revealed that the alleged interaction was not witnessed by staff or peers, however a separate document in the investigation file labeled Incident Witness Interviews with the DON's name listed underneath, dated October 04, 2024, revealed a discrepancy that the writer went to the dining room and spoke to residents (included three resident names). When questioned on what had occurred, they collectively stated that when Resident #33 walked into the mileu, Resident #13 let out a scream, but did not make physical contact with her. A Late Entry Nurses Note dated October 07, 2024, by the DON, revealed that on October 04, 2024 at 9:27 AM, a focused assessment was completed on the resident's right arm. The note indicated that the resident's range of motion as at baseline and there was no discoloration, no abrasion, and no disruption of visible skin, no tenderness or complaint of discomfort, and no evidence of trauma or injury. Upon review of the resident's clinical record, there was no evidence that date (October 04, 2024) of a description of an incident, or any further explanation as to why the resident's right arm was assessed, or that the facility notified the provider or the resident's family. An IDT Note dated October 08, 2024 at 3:42 revealed that in the past week, the resident had one incident related to a behavioral disturbance. The note revealed that Resident #13 made allegations towards peers and that no signs or evidence that anything had occurred. The note indicated that per male peer that he walked into the dining room and Resident #13 began screaming. In attendance of the IDT review were the ADON (Staff #640), the DON (Staff #618), the behavioral health nurse practitioner, and the SS Director (Staff #672). A Behavior Note dated October 09, 2024 at 9:02 AM indicated that Resident #13 is withdrawn, turned away from staff, and refusing to speak to staff. A formal request was made to the facility on [DATE] at 10:45 AM, for a log of all facility Self-Reports, all incidents and accidents, and all reportable and non-reportable investigations for the timeframe of August through October 2024. Upon review of facility provided documents, there was no evidence that the facility completed an Internal Investigation for the incident of Resident #13 punching another resident on September 16, 2024, nor took steps to prevent further abuse or retaliation. -Regarding Resident #33: Resident #33 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, dementia, depression, and anxiety. The resident's admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident was unable to complete the interview for cognitive assessment. The assessment also indicated that the resident demonstrated physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, and/or abusing others sexually. Review of the resident's care plan revealed a care plan dated July 08, 2024 that the resident has a behavior concerns due to impaired cognitive status. An intervention dated September 17, 2024, revealed that the resident exhibits sexually inappropriate behavioral symptoms. There was no evidence of any updates to the care plan regarding a resident-to-resident incident reported on October 04, 2024. An IDT Note dated September 3, 2024, indicated that in the past week, Resident #33 continued to have inappropriate grabbing episodes, where resident attempted to grab a female staff inappropriately as she was passing by the resident. A Behavior Note dated September 11, 2024, indicated that Resident #33 was sitting in hallway with other residents, and as another resident was wheeling down the hall in her wheelchair, Resident #33 stuck his foot out in front of her. The intervention and outcome section of the note indicated that the staff asked patient not to do that. A Nurses Note dated September 16, 2024, revealed that Resident #33 waits for staff to walk out of room and then will grab the breast of female residents. This happened 3 different times throughout the day today. Patient was redirected and told not to touch other people each time it happened. Review of the clinical record and facility-provided documents revealed no evidence that the facility investigated or reported the incident of alleged sexual abuse on September 16, 2024. A Psychiatry/Mental Health note dated September 17, 2024, revealed that the provider met with Resident #33 for follow up to report of his inappropriate behaviors. The note revealed that Resident #33 states he touched a female resident because I think she wanted me to. I think it's in her character. The note revealed that we discussed that he cannot touch other people or go into other's rooms. An IDT Note dated September 18, 2024 revealed that in the past week, staff reported Resident #33 to have sexual inappropriate behavior attempting to grope female staff and use inappropriate language toward staff. The note revealed no evidence of addressing Resident #33's grabbing the breast of female residents. The note indicated in attendance of the IDT review was the ADON (Staff #640), the psychiatrist, the SS Director (Staff #672) and the interim administrator (Staff #72). A progress note dated October 04, 2024 by the LPN (Staff #648) revealed that according to another resident, the patient twisted resident's arm in the dining room. A formal request was made to the facility on [DATE] at 10:45 AM, for a log of all facility Self-Reports, all incidents and accidents, and all reportable and non-reportable investigations for the timeframe of August through October 2024. Upon review of facility provided documents, there was no evidence that the facility completed an Internal Investigation for the incident of Resident #33 repeatedly grabbing the breasts of a female resident on September 16, 2024, or that the facility completed the mandated self-reporting for an allegation of sexual abuse. An interview was conducted with a certified nursing assistant (CNA/Staff #642) on October 23, 2024 at 10:02 AM. Regarding the incident on October 04, 2024, the CNA stated that she did not witness it, that she was in another resident's room and she heard Resident #13 yelling Help, Help. The CNA confirmed that she was the first staff to respond, and that she went into the dining room and Resident #13 said that Resident #33 twisted her arm. The CNA stated that Resident #33 was seated in the dining room when she entered. She also stated that, at that time, it was only those two residents in the dining room, that no other residents were present. She stated that she then separated the residents. She stated that then the DON came down and did a report of the incident, that the staff were instructed to provide extra supervision, and that the residents were to sit at separate tables. She further stated that her understanding of the facility's abuse policy was to report any allegation of abuse to the supervisor or to the Administrator immediately. A telephonic interview was conducted with the LPN (Staff #648) who confirmed she was the unit nurse at the time of the incident on October 04, 2024. She stated that she did not witness the incident, and the residents were left alone in the dining room for some period of time. She stated that the CNA had called her into the dining room and that Resident #33 had grabbed Resident #13's arm and twisted. The LPN stated that she called the ADON and let him know what had happened, and he sent the DON and she took care of it. She further stated that when she went into the dining room to assess the incident, that Resident #33 was sitting about 3 to 4 feet away from Resident #13. The LPN additionally stated that after the incident, neither resident was moved off of the unit. An interview was conducted with the ADON (Staff #640) on October 24, 2024 at 9:24 AM. The ADON stated that regarding the incident on October 04, 2024, that there was an allegation that Resident #33 twisted Resident #13's arm, that the facility did an investigation and made sure there was no injury, and that staff and residents were interviewed. When asked if the incident was witnessed by anybody, the ADON stated I don't believe so And when asked to clarify if he facility could determine with certainty that this alleged event happened or did not happen, the ADON confirmed that the facility would not be able to determine with certainty because it was an unwitnessed event. When reviewing the clinical record together, the ADON stated that he was not able to find any record that the resident's family was notified of the incident. Further, the ADON was asked to review the care plan for any interventions put in place to keep the two residents separated for safety, the ADON stated that he could not find any evidence of this in the care plan. The ADON stated that the impact on a resident who is not protected from potential abuse may be continued abuse. An interview was conducted with the DON (Staff #618) on October 24, 2024 at 10:14 AM. The DON stated that she was made aware of the accusation and went in the dining room to assess the incident within 5 to 10 minutes. She stated that nobody in the dining room saw what happened. She stated that Resident #33 was still in the dining room, seated approximately 8 feet away from Resident #13. She stated that at that time, the residents had not been separated. The DON stated that if the abuse policy is not followed, that there is potential for harm to a resident. An interview was conducted with the Administrator (Staff #629) on October 24, 2024 at 10:23 AM. The Administrator stated that in cases of alleged abuse the facility takes steps to ensure residents are protected, including to make sure residents are separated, to make sure there is not any retribution on the resident during the investigation process. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation revised May 04, 2023 revealed that the facility will provide a safe resident environment and protect residents from abuse, including verbal, mental, sexual, and physical abuse. The policy defines abuse as the willful infliction of injury or intimidation, with resulting physical harm, pain, or mental anguish. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. When the facility has identified abuse, the facility should take appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. This includes: take steps to prevent further abuse, report the allegation to the appropriate authorities within the required timeframes, conduct a thorough investigation of the allegation, document and report the result of the investigation of the allegation, take appropriate corrective action, and revise the resident care plan if indicated. The policy further defines types of abuse. Physical abuse includes but is not limited to hitting, slapping, punching, biting, and kicking. Sexual abuse includes non-consensual sexual contact of any type with a resident who appears to want the contact to occur but lacks the cognitive ability to consent, or a resident who does not want the contact to occur. Review of the facility's policy titled Freedom from Abuse, Neglect, and Exploitation: Preventing and Prohibiting Abuse, revised May 04, 2023, revealed that allegations of abuse will be investigated including identifying and interviewing involved persons, witnesses, and others who may have knowledge to the extent possible, determining whether abuse occurred, and documenting the investigation. During an investigation of alleged abuse, the facility will protect residents from harm during the investigation, to include: responding quickly to protect the alleged victim, increased supervision, room changes if necessary, protection from retaliation, and providing emotional support and counseling o the resident, as needed. Review of the facility's policy titled Freedom from Abuse, Neglect, and Exploitation: Abuse Reporting and Responsibilities of Covered Individuals, revised May 04, 2023, revealed that the facility will report to the State Agency and law enforcement any reasonable suspicion of a crime against any resident within the time frames required by federal and state law. Further, for allegations of abuse, the facility will report immediately, but not later than 2 hours, all alleged violations involving abuse and alleged violations in which the result was serious injury.

