Every finding on record at Sunview Respiratory and Rehabilitation

Based on resident and staff interviews, facility documentation and policy review, the facility failed to ensure there was sufficient staff to meet the needs of the residents. The deficient practice could result in residents not receiving appropriate care and treatment that they need. Number of residents sampled: 104.Findings include:The PBJ (Payroll-Based Journal) Staffing Data Report revealed that the facility consistently triggered for excessively low weekend staffing for all three quarters in 2025 and, the 1st quarter of 2026. Per the report, submitted weekend staffing data was excessively low.The facility assessment reviewed on May 7, 2026 revealed that the facility was licensed to provide care for 127 residents, had an average daily census of 108. Average census for short stay residents is 13, for long-stay residents is 117, including an average of 30-40 residents with vent/trach and/or dialysis needs, and the facility averages 65 admission and discharge per month.Reviewed the facility assessment staffing plan and it included the following:-Full time Director of nursing (DON)-Full time Licensed Practical Nurse Assistant Director of Nursing-Full time night shift Unit Manager Post-Acute Rehabilitation Supervisor-Full Time Nursing Assistant (CNA)-Restorative Certified Nursing Assistant (CNA) up to two and half full days-Registered Nurse/Licensed Practical Nurse (RN/LPN) post-acute 6AM-6PM: up to 6- Registered Nurse/Licensed Practical Nurse (RN/LPN) post-acute 6PM-6AM: up to 6-Registered Nurse/Licensed Practical Nurse (RN/LPN) post-acute 6AM-6PM: up to 1- Registered Nurse/Licensed Practical Nurse (RN/LPN) post-acute 6PM-6AM: up to 1-Certified Nursing Assistant (CNA) 6AM-6PM: up to 12-Certified Nursing Assistant (CNA) 6pm-6am: up to 10Reviewed the staff schedule, and based on the review, there were three units in the facility (Canyon, Central, and [NAME]), and the shifts are 6AM-6PM, and 6PM-6AM. Reviewed assignment sheet, Daily Posting, and Punch details of the first quarter of the PBJ (Payroll-Based Journal) from October 1, 2025 through December 31, 2025.On October 24, 2025, Daily Posting revealed that the census was 102, and there were a total of 14 RN/LPN, and 18 CNAs. The daily posting revealed 384 total hours between nursing and CNA staff.6AM-6PM: Canyon: Two RNs/LPNs, Four CNAs6AM-6PM: Central: One RNS/LPN, Two CNAs6AM-6PM: [NAME]: Three RNs/LPNs, Five CNAs6PM-6AM: Canyon: Three RNs/LPNs, Three CNAs6PM-6AM: Central: One RNs/LPNs, Three CNAs6PM-6AM: [NAME]: Three RNs/LPNs, Three CNAsReview of the Punch-Details for October 24, 2025 revealed that there were 135.75 hours for RN/LPN total, and 181.56 hours for CNA.On October 25, 2025, Daily Posting revealed that the census was 101, and there were a total of 14 RN/LPN, and 19 CNAs. The daily posting revealed 396 total hours between nursing and CNA staff.6AM-6PM: Canyon: Two RNs/LPNs, Four CNAs6AM-6PM: Central: One RNS/LPN, Two CNAs6AM-6PM: [NAME]: Three RNs/LPNs, Five CNAs6PM-6AM: Canyon: Three RNs/LPNs, Three CNAs6PM-6AM: Central: One RNs/LPNs, Three CNAs6PM-6AM: [NAME]: Three RNs/LPNs, Three CNAsReview of the Punch-Details for October 25, 2025 revealed that there were 135.75 hours for RN/LPN total, and 181.56 hours for CNA.On October 26, 2025, Daily Posting revealed that the census was 99, and there were a total of 14 RN/LPN, and 18 CNAs. The daily posting revealed 384 total hours between nursing and CNA staff.6AM-6PM: Canyon: Three RNs/LPNs, Four CNAs6AM-6PM: Central: One RNS/LPN, Two CNAs6AM-6PM: [NAME]: Three RNs/LPNs, Five CNAs6PM-6AM: Canyon: Three RNs/LPNs, Three CNAs6PM-6AM: Central: One RNs/LPNs, One CNAs6PM-6AM: [NAME]: Three RNs/LPNs, Three CNAsReview of the Punch-Details for October 26, 2025 revealed that there was 79 hours for RN/LPN total, and 117.34 hours for CNA.Reviewed assignment sheet, Daily Posting, and Punch-in details of the second quarter of the PBJ (Payroll-Based Journal) from January 3, 2025 through January 5, 2025.On January 3, 2025, assignment sheet revealed the following assignments:6AM-6PM: Canyon: Three RNs/LPNs, Four CNAs6AM-6PM: Central: One RNS/LPN, Two CNAs6AM-6PM: [NAME]: Three RNs/LPNs, Four CNAs6PM-6AM: Canyon: Three RNs/LPNs, Three CNAs6PM-6AM: Central: One RNs/LPNs, Two CNAs6PM-6AM: [NAME]: Three RNs/LPNs, Three CNAsReview of the Punch-Details for January 3, 2025 through January 5, 2025 revealed that there was 42.19 hours for RN/LPN total, and 178 hours for CNA.On January 4, 2025, Daily Posting revealed that there were a total of 14 RN/LPN and 18 CNAs. The daily posting revealed 380 total hours between nursing and CNA staff.The assignment sheet revealed:6AM-6PM: Canyon: Three RNs/LPNs, Four CNAs6AM-6PM: Central: One RNS/LPN, Two CNAs6AM-6PM: [NAME]: Three RNs/LPNs, Four CNAs6PM-6AM: Canyon: Three RNs/LPNs, Three CNAs6PM-6AM: Central: One RNs/LPNs, Two CNAs6PM-6AM: [NAME]: Three RNs/LPNs, Three CNAsReview of the Punch-Details for January 4, 2025 revealed that there was 63.57 hours for RN/LPN total, and 175 hours for CNAOn January 5, 2025, Daily Posting revealed that there were a total of 14 RN/LPN and 18 CNAs. The daily posting revealed 386 total hours between nursing and CNA staff.Review of the assignment sheet for January 5, 2026 revealed:6AM-6PM: Canyon: Three RNs/LPNs, Four CNAs6AM-6PM: Central: One RNS/LPN, Two CNAs6AM-6PM: [NAME]: Three RNs/LPNs, Four CNAs6PM-6AM: Canyon: Three RNs/LPNs, Three CNAs6PM-6AM: Central: One RNs/LPNs, Two CNAs6PM-6AM: [NAME]: Three RNs/LPNs, Three CNAsReview of the Punch-Details for January 5, 2025 revealed that there were 65.76 hours for RN/LPN total, and 210.44 hours for CNA.During resident interviews conducted during the initial pool on May 5, 2026, several residents who were alert and oriented reported experiencing long wait times before receiving the assistance they needed. One male resident mentioned that he often had to wait up to an hour a couple of times a week for help and noted that there was no specific day or time when this problem was more common. A male resident shared that he had to wait 40 to 50 minutes for assistance, explaining that the staff was supposed to change him at 5:00 a.m. that morning but was unable to do so. As a result, he ended up wet, including his bed sheets. A female resident reported waiting an hour for the assistance she needed, which prompted her to request a bedside commode to avoid soiling herself. Additionally, a female resident pointed out that the facility tends to be short-staffed on weekends.In an interview with an alert and oriented male resident conducted on May 6, 2026 at 11:19 a.m., he stated that sometimes staff takes a long time to respond the room; and that the facility was short-staff yesterday (May 5, 2026). He stated that yesterday (May 5, 2025) staff was doing a bed change and moved him out of bed. He said that it took a long time for staff to change the bed.On May 7, 2026, 1:06 PM., Resident (resident #49), who reported that the facility is always short of staff, especially on weekends. She added that she requires total assistance with her care, and every time she pushes her call light it takes at least an hour for the staff to answer. The resident said that even if the staff answer her call light, the staff will just turn her call light off and tell her that they will be back because they are with another resident.On May 5, 2026 at 3:06 PM, during an interview with resident #148, she stated that between 4:00 PM to 6:00 PM dinner, staff all go to the dining room, and no one is assigned to work on the floor to answer call lights. During the resident interview, a family member(daughter) was visiting the resident. The daughter stated that she had witnessed no staff to be available. The daughter added that when she calls her mom (resident #148), the resident complains about not enough staff available on the floor.During an interview on May 7, 2026 at 2:39 PM, a Certified Nursing Assistant CNA (staff #80), mentioned that the facility often faces staffing shortages. She noted that each of the three units normally has two CNAs and one nurse, even on weekends. She mentioned that staff members usually support each other; so if one unit is short a CNA, the less busy unit often helps out.An interview with a Licensed Practical Nurse (staff #68), conducted on April 8, 2025, at 10:35 a.m., revealed that staffing levels were determined based on the facility census. She explained that staffing ratios remained consistent for both weekdays and weekends. She shared that regular shifts run from 6 am to 6 pm and 6 pm to 6 am, with three units in the facility. Typically, each shift includes one nurse and two CNAs per unit.During an interview with the staffing coordinator (staff #147), on May 8, 2025, at 9:23 a.m., the staffing coordinator stated that staffing ratios are based on resident census. She added that each of the three units typically has two CNAs and one nurse per shift, and that CNAs are generally good at assisting one another with their tasks. She clarified that she isn't directly involved with submitting staffing data to CMS, as the facility's corporate office manages this. Overall, she stated that the facility has enough staff to meet residents' care needs.During an interview with the Director of Nursing (staff #97), on May 8, 2026, at 10:46 a.m., she clarified that she wasn't working at the facility during 2025 but has been there since January 2026. She mentioned that the staffing data reported to CMS for the quarterly PBJ reports is pulled directly from their payroll software, which tracks who worked and the hours worked each day. The DON stated the risks of sufficient staffing in the facility, could significantly increase the likelihood of bedsores, falls, missed medications, and also degrades facility ratings and exacerbates burnout among existing staff.Review of the facility policy titled, Sufficient Staff, revealed that it is the policy of this facility to have sufficient nursing staff with the appropriate competencies and skillsets to provide nursing and related services to promote resident safety and attain or maintain the highest practicable mental, psychosocial well-being of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment.

Based on observations, staff interviews, review of records and facility policy, the facility failed to ensure expired medications were discarded for 1 (Resident #109) of 104 residents. The deficient practice could result in adverse drug reactions.Findings include:Resident #109 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included: seizures, atrial fibrillation, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, acute respiratory failure with hypoxia, and hypertensive heart disease without heart failure.The order summary revealed an order dated September 9, 2025 for Ativan Solution 2 MG/ML (Lorazepam) with instructions to inject 1 ml intramuscularly every 6 hours as needed for seizure activity. Further review of the order summary revealed an order status of discontinued with no end date indicated.During an observation of the Central Section medication storage room on May 7, 2026, at approximately 10:57 a.m., the following medication was found to be stored past expiration: - 1 vial of Lorazepam, expiration date December, 2025, located in the medication storage refrigerator, inside the controlled medications lock box.An interview was conducted on May 7, 2026 at approximately 11:04 a.m., with Licensed Practical Nurse (LPN/Staff #9). Staff #9 stated that expiration date of the Ativan Solution was December, 2025. Staff #9 further stated that the risk associated with storing expired medications is that the composition changes and that it could be too potent or not strong enough, depending on the medication.An interview was conducted on May 7, 2026 at approximately 12:32 p.m., with Licensed Practical Nurse (LPN/Staff #11). Staff #11 stated that the expected time frame for disposal of expired medications is as soon as it is noticed. Additionally, Staff #11 reported that they are not trained on the removal of expired medications. Further, Staff #11 stated that expired medications should not be left in medication storage and the expectation is that another nurse would verify the expiration date, and log it in the controlled substances binder. Staff #11 then stated the potential risk depends on the medication, but that the potential harm would be an adverse or reduced effect depending on the medication and patient.An interview was conducted on May 7, 2026 at approximately 12:49 p.m., with Licensed Practical Nurse (LPN/Staff #86). Staff #86 stated that expired medications should not be kept in medications storage. Additionally, Staff #86 stated the expectation for disposing of expired medications was that staff should make sure they are checking dates and not giving expired medications. Staff #86 further stated if they find expired medications, staff are to dispose of them and make sure they have up to date medications. Further, Staff #86 revealed that the potential risk would be that someone might use it and it could affect the patient with side effects and adverse reactions.An interview was conducted on May 7, 2026 at approximately 1:16 p.m., with the Director of Nursing (DON/Staff #97). Staff #97 revealed that there isn't a routine cadence if an expired medication is found, and that staff bring it to her, they verify the amount together and they would 'waste' it with another Registered Nurse, and then scan the paper into medical records. Additionally, Staff #97 stated that they do not have an expected time frame for expired medication disposal. Further, Staff #97 stated that facility staff 'routinely' audit the medical storage rooms. When asked if expired medications should be left in medication storage, Staff #97 stated that nursing would have never administered the medication and that it would have been brought to her. She further stated that the expectation regarding expired medication was that staff identify the expired medication and that they immediately bring them to her.Review of the facility policy titled, Medication Access and Storage, revised June 2025, revealed that facility policy states in procedure 11, that outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists.Review of the policy titled, Medication, Destruction of, revised January 2025, revealed that facility policy states in Key Procedure Point 1, that medications not returned to the Pharmacy for credit will be destroyed following receiving a physician's order discontinuing its use, the resident's discharge, the resident's death or passage of its expiration date. Additionally, Procedure 1 states that discontinued drugs will be destroyed following discontinuance or after discharge, licensed staff of non-liquid drugs, and that all scheduled/legend drugs will be destroyed by two personnel licensed or registered in the health field.

Based on interviews and record review the facility failed to implement policies and procedures to prohibit and prevent abuse for one resident (R)444 when (1) Staff failed to identify non consensual sexual acts between R444 and R3 as sexual abuse; (2) Report the abuse within the time frame required by State law and federal requirements; and, (3) Conduct a thorough investigation. The failure of the facility to recognize non consensual sexual acts between minors and adults has the potential to put all minors in the facility at risk for serious psychosocial harm such as post traumatic stress disorder or psychological trauma. As a result, the situation of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified.An immediate jeopardy was called in the presence of the Administrator, Clinical Resource (staff #315) and Director of Operations (staff #316) were notified of the Immediate Jeopardy on April 3, 2025 at 12:08 p.m.The facility's removal plan was accepted on April 3, 2026 at 5:29 p.m. and included the following actions taken:In-house review, assessment and checking against the Sex Offender Registry of their current residents;In-service training of all staff on Recognizing/Identifying, reporting, responding and implementing interventions for allegations abuse and neglect, EJA (Elder Justice Act), Recognizing/identifying inappropriate behaviors and Actions to take; and, Resident Rights; Review of current protocols for minors and justice involved residents admitted at the facility; Interviews conducted with all current interviewable residents regarding abuse;Review of their Grievance logs to identify any complaints from residents related to any inappropriate behaviors of staff and/or other residents.Multiple observations were conducted on April 3, 2026 and revealed the facility implementing their action plan to include conducting inservice training on recognizing/Identifying, reporting, responding and implementing interventions for allegations abuse and neglect, EJA (Elder Justice Act), recognizing/identifying inappropriate behaviors and Actions to take; and, Resident Rights with sign-in sheets of their staff, monitoring residents for inappropriate behaviors every shift and records of quiz on abuse completed by staff.Interviews with multiple staff were conducted on April 3, 2026 revealed that staff verbalized their understanding on how to identify/recognize abuse and inappropriate behaviors, what to do when they see or hear allegations of abuse or inappropriate behaviors, and actions to take to intervene/mitigate the situation. On April 3, 2026 at 6:35 p.m., IJ was removed but noncompliance remained at the lower scope and severity of isolated, actual harm that is not immediate. Findings include:A facility self-report dated May 19, 2025 submitted to the State Agency (SA) by the former Director of Nursing (DON/Staff #66) revealed that on May 19, 2025, a staff member overheard Resident #444 made a statement that suggested he received sexual acts from Resident #3. According to the report, both residents were determined to be cognitively intact and had a BIMS score of 15; and that, during separate interviews, each resident acknowledged the encounter, asserted it was consensual, and that it occurred on May 18, 2025. Further, the report included that staff had previously witnessed residents #444 and #3 together but reported that there was no inappropriate behavior at that time. The report revealed the police were notified and appropriate reporting to state regulatory authorities was completed. The report did not identify Resident #444 as a minor. -Resident #444 (alleged victim/minor) was admitted to the facility on [DATE], with diagnoses of traumatic brain injury, attention deficit hyperactivity disorder (ADHD), anxiety and depression. Review of the clinical record indicated that the resident was alert and oriented; however, all decisions and consents for Resident #444 were made by the resident's legal guardian/parent. A care plan dated May 13, 2025 revealed Resident #444 was at risk for impaired cognitive function or impaired thought process due to recent hospitalization. Interventions included the resident needed supervision/assistance with all decision making, and to include resident-centered behavioral interventions. A daily skilled note dated May 18, 2025 at 10:16 p.m. revealed the resident was alert and oriented x 4 and had no active behavioral symptoms. A BIMS (Brief Interview for Mental Status) assessment dated [DATE] revealed Resident #444 had a score of 15 indicating intact cognition. A nursing note dated May 19, 2025 included that Resident #444 was placed on change of condition (COC) monitoring for psychosocial wellbeing for a reported event; and that, the resident, family, case manager, and provider were notified. A care plan initiated May 19, 2025 revealed Resident #444 had a potential for a psychosocial well-being problem due to a reported event. Interventions included for 1:1 staff initiated on May 19, 2025. However, there was no evidence found in the clinical record that interventions to protect Resident #444 from further abuse was put in place on May 18, 2025, the date the incident happened. A nursing note dated May 20, 2025 included the decision was to discharge Resident #444 back to the acute care hospital based on the family's request. A Nursing Home to Hospital Transfer Form revealed Resident #444 was transferred to acute hospital on May 20, 2025, for a pediatric psychiatric evaluation. -Resident #3 (alleged perpetrator) was admitted on [DATE] with diagnoses of ADHD, schizophrenia, and mood disorder. A care plan initiated May 10, 2025 revealed Resident #3 was at risk for impaired cognitive function or impaired thought process due to new environment, mental illness, and recent hospitalization. Interventions included to monitor, document, and report to the physician any changes in cognitive function, decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. The nursing note dated May 19, 2025 revealed Resident #3 was placed on COC monitoring for psychosocial well-being for a reported event. A care plan initiated May 19, 2025 included that Resident #3 had potential for a psychosocial well-being problem due to a reported event. Interventions included for a psychiatric evaluation on May 19, 2025. The psychiatric provider note dated May 19, 2025, at 7:15 p.m. revealed that according to staff, Resident #3 had increased anxiety with pacing and worrying; and that, the resident reported increased anxiety about a recent event, but did not wish to discuss the details of the event. The documentation also included that the resident reported having feelings of excess worrying and nervousness. Diagnosis included anxiety. The police report shows the incident was reported on May 19, 2025, at 6:49 p.m., which is nearly 24 hours after it happened on May 18, 2025. The call was classified as a sexual assault of a minor. The report synopsis revealed that on May 18, 2025, at approximately 9:00 p.m., Resident #3 sexually assaulted Resident #444 while at the facility. The police report included a witness statement from a Licensed Practical Nurse (LPN/staff #312) who reported she often observed Resident #444 and Resident #3 hanging out together and talking at the facility for approximately a week before the incident. The LPN reported that on May 18, 2025 at approximately 9:00 p.m., she went to utilize the mirror in another resident's room and opened the closed door. The LPN reported that she saw Resident #3 positioned on her knees, with Resident #444 in the bathroom. The LPN reported that she informed her supervisor of the incident; and, Resident #3 was placed in a separate wing of the facility. The police report revealed a statement from Resident #3 who reported that both Resident #3 and Resident #444 went into the bathroom in another resident's room; and that, Resident #3 reported that she performed oral sex for approximately 2 minutes on Resident #444, who had asked for it. The report also included that Resident #3 reported knowing how old Resident #444 was prior to engaging in sexual acts in the restroom. Further, the police report revealed Resident #444 reported he and Resident #3 were watching a movie in another resident's room. According to the report, Resident #444 asked Resident #3 for oral sex, proceeded to the bathroom, closed the door, and then Resident #3 conducted oral sex. Further, the police report revealed that the offense for Resident #3 included 1 count of completed statutory rape and sexual conduct with minor. A facility 5-day investigation report was signed by the former DON (Staff #66) and dated May 21, 2025 submitted to the State Agency revealed that on or about May 19, 2025 at approximately 6:15 p.m., Resident #444 who was alert and oriented to person, place, time, and event was overheard by a staff making statements that he allegedly had received sexual acts from Resident #3. According to the report, a comprehensive investigation was immediately initiated; and, both Residents #444 and #3 were instructed to refrain from spending time together or having any physical contact to mitigate the risk of further occurrence. It also included that visual safety monitoring was implemented for both residents while the investigation was ongoing. According to the report, both residents were determined to be cognitively intact and had a BIMS score of 15. The report revealed that an interview was conducted on May 19, 2025 at approximately 6:26 p.m. with Resident #444 who confirmed that a sexual encounter occurred between and mutually consented by him and Resident #3. Per the documentation, Resident #444 reported that the incident occurred one time on May 18, 2025, and was interrupted by staff; and that, both Resident #444 and Resident #3 put their clothes on before staff entered the restroom. Continued review of the facility 5-day investigation revealed an interview was conducted on May 19, 2025 at 6:45 p.m. with Resident #3 who initially denied any incident; however, retracted and acknowledged that she and Resident #444 voluntarily engaged in the act; and that, Resident #444 requested for it. Per the documentation, Resident #3 reported that the encounter was interrupted by a staff. Further review of the facility investigation revealed an interview conducted on May 18, 2025 with the nurse on duty (LPN/Staff #312), who stated she observed Residents #444 and #3 together in one of the resident rooms, but, there was no inappropriate behavior noted at that time. The LPN reported that both residents reported that they were watching videos together and denied any misconduct; and, both were directed to return to their respective rooms. The report concluded that the facility was unable to substantiate that abuse occurred, and the incident occurred between two consenting individuals. Despite knowledge of Resident #444's minor status, the facility failed to include this information in its initial and 5-day reports to the State Agency. Moreover, the facility did not identify the incident between Resident #444 and Resident #3 as sexual abuse, instead describing it as an encounter between consenting individuals. The facility failed to initiate a thorough investigation; specifically, it did not interview the resident who was allegedly present in the room while the residents #444 and #3 were in the bathroom, nor did it interview other residents—particularly those identified as minors and admitted at the time. Additionally, the facility did not review all relevant circumstances surrounding the event, including how the incident may have occurred, as required by its policy. The facility's report included a list of staff members and residents who were interviewed; and, all staff interviewed reported not seeing or hearing any incident. The report did not indicate what the interviewed residents had seen or heard. Further, the report did not include any interview or a written statement from the nurse (staff #312) who entered the room and found Residents #444 and #3 on the night of the incident. The facility investigation also did not include appropriate corrective actions taken to protect residents from possible abuse such as assessment and monitoring of other residents at risk, and any interventions/supervision put in place to protect other residents at risk. There was no evidence found that the facility reported this incident to DCS (Department of Child Services) despite knowing that Resident #444 was identified as a minor. The APS (Adult Protective Services) investigative report dated August 19, 2025, revealed that the allegation against the facility was neglect of a vulnerable adult, identified as Resident #3, and that the allegation was verified. The report revealed that Resident #3 was identified as a vulnerable adult due to having serious mental illness (SMI); and that, Resident #3 sexually assaulted Resident #444 while at the facility, and the case was verified because the sexual assault occurred. A phone interview with the legal guardian/family of Resident #444 was conducted on March 3, 2026, at 10:42 a.m. The legal guardian/family stated that she was the legal guardian of Resident #444 at the time of the incident; and that, a facility staff called and informed her several days before the incident that Resident #444 had developed an inappropriate relationship with another resident. She stated that approximately two days after the initial phone call, staff called and informed her that there was an incident where a staff member caught Resident #444 receiving oral sex from another resident. She stated that Resident #444 should have been under staff supervision and all staff should have been aware that Resident #444 was a minor and required supervision; but that, the facility did not do an adequate job protecting Resident #444. Further, the legal guardian stated that Resident #444 had a negative psychosocial impact as a result of the incident that occurred. A phone interview was conducted with an LPN (Staff #179) on March 3, 2026, at 9:57 a.m. The LPN stated that prior to the incident, Resident #3 and Resident #444 were hanging out together a lot, and that staff had warned Resident #3 that Resident #444 was a minor. The LPN further stated that after the incident, Resident #444 told staff that Resident #3 had performed oral sex on him. An interview with the social services supervisor (SS/Staff #254) was conducted on March 3, 2026, at 2:28 p.m. Staff #254 stated that a pediatric resident can make simple choices such as food, clothing, and activity choices; however, healthcare decisions and consent would be obtained from the resident's parent or legal guardian. Staff #254 stated that it was inappropriate and was illegal for an adult resident and a pediatric/minor resident to have a sexual relationship while at the facility. Further, Staff #254 stated that she was not sure what supervision measures the facility implemented for pediatric/minor residents. In an interview with a CNA (Staff #123) conducted on March 4, 2026, at 12:00 p.m., the CNA stated that prior to the incident, Resident #444 was not supervised directly by staff, and had freedom to roam the facility without anyone directly watching. The CNA said that when she came to work for her shift on day shift, she was informed that there had been an incident between Resident #444 and Resident #3. She said that she was told that during the night shift, a nurse walked in the bathroom of another resident's room and found Resident #3 performing oral sex on Resident #444. During an interview with the unit manager (Staff #82) conducted on March 4, 2026, at 12:26 p.m., the unit manager stated that the facility accepts and admits pediatric residents; and, if the resident has a legal guardian, then healthcare decisions and consents are obtained from the resident's legal guardian. The unit manager stated that there would be no scenario where a child/minor could consent to have sex with an adult while in the facility, because the child would not be of consenting age. She stated that it would be considered sexual molestation or rape if an adult has a sexual act with a child who cannot legally consent; and, it would be important for facility staff to be able to identify possible situations of sexual abuse and rape in order to protect the residents. Regarding the incident between Resident #3 and Resident #444, the unit manager stated that prior to the incident, there was a fear amongst staff that something would happen between Resident #444 and Resident #3, because both residents were spending a lot of time together; and that, Resident #444's TBI-related behaviors were noticeable, and the resident showed no remorse for his actions. She said that prior to the incident, she called and informed the legal guardian of Resident #444, that Resident #444 was spending time with another resident and the facility did not want anything inappropriate to happen. She also said that she informed the legal guardian that Resident #444 had been instructed to stay within public areas in the facility; and she requested the legal guardian to speak to Resident #444 to encourage compliance. Regarding the incident, the unit manager said that she was told that it occurred on night shift and a nurse walked in and saw the Residents #3 and #444 engaged in what appeared to be oral sex. The LPN said that both residents were separated, and the former DON (Staff #66) was the main person who conducted the investigation afterward. She stated that both Residents #3 and #444 initially denied the allegation; but later, Resident #444 admitted that oral sex occurred. A phone interview was conducted on March 4, 2026, at 1:35 p.m. with another LPN (Staff #85) who stated that she was working on the night shift on May 18, 2025 when the incident occurred. She stated that earlier in the evening, Residents #3 and #444 were spending time together with another resident and were walking the halls together. The LPN said that while she was in the middle of evening medication pass, sometime around 7:00 p.m. – 9:00 p.m., a nurse (Staff #312) from another unit came and asked her if either Resident #444 or Resident #3 was one of her assigned residents. She told the nurse (Staff #312) one of the residents was; and, the nurse (Staff #312) told her that there was an incident. The LPN said that the nurse (Staff #312) reported that when the nurse (Staff #312) walked into the room of another resident, the nurse (Staff #312), found Residents #444 and #3 together in the bathroom; and that, Resident #3 was on her knees in front of Resident #444 who was standing and had his pants down. The LPN said that the nurse (Staff #312) reported that Resident #444 quickly pulled his pants up when he saw the nurse (Staff #312); and that, the nurse told her that it looked like Resident #3 was performing oral sex on Resident #444. The LPN said that both she and the nurse (Staff #312) went to the room where both Residents #3 and #444 were found. The LPN stated that upon arriving to the room, the resident who stays in that room was very upset and told both nurses that he had no idea what was going on, and had no idea that a sexual encounter was going on in his bathroom. The LPN stated that Residents #3 and #444 were separated and reported the incident to the DON (staff #66) at that time. The LPN further stated that the police came to the facility the following day. A telephone interview with a DCS child safety specialist who was assigned to the case of Resident #444 was conducted on March 5, 2026, at 9:03 a.m. The DCS child safety specialist stated that Resident #444 reported that Resident #3 had performed oral sex on him; and they had been caught by a nurse at the facility. The DCS child safety specialist stated that the incident at the facility, including the ripple-effect aftermath, had a negative psychosocial effect on Resident #444. During a phone interview conducted with the former administrator (Staff #38) on March 5, 2026, at 12:46 p.m., the former administrator stated the facility staff knew that medical consents and healthcare decisions were needed to be obtained from the residents' families/legal guardian for pediatric residents/minors admitted at the facility. The former administrator stated that a child was not able to consent to have sex with an adult, because a minor is smaller than an adult and could be overpowered He also said that the child's brain development is not fully there to be able to consent. The former administrator said that it was important for facility staff to be able to recognize possible instances of sexual abuse in order to prevent abuse from occurring; and, if staff sees/observes/has knowledge of an instance of possible sexual abuse, staff were expected to report the allegation to supervisors immediately, and then the facility would report to mandated entities within 2 hours. Regarding the incident between Resident #3 and Resident #444, the former administrator stated that he could not recall the details or when he had learned of it, but remembered that a nurse walked in and found Resident #3 positioned on her knees and Resident #444 was standing; and that, he was informed that Resident #3 had taken care of Resident #444 in a sexual way. The former administrator said that the former DON (Staff #66) had reported the incident right away, and led investigation of the incident. Regarding the outcome of the investigation, the former administrator said that he knew the incident was involving an adult and a minor, and that we assumed it happened. He further stated that he saw it as a crime, but did not know if it was sexual abuse. During a phone interview with the former DON (Staff #66) conducted on March 6, 2026, at 10:48 a.m., the former DON stated that the process for determining the necessary supervision level for each resident was by screening residents prior to admission and through nursing assessments; and that, this information would be communicated to staff typically through a care plan and a physician's order. Regarding consent, the former DON stated that consents would be obtained from the resident's parent or legal guardian for residents who were minors which was any resident under the age of 18. The former DON stated that any resident who was alert and oriented could consent to sexual decisions; and that, minors could consent to sexual activity with an adult. She also stated that she sees this happen all the time; and, she did not know the difference between assent and consent. The former DON stated that sexual abuse was unwanted sexual activity, and statutory rape was an instance where there was sexual conduct involving an adult and a minor that was not able to consent. She stated that