Based on clinical review, staff interviews, and facility policy, the facility failed to ensure that physician orders were followed according to professional standards for two out of five residents (#24 and #29). The deficient practice could result in residents not receiving care that meets professional standards. Findings include: -Resident (#24) was admitted to the facility on [DATE] with diagnoses that included Type II Diabetes Mellitus with hyperglycemia. The care plan for Diabetes Mellitus dated September 24, 2024, included an intervention to administer medications as ordered and to refer to current orders and/or medication administration record. The care plan also included to monitor for potential side effects and to report changes or abnormalities to the medical provider as applicable. The minimum data set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 15, indicating intact cognition. Review of the clinical record revealed a physician's order dated September 25, 2024, Novolog solution 100 unit/ml (Insulin Aspart), inject as per sliding scale: if 0 - 69 = 69 give glucose and notify physician; 70 - 149 = 0 units; 150 - 199 = 1 unit; 200 - 249 = 3 units; 250 - 299 = 5 units; 300 - 349 = 7 units; 350+ = 8 units and notify physician, subcutaneously before meals for diabetes. Review of the Medication Administration Record (MAR) dated September 2024 revealed: -September 29, 2024 that blood sugar of 374 and 8 units of insulin were administered. A review of progress notes revealed no evidence that the physician was notified when the residents blood sugar was 374 or that 8 units of Novolog solution were administered. An interview was conducted on October 24, 2024 at 9:25 AM with RN (Staff #644) who stated that physician communications would be documented in the progress notes. The RN reviewed the clinical record and stated that there was no evidence of the physician being notified about the resident's blood sugar being 374 and her receiving 8 units of Novolog solution. She also stated that it would be expected for the physician to be notified. The RN further stated that a risk to the resident for not contacting the physician when the resident's blood sugar was 374 could be that the resident could go into diabetic ketoacidosis (DKA). An interview was conducted with the Director of Nursing (DON/ Staff #618) on October 24, 2024 at 10:30 AM, who stated that the physician would be notified in regards to a resident's blood sugar if it states to do so in the physician order or if the staff had concerns or questions. The DON stated that the physician should have been notified about resident's blood sugar on September 29, 2024. She reviewed the clinical record and stated that there was no evidence showing the physician was notified. The DON (Staff #618) stated the risk to the resident could be the resident being hyperglycemic. She further stated that the physician not being notified did not meet facility expectations. The facility's policy, Pharmacy services, Medication Administration, revised on May 4, 2023 revealed that medications will be prepared and administered in accordance with prescriber's orders and accepted professional standards and principles. 51124 -Regarding Resident #29: Resident #29 was originally admitted to the facility on [DATE] with diagnoses that included Type II Diabetes Mellitus, respiratory failure, and chronic kidney disease. The resident's quarterly minimum data set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 11, indicating moderately impaired cognition. The resident's care plan for Diabetes Mellitus dated September 24, 2024, included an intervention to administer medications as ordered. A physician order dated March 2, 2024 prescribed: Humalog Injection solution (Insulin Lispro), inject as per sliding scale: if 0 - 69 = 0 units Give glucose and notify physician; 70 - 149 = 0 units; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350+ = 12 units; 350 > give 12 units and notify physician, subcutaneously before meals and at bedtime for diabetes. An additional physician order dated August 30, 2024 prescribed: Humalog Injection solution (Insulin Lispro), inject as per sliding scale: if 0 - 69 = 0 Units Give glucose and notify physician; 70 - 149 = 0 Units;150 - 199 = 2 Units; 200 - 249 = 4 Units; 250 - 299 = 7 Units; 300 - 349 = 10 Units; 350+ = 12 Units; 350 > give 12 units and notify physician, subcutaneously before meals and at bedtime for diabetes. Review of the Medication Administration Record (MAR) dated August 2024 revealed: -August 09, 2024 at 4:00 PM, that blood sugar of 408 and 12 units of insulin were administered. The MAR dated September 2024 revealed: -September 02, 2024 at 12:00 PM, that blood sugar of 410 and 12 units of insulin were administered. Review of the clinical record revealed no evidence that the physician was notified as ordered when the resident's blood glucose was greater than 350 and 12 units of insulin were administered on August 09 and September 02, 2024. An interview was conducted on October 24, 2024 at 8:52 AM, with the Assistant Director of Nursing (ADON/ Staff #640), who stated that it is his expectation that staff call the provider if a physician order indicates to call the physician if something such as a resident's vital sign or lab results was out of parameters. He further stated that it was his expectation that the staff would document in the electronic health record that the call to the provider was made. The ADON stated that staff can either document this provider communication through the MAR when administering medication or the nurse could enter a progress note. When Resident #29's MAR for August and September 2024 were reviewed together with the ADON, he stated that he could not find any evidence that the provider was notified as ordered on August 09 or September 02, 2024. He stated that the impact on a resident if the provider was not called would be that the facility staff may miss an order and that the physician would not know what was going on with the resident. An interview was conducted with the Director of Nursing (DON / Staff #618) on October 24, 2024 at 9:43 AM, who stated it was her expectation that if a resident has something, for example vital signs or labs, outside parameters and if they have an order stating to notify the physician, that the nurse would call the physician. The DON stated that if the issue was critical, that the physician should be notified immediately, and if it is not critical, that the physician would still be communicated with. She stated that in both cases, the communication with the physician should be documented in the medical record. When reviewing Resident #29's clinical record together, the DON stated that the lack of documentation regarding physician communication would not meet her expectation, and that the provider needs to be looped in. The facility's policy, Pharmacy services, Medication Administration, revised on May 4, 2023 revealed that medications will be prepared and administered in accordance with prescriber's orders and accepted professional standards and principles.

Based on observations, staff interviews, review of records, 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 residents (#43 and #21). The medication error rate was 7.41%. The deficient practice could result in further medication errors. Findings include: Resident #43 was admitted to the facility on [DATE] with diagnoses that included chronic obstruction pulmonary disease, type 2 diabetes mellitus, insomnia and hypertension. During a medication administration observation conducted on [DATE] at approximately 8:24 am with a Registered Nurse (RN/staff #700), the RN was observed to administer. - one Jardiance (Empagliflozin) 10mg tablet with expiration date August, 2025 and one Farxiga Oral Tablet 5 MG (Dapagliflozin Propanediol) with expiration date October, 2025, were given to resident #43. However, review of the physician's order revealed that Jardiance (Empagliflozin) 10mg tablet, was discontinued on [DATE]. A new order Farxiga Oral Tablet 5 mg (Dapagliflozin Propanediol), give 1 tablet by mouth in the morning were active from [DATE]. Resident #21 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, resistance to multiple antimicrobial drugs, and hypertension. During a medication administration observation conducted on [DATE] at approximately 9:30 am with a licensed practical nurse (LPN/staff # 710), the LPN were observed putting Amiodarone HCl Oral Tablet 200 MG 1 tablet that expired on [DATE] in a small paper cup. When asked regarding expired medication, she stated that she haven't looked at the expiration date. An Interview was conducted on [DATE] at 12:41pm with a licensed practical nurse (LPN/staff # 710), that was observed during the medication, who stated that we follow 5 rights during medication administrations including right patient, dose, route, medication and time. She also stated that we should dispense medication directly on cup and not on hand because our hands have bacteria, even if we sanitized and wash hand, we should not get into practice of touching medication while giving to patient, we should follow orders, rules, guidelines, protocol, and they are in place for reason. When asked regarding expiration medication then she stated that never give expired medication because medication has shelf-live and would be given according to shelf-life. An addition observation was conducted for medication cart North 1 on [DATE] at 1:01pm revealing that expired medication Amiodarone HCl Oral Tablet 200 MG remained on the medication cart and staff #710 stated that I am sorry, we missed this medication, it should be discarded to Rx destroyer. An Interview was conducted on [DATE] at 1:52 pm with a Registered Nurse (RN/staff #700), that was observed during the medication, who stated that we follow 7 rights during medication administrations including right patient name, medication, dose, reason, right documentation, time (med expiration), and route. She further stated that during medication administration, we use bubble method to dispense medication directly to cup from medication strip, where you don't touch medication, you pop up directly into cup without touching it because touching medication directly can cause cross contamination, cause infection and if you touch medication with hand then there is a chance of observing medication to your skin the effect of drug. Regarding expired medication, she stated that for blood pressure and over the counter medication, we use Rx destroyer and for narcotics, do two-person verification before destroying to Rx destroyer. She further stated that risk for giving expiration medication would be non-effectiveness, cause harm, cause rebound with BP, and mess with other medications. An Interview was conducted on [DATE] with director of nursing (DON/ staff # 618) who stated that we administration medication according to physician order and follow five rights including: right medication, route, patient, form (IV/oral/rectal/capsule/tablet), time (right time), and expiration. She further stated that during med pass, we dispense medication from bubble cart to medicine cup and it should go directly into cup and not from hand to cup else there will be potential for infection. She then stated that risk of using expiry medication would be efficacy of medication can't be effective by expiration dates. Regarding resident #43 she stated that resident was on Empagliflozin (generic is Jardiance) 10mg tablet starting [DATE] and ended [DATE], and on Farxiga Oral Tablet 5 mg daily starting [DATE] and medication is currently active. When asked during med pass, it was observed that staff #700 giving Jardiance (Empagliflozin) 10mg tablet to resident #43 then she stated that she has to go and pull out Jardiance (Empagliflozin) from medication cart and stated that staff are reading the box/cart instead of physician order. Review of the facility provided policy titled, Medication Administration, reviewed and revised on [DATE] revealed that medications will be prepared and administered in accordance with prescriber's order, manufacturer's specifications (not recommendations) and accepted professional standards and principles. It further revealed that the relative significance of medication errors is a matter of professional judgement. However, three general guidelines can be used in determining is a medication error is significant or not: resident condition, drug category and frequency of error.