there could be possible harm to a minor who was involved in a sexual encounter with an adult. Further, the former DON stated that the importance of staff being able to recognize possible instances of crimes or abuse would be so that staff could report it. She also said that if staff failed to recognize instances of abuse or crimes within the facility, then the risk of ongoing abuse or crimes to the residents. Regarding the incident between Resident #3 and Resident #444, the former DON stated that on May 18, 2025, Residents #3 and #444 were in another resident's room watching a movie together on a phone, and the nurse walked in to give the other resident evening medications when the nurse saw Residents #3 and #444 together watching the movie. The former DON stated that the nurse asked Resident #3 and Resident #444 to go back to their rooms, and the nurse reported the incident to her. The former DON stated that there was nothing going on other than watching movies; and that, she directed one of the night nurses to sit with Resident #444 all night. She said that the following day, a staff overheard Resident #444 state that he asked Resident #3 to give him a sexual favor. The former DON stated that both Residents #3 and #444 were then interviewed by multiple staff and eventually one of the residents admitted that the act was started but never carried out. The former DON said that the incident was reported to mandated entities, was investigated, and the police came to the facility and conducted interviews. Further, the former DON further stated that she did not consider this incident as a case of sexual abuse because it could not be considered abuse if it was not unwanted. The former DON also said that Resident #444 could consent to have sexual activity with an adult. An interview was conducted with the facility's current Director of Nursing (DON / Staff #212) on March 6, 2026, at 11:29 a.m. The current DON stated that a minor would be considered a resident who was under the age of 18 and would need a parent or legal guardian to give consent for healthcare decisions. She stated that assent was an expression of agreement; and, consent was the legal ability to agree to something; and that, the importance of determining whether a resident can consent was to ensure the safety of residents. She stated that sexual abuse was a situation in which a resident was the recipient of unwanted sexual acts, or if the resident was a recipient of sexual acts and could not consent to those acts. She said that statutory rape was a case in which sex occurred between a minor who could not legally consent and an adult; and, if a resident was involved in a situation of statutory rape or sexual abuse then the outcome could be physical or psychological harm, and there could be other social implications as well. The current DON stated that it was not acceptable for an adult to sexually touch a minor who could not legally give consent. Regarding the incident between Resident #444 and Resident #3, the current DON said that she reviewed the facility's investigation and based on the investigation, the incident involved a minor and an adult and it appeared to be a crime. However, she stated that she could not speak directly to the details of the incident because she was not employed by the facility at that time. The current DON stated that this kind of incident required immediate reporting and investigation. During an interview conducted with the facility's current administrator (Staff #170) on March 6, 2026, at 1:43 p.m., the current administrator stated that it was extremely important for staff to be able to recognize possible instances of abuse or crimes within the facility in order to protect the residents. He said that if a staff failed to recognize abuse or crimes, then the abuse could be ongoing and detrimental to the health and wellbeing of the residents. The current administrator also said that if an allegation of abuse or a crime were suspected by staff, it was his expectation that staff would move the residents out of harm's way and to notify the administrator immediately. He said that the facility would then report the allegation to mandated entities within 2 hours. He stated that sexual abuse was any unwanted or non-consented sexual act from one person to another. Further, the current administrator stated that it was not acceptable for an adult to sexually touch or have sex with a minor who could not legally consent because the minor could experience psychological harm. An interview with the former DON (Staff #66) was conducted on April 3, 2026 at 11:52 a.m. The former DON stated abuse could be physical, emotional, physical, sexual, verbal and financial. She stated that she was the DON at the time of the incident between Resident #444 and #3. She stated that Resident #444 who was under the age of eighteen, was not identified as a minor in the facility reported incident to the State Agency, because was when they discussed the incident, it was determined after conducting interviews with Residents #444 and #3 that the act was consensual between Residents #444 and #3; and that, Resident #444 sought out the sexual act. The former DON said that the facility did not identify that Resident #444 was a minor in their 5-day report because she entered the date of birth of Resident #444 in complaint portal; but, was not able to give a reason as to why the resident was not described as a minor in their reports. She stated a minor cannot give consent for sexual activity; and, if there are allegations involving a minor at the facility, the incident will be reported to the State Agency, APS (Adult Protective Services), and Department of Public Safety. She stated that mandatory reports included healthcare workers, the administrator, social workers and herself. Regarding Resident #444, the former DON stated that the resident's family called and informed APS of the incident. Staff #66 said she called to verify that the report was made to APS. She said that after reviewing the notification laws, CPS (Child Protective Services) should have been notified of the incident as soon as possible. Review of the facility policy titled Abuse: Prevention of and Prohibition Against, revised October 2022, revealed it is their policy that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Sexual abuse is non-consensual sexual contact of any type with a resident. All personnel, residents, visitors, etc. are encouraged to report incidents and grievances without the fear of retribution. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, asper this policy and applicable regulations. The facility will act to protect and prevent abuse and neglect from occurring within the facility by: Supervising staff to identify and correct any inappropriate or unprofessional behaviors; -Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship, and the resident's right to establish a relationship with another individual; which may include the development of or the presence of an ongoing sexually intimate relationship; Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur, to include validating that the facility has deployed the correct number of competent staff on each shift to meet the needs of the residents; Identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as: (a)verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating; physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; and, sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing. Continued review of the policy included that the facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the Facility administrator immediately. The Facility will assist staff in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property. This includes identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. Further, the policy included all allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. The investigation will include the following: An interview with the person(s) reporting the incident; An interview with the resident(s); Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; A review of the resident's medical record; An interview with staff members (on all shifts) who may have information regarding the alleged incident; Interviews

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to protect the resident's (#444) right to be free from sexual abuse by another resident (#3) on March 18, 2025 . when R3, an adult was found performing a sexual act on R444, a minor. The facility failed to specifically to (1) address R444's inappropriate interactions with staff; (2) provide supervision when the minor was noted to spend time with a cognitively impaired resident; and, (3) identify sexual contact between a minor and an adult as sexual abuse. When a minor has been the victim of molestation or statutory rape it has the potential to cause long lasting effects, psychological trauma and post traumatic stress disorder. As a result, the situation of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. Due to the potential for serious psychosocial harm an immediate jeopardy was called in the presence of the Administrator, Clinical Resource (staff #315) and Director of Operations (staff #316) on April 3, 2025 at 12:08 p.m.The facility's removal plan was accepted on April 3, 2026 at 5:29 p.m. and included the following actions taken:In-house review, assessment and checking against the Sex Offender Registry of their current residents;In-service training of all staff on Recognizing/Identifying, reporting, responding and implementing interventions for allegations abuse and neglect, EJA (Elder Justice Act), Recognizing/identifying inappropriate behaviors and Actions to take; and, Resident Rights; Review of current protocols for minors and justice involved residents admitted at the facility; Interviews conducted with all current interviewable residents regarding abuse;Review of their Grievance logs to identify any complaints from residents related to any inappropriate behaviors of staff and/or other residents.Multiple observations were conducted on April 3, 2026 and revealed the facility implementing their action plan to include conducting inservice training on recognizing/Identifying, reporting, responding and implementing interventions for allegations abuse and neglect, EJA (Elder Justice Act), recognizing/identifying inappropriate behaviors and Actions to take; and, Resident Rights with sign-in sheets of their staff, monitoring residents for inappropriate behaviors every shift and records of quiz on abuse completed by staff.Interviews with multiple staff were conducted on April 3, 2026 revealed that staff verbalized their understanding on how to identify/recognize abuse and inappropriate behaviors, what to do when they see or hear allegations of abuse or inappropriate behaviors, and actions to take to intervene/mitigate the situation. On April 3, 2026 at 6:35 p.m., IJ was removed but noncompliance remained at the lower scope and severity of isolated, actual harm that is not immediate.Findings include:A facility self-report dated May 19, 2025 submitted to the State Agency (SA) by the former Director of Nursing (DON/Staff #66) revealed that on May 19, 2025, a staff member overheard Resident #444 made a statement that suggested he received sexual acts from Resident #3. According to the report, both residents were determined to be cognitively intact and had a BIMS score of 15; and that, during separate interviews, each resident acknowledged the encounter, asserted it was consensual, and that it occurred on May 18, 2025. Further, the report included that staff had previously witnessed residents #444 and #3 together but reported that there was no inappropriate behavior at that time. The report revealed the police were notified and appropriate reporting to state regulatory authorities was completed. However, The facility did not accurately and appropriately reported the incident because they reported to the SA (State Agency) that the incident was consensual. -Resident #444 (alleged victim/minor) was admitted to the facility on [DATE], with diagnoses of traumatic brain injury, attention deficit hyperactivity disorder (ADHD), anxiety and depression. Review of the discharging hospital History and Physical Note dated April 28, 2025, revealed that Resident #444 was a minor, and previously healthy until involved in an accident in January 2025, that led to a traumatic brain injury (TBI) with subarachnoid hemorrhage, diffuse axonal injury, open tibia/fibula fractures, psychosis, and insomnia. The clinical record revealed documentations that decisions and consent were made by the resident's legal guardian/parent. A care plan dated May 13, 2025 revealed Resident #444 was at risk for impaired cognitive function or impaired thought process due to recent hospitalization. Interventions included the resident needed supervision/assistance with all decision making, and to include resident-centered behavioral interventions. The care plan dated May 14, 2025, revealed Resident #444 required psychotropic medications due to TBI induced psychosis as evidenced by delusions. Interventions included to observe for dizziness, drowsiness, sedation, agitation, restlessness, confusion, and mood changes. A social service summary note dated May 14, 2025 revealed Resident #444 was alert, verbally responsive, was able to make simple needs known, and interacted well with known social support systems and staff upon early observations. The note included that staff would continue to monitor as needed. An admission provider note dated May 14, 2025 included Resident #444 had diffuse axonal injury and ADHD. The documentation included that the resident was alert and oriented x 4, was calm and lucid. The plan included for a psychiatric consult; however, the documentation did not include the reason for the psych consult. A daily skilled note dated May 14, 2025 included the resident was alert and oriented x 3. A physical medicine and rehab note dated May 15, 2025 revealed the resident appeared well developed and well nourished, and had anxiety and depression. The plan included to continue psychiatric medications and to monitor for behaviors that interfere with therapies. An internal medicine provider note dated May 16, 2025, revealed that Resident #444 was alert and oriented x 4, had ADHD, and had no behaviors. The plan included for a psychiatry consult. An internal medicine provider note dated May 17, 2025 included the resident was up ambulating in the halls and had no behavioral issues reported by nursing. The plan included for a psychiatry consult. A daily skilled note dated May 18, 2025 at 10:16 p.m. revealed the resident was alert and oriented x 4 and had no active behavioral symptoms. The clinical record revealed no documentation of any behavioral symptoms prior to May 18, 2026 at 10:16 p.m. A nursing note dated May 19, 2025 at 12:45 p.m. included the resident was transported to a follow-up appointment at the hospital, and that, facility staff accompanied the resident. An internal medicine provider note dated May 19, 2025 at 1:03 p.m. revealed the resident was chronically ill appearing and seen sitting in bed. The plan included for a psychiatric consult. A BIMS (Brief Interview for Mental Status) assessment dated [DATE] revealed Resident #444 had a score of 15 indicating intact cognition. A nutrition note dated May 19, 2025 included a mini nutritional assessment (MNA) was not indicated due to Resident #444's adolescent status. The note also included the resident needed one to one sitter due to restlessness and behaviors. A social service note dated May 19, 2025 revealed a psychosocial assessment was conducted and the resident denied experiencing symptoms of anxiety or depression. A nursing note dated May 19, 2025 included that Resident #444 was placed on change of condition (COC) monitoring for psychosocial wellbeing for a reported event; and that, the resident, family, case manager, and provider were notified. However, the document did not include what the reported event was about. The daily skilled note dated May 19, 2025 revealed the resident was alert and oriented x4 and had no active symptoms or treatments affecting level of consciousness, cognition, sleep, mood or behavior. A care plan initiated May 19, 2025 revealed Resident #444 had a potential for a psychosocial well-being problem due to a reported event. Interventions included for 1:1 staff initiated on May 19, 2025. However, there was no evidence found in the clinical record that interventions to protect Resident #444 from further abuse was put in place on May 18, 2025, the date the incident happened. A staff schedule for May 2025 revealed that Resident #444 did not have a one to one sitter until May 18, 2025 from 11:00 p.m. to 6:00 a.m.; and, continued to have an assigned sitter on May 19 and until the resident discharged on May 20, 2025. The eMAR (electronic medication administration record) note dated May 20, 2025 included resident was on COC for psychosocial well being monitoring every shift for 3 Days related to a reported event. Per the documentation, resident #444 was alert and oriented x 4, was pleasant and cooperative with all care, denied feeling unsafe or in danger and continued to have a sitter for one on one. An internal medicine progress note dated May 20, 2025 revealed Resident #444 was socially appropriate, had interacted positively with peers and staff, and, had no signs of withdrawal, anxiety, or frustration noted. It also included no behavioral disturbances related to ADHD or TBI during this stay; and that, the family was involved and supportive. The plan included for a psychiatry consult. Despite documentation of a plan for a psychiatric consult, there was no evidence that the resident was scheduled for or received a psychiatry consult. A nursing note dated May 20, 2025 included the decision was to discharge Resident #444 back to the acute care hospital based on the family's request. A Nursing Home to Hospital Transfer Form revealed Resident #444 was transferred to acute hospital on May 20, 2025, for a pediatric psychiatric evaluation. The clinical record revealed no documentation of any incident/event or change in behavior that would result in hospital transfer for pediatric psychiatric evaluation for Resident #444. There was also no documentation found in the clinical record that the resident was sexually abused and/or documentation of any inappropriate behaviors exhibited towards staff or other residents. There was also no evidence found in the clinical record that the care plan for Resident #444 addressed supervision or discouraging Resident #444 from hanging out with other residents. -Resident #3 admitted on [DATE] with diagnoses of ADHD, schizophrenia, and mood disorder. The admission noted dated May 10, 2025 revealed Resident #3 was a [AGE] year old female who was alert and oriented X4 and was ambulatory. A care plan initiated May 10, 2025 revealed Resident #3 was at risk for impaired cognitive function or impaired thought process due to new environment, mental illness, and recent hospitalization. Interventions included to monitor, document, and report to the physician any changes in cognitive function, decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. A social service summary dated May 14, 2025 included Resident #3 was able to make simple needs known, had interacted well with known social support systems and staff upon early observations. It also included that staff will continue to monitor as needed. The initial psychiatric evaluation/note dated May 14, 2025 revealed Resident #3 had a history of schizophrenia and was managed with psychotropic medications. The note revealed the resident stopped taking psychotropic medications by choice after ending court ordered treatment 2 months ago. According to the documentation, the resident denied any anxiety; and, the resident's judgment was fair. The note also included that education was provided to the resident that schizophrenia was an enduring mental illness which would require antipsychotic use indefinitely; and that, not taking antipsychotics put the resident at high risk for resurfacing psychotic symptoms, and potentially impacting the safety of others. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a BIMS score of 15, indicating intact cognition. The assessment also included the resident had no behaviors toward others, and no pacing; had active diagnosis of schizophrenia; and, was not taking any anti-anxiety medication. A daily skilled note dated May 18, 2025 included the resident was alert and oriented x 3, and had no active symptoms or treatments effecting level of consciousness, cognition, sleep, mood, or behavior. The nursing note dated May 19, 2025 revealed Resident #3 was placed on COC monitoring for psychosocial well-being for a reported event. However, the document did not include what the reported event was about. A care plan initiated May 19, 2025 included that Resident #3 had potential for a psychosocial well-being problem due to a reported event. Interventions included for a psychiatric evaluation on May 19, 2025. The psychiatric provider note dated May 19, 2025, at 7:15 p.m. revealed that according to staff, Resident #3 had increased anxiety with pacing and worrying; and that, the resident reported increased anxiety about a recent event, but did not wish to discuss the details of the event. The documentation also included that the resident reported having feelings of excess worrying and nervousness. The diagnosis included anxiety. Recommendations included to start hydroxyzine (anti-anxiety medication) 25 mg every six hours as needed (PRN). A physician order dated May 19, 2025 included for hydroxyzine HCl oral tablet 25 mg, to give 1 tablet by mouth every 6 hours as needed for anxiety as evidenced by verbalization of anxiety for 14 days. Review of the Medication Administration Record (MAR) for May 2025 revealed the hydroxyzine was administered to the resident on May 21 and May 22, 2025. The police report shows the incident was reported on May 19, 2025, at 6:49 p.m., which is nearly 24 hours after it happened on May 18, 2025. The call was classified as a sexual assault of a minor. The report synopsis revealed that on May 18, 2025, at approximately 9:00 p.m., Resident #3 sexually assaulted Resident #444 while at the facility. The police report included a witness statement from a Licensed Practical Nurse (LPN/staff #312) who reported she often observed Resident #444 and Resident #3 hanging out together and talking at the facility for approximately a week before the incident. The LPN reported that on May 18, 2025 at approximately 9:00 p.m., she went to utilize the mirror in another resident's room and opened the closed door. The LPN reported that she saw Resident #3 positioned on her knees, with Resident #444 in the bathroom. The LPN reported that she informed her supervisor of the incident; and, Resident #3 was placed in a separate wing of the facility. The police report revealed a statement from Resident #3 who reported that both Resident #3 and Resident #444 went into the bathroom in another resident's room; and that, Resident #3 reported that she performed oral sex for approximately 2 minutes on Resident #444, who had asked for it. The report also included that Resident #3 reported knowing how old Resident #444 was prior to engaging in sexual acts in the restroom. Further, the police report revealed Resident #444 reported he and Resident #3 were watching a movie in another resident's room. According to the report, Resident #444 asked Resident #3 for oral sex, proceeded to the bathroom, closed the door, and then Resident #3 conducted oral sex. Further, the police report revealed that the offense for Resident #3 included 1 count of completed statutory rape and sexual conduct with minor. A facility 5-day investigation report was signed by the former DON (Staff #66) and dated May 21, 2025 submitted to the State Agency revealed that on or about May 19, 2025 at approximately 6:15 p.m., Resident #444 who was alert and oriented to person, place, time, and event was overheard by a staff making statements that he allegedly had received sexual acts from Resident #3. According to the report, a comprehensive investigation was immediately initiated; and, both Residents #444 and #3 were instructed to refrain from spending time together or having any physical contact to mitigate the risk of further occurrence. It also included that visual safety monitoring was implemented for both residents while the investigation was ongoing. According to the report, both residents were determined to be cognitively intact and had a BIMS score of 15. The report revealed that an interview was conducted on May 19, 2025 at approximately 6:26 p.m. with Resident #444 who confirmed that a sexual encounter occurred between and mutually consented by him and Resident #3. Per the documentation, Resident #444 reported that the incident occurred one time on May 18, 2025, and was interrupted by staff; and that, both Resident #444 and Resident #3 put their clothes on before staff entered the restroom. Continued review of the facility 5-day investigation revealed an interview was conducted on May 19, 2025 at 6:45 p.m. with Resident #3 who initially denied any incident; however, retracted and acknowledged that she and Resident #444 voluntarily engaged in the act; and that, Resident #444 requested for it. Per the documentation, Resident #3 reported that the encounter was interrupted by a staff. Further review of the facility investigation revealed an interview conducted on May 18, 2025 with the nurse on duty (LPN/Staff #312), who stated she observed Residents #444 and #3 together in one of the resident rooms, but, there was no inappropriate behavior noted at that time. The LPN reported that both residents reported that they were watching videos together and denied any misconduct; and, both were directed to return to their respective rooms. The report concluded that the facility was unable to substantiate that abuse occurred, and the incident occurred between two consenting individuals. The APS (Adult Protective Services) investigative report dated August 19, 2025, revealed that the allegation against the facility was neglect of a vulnerable adult, identified as Resident #3, and that the allegation was verified. The report revealed that Resident #3 was identified as a vulnerable adult due to having serious mental illness (SMI); and that, Resident #3 sexually assaulted Resident #444 while at the facility, and the case was verified because the sexual assault occurred. A phone interview with the legal guardian/family of Resident #444 was conducted on March 3, 2026, at 10:42 a.m. The legal guardian/family stated that she was the legal guardian of Resident #444 at the time of the incident; and that, a facility staff called and informed her several days before the incident that Resident #444 had developed an inappropriate relationship with another resident. She stated that she was asked by the facility staff to speak to Resident #444 about it. The legal guardian stated that she was unable to come to the facility; but that, Resident #444 was under the facility's care, and it was the facility's responsibility to handle the situation and ensure the resident's safety. The legal guardian stated that approximately two days after the