Based on observation, interviews, review of documentation, and review of facility policies, the facility failed to implement written policies and procedures that prohibit and prevent abuse for two of two sampled residents (#11 and #13). The deficient practice could lead to a failure of the facility to investigate and report allegations of abuse, and could lead to harm to a resident. -Regarding Resident #11: Resident #11 was admitted to the facility on [DATE], with diagnoses that included dementia, psychotic disorder, major depressive disorder, anxiety, chronic obstructive pulmonary disease, and adult failure to thrive. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. Review of the facility's Visitor Sign In log revealed that a male and female visitor had signed into the facility on [DATE] at 6:07 to visit room [ROOM NUMBER], with no sign out time. A nursing progress note dated September 04, 2024, revealed that at approximately 7:05 PM, certified nursing assistants (CNAs) made the writer aware that two CNAs had knocked on Resident #11's room door a couple of times with no answer. The two CNAs then entered the room, and stated that they saw a completely naked male in the room. The naked male then ran into the restroom. The licensed practical nurse (LPN) then knocked and opened the patient's room. The male had no shirt on, but had put on his pants, and his belt was still unbuckled. An additional female visitor was sitting at the foot of the bed, while the resident laid in the bed. The nurse asked what the situation was. The male visitor made a terrible joke while holding money in his hand that he was paying for sexual intercourse, but then said it was a joke. He then stated that he was just trying to take a shower. The nurse noted that at that time there was no shower water running and there was no scent of soap. The nurse notified the visitor that showers are for residents only. Resident #11 stated that she was not aware of this, and the male visitor kept blaming the resident for the situation. The note indicated that the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were made aware. The resident's daughter/ power of attorney (POA) was called and made aware of the situation. The resident's daughter stated that the resident used to live with the visitors but the daughter does not know them well, and that she would like the visitors listed as (Do Not Return) for the current time and would like to speak to her mother about the incident. Review of the resident's clinical record revealed no evidence of communication from the facility to the provider regarding the incident involving the naked male visitor in Resident #11's room on September 04, 2024. Review of the state agency reporting system revealed no evidence that the facility submitted a Self-Report form for an allegation of sexual abuse for Resident #11. A nursing Alert Note dated September 5, 2024 revealed that at 1:20 AM, an LPN (Staff #621) received a message from the DON and night ADON to have both visitors (the male and female) leave the facility. The LPN entered the patient's room and observed the male visitor sitting in the resident's wheelchair and the female visitor sitting at the foot of the bed. The writer informed the visitors that they needed to leave the facility. The LPN observed the male visitor grabbing items from the bathroom, and that the bathroom and shower floor were wet. A Communication with Resident note dated September 05, 2024 at 9:25 AM, revealed that the DON (Staff # 618) spoke to resident regarding events from last night, that the resident denies any wrong doings and that the resident instructed the male visitor to take a shower because he was filthy. The resident denied any physical contact, and has no concerns with visitors. A Weekly Skin Observation dated September 05, 2024, revealed that Resident #11 had no new skin issues. Review of the facility's Internal Investigation dated September 05, 2024 indicated that the allegation was of a male visitor naked in resident room on September 04, 2024 at 7:05 PM. The portion of the investigation indicating notification to the state department, notification to adult protective services, and notification to police was crossed out manually, with N/A (not applicable) handwritten across the section. The internal investigation revealed no evidence of notes of staff interviews. The investigation revealed no evidence of which two CNA's initially entered the resident's room. The investigation also revealed no evidence of interviews of residents surrounding Resident #11's room. Review of the facility's Visitor Sign In log revealed that the male visitor had also signed in to visit the resident on the following dates after the incident: -September 11, 2024 -September 18, 2024 -October 04, 2024 -October 14, 2024. A formal request was made to the facility on [DATE] at 10:45 AM for a log of all facility Self-Reports, all incidents and accidents, and all reportable and non-reportable investigations for the timeframe of August through October 2024. Upon review of facility provided documents, there was no evidence that the facility completed the mandated self-reporting of the incident of alleged sexual abuse for Resident #11. A follow-up formal request dated October 22, 2024 at 2:22 PM for the facility to specify if the incident regarding Resident #11 was reported, in which the facility indicated that the incident was only investigated internally. Review of the resident's electronic medical record on October 23, 2024 at 2:12 PM, revealed no evidence that the Special Instructions banner at the top of the resident's chart had any information regarding the male and female visitors. However, on October 24, 2024, the DON provided a copy of the Special Instructions banner that was now updated to indicate (the male and female visitors) CANNOT visit per POA. A telephonic interview was conducted on October 22, 2024 at 10:57 AM with Resident #11's daughter and POA. The daughter recalled the incident events and stated that she got conflicting stories from her mother and from the facility staff. The daughter stated that her mother has known this man for approximately [AGE] years, as they used to live in the same apartments, although they were not roommates. The daughter stated that she was told by facility staff that the male visitor was in her mother's room and did not have any clothes on, and that he was taking a shower, and that he made some remarks that he was giving out sexual favors to the ladies. She stated that her mother said the male visitor did not take a shower. The daughter stated that her mother would not have asked the male visitor to get undressed. The daughter stated that she instructed the facility that she did not want the male visitor back until she could talk to her mother about the incident. She said that in one instance, the facility called and tried to keep the male visitor from entering the facility, but she had let the facility know that she had talked to her mother and that it was OK for him to be there. The daughter further stated that she had no concerns about any further incidents, that he has been back to the facility, and he has been behaving. He brings her food. He's the only one who visits her. I would not let him be there if I was worried about my mom's safety. An interview was conducted on October 22, 2024 at 1:42 PM with Resident #11. The resident stated that it was the nurse who said her male visitor was naked in the room. The resident stated that he was wearing jeans and had no shirt on, and that he is a construction worker. Resident #11 stated that she told the visitor to take a shower because he was dirty. The resident stated that she did not feel uncomfortable or unsafe regarding the incident. An Interview was conducted with the Assistant director of nursing (ADON/Staff #640) on October 2, 2024 at 7:27 AM. The ADON stated that it was the facility's policy that staff are to report any allegation of abuse, including sexual abuse, to the abuse coordinator immediately, and that the abuse coordinator has 2 hours to report the allegation to the state department, and then an internal investigation is completed by the facility. On October 24, 2024 at 8:11 AM, a call was placed to the LPN (Staff #683) for a telephonic interview with no return call. An interview was conducted on October 24, 2024 at 8:28 AM with Social Services Director (SS Director / Staff #672). The SS Director stated I have no knowledge of this incident. She stated that she is part of the daily stand-up meeting with facility leadership, and that she did not recall the incident being discussed. She stated that if she had been made aware of the incident, that she would have had started the grievance process for it. A follow-up interview was conducted with the ADON (Staff #640) on October 24, 2024 at 9:18 AM. In regard to Resident #11's incident on September 04, 2024, the ADON stated I recall the incident happening, but I don't recall the details and that he remembered it being reported to facility leadership that someone was showering in the resident's personal bathroom and that the male was naked because he was showering. He stated he could not recall if he incident was discussed by facility leadership after the incident, and that he did not know the details of the internal investigation. An interview was conducted with the DON (Staff #618) on October 24, 2024 at 10:00 AM. Regarding Resident #11's incident on September 04, 2024, the DON stated that I did the investigation. When asked if she was concerned of potential for abuse if a resident with a diagnosis of dementia and a moderate cognitive impairment had a naked male visitor in her room, the DON stated that she would need more information. The DON stated that staff called her as soon as it happened, that she directed staff to escort the male visitor off the property, that the staff did an initial interview with the resident that evening, where the resident stated that she instructed the male to take a shower because he was filthy. She stated that the facility staff notified the resident's daughter of the incident. The DON stated that staff monitored the resident the rest of the evening, and that the next morning (September 05, 2024) the DON came into the facility and did the investigation. The DON stated that the facility's policy on reporting allegations of abuse is that it is supposed to be reported to the abuse officer, who was the interim administrator at the time (Staff #72), and that he was notified of the incident when he read the investigation report on either September 05 or September 06, 2024, and that she was not sure exactly when he was notified. She stated that she did not know if he reported it to anyone. When asked if the DON reported the allegation to any of the state agencies or the police, the DON stated that It's up to the abuse coordinator. She also stated that she was not sure on the mandated reporting time requirement, and that she would have to look at the policy. She then described her investigation process. She stated she interviewed Resident #11 on September 05, 2024, that she interviewed the staff, but could not remember who the CNA staff was who initially entered the resident's room and saw the naked male visitor. She also stated that she interviewed the residents across the hall from Resident #11, despite no evidence of staff or resident interviews within the Internal Investigation. The DON stated that the resident was kept safe, as the facility notified the front desk staff that the male visitor was not allowed back. She further stated that the male visitor has not been back to the facility since the incident, and that he still is not allowed back, despite evidence of multiple entries on the facility's Visitor Sign In log to contradict this statement. Further, the DON stated that if there is a potential for abuse for a resident, and the facility does not protect the resident, that there could be continued abuse or harm to that resident. -Regarding Resident #13: Resident #13 was admitted to the facility on [DATE] with diagnoses that included hemiplegia affecting the left side, dementia, traumatic brain injury, and major depressive disorder. The resident's admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident was unable to complete the interview for cognitive assessment. An order dated August 16, 2024 indicated for behavior tracking for physical aggression every shift. A care plan initiated September 17, 2024 indicated a focus that Resident #13 has been and continues to be at risk for verbal and physical aggression (due to) history of aggression. The care plan also revealed an intervention revised October 21, 2024, that Resident #13 has a history of falsely accusing fell ow residents of aggression towards her. She also has a history of being aggressive towards other residents. An additional intervention dated September 17, 2024, indicated to monitor, document, and report incidents of resident posing danger to self and others. A Behavior Note dated September 11, 2024 at 11:58 AM, indicated that Resident #13 was wheeling down the hallway, as she passed by another resident, he stuck his foot out. Resident #13 yelled at the other resident Hey dipshit, don't do that. I don't like you and I had a way to hurt you, I would. The note revealed that staff redirected Resident #13 back to her room. A Behavior Note dated September 13, 2024 at 5:13 PM, indicated that another resident touched Resident #13's wheelchair. The resident then stated if you put your hand on my wheelchair again, I am going to pop you one. The note indicated that staff redirected Resident #13 into her room and away from the situation. An additional Behavior Note dated September 16, 2024 at 11:55 AM, indicated Resident #13 was coming out of her room, that she made a fist with her right hand, and punched another resident. The note indicated that the resident stated the other resident had it coming. The note indicated that the staff told Resident #13 that her behavior was unacceptable and not to do it again. Review of the clinical record and facility-provided documents revealed no evidence that the facility investigated or reported the incident of alleged abuse on September 16, 2024. An Interdisciplinary Team (IDT) Note dated September 18, 2024 at 12:52 PM indicated that in the past week, Resident #13 had one incident of aggression toward another resident. The note indicated that No other behavioral episodes reported. The note indicated that staff was educated to allow the resident to have her space when attending activities. The note further indicated that in attendance of the IDT review was the ADON (Staff #640), the behavioral therapist, the psychiatrist, the SS Director (Staff #672), and the interim administrator (Staff #72). Review of the facility's Internal Investigation file dated October 04, 2024 indicated that at 9:27 AM staff alerted the DON and ADON to a potential resident to resident incident. Resident #13 made an accusation against a male peer (Resident #33) that he grabbed her arm and twisted, that she yelled help and he let go. The investigation revealed that both residents were interviewed, and that Resident #13 was assessed with no physical findings and denies feeling unsafe. The investigation indicates that Resident #33 reports he did not touch Resident #13. The file also revealed that the alleged interaction was not witnessed by staff or peers, however a separate document in the investigation file labeled Incident Witness Interviews with the DON's name listed underneath, dated October 04, 2024, revealed a discrepancy that the writer went to the dining room and spoke to residents (included three resident names). When questioned on what had occurred, they collectively stated that when Resident #33 walked into the mileu, Resident #13 let out a scream, but did not make physical contact with her. Additionally, the portion of the Internal Investigation for notification of family or POA was revealed to be left blank, despite having two family members listed in Resident #3's emergency contact file. The portion of the investigation indicating notification to the state department, notification to adult protective services, and notification to police was crossed out manually, with N/A (not applicable) handwritten across the section. A Late Entry Nurses Note dated October 07, 2024, by the DON, revealed that on October 04, 2024 at 9:27 AM, a focused assessment was completed on the resident's right arm. The note indicated that the resident's range of motion as at baseline and there was no discoloration, no abrasion, and no disruption of visible skin, no tenderness or complaint of discomfort, and no evidence of trauma or injury. Upon review of the resident's clinical record, there was no evidence that date (October 04, 2024) of a description of an incident, or any further explanation as to why the resident's right arm was assessed, or that the facility notified the provider or the resident's family. An IDT Note dated October 08, 2024 at 3:42 revealed that in the past week, the resident had one incident related to a behavioral disturbance. The note revealed that Resident #13 made allegations towards peers and that no signs or evidence that anything had occurred. The note indicated that per male peer that he walked into the dining room and Resident #13 began screaming. The note further indicated that no resident-to resident incident was suspected or found. In attendance of the IDT review were the ADON (Staff #640), the DON (Staff #618), the behavioral health nurse practitioner, and the SS Director (Staff #672). A Behavior Note dated October 09, 2024 at 9:02 AM indicated that Resident #13 is withdrawn, turned away from staff, and refusing to speak to staff. A formal request was made to the facility on [DATE] at 10:45 AM, for a log of all facility Self-Reports, all incidents and accidents, and all reportable and non-reportable investigations for the timeframe of August through October 2024. Upon review of facility provided documents, there was no evidence that the facility completed an Internal Investigation for the incident of Resident #13 punching another resident on September 16, 2024, or that the facility completed the mandated self-reporting for an allegation of physical abuse. Further, there was no evidence that the facility completed the mandated self-reporting of the incident on October 04, 2024 of alleged resident-to-resident physical abuse for Resident #33 against Resident #13. A follow-up formal request dated October 22, 2024 at 2:22 PM, for the facility to specify if the October 04, 2024 incident regarding Resident #33 and Resident #13 was reported, in which the facility indicated that the incident was only investigated internally. -Regarding Resident #33: Resident #33 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, dementia, depression, and anxiety. The resident's admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident was unable to complete the interview for cognitive assessment. The assessment also indicated that the resident demonstrated physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, and/or abusing others sexually. Review of Resident #33's physician orders revealed an order dated July 10, 2024, for a behavioral health psychiatric evaluation. Additionally, an order dated July 06, 2024 indicated for behavior tracking every shift for restlessness and agitation. A care plan dated July 08, 2024, indicated that the resident has behavior concerns due to impaired cognitive status. An intervention dated September 17, 2024, revealed that the resident exhibits sexually inappropriate behavioral symptoms. There was no evidence of any updates to the care plan regarding a resident-to-resident incident reported on October 04, 2024. An IDT Note dated September 3, 2024 at 3:40 PM, indicated that in the past week, Resident #33 continued to have inappropriate grabbing episodes, where resident attempted to grab a female staff inappropriately as she was passing by the resident. A Behavior Note dated September 11, 2024, indicated that Resident #33 was sitting in hallway with other residents, and as another resident was wheeling down the hall in her wheelchair, Resident #33 stuck his foot out in front of her. The intervention and outcome section of the note indicated that the staff asked patient not to do that. A Nurses Note dated September 16, 2024 at 6:31 PM, revealed that Resident #33 waits for staff to walk out of room and then will grab the breast of female residents. This happened 3 different times throughout the day today. Patient was redirected and told not to touch other people each time it happened. Review of the clinical record and facility-provided documents revealed no evidence that the facility investigated or reported the incident of alleged sexual abuse on September 16, 2024. A Psychiatry/Mental Health note dated September 17, 2024 at 5:15 PM revealed that the provider met with Resident #33 for follow up to report of his inappropriate behaviors. The note revealed that Resident #33 states he touched a female resident because I think she wanted me to. I think it's in her character. The note revealed that we discussed that he cannot touch other people or go into other's rooms. An IDT Note dated September 18, 2024 revealed that in the past week, staff reported Resident #33 to have sexual inappropriate behavior attempting to grope female staff and use inappropriate language toward staff. The note revealed no evidence of addressing Resident #33's grabbing the breast of female residents. The note indicated in attendance of the IDT review was the ADON (Staff #640), the psychiatrist, the SS Director (Staff #672) and the interim administrator (Staff #72). A progress note dated October 04, 2024 by the LPN (Staff #648) revealed that according to another resident, the patient twisted resident's arm in the dining room. The intervention and outcome section of the note indicated that the patients were separated in the dining room. A formal request was made to the facility on [DATE] at 10:45 AM, for a log of all facility Self-Reports, all incidents and accidents, and all reportable and non-reportable investigations for the timeframe of August through October 2024. Upon review of facility provided documents, there was no evidence that the facility completed an Internal Investigation for the incident of Resident #33 repeatedly grabbing the breasts of a female resident on September 16, 2024, or that the facility completed the mandated self-reporting for an allegation of sexual abuse. Further, there was no evidence that the facility completed the mandated self-reporting of the incident on October 04, 2024 of alleged resident-to-resident physical abuse for Resident #33 against Resident #13. An interview was conducted with a certified nursing assistant (CNA/Staff #642) on October 23, 2024 at 10:02 AM. Regarding the incident on October 04, 2024, the CNA stated that she did not witness it, that she was in another resident's room and she heard Resident #13 yelling Help, Help. The CNA confirmed that she was the first staff to respond, and that she went into the dining room and Resident #13 said that Resident #33 twisted her arm. The CNA stated that Resident #33 was seated in the dining room when she entered. She also stated that, at that time, it was only those two residents in the dining room, that no other residents were present. She stated that she then separated the residents. She stated that then the DON came down and did a report of the incident, that the staff were instructed to provide extra supervision, and that the residents were to sit at separate tables. She further stated that her understanding of the facility's abuse policy was to report any allegation of abuse to the supervisor or to the Administrator immediately. A telephonic interview was conducted with the LPN (Staff #648) who confirmed she was the unit nurse at the time of the incident on October 04, 2024. She stated that she did not witness the incident, and the residents were left alone in the dining room for some period of time. She stated that the CNA had called her into the dining room and that Resident #33 had grabbed Resident #13's arm and twisted. The LPN stated that she called the ADON and let him know what had happened, and he sent the DON and she took care of it. The nurse stated that other residents were in the dining room but that all the residents in there would not be able to say what happened (due to cognitive or communicative deficits). The LPN stated that she assessed Resident #13's arm and she didn't have any marks. She further stated that when she went into the dining room to assess the incident, that Resident #33 was sitting about 3 to 4 feet away from Resident #13. The LPN additionally stated that after the incident, neither resident was moved off of the unit. An interview was conducted with the ADON (Staff #640) on October 24, 2024 at 9:24 AM. The ADON stated that regarding the incident on October 04, 2024, that there was an allegation that Resident #33 twisted Resident #13's arm, that the facility did an investigation and made sure there was no injury, and that staff and residents were interviewed. When asked if the incident was witnessed by anybody, the ADON stated I don't believe so And when asked to clarify if he facility could determine with certainty that this alleged event happened or did not happen, the ADON confirmed that the facility would not be able to determine with certainty because it was an unwitnessed event. When asked if this allegation of physical abuse was reported to the state agency as required by the facility's policy, the ADON stated I would have to believe it was. When reviewing the clinical record together, the ADON stated that he was not able to find any record that the resident's family was notified of the incident. Further, the ADON was asked to review the care plan for any interventions put in place to keep the two residents separated for safety, the ADON stated that he could not find any evidence of this in the care plan. The ADON stated that the impact on a resident who is not protected from potential abuse may be continued abuse. An interview was conducted with the DON (Staff #618) on October 24, 2024 at 10:14 AM. The DON stated that she was made aware of the accusation and went in the dining room to assess the incident within 5 to 10 minutes. She stated that nobody in the dining room saw what happened. She stated that Resident #33 was still in the dining room, seated approximately 8 feet away from Resident #13. She stated that at that time, the residents had not been separated. When asked how she could possibly rule out that the allegation had occurred since it was not witnessed, the DON stated that's why I assessed her arm. She further stated that she discussed the incident with the Administrator (Staff #629) within the hour. She stated to her knowledge, the Administrator did not complete the mandated reporting of the allegation of abuse. When asked what the facility's policy requires regarding mandated reporting, the DON stated that she notified the abuse officer (Staff #629) immediately, and that the facility has 2 hours to complete the mandated reporting if there is serious injury. When asked what the policy states if there is no apparent injury, the DON stated that she would have to look at the policy. The DON stated that if the abuse policy is not followed, that there is potential for harm to a resident. An interview was conducted with the Administrator (Staff #629) on October 24, 2024 at 10:23 AM. The Administrator stated that his role in cases of alleged abuse is to help the DON investigate, and to report to the state department if the allegation is substantiated. He then stated that the facility has 2 hours to report any allegations of abuse. He stated that he knew the incident on October 04, 2024 was not reported to the state. When questioned why it is important for the facility to report to the required entities any allegation of abuse, the Administrator stated that sometimes the facilities unsubstantiate an allegation, but the state department may still be more experienced in investigating. The Administrator stated that in cases of alleged abuse the facility takes steps to ensure residents are protected, including to make sure residents are separated, to make sure there is not any retribution on the resident during the investigation process. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation revised May 04, 2023 revealed that the facility will provide a safe resident environment and protect residents from abuse, including verbal, mental, sexual, and physical abuse. The policy defines abuse as the willful infliction of injury or intimidation, with resulting physical harm, pain, or mental anguish. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. When the facility has identified abuse, the facility should take appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. This includes: take steps to prevent further abuse, report the allegation to the appropriate authorities within the required timeframes, conduct a thorough investigation of the allegation, document and report the result of the investigation of the allegation, take appropriate corrective action, and revise the resident care plan if indicated. The policy further defines types of abuse. Physical abuse includes but is not limited to hitting, slapping, punching, biting, and kicking. Sexual abuse includes non-consensual sexual contact of any type with a resident who appears to want the contact to occur but lacks the cognitive ability to consent, or a resident who does not want the contact to occur. Review of the facility's policy titled Freedom from Abuse, Neglect, and Exploitation: Abuse Reporting and Responsibilities of Covered Individuals, revised May 04, 2023, revealed that the facility will report to the State Agency and law enforcement any reasonable suspicion of a crime against any resident within the time frames required by federal and state law. Further, for allegations of abuse, the facility will report immediately, but not later than 2 hours, all alleged violations involving abuse and alleged violations in which the result was serious injury.