initial phone call, staff called and informed her that there was an incident where a staff member caught Resident #444 receiving oral sex from another resident. She stated that Resident #444 should have been under staff supervision and all staff should have been aware that Resident #444 was a minor and required supervision; but that, the facility did not do an adequate job protecting Resident #444. Further, the legal guardian stated that Resident #444 had a negative psychosocial impact as a result of the incident that occurred. However, there was no evidence found in the clinical records that interventions were put in place to supervise or discourage Resident #444 and #3 from hanging out with each other; and, no evidence found of any actions or preventive measures taken such as increase supervision or monitoring of Residents #444 and #3. A phone interview was conducted with an LPN (Staff #179) on March 3, 2026, at 9:57 a.m. The LPN stated that prior to the incident, Resident #3 and Resident #44 were hanging out together a lot, and that staff had warned Resident #3 that Resident #444 was a minor. Regarding the incident, The LPN stated it occurred on the night shift; but, she was not sure if the sexual act was witnessed by anyone. The LPN stated that after the incident, a sitter was assigned and provided to Resident #444 who demonstrated sexually inappropriate behaviors toward the sitters. The LPN further stated that after the incident, Resident #444 told staff that Resident #3 had performed oral sex on him. A phone interview was conducted on March 3, 2026, at 12:39 p.m. with another LPN (Staff #106) who stated that she had been informed through staff report that Resident #3 and Resident #444 were found by a staff having a sexual encounter in a room. Prior to the incident, the LPN stated that another staff said that staff need to watch out for the two residents (#3 and #444) because this is a young kid. In an interview conducted with a certified nursing assistant (CNA/Staff #117) on March 3, 2026, at 1:23 p.m., the CNA stated that she was informed of an alleged sexual incident between Resident #3 and Resident #444 through verbal staff report before she came onto shift. The CNA stated that she could not recall whether or not Resident #444 had a one to one sitter at the time of the incident; but that, she remembered that during report she was instructed to supervise Resident #444. The CNA further stated that prior to the incident, she had seen Residents #3 and #444 eating meals together in the dining room. An interview with the social services supervisor (SS/Staff #254) was conducted on March 3, 2026, at 2:28 p.m. Staff #254 stated that on admission, the nurse would receive information from the discharging hospital on whether a resident could consent for themselves; and, this information is also in the admission paperwork which would be uploaded in the medical record. Staff #254 stated that a resident would be assessed upon admission to determine if the resident had the mental cognition to make their own decisions; and that, if the resident were a pediatric patient/minor, then the resident's legal guardian or parent would provide consent. Regarding choices, Staff #254 stated that simple choices such as food, clothing, and activity choices would be up to the pediatric resident; however, healthcare decisions and consent would be obtained from the resident's parent or legal guardian. Staff #254 stated that it was inappropriate and was illegal for an adult resident and a pediatric/minor resident to have a sexual relationship while at the facility. Further, Staff #254 stated that she was not sure what supervision measures the facility implemented for pediatric/minor residents. In a phone interview conducted with an LPN (Staff #120) on March 4, 2026, at 11:09 a.m., the LPN stated that she was familiar with Resident #444, and had completed his admission assessments from the hospital. She stated she received a report from the hospital that the resident was a minor and may have some cognitive deficits. The LPN stated that staff did not usually take care of kids at our facility; and that, Resident #444 was polite, but interactions with Resident #444 were awkward. She said that Resident #444 had a legal guardian who was the resident's family whom she would call to get consents for admission. She stated that Resident #444 had some behaviors, and had demonstrated sexually inappropriate behavior to another staff member. The LPN said that she was informed through verbal report of the incident between Resident #444 and Resident #3 approximately 1-2 days after the incident occurred; and, had heard that staff had found Resident #3 on her knees in a bathroom with Resident #444, and there was an allegation of a sexual encounter. An interview was conducted on March 4, 2026, at 11:53 a.m. with a licensed nursing assistant (LNA / Staff #178) who stated Resident #444 walked around the facility; and that, prior to the incident, the resident did not have any supervision interventions care planned. She stated that after the incident, Resident #444 needed a one on one sitter; however, she was not informed why the resident needed one to one supervision. In an interview with a CNA (Staff #123) conducted on March 4, 2026, at 12:00 p.m., the CNA stated that prior to the incident, Resident #444 was not supervised directly by staff, and had freedom to roam the facility without anyone directly watching. The CNA said that when she came to work for her shift on day shift, she was informed that there had been an incident between Resident #444 and Resident #3. She said that she was told that during the night shift, a nurse walked in the bathroom of another resident's room and found Resident #3 performing oral sex on Resident #444. She stated she was not sure whether or not the resident who was admitted to the room was in the room or not at the time the incident between Residents #444 and #3 occurred. The CNA stated that when she returned to work on day shift on May 20, 2025, she was informed that she was assigned to be the one on one sitter for Resident #444; and, during that shift, Resident #444 seemed sad or depressed. Further, the CNA said that later that day on May 20, 2025, Resident #444 was discharged to the hospital. During an interview with an LPN / unit manager (Staff #82) conducted on March 4, 2026, at 12:26 p.m., the unit manager stated that the facility accepts and admits pediatric residents; and, if the resident has a legal guardian, then healthcare decisions and consents are obtained from the resident's legal guardian. The unit manager stated that there would be no scenario where a child/minor could consent to have sex with an adult while in the facility, because the child would not be of consenting age. She stated that it would be considered sexual molestation or rape if an adult has a sexual act with a child who cannot legally consent; and, it would be important for facility staff to be able to identify possible situations of sexual abuse and rape in order to protect the residents. Regarding the incident between Resident #3 and Resident #444, the unit manager stated that prior to the incident, there was a fear amongst staff that something would happen between Resident #444 and Resident #3, because both residents were spending a lot of time together. She said that Staff #82 stated that prior to the incident, she called and informed the legal guardian of Resident #444, that Resident #444 was spending time with another resident and the facility did not want anything inappropriate to happen. She also said that she informed the legal guardian that Resident #444 had been instructed to stay within public areas in the facility; and she requested the legal guardian to speak to Resident #444 to encourage compliance. The unit manager said that the legal guardian told her that Resident #444 had a TBI that impaired the resident's judgment; and that, the resident had a lot of sexual urges and behaviors. The unit manager said that prior to the incident, the resident's TBI-related behaviors were noticeable, and the resident showed no remorse for his actions. Regarding the incident, the unit manager said that she was told that it occurred on night shift and a nurse walked in and saw the Residents #3 and #444 engaged in what appeared to be oral sex. The LPN said that both residents were separated, and the former DON (Staff #66) was the main person who conducted the investigation afterward. She stated that both Residents #3 and #444 initially denied the allegation; but later, Resident #444 admitted that oral sex occurred. A review of the clinical record was conducted with the unit manager who stated that Resident #444 was discharged to the hospital on May 20, 2025, in order to get a pediatric psychiatric evaluation, because the facility's psychiatric provider was not able to perform a pediatric psychiatric evaluation. In a phone interview with another CNA (Staff #221) conducted on March 4, 2026, at 1:29 p.m., the CNA stated she was informed the day after the incident occurred through verbal report from staff that an adult resident and a kid resident were found by a staff member having a sexual encounter in another resident's room. The CNA stated that prior to the incident, staff were trying to keep an eye on the minor resident (#444); and that, after the incident, the residents were kept separated. A phone interview was conducted on March 4, 2026, at 1:35 p.m. with another LPN (Staff #85) who stated that she was working on the night shift on May 18, 2025 when the incident occurred. She stated that earlier in the evening, Residents #3 and #444 were spending time together with another resident and were walking the halls together. The LPN said that while she was in the middle of evening medication pass, sometime around 7:00 p.m. – 9:00 p.m., nurse (Staff #312) from another unit came and asked her if either Resident #444 or Resident #3 was one of her assigned residents. She told the nurse (Staff #312) one of the residents was; and, the nurse (Staff #312) told her that there was an incident. The LPN said that the nurse (Staff #312) reported that when the nurse (Staff #312) walked into the room of another resident, the nurse (Staff #312), found Residents #444 and #3 together in the bathroom; and that, Resident #3 was on her knees in front of Resident #444 who was standing and had his pants down. The LPN said that the nurse (Staff #312) reported that Resident #444 quickly pulled his pants up when he saw the nurse (Staff #312); and that, the nurse told her that it looked like Resident #3 was performing oral sex on Resident #444. The LPN said that both she and the nurse (Staff #312) went to the room where both Residents #3 and #444 were found. The LPN stated that upon arriving to the room, the resident who stays in that room was very upset and told both nurses that he had no idea what was going on, and had no idea that a sexual encounter was going on in his bathroom. The LPN stated that Residents #3 and #444 were separated and reported the incident to the DON (staff #66) at that time. The LPN further stated that the police came to the facility the following day. During a phone interview with a Department of Child Services (DCS) staff conducted on March 4, 2026, at 2:58 p.m. the DCS staff stated that DCS only became involved with the incident when Resident #444 was discharged to the hospital; and the hospital reported the incident to them. The DCS staff stated that the facility did not inform DCS of the incident. The DCS staff said that Resident #444 reported that he was caught by a facility staff having oral sex with another resident. Further, the DCS staff stated that based on the resident's age, Resident #444 was not able to give consent. A phone interview was conducted with another LPN (Staff #102) on March 5, 2026, at 8:48 a.m. The LPN stated that she found out about the incident the day after the incident; and she was verbally informed through verbal report that Resident #444 and Resident #3 were visiting the room of another resident and both Residents #3 and #444 were seen by staff doing something inappropriate based on the residents' ages. A telephone interview with a DCS child safety specialist who was assigned to the case of Resident #444 was conducted on March 5, 2026, at 9:03 a.m. The DCS child safety specialist stated that prior to the incident, Resident #444 had suffered a brain injury that affected the resident's decision-making ability; and that, Resident #444 had maladaptive behaviors. The DCS child safety specialist stated that Resident #444 reported that Resident #3 had performed oral sex on him; and they had been cau