Based on resident and staff interviews, a food test tray, and policy review, the facility failed to ensure food was provided that was palatable and at a temperature that is safe for consumption.The deficient practice has the potential for residents to acquire food-born illness. Review of the lunch menu for October 22, 2024 revealed the following: -Chili Cheese Dog -Sweet Potato Fries -Herb [NAME] Beans -Banana Pudding An observation was conducted on October 22, 2024 at 12:50 PM of a test tray. The test tray temperatures were taken by staff as follows: -Chili Cheese Dog-123 F -Sweet Potato Fries-121 F -Banana Pudding 63 F The test tray sampled by surveyors who reported that the chili cheese dog cooked but served cold. Two of the seven surveyors noted that the sweet potato fries were cold but crunchy. Additionally, three out of seven surveyors indicated that the banana pudding was not chilled. An interview conducted on October 21, 2024 at 9:06 a.m. with Resident # 32, with a BIMS Score of 11, stated that on October 20, 2024, he had to push his call light three times for because his lunch hasn't delivered yet. The resident stated that he to stepped out from his room to find staff regarding the lunch tray and it was not delivered until two-thirty p.m., and was cold. An interview conducted on October 21, 2024 at 10:36 a.m. with Resident #15, with a BIMS Score of 15, stated that staff deliver food cold every time. An interview conducted on October 21, 2024 at 2:16 p.m. with Resident #36, with a BIMS Score of 13, revealed that food always arrives cold and not looking appetizing. An interview conducted on October 21, 2024 at 2:30 p.m. with Resident #7, with a BIMS Score of 13, stated that food is always cold, bland, and not appetizing. An interview conducted on October 21, 2024 at 2:30 p.m. with Resident # 11, with a BIMS Score of 11, stated that food is horrible. The resident stated that she tries not to eat the food because it's nasty by the time she receives her meal. An interview conducted on October 22, 2024 at 11:30 a.m. with Resident # 49, with a BIMS Score of 14, stated that food is terrible. The resident stated for the last two nights, the soup, mashed potatoes, and the meat are cold already when she received the tray. An interview was conducted on October 23, 2024, with the Dietary Manager (Staff #669). She reported that a few residents had complained about cold food over the past three months. The Dietary Manager emphasized that whenever residents express concerns about food temperature, she promptly addresses the issue with her staff. This includes checking the food temperature before serving and ensuring that food is covered when presented to the residents. For room trays, the staff serves the food on plates, covers the plates, and places them in a warmer before delivering the trays to the residents' rooms. Review of the Facility Policy titled Food and Nutrition Services revealed that facility will procure food from sources approved or considered satisfactory by federal, state or local authorities. Food items will be stored, prepared, distributed and served in accordance with professional standards for food safety. Review of the Facility Guideline titled Serving Temperatures for Hot and Cold Foods revealed that staff will follow the guidelines when serving hot and cold beverages and food. Review of the Facility Procedure titled Serving Temperatures for Hot and Cold Foods revealed that foods will be serve at the following temperature to ensure a safe and appetizing dining experience. The minimum serving temperatures do not reflect the required temperatures needed for preparation, cooking or cooling of foods.

Based on clinical record review, staff interviews, facility documentation, and facility policy, the facility failed to ensure one resident (#420) was free from misappropriation of resident medications. The deficient practice could result in further incidents of misappropriation. -Findings Include: Resident #420 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, major depressive disorder, post-traumatic stress disorder, and heart failure. A physician order dated January 26, 2023, for Oxycodone HCl Oral Tablet 20 mg to give 1 tablet by mouth every 3 hours as needed for pain. The order was placed by a licensed practical nurse (LPN/Staff #220) and discontinued the same day by the same LPN. An additional order dated February 02, 2023 revealed Morphine Sulfate Oral Tablet 15 MG to give 1 tablet by mouth every 3 hours as needed by pain. The order was placed by the LPN (Staff #220) and was also discontinued that same day by the same LPN. Review of the personnel file for the LPN (Staff #220) revealed a Disciplinary Action document dated December 9, 2022, for a probationary period for failure to follow departmental policy and procedure when dispensing narcotics. Employee signs out narcotics in narc book but fails to document in eMAR (electronic medical administration record). An additional 30-Day Performance Improvement Plan dated December 09, 2022 indicated, as a corrective action step, that the LPN (Staff #220) would be required to have the oversight of an LPN who must cosign the dispense of the narcotic and accompany the employee to administer the narcotic to the patient. The Improvement Plan also indicated to follow up with employee every 7 days and record development below. However, the spaces provided by the form were left blank. An additional Disciplinary Action document dated February 08, 2023, for the LPN (Staff #220), revealed that the type of action was termination. The details indicated an investigation for narcotic diversion, and that the supervisor met with employee, she had no answers as to investigation outcome, and that the facility's investigation was substantiated. The supervisor's name was listed as the DON at that time (Staff #55). A review of the SA incident reporting system revealed a Reportable Event Record submitted by the facility dated February 06, 2023, revealed that on February 03, 2023, it was identified that a nurse was possibly diverting narcotics. The nurse in question was suspended pending investigation on February 03, 2023, and the investigation was initiated. The Reportable Event Record indicated that the interventions implemented after the incident were that the nurse was suspended and terminated, the pharmacy will no longer accept scripts printed from the electronic medical record, the physicians must E-prescribe, call the pharmacy themselves, or write the narcotic scripts on their own script pad, and that the DON or designee will obtain the daily narcotic logs and match them with what was ordered and delivered in the cart. Review of the state reporting system revealed that the facility's Administrator at that time (Staff #82) filed a Self-Report form dated February 06, 2023 at 7:24 PM for an allegation of misappropriation (narcotic diversion) for Resident #420. A Complaint Form dated February 08, 2023 to the state board of nursing revealed that the DON at that time (Staff #55) filed a complaint against the LPN (Staff #220). The complaint specified that during the facility's investigation of possible narcotic diversion by the LPN, that the facility identified over 34 orders that had been started and discontinued in the same shift that she worked and that each prescription (was) the physical prescription with identical handwriting/DEA#/signature with different patient information in the middle. If you look at the top right if the prescription you will see a faint line where the new patient's information was overlaid on the existing signed prescription. Later during the same shift (Staff #220) would receive the medication from the pharmacy and discontinue the medication from the medical record so there was (no) evidence of it being ordered. We did verify with all physicians for attached and signed prescriptions that they did not sign or prescribe them. The complaint specified that no harm occurred to the patients involved, that the LPN was terminated, and that authorities were notified. A telephonic interview was conducted on October 23, 2024 at 10:47 AM with the Director of Nursing (DON/Staff #55), who was no longer employed at the facility. When asked to describe the incident of the LPN (Staff #220) diverting narcotics, the DON stated that she suspended the nurse immediately when she knew about the missing medications. She stated that initially, her Assistant Director of Nursing (ADON) had identified that morphine was missing. According to the investigation, it was the DON's understanding that the LPN would order medications at the beginning of her shift, the medications would be delivered from the pharmacy, and then the LPN would discontinue the order from the computer. The LPN had an old prescription form from a patient that was printed and signed by one of the facility's providers. The LPN would then fold the new prescription with the new details over the old signed prescription paper, and there was a faint line on all of her orders that signified where she folded the paper. The DON stated that she verified with the provider that he did not write those prescriptions. The DON stated that after the incident, that the facility put in place interventions to prevent recurrence of narcotic diversion, including using strictly prescription pads or computer orders and daily cross checks with the pharmacy. A telephonic interview was conducted on October 23, 2024 at 11:04 AM, with the Administrator (Staff #82), who was no longer employed by the facility. The Administrator stated that the incident was first noted by the ADON at the time, who noticed a missing bottle of morphine. An investigation started and it was discovered that the LPN (Staff #220) was printing orders, falsifying the signature, sending the script to the pharmacy, and getting medications delivered. The Administrator stated that is was hundreds of pills that were diverted, and that the employee was terminated. The facility policy titled Freedom from Abuse, Neglect, and Exploitation: Preventing and Prohibiting Abuse, revised May 04, 2023, revealed that it is the facility's policy to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property.

Based on observation, clinical record review, staff and resident interviews, and policy review, the facility failed to ensure one resident (#12) was provided shower and dressing in timely manner. This deficient practice could result in residents not being provided hygiene care and services. Findings include: Resident #12 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic kidney diseases, anxiety, and depression. Review of the care plan dated November 30, 2023 revealed the resident had activities of daily living (ADL) performance deficit related to general weakness. Review of the admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS also revealed that the resident required two or more-person assistance with shower/bathing self. Review of the resident bathing schedule showed that resident was schedule for bathing every Tuesday and Friday. Review of progress note dated June 19, 2024 showed that resident was asked for shower at 2:45a.m. It further revealed that resident refused shower and stated she was too tired. Further review of progress note dated October 8, 2024 showed that resident was asked for shower at 12:27a.m. and resident refused shower and she stated that she got one on Monday. Review of shower sheets for resident #12 from June-October, 2024 revealed that resident got showers on following days: June: 4, 7, 18, 21, 25 July: 2, 9, 16, 19, 23 Aug: 5, 9, 18, 20, 27 September: 3, 10, 13, 16, 23, 27, 30 October: 4, 8, 11, 14, 21 An interview was conducted with resident #12 on October 21, 2024 at 12:43 pm in presence of daughter and daughter stated that one of the ongoing issues is bathing because my mother is not moveable, she is not getting schedule bath specially with agency staffs. There is one aid who makes sure she gets at least one in a week. She is scheduled to get bath on Tuesday and Friday and she rarely get Friday bath. I talk to administrator and director of nursing several times and they mention that they will change schedule but nothing happened so far. If there is agency staff person during night shift then they will come in morning around 1 am or 4 am for bath while I am sleeping. An interview was conducted again with resident #12 on October 23, 2024 at 11:52 am and resident stated that I cannot walk and I need one-person assistance with changing, bathing and bathroom. I get bed bath every Tuesday but not Friday. If I refuse bath then they supposed to bring form for refusal but when I refuse they say okay. Only time I refuse when they come middle of night when I am sleeping. I have to remine them every time that its Friday and I want bath. I have an issue with anxiety and there is time when I feel they are not taking me seriously and it happen mostly with agency staffs. An interview was conducted with certified nursing assistance (CNA #684) on October 23, 2024 at 12:40 pm and she stated that I don't feel like there is enough staff because we have 3 CNA for whole 2nd floor and we are running around and there are not enough CNA for patient to get adequate care. I feel like I am over whelmed because of not having enough staff and specially 2nd floor has lot of incontinent residents and they are not getting adequate care. When we are under staff, it's hard to answer residents in timely manner. She further stated that shower is schedule for every resident twice a week. Resident #12 is scheduled for Tuesday and Friday shower. If resident refuse shower then they have to wait until next schedule date. She also stated shower supposed to be done by 10:30pm and as far as it done before 10:30pm then it's not too late. We have lot of agency staff specially at night and weekend and that's why shower get missed lot of time. She then stated that risk for not getting shower/bath would be skin/hair irritation, fungus growing under folds. An interview was conducted with certified nursing assistance (CNA #622) on October 24, 2024 at 7:42 am and she stated that showers are provided by CNA. We have schedule shower for both day and night. Night shower has to be done before 10pm. If residents ask after 10pm then we provide and its usually not a problem. She further stated that risk for resident not getting schedule shower would be skin break down, dry skin, odor, itchiness. At night shift I usually ask for shower after vital and before going to bed and not at midnight. An interview was conducted with certified nursing assistance (CNA #657) on October 24, 2024 at 8:03 am and she stated that night showers are provider before 10pm, that is after taking resident vitals and before going to bed. So far, I have just done bed bath and if resident refuses then we write in shower sheet that they refused and then CNA and nurse sign it, and let next shift know. She further stated that risk for not getting schedule shower would be getting infection. An interview was conducted with director of nursing (DON #618) on October 24, 2024 at 11:01 am and she stated that we offer shower/bathing minimum twice a week and if resident wants then we try to accommodate every day. She further stated that we offer shower before 10pm so that we not walking them up residents' middle of night. She also stated that risk of not having shower/bath would be poor hygiene and shower helps to maintain general health of wellness. She further stated that resident #12 is scheduled for shower/bath every Tuesday and Friday and waking up resident middle of night shouldn't have happened. Review of the facility policy titled, Activities of Daily Living (ADLs/Maintain Abilities revised on May 4, 2024 indicated that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure that one resident (#24) of five sampled residents was not administered an unnecessary medication. The deficient practice could result in further incidents of residents receiving unnecessary medications. Findings include: Resident (#24) was admitted to the facility on [DATE] with diagnoses that included Type II Diabetes Mellitus with hyperglycemia. The care plan for Diabetes Mellitus dated on September 24, 2024 included the intervention to administer medications as ordered and to refer to current orders and/or medication administration record. The care plan also included to monitor for potential side effects and to report changes or abnormalities to medical provider as applicable. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact. A review of the current order summary revealed an order for Lantus solution 100 Unit/Milliliter (ML) (insulin Glargine) Inject 20 unit subcutaneously at bedtime for manage hyperglycemia, hold for blood sugar (BS) less than 100; scheduled for 9:00 PM dated September 25, 2024. However, There was no evidence of a current order for Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 15 units subcutaneously one time a day for diabetes mellitus, hold for BS less than 100. A review of the October 2024 Medication Administration Record (MAR) revealed an order for Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 15 unit subcutaneously one time a day for diabetes mellitus, hold for BS less than100; scheduled for 8:00 PM with a start date of September 27, 2024 and a discontinue date of October 20, 2024. Further review of the October 2024 MAR revealed an order dated September 30, 2024 for Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 20 unit subcutaneously at bedtime for manage hyperglycemia, hold for BS less than 100; scheduled for 9:00 PM. The MAR for October 2024 also revealed that resident (#24) received both orders of Insulin Glargine on the following dates: - October 5, 2024 - October 6, 2024 - October 14, 2024 An interview was conducted with RN (Staff #644) on October 23, 2024 at 1:29 PM who stated the resident (#24) did have two separate orders for insulin glargine, one for 15 units and one for 20 units per night. She stated that she would clarify with the physician because both of the orders were scheduled close together. The RN (Staff #644) also stated that there was no evidence showing the two orders were clarified with the physician. An interview was conducted on October 24, 2024 at 9:34 AM with Physician (Physician/Staff #700) who stated he was not aware of staff contacting him to clarify the two orders for Insulin Glargine. He also stated that staff usually contacts him to clarify orders. The physician stated that he did not know why there would be two orders unless there was a change in the dose. He further stated that he does not remember a conversation about discontinuing the first Insulin Glargine order. In an interview conducted on October 24, 2024 at 10:39 AM with the Director of Nursing (DON/Staff #618), who stated that staff would contact the physician if they needed clarification on an order. The DON stated that the two separate orders for Insulin Glargine should have been clarified with the physician, and that there was no evidence that the physician was contacted to clarify the order. She further stated that the pharmacy should have caught the duplicate order for Insulin Glargine. The DON (Staff #618) stated the risks to the resident by not clarifying the orders would be that the resident (#24) could receive too much Insulin Glargine and become hypoglycemic. The DON also stated that this did not meet facility expectations by not clarifying the physician's orders. The facility's policy, Pharmacy Services, Medication Management dated November 2017, indicated that the resident's medication regime will be evaluated and modified for efficacy and adverse consequences. The policy also revealed that the physician plays a key leadership role in medication management by developing, monitoring, and modifying the medication regimen in conjunction with residents, their families, and/or representatives, other professionals and direct care staff, the interdisciplinary team.