Based on interviews, records, and policy review, the facility's QAPI program did not show it is actively addressing all care and services for residents. Specifically, the facility failed to: (1) Conduct a root cause analysis to identify why the sexual abuse incident between residents occurred; (2) Clearly define the problem or outline specific actions to fix it, including measurable goals, timelines, how effectiveness would be evaluated, and who is responsible; (3) Identify specific changes to policies, procedures, or practices that were or will be put in place; and, (4) Set up ongoing monitoring with clear baselines, target goals, and timelines. Because of these gaps, the facility did not implement clear corrective actions or provide appropriate staff training, which may lead to weak systems for identifying, assessing, and responding to potential sexual abuse incidents.Findings include:Review of the Quality Improvement Plan/Action Plan dated May 20, 2025 revealed the item/problem identified was that minors were admitted to the facility. Causal factor included lack of communication to the facility's IDT (interdisciplinary team) regarding admission of minors. Interventions included monitoring of date of birth daily on each admission, in-service training of admission and marketing staff on the new process for admission of minors, review of census in daily stand-up meetings and complete a full house review of the date of birth of all current residents.However, the plan did not look into the root cause of the sexual abuse incident between the two residents or show that the facility fully investigated why it happened. Aside from general monitoring, the QAPI plan did not include a clear plan to fix the issue. It was missing details like goals, timelines, specific actions to correct the problem, who is responsible for each step, how the facility will check if the actions are working. The facility's QAPI plan showed that staff training focused on a new process for admitting minors, not on the abuse-related deficiency. The plan also did not include key details about the training, such as the content, who will be trained, the timeline for completion, and how the training will be documented and verified. In addition, the plan did not include any system-wide changes made or planned in direct response to the abuse incident. During an interview with the Administrator on April 2, 2026 at 3:40 p.m., he stated that the facility holds QAPI (Quality Assurance and Performance Improvement) meetings monthly, but at least quarterly. These meetings are attended by the Administrator, DON, IDT team, medical director or family representative, and staff. He explained that the purpose of QAPI is to identify areas of concern. He stated that a QAPI meeting was held at the time of the incident involving Residents #444 and #3, during which the facility discussed admitting residents under the age of eighteen. The Administrator said the facility decided not to admit any residents under eighteen going forward. He further stated that after the incident between Resident #444 and #3, the facility initiated and continued to provide training on Abuse, Neglect and Exploitation during their monthly all staff meeting. The administrator said since the investigation which occurred earlier this month the facility has not admitted anyone under the age of 18. He stated the facility was waiting for the 2567 to be sent out to determine what policies and procedures might needed to be implemented.An interview with the Clinical resource was conducted on April 3, 2026 at 8:50 a.m. The clinical resource stated that QAPI meeting is usually held every month at a minimum; and, they discuss all the identified areas of concerns, trends, action plans in place. She stated that the actions in place are monitored to ensure that it is being implemented and were reviewed whether they are effective of not. In another interview with the Administrator conducted on April 3, 2026 at 9:43 a.m., he stated that the issues were identified during the monthly QAPI meeting which are attended by the administrator, DON and the IDT team. he stated that staff can also bring up quality concerns to their managers who would then shared with him and the QAPI committee. He stated that the QAPI committee will then come up with systems in place to address the issue and have specific plans to correct the issue. He said that the action plans will then be implemented and audits are conducted to ensure that staff were following the intervention that is in place. The quality concern will stay in QAPI for 90 days or longer to ensure that it is working. He said that the tools that they use to correct the identified quality concern includes in-service training of staff, audits, and data collection/analysis if needed; and if the action in place is not working, the QAPI will reevaluate and revise or put and implement new actions to take and monitor implementation to address the identified quality issue.Review of the facility policy titled Abuse: Quality Assessment and Performance Improvement, revised September 2020, revealed it is their policy that the facility will prioritize through identification of high risk, high volume, or problem-prone areas; and that, the facility may utilize the following established Performance Improvement tools/Processes. The members of the QAPI committee functions include: QAPI plan, identifying and prioritizing PIPs, implementing actions to correct quality issues, and monitoring to ensure the corrective action implemented is being sustained. The QAPI Plan will include (1) Design and scope; (2) Governance and leadership; (3) Feedback, data systems, and monitoring; (4) Performance improvement projects (QITs); and, (5) Systemic analysis and systemic action. Identification of, and prioritizing of, PIPs through: (1) Open-door policy for staff reporting of quality problems; (2) Staff meetings; (3) Resident Council; (4) Grievances; (5) Systematic review of facility data, data sources, and comparative data, from market, state, and national sources; and, (6) Prioritizing through identification of high-risk, high volume, or problem-prone issues.

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure an allegation of sexual abuse was thoroughly investigated for two residents (#444 and #3). The deficient practice could result in an allegation of sexual abuse not being investigated timely and/or possible ongoing abuse of a resident.Findings include:A facility self-report dated May 19, 2025 submitted to the State Agency (SA) by the former Director of Nursing (DON/Staff #66) revealed that on May 19, 2025, a staff member overheard Resident #444 made a statement that suggested he received sexual acts from Resident #3. According to the report, both residents were determined to be cognitively intact and had a BIMS score of 15; and that, during separate interviews, each resident acknowledged the encounter, asserted it was consensual, and that it occurred on May 18, 2025. Further, the report included that staff had previously witnessed residents #444 and #3 together but reported that there was no inappropriate behavior at that time. The report revealed the police were notified and appropriate reporting to state regulatory authorities was completed.The report did not identify Resident #444 as a minor.-Resident #444 (alleged victim/minor) was admitted to the facility on [DATE], with diagnoses of traumatic brain injury, attention deficit hyperactivity disorder (ADHD), anxiety and depression.A nursing note dated May 19, 2025 included that Resident #444 was placed on change of condition (COC) monitoring for psychosocial wellbeing for a reported event; and that, the resident, family, case manager, and provider were notified. However, the document did not include what the reported event was about.A care plan initiated May 19, 2025 revealed Resident #444 had a potential for a psychosocial well-being problem due to a reported event. Interventions included for 1:1 staff initiated on May 19, 2025.However, there was no evidence found in the clinical record that interventions to protect Resident #444 from further abuse was put in place on May 18, 2025, the date the incident happened.-Resident #3 (alleged perpetrator) was admitted on [DATE] with diagnoses of ADHD, schizophrenia, and mood disorder.The nursing note dated May 19, 2025 revealed Resident #3 was placed on COC monitoring for psychosocial well-being for a reported event. The document did not include what the reported event was about.A care plan initiated May 19, 2025 included that Resident #3 had potential for a psychosocial well-being problem due to a reported event. Interventions included for a psychiatric evaluation on May 19, 2025. The psychiatric provider note dated May 19, 2025, at 7:15 p.m. revealed that according to staff, Resident #3 had increased anxiety with pacing and worrying; and that, the resident reported increased anxiety about a recent event, but did not wish to discuss the details of the event. The documentation also included that the resident reported having feelings of excess worrying and nervousness. There was no evidence found that appropriate actions were taken on May 18, 2025 to protect all residents including Resident #444 from further abuse by resident #3.The police report shows the incident was reported on May 19, 2025, at 6:49 p.m., which is nearly 24 hours after it happened on May 18, 2025. The report synopsis revealed that on May 18, 2025, at approximately 9:00 p.m., Resident #3 sexually assaulted Resident #444 while at the facility. The police report included a witness statement from a Licensed Practical Nurse (LPN/staff #312) who reported she often observed Resident #444 and Resident #3 hanging out together and talking at the facility for approximately a week before the incident. The LPN reported that on May 18, 2025 at approximately 9:00 p.m., she went to utilize the mirror in another resident's room and opened the closed door. The LPN reported that she saw Resident #3 positioned on her knees, with Resident #444 in the bathroom. The LPN reported that she informed her supervisor of the incident; and, Resident #3 was placed in a separate wing of the facility. The police report revealed a statement from Resident #3 who reported that both Resident #3 and Resident #444 went into the bathroom in another resident's room; and that, Resident #3 reported that she performed oral sex for approximately 2 minutes on Resident #444, who had asked for it. The report also included that Resident #3 reported knowing how old Resident #444 was prior to engaging in sexual acts in the restroom. Further, the police report revealed Resident #444 reported he and Resident #3 were watching a movie in another resident's room. According to the report, Resident #444 asked Resident #3 for oral sex, proceeded to the bathroom, closed the door, and then Resident #3 conducted oral sex. Further, the police report revealed that the offense for Resident #3 included 1 count of completed statutory rape and sexual conduct with minor.A facility 5-day investigation report was signed by the former DON (Staff #66) and dated May 21, 2025 submitted to the State Agency revealed that on or about May 19, 2025 at approximately 6:15 p.m., Resident #444 who was alert and oriented to person, place, time, and event was overheard by a staff making statements that he allegedly had received sexual acts from Resident #3. According to the report, a comprehensive investigation was immediately initiated; and, both Residents #444 and #3 were instructed to refrain from spending time together or having any physical contact to mitigate the risk of further occurrence. It also included that visual safety monitoring was implemented for both residents while the investigation was ongoing. According to the report, both residents were determined to be cognitively intact and had a BIMS score of 15. The report revealed that an interview was conducted on May 19, 2025 at approximately 6:26 p.m. with Resident #444 who confirmed that a sexual encounter occurred between and mutually consented by him and Resident #3. Per the documentation, Resident #444 reported that the incident occurred one time on May 18, 2025, and was interrupted by staff; and that, both Resident #444 and Resident #3 put their clothes on before staff entered the restroom.Continued review of the facility 5-day investigation revealed an interview was conducted on May 19, 2025 at 6:45 p.m. with Resident #3 who initially denied any incident; however, retracted and acknowledged that she and Resident #444 voluntarily engaged in the act; and that, Resident #444 requested for it. Per the documentation, Resident #3 reported that the encounter was interrupted by a staff.Further review of the facility investigation revealed an interview conducted on May 18, 2025 with the nurse on duty (LPN/Staff #312), who stated she observed Residents #444 and #3 together in one of the resident rooms, but, there was no inappropriate behavior noted at that time. The LPN reported that both residents reported that they were watching videos together and denied any misconduct; and, both were directed to return to their respective rooms. The report concluded that the facility was unable to substantiate that abuse occurred, and the incident occurred between two consenting individuals. This report was signed by the former DON (staff #66).Despite knowledge of Resident #444's minor status, the facility failed to include this information in its initial and 5-day reports to the State Agency. Moreover, the facility did not identify the incident between Resident #444 and Resident #3 as sexual abuse, instead describing it as an encounter between consenting individuals. The facility failed to initiate a thorough investigation; specifically, it did not interview the resident who was allegedly present in the room while the residents #444 and #3 were in the bathroom, nor did it interview other residents-particularly those identified as minors and admitted at the time. Additionally, the facility did not review all relevant circumstances surrounding the event, including how the incident may have occurred, as required by its policy. The facility's report included a list of staff members and residents who were interviewed; and, all staff interviewed reported not seeing or hearing any incident. The report did not indicate what the interviewed residents had seen or heard. Further, the report did not include any written statement from the nurse (staff #312) who entered the room and found Residents #444 and #3 on the night of the incident.In their investigation, the facility included a statement regarding an interview with the nurse (staff #312) conducted during their investigation. The facility reported that the nurse (#312) reported seeing resident #444 and #3 together in one of the resident rooms but noted no inappropriate behavior at the time.Because of their failure to recognize the incident as a potential allegation of abuse, the facility did not initiate a thorough investigation to include: (1) Taking appropriate corrective actions taken to protect residents from possible abuse; (2) Assessment and monitoring of other residents at risk; Notification of the alleged violation to local law enforcement and DCS (Department of Child Services); and, any interventions/supervision put in place to protect other residents at risk. This placed residents at risk for harm. There was no evidence found that the facility reported this incident to DCS (Department of Child Services) despite knowing that Resident #444 was identified as a minor.Review of staff schedules and punch details revealed that none of the 6 staff members interviewed in their investigation worked during the night shift of the incident on May 18, 2025.The APS (Adult Protective Services) investigative report dated August 19, 2025, revealed that the allegation against the facility was neglect of a vulnerable adult, identified as Resident #3, and that the allegation was verified. The report revealed that Resident #3 was identified as a vulnerable adult due to having serious mental illness (SMI); and that, Resident #3 sexually assaulted Resident #444 while at the facility, and the case was verified because the sexual assault occurred.A phone interview was conducted with an LPN (Staff #179) on March 3, 2026, at 9:57 a.m. The LPN stated that prior to the incident, Resident #3 and Resident #44 were hanging out together a lot, and that staff had warned Resident #3 that Resident #444 was a minor. The LPN further stated that after the incident, Resident #444 told staff that Resident #3 had performed oral sex on him.However, there was no evidence found in the clinical records that interventions were put in place to supervise or discourage Resident #444 and #3 from hanging out with each other; and, no evidence found of any actions or preventive measures taken such as increase supervision or monitoring of Residents #444 and #3. In an interview with a CNA (Staff #123) conducted on March 4, 2026, at 12:00 p.m., the CNA stated that prior to the incident, Resident #444 was not supervised directly by staff, and had freedom to roam the facility without anyone directly watching. A phone interview was conducted on March 4, 2026, at 1:35 p.m. with another LPN (Staff #85) who stated that the incident to the DON (staff #66) at that time of the incident; but; the police came to the facility the following day.During a phone interview with a Department of Child Services (DCS) staff conducted on March 4, 2026, at 2:58 p.m. the DCS staff stated that DCS only became involved with the incident when Resident #444 was discharged to the hospital; and the hospital reported the incident to them. The DCS staff stated that the facility did not inform DCS of the incident. During a phone interview conducted with the former administrator (Staff #38) on March 5, 2026, at 12:46 p.m., the former administrator stated it was important for facility staff to be able to recognize possible instances of sexual abuse in order to prevent abuse from occurring; and, if staff sees/observes/has knowledge of an instance of possible sexual abuse, staff were expected to report the allegation to supervisors immediately, and then the facility would report to mandated entities within 2 hours. The former administrator said that the former DON (Staff #66) had reported the incident right away, and led investigation of the incident; however, he stated that he could not answer questions related to discrepancies on when it was reported to him as the incident happened long time ago. During a phone interview with the former DON (Staff #66) conducted on March 6, 2026, at 10:48 a.m., the former DON stated that on May 18, 2025, Residents #3 and #444 were in another resident's room watching a movie together on a phone, and the nurse walked in to give evening medications to the other resident (in the room where both Resident #3 and #444 was found). The former DON said that the nurse then saw Residents #3 and #444 together watching the movie; and the nurse Resident #3 and Resident #444 to go back to their rooms, and nurse reported the incident to her. The former DON stated that there was nothing going on other than watching movies; and that, she directed one of the night nurses to sit with Resident #444 all night. She stated the incident was not reported or investigated until the following day, May 19, 2025, when a staff overheard Resident #444 state that he asked Resident #3 to give him a sexual favor. The former DON stated that both Residents #3 and #444 were then interviewed by multiple staff and eventually one of the residents admitted that the act was started but never carried out. The former DON said that the incident was reported the following day to mandated entities, was investigated, and the police came to the facility and conducted interviews; and that, she did not consider this incident as a case of sexual abuse because it could not be considered abuse if it was not unwanted and this was why it was not reported on May 18, 2025. She further stated that Resident #444 could consent to have sexual activity with an adult. The former DON also said that the facility conducted a thorough investigation; and that, a thorough investigation included conducting staff interviews during and surrounding the incident, and from staff who were familiar with the residents involved. She further stated that she conducted an interview with the other resident present in the room of the restroom where both Resident #3 and Resident #444 were found; however, the interview was not documented in their facility investigative report. An interview was conducted with the facility's current Director of Nursing (DON / Staff #212) on March 6, 2026, at 11:29 a.m. The current DON stated that a minor would be considered a resident who was under the age of 18 and would need a parent or legal guardian to give consent for healthcare decisions. She stated that assent was an expression of agreement; and, consent was the legal ability to agree to something; and that, the importance of determining whether a resident can consent was to ensure the safety of residents. She stated that sexual abuse was a situation in which a resident was the recipient of unwanted sexual acts, or if the resident was a recipient of sexual acts and could not consent to those acts. She said that statutory rape was a case in which sex occurred between a minor who could not legally consent and an adult; and, if a resident was involved in a situation of statutory rape or sexual abuse then the outcome could be physical or psychological harm, and there could be other social implications as well. The current DON stated that it was not acceptable for an adult to sexually touch a minor who could not legally give consent. Regarding the incident between Resident #444 and Resident #3, the current DON said that she reviewed the facility's investigation and based on the investigation, the incident involved a minor and an adult and it appeared to be a crime. However, she stated that she could not speak directly to the details of the incident because she was not employed by the facility at that time. The current DON stated that this kind of incident required immediate reporting and investigation.During an interview conducted with the facility's current administrator (Staff #170) on March 6, 2026, at 1:43 p.m., the current administrator stated that it was extremely important for staff to be able to recognize possible instances of abuse or crimes within the facility in order to protect the residents. He said that if a staff failed to recognize abuse or crimes, then the abuse could be ongoing and detrimental to the health and wellbeing of the residents. The current administrator also said that if an allegation of abuse or a crime were suspected by staff, it was his expectation that staff would move the residents out of harm's way and to notify the administrator immediately. He said that the facility would then report the allegation to mandated entities within 2 hours. He stated that sexual abuse was any unwanted or non-consented sexual act from one person to another. Further, the current administrator stated that it was not acceptable for an adult to sexually touch or have sex with a minor who could not legally consent because the minor could experience psychological harm.Review of the facility policy titled Abuse: Prevention of and Prohibition Against, revised October 2022, revealed it is their policy that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Sexual abuse is non-consensual sexual contact of any type with a resident. All personnel, residents, visitors, etc. are encouraged to report incidents and grievances without the fear of retribution. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations. The policy included all allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. The investigation will include the following:An interview with the person(s) reporting the incident;An interview with the resident(s);Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate;A review of the resident's medical record;An interview with staff members (on all shifts) who may have information regarding the alleged incident;Interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident;An interview with staff members (on all shifts) having contact with the accused employee; and,A review of all circumstances surrounding the incident.The policy continued that if an allegation of abuse, neglect, misappropriation of resident property, or exploitation is reported, discovered or suspected, the Facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation:Respond immediately to protect the alleged victim and integrity of the investigation;Examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed;Increase supervision of the alleged victim and residents;Make room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator;Protect the involved persons from retaliation; and,Provide emotional support and counseling to the resident during and after the investigation, as needed.

Based on record reviews, staff interviews, and review of facility policy and procedure, the facility failed to ensure an allegation of sexual abuse was reported in accordance with federal requirements when the facility failed to (1) Report the allegation of abuse to the State Agency, local law enforcement, adult protective services and department of children services immediately but no later than within 2 hours; (2) Failed to provide an accurate 5 day report; and, (3) Take appropriate corrective actions for one of one resident (R)#444 investigated for alleged sexual assault. The deficient practice resulted in the facility putting residents at for further abuse and placed the residents at risk for harm. Findings include: A facility self-report dated May 19, 2025 submitted to the State Agency (SA) by the former Director of Nursing (DON/Staff #66) revealed that on May 19, 2025, a staff member overheard Resident #444 made a statement that suggested he received sexual acts from Resident #3. According to the report, both residents were determined to be cognitively intact and had a BIMS score of 15; and that, during separate interviews, each resident acknowledged the encounter, asserted it was consensual, and that it occurred on May 18, 2025. Further, the report included that staff had previously witnessed residents #444 and #3 together but reported that there was no inappropriate behavior at that time. The report revealed the police were notified and appropriate reporting to state regulatory authorities was completed.However, the report did not identify Resident #444 as a minor.-Resident #444 (alleged victim/minor) was admitted to the facility on [DATE], with diagnoses of traumatic brain injury, attention deficit hyperactivity disorder (ADHD), anxiety and depression.A nursing note dated May 19, 2025 included that Resident #444 was placed on change of condition (COC) monitoring for psychosocial wellbeing for a reported event; and that, the resident, family, case manager, and provider were notified. However, the document did not include what the reported event was about.-Resident #3 (alleged perpetrator) was admitted on [DATE] with diagnoses of ADHD, schizophrenia, and mood disorder.The nursing note dated May 19, 2025 revealed Resident #3 was placed on COC monitoring for psychosocial well-being for a reported event. However, the document did not include what the reported event was about.The police report shows the incident was reported on May 19, 2025, at 6:49 p.m., which is nearly 24 hours after it happened on May 18, 2025. The call was classified as a sexual assault of a minor. The report synopsis revealed that on May 18, 2025, at approximately 9:00 p.m., Resident #3 sexually assaulted Resident #444 while at the facility. The police report included a witness statement from a Licensed Practical Nurse (LPN/staff #312) who reported she often observed Resident #444 and Resident #3 hanging out together and talking at the facility for approximately a week before the incident. The LPN reported that on May 18, 2025 at approximately 9:00 p.m., she went to utilize the mirror in another resident's room and opened the closed door. The LPN reported that she saw Resident #3 positioned on her knees, with Resident #444 in the bathroom. The LPN reported that she informed her supervisor of