Based on observation, record review, and staff interviews, the facility failed to ensure that one resident (#43) was free from significant medication errors. The deficient practice could result in residents receiving unnecessary medications. Findings include: Resident #43 was originally admitted to the facility on [DATE] with diagnoses that included chronic obstruction pulmonary disease, type 2 diabetes mellitus, insomnia and hypertension. A care plan initiated on February 7, 2024 revealed the resident has potential for fluctuating blood glucose levels related to diabetes. Interventions included to give medication as ordered by the physician and monitor for signs and symptoms of hypoglycemia and hyperglycemia. The quarterly Minimum Data Set assessment dated [DATE] revealed the resident had cognitive skills for daily decision making as 0 indicating independence in decisions regarding tasks of daily life. During a medication administration observation conducted on October 22, 2024 at approximately 8:24 am with a Registered Nurse (RN/staff #700), the RN was observed to administer. - One Jardiance (Empagliflozin) 10mg tablet with expiration date August, 2025 and one Farxiga Oral Tablet 5 MG (Dapagliflozin Propanediol) with expiration date October, 2025, were given to resident #43. However, review of the physician's order revealed that Jardiance (Empagliflozin) 10mg tablet, was discontinued on August 28, 2024. A new order Farxiga Oral Tablet 5 mg (Dapagliflozin Propanediol), give 1 tablet by mouth in the morning were active from August 28, 2024. An Interview was conducted on October 23, 2024 at 9:04am with license practical nurse (LPN/ staff #685) and she stated that she looks at medication administration record (MAR) regarding what medication to be given to resident. Also, if medications are coming from hospital then staff verify from inhouse physician and then put in order list and on MAR. She further stated that resident #43 is a veteran and if medications come from VA hospital then we check from assistance director of nursing (ADON) and director of nursing (DON) whether medication from pharmacy or VA to continue and we don't give medication not listed in order. When asked staff #685 to pull out resident #43 blood sugar medication, she unlocked north 2 cart and showed Jardiance (Empagliflozin) 10mg tablet with expiration date August, 2025. She then looked into point click care in her computer for Jardiance order and stated that Jardiance (Empagliflozin) was discontinued and replace with Farxiga Oral Tablet 5 MG (Dapagliflozin Propanediol) and it was put on reorder by a nurse yesterday. An interview was conducted on October 23, 2024 at 10:30 am with registered nurse and she stated that resident #43 Jardiance (Empagliflozin) 10mg tablet medication was discontinued on August 28, 2024 and was started on Farxiga Oral Tablet 5 mg from August 29, 2024. She further stated that staff supposed to take out Jardiance and discard in Rx destroyer. An Interview was conducted on October 23, 2024 with director of nursing (DON/ staff # 618) who stated that we administration medication according to physician order and follow five rights including: right medication, route, patient, form (IV/oral/rectal/capsule/tablet), time (right time), and expiration. Regarding resident #43 she stated that resident was on Empagliflozin (generic is Jardiance) 10mg tablet starting September 14,2024 and ended September 28, 2024, and on Farxiga Oral Tablet 5 mg daily starting September 29, 2024 and medication is currently active. When asked during med pass, it was observed that staff #700 giving Jardiance (Empagliflozin) 10mg tablet to resident #43 then she stated that she has to go and pull out Jardiance (Empagliflozin) from medication cart and stated that staff are reading the box/cart instead of physician order. Review of the facility provided policy titled, Medication Administration, reviewed and revised on May 4, 2023 revealed that medications will be prepared and administered in accordance with prescriber's order, manufacturer's specifications (not recommendations) and accepted professional standards and principles. It further revealed that the relative significance of medication errors is a matter of professional judgement. However, three general guidelines can be used in determining is a medication error is significant or not: resident condition, drug category and frequency of error.

Based on observations, staff interviews, facility documentation, policies and procedure, the facility failed to ensure expired medications were appropriately disposed of and not available for resident use. The deficient practice could result in residents receiving expired medications. Findings include: During a medication administration observation conducted on October 22, 2024 at approximately 9:30 am with a licensed practical nurse (LPN/staff #710), the LPN were observed putting Amiodarone HCl Oral Tablet 200 MG in a small paper cup for administration. The medication was observed to be expired on on September 30, 2024. When asked regarding expired medication, she stated that she haven't looked at the expiration date and was observed taking out expired medication from cup and putting in biohazard bin. She then put medication strip bubble of Amiodarone HCl Oral Tablet with expired on September 30, 2024 back into North 1 cart drawer. An Interview was conducted on October 22, 2024 at 12:41pm with a licensed practical nurse (LPN/staff # 710), that was observed during the medication, who stated that we follow 5 rights during medication administrations including right patient, dose, route, medication and time. She also stated that we should dispense medication directly on cup and not on hand because our hands have bacteria, even if we sanitized and wash hand, we should not get into practice of touching medication while giving to patient, we should follow orders, rules, guidelines, protocol, and they are in place for reason. When asked regarding expiration medication then she stated that never give expired medication because medication has shelf-live and would be given according to shelf-life. An addition observation was conducted for medication cart North 1 on October 22, 2024 at 1:01pm revealing that expired medication Amiodarone HCl Oral Tablet 200 MG remained on the medication cart and staff #710 stated that I am sorry, we missed this medication, it should be discarded to Rx destroyer. An Interview was conducted on October 22, 2024 at 1:52 pm with a Registered Nurse (RN/staff #700), that was observed during the medication, who stated that we follow 7 rights during medication administrations including right patient name, medication, dose, reason, right documentation, time (med expiration), and route. Regarding expired medication, she stated that for blood pressure and over the counter medication, we use Rx destroyer and for narcotics, do two-person verification before destroying to Rx destroyer. She then stated that risk for giving expiration medication would be non-effectiveness, cause harm, cause rebound with BP, and mess with other medications. An Interview was conducted on October 23, 2024 with director of nursing (DON/ staff # 618) who stated that staff administration medication according to physician order and follow five rights including: right medication, route, patient, form (IV/oral/rectal/capsule/tablet), time (right time), and expiration. She further stated that during med pass, we dispense medication from bubble cart to medicine cup and it should go directly into cup and not from hand to cup else there will be potential for infection. She then stated that risk of using expiry medication would be efficacy of medication can't be effective beyond the expiration dates. Review of the facility provided policy titled, Labeling and Storage of Drugs and Biologicals, reviewed and revised on May 4, 2023 revealed that medications labelling and biological dispensed by the pharmacy must be consistent with applicable federal and state requirements and currently accepted pharmaceutical principles and practices.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure proper hand hygiene was conducted during medication administration. The deficient practice could result in contaminated medications being administered to residents. Findings: During the Medication Administration observation with the registered nurse (RN/ staff #700) on October 22, 2024 at 7:56 a.m., for resident #426, the RN dispense following tablets from med strip bubble to her bare hand and then to the small plastic cup placed on north 2 cart. - metFORMIN HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth two times a day for Diabetes management - Cholecalciferol Tablet 1000 UNIT Give 1 tablet by mouth one time a day for Supplement During the Medication Administration observation with the registered nurse (RN/ staff #700) on October 22, 2024 at 8:08 a.m., for resident #49, the RN dispense following tablets from med strip bubble to her bare hand and then to the small plastic cup placed on north 2 cart. - Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) Give 3 tablet by mouth one time a day for PTSD - ARIPiprazole Oral Tablet 2 MG (Aripiprazole) Give 1 tablet by mouth two times a day for PTSD During the Medication Administration observation with the registered nurse (RN/ staff #700) on October 22, 2024 at 8:24 a.m., for resident #43, the RN dispense following tablets from med strip bubble to her bare hand and then to the small plastic cup placed on north 2 cart. - busPIRone HCl Oral Tablet (Buspirone HCl) Give 10 mg by mouth three times a day for anxiety AEB restlessness - Memantine HCl Oral Tablet 10 MG (Memantine HCl) Give 1 tablet by mouth every 12 hours for dementia aeb confusion and impulsive behaviors - Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth two times a day for NUEROPATHY - Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) Give 1 tablet by mouth three times a day for Parkinson - Aspirin 81 Oral Tablet Chewable (Aspirin) Give 1 tablet by mouth one time a day for DVT PPX - Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 25 mg by mouth one time a day for HTN: hold for SBP<110 or HR<60 - Farxiga Oral Tablet 5 MG (Dapagliflozin Propanediol) Give 1 tablet by mouth in the morning - Jardiance (Empagliflozin) 10mg tablet with expiration date August, 2025 - AmLODIPine Besylate Tablet 5 MG Give 1 tablet by mouth one time a day for HTN hold for SBP <110 HR <60 - Hydroxyurea Oral Capsule 500 MG (Hydroxyurea) Give 1 capsule by mouth every 12 hours for thrombocytopenia. An Interview was conducted on October 22, 2024 at 12:41pm with a licensed practical nurse (LPN/staff # 710), that was observed during the medication, who stated that we follow 5 rights during medication administrations including right patient, dose, route, medication and time. She also stated that we should dispense medication directly on cup and not on hand because our hands have bacteria, even if we sanitized and wash hand, we should not get into practice of touching medication while giving to patient, we should follow orders, rules, guidelines, protocol, and they are in place for reason. An Interview was conducted on October 22, 2024 at 1:52 pm with a Registered Nurse (RN/staff #700), that was observed during the medication, who stated that we follow 7 rights during medication administrations including right patient name, medication, dose, reason, right documentation, time (med expiration), and route. She further stated that during medication administration, we use bubble method to dispense medication directly to cup from medication strip, where you don't touch medication, you pop up directly into cup without touching it because touching medication directly can cause cross contamination, cause infection and if you touch medication with hand then there is a chance of observing medication to your skin the effect of drug. An Interview was conducted on October 23, 2024 with director of nursing (DON/ staff # 618) who stated that we administration medication according to physician order and follow five rights including: right medication, route, patient, form (IV/oral/rectal/capsule/tablet), time (right time), and expiration. She further stated that during med pass, we dispense medication from bubble cart to medicine cup and it should go directly into cup and not from hand to cup else there will be potential for infection. Review of the facility provided policy titled, Medication Administration, reviewed and revised on May 4, 2023 revealed that staff will observe infection prevention practices during the administration of medications.

Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure that care and services were provided to prevent the development of a pressure ulcer for one resident (#14). Findings include: Resident #14 was admitted to the facility on (MONTH) 19, (YEAR) and readmitted on (MONTH) 5, (YEAR). [DIAGNOSES REDACTED]. A Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 5, (YEAR) revealed a score of 14, which indicated the resident was at moderate risk for pressure ulcer development. The Admit/Readmit Screener dated (MONTH) 5, (YEAR) included the resident had a stage 2 pressure ulcer on the coccyx and did not utilize any devices which may effect skin integrity. The documentation did not include that the resident had a pressure ulcer to the left calf area. Review of a wound assessment dated (MONTH) 5, (YEAR) completed by the Assistant Director of Nursing (RN/staff #162), identified an unstageable pressure ulcer located on the resident's coccyx and a stage 2 pressure ulcer located on the right ischial tuberosity. The documentation did not include that the resident had a pressure ulcer to the left calf area. Review of the skin care plan dated (MONTH) 5, (YEAR) revealed the resident was at risk for skin impairment, related to an unstageable pressure ulcer to the sacrum and due to the use of a leg brace. The goal included for the resident to have improved skin integrity by participating in rehab and using preventative skin treatments. Interventions included the following: administer wound treatments, check skin underneath brace and report to MD for changes in skin integrity, consult with wound physician or wound clinician as necessary, observe skin during routine care and report changes, and review skin weekly or when changes occur. The admission physician orders [REDACTED]. The orders also included for physiatry and for occupational and physical therapy evaluations and treatment. The admission orders [REDACTED]. Review of the Physical Therapy Evaluation and Plan of Treatment dated (MONTH) 6, (YEAR) revealed the following precaution: weight bearing as tolerated, with knee immobilizer on left leg. A Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 12, (YEAR) revealed a score of 14, indicating the resident was at moderate risk for pressure ulcer development. According to the admission Minimum Data Set (MDS) assessment dated (MONTH) 12, (YEAR), the resident had a BIMS (Brief Interview for Mental Status) score of 12, which indicated moderate cognitive impairment. The MDS also identified that the resident required extensive assistance of 2 or more persons with bed mobility, transfers, toileting and dressing, and required extensive assistance of one with locomotion on and off the unit. The MDS assessment also indicated the presence of one stage 2 pressure ulcer and one unstageable pressure ulcer, which were both present on admission. Per the MDS, the care area for pressure ulcers triggered and included to proceed with care planning. Review of the clinical record revealed there were no weekly skin checks or any documentation regarding the condition of resident #14's skin under the knee immobilizer from (MONTH) 6, through (MONTH) 16, (YEAR). According to a nurse practitioner note dated (MONTH) 17, (YEAR), the resident was seen this morning by the wound care team. The resident just completed her shower, so they were able to view her wounds, while she was standing. The note included that the resident had a right buttock stage 2 pressure ulcer and an unstageable pressure ulcer to the sacrum. There was no documentation that the resident had a pressure ulcer to the left leg. A daily skilled nursing note dated (MONTH) 18, (YEAR) at 9:54 p.m., now documented that the resident had an unstageable pressure ulcer on the left lower calf. The note did not include a description of the wound bed and there were no measurements. Further review of the clinical record revealed there was no documentation that the physician was notified of the unstageable pressure ulcer, nor any orders for treatment on (MONTH) 18. A nurse's note dated (MONTH) 19, (YEAR) revealed the resident had a wound on the left lower extremity calf, underneath the brace. A new treatment had been put in place as well as new orders to check the skin under the brace every shift, and for the brace to be off at night. Review of a wound assessment dated (MONTH) 19, (YEAR) at 11:05 a.m. revealed a new unstageable pressure wound was located on the resident's left calf. The wound bed was described as having 100% eschar, and surrounding skin was intact. There was no documentation of any measurements of the pressure ulcer. Review of the physician orders [REDACTED]. Monitor for any signs/symptoms of infection every day shift to the left lower extremity. A care plan for the left lower calf unstageable pressure ulcer revealed a goal that the resident would not develop further skin breakdown through the next review date. Interventions initiated on (MONTH) 19, (YEAR) included to consult the Durable Medical Equipment provider to ensure proper fit of the leg brace, and to float heels while resident is in bed and as she allows. Review of the wound assessment dated (MONTH) 24, (YEAR) revealed the resident had an unstageable pressure ulcer to the left calf. The documentation included the wound measured 2.9 cm x 1.5 cm (this was the first documentation of any measurements), the wound bed was described as having 100% eschar and the surrounding skin was intact. An observation was conducted on (MONTH) 1, (YEAR) at 9:36 a.m. of the resident sitting in a wheelchair. The resident's left leg had a knee immobilizer in place, which extended from her mid-thigh to below her calf. At this time, the resident stated that she had a wound on her left leg from the splint on her leg. An interview with a Physical Therapist (PT/staff #119) was conducted on (MONTH) 3, (YEAR) at 11:05 a.m. The therapist stated that she did the initial physical therapy evaluation on resident #14 and that the resident came from the hospital, with the immobilizer. Staff #119 stated that she did not see the problem on the resident's leg until it was reported to her by nursing. She said that as soon as the wound was discovered, the therapist contacted the prosthetics company who modified the knee immobilizer by flaring the lower end, and applied lamb's wool to reduce the pressure to the area. She also stated that therapy educated the nursing staff on how to loosen the lower end of the immobilizer. In an interview with a Licensed Practical Nurse (LPN/staff #147) on (MONTH) 3, (YEAR) at 11:10 a.m., she stated that the night nurse identified the wound. She stated that the process when a wound is discovered is that the nurse notifies the care manager, the MDS nurse and the physician. She stated that the care manager then notifies the wound nurse and others. She said the nurses are to do weekly skin checks, which are recorded in the electronic record. Staff #147 stated that when resident #14 was admitted , staff only took the immobilizer off when she was showered. She stated the nurses were under the impression that the resident was to wear the brace at all times. Staff #147 stated that when the wound was discovered, the nurses verified the orders with the orthopedic physician regarding when to remove the immobilizer. An observation of wound care was conducted on (MONTH) 3, (YEAR) at 12:25 p.m. The wound care was performed by staff #147 and assisted by a Registered Nurse. The wound bed on the resident's left lower calf was observed to be obscured with slough and the wound measurements were 3.0 x 1.2 cm. During the procedure, it was observed that there was lamb's wool on the interior surface of the knee immobilizer. According to the wound assessment dated (MONTH) 3, (YEAR), the wound bed was described as having 90% slough and measured 3.0 x 1.2 cm, with surrounding skin intact. An interview with a certified nursing assistant (CNA/staff #170) was conducted on (MONTH) 3, (YEAR) at 2:07 p.m. She stated that there is a sheet on the inside of the closet door which informs the CNAs of the resident's care needs regarding transfers, hygiene, and other care. She said she will also get information from the nurse before giving care to someone. She stated that CNAs are responsible for putting on the leg brace when getting the resident out of bed and taking it off when putting her back to bed. She stated that if she were to notice a new sore, or even a red area that wasn't there before, she would notify the nurse immediately. In an interview conducted with the Director of Nursing (DON/staff #224) on (MONTH) 3, (YEAR) at 2:44 p.m., the DON stated that on admission the nurses should complete a skin check, report any pressure ulcers, complete a Braden Scale for Pressure Ulcer Risk and put appropriate precautions in place, such as obtaining a low air loss mattress order, floating the resident's heels and complete a wound assessment. She stated that routinely the CNAs will notify the nurse if they observe skin problems or changes, and the nurse will get an RN to assess the skin. Staff #224 stated that if a resident was admitted with a brace, she would expect that skin checks under the brace would be included in the care plan and that there would be orders to remove or not remove the brace. Review of a policy titled, Pressure Ulcer/Injury Risk Assessment revealed that the purpose was to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries. Once the risk assessment is completed and risk factors are identified, a resident centered care plan should be created to address the risks for developing pressure ulcers. The policy included to conduct a comprehensive skin assessment and document the findings on the skin assessment tool. If a new skin alteration is noted, initiate a form related to the type of alteration in skin (pressure or non-pressure). The policy also stated to develop the resident centered care plan and interventions based on the risk factors identified in the assessment, the condition of the skin, the resident's overall condition and goals. The effects of the interventions must be evaluated. The care plan must be modified as the resident's condition changes or if current interventions are deemed inadequate. The policy also stated that the information obtained should be recorded in the resident's medical record, including the condition of the resident's skin (size and location of any red or tender areas) that are identified. If a new skin issue is identified, there should be documentation in the medical record that the physician was notified and a change in the plan of care if indicated. A review of the Skin Impairment - Documentation and Monitoring Flow policy revealed the following steps to be completed upon admission: complete an admission skin assessment and identify any devices in use (brace, splint, etc.); complete an initial wound evaluation; obtain treatment orders from physician and obtain skin care orders when using devices, notify wound care nurse, and initiate care plan with preventative measures. Steps that were to be done weekly included the following: wound nurse to conduct wound rounds and measure wound and complete weekly wound evaluations; obtain wound MD consult if available; obtain recommendations from other disciplines; update care plan; ensure attending physician addresses wound in progress notes; notify MD of changes and ensure treatment is done as ordered. This policy also included to ensure accurate description and staging of the wound; obtain a treatment order that is appropriate to the type of wound, ensure all documentation matches (i.e. location of wound and staging) on the weekly skin checks, on the wound reviews, on the care plan and the treatment orders. A review of a facility policy titled, Prevention of Pressure Ulcers/Injuries revealed the purpose was to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. The policy included to review the resident's care plan and identify risk factors, as well as the interventions designed to reduce or eliminate those risk factors. Assess the resident on admission for existing pressure ulcer/injury risk factors and repeat the risk assessment weekly and upon any changes in condition. The policy further included to conduct a comprehensive skin assessment upon admission which includes: a. skin integrity-any evidence of existing or developing pressure ulcers or injuries; b. tissue tolerance-the ability of the skin to endure the effects of pressure; c. areas of impaired circulation due to pressure from positioning or medical devices. In addition, the policy stated to inspect the skin daily when performing or assisting with care as follows: a. identify any signs of developing pressure injuries (i.e. nonblanchable [DIAGNOSES REDACTED]); b. inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). Evaluate, report and document changes in the skin and review the interventions and strategies for effectiveness on an ongoing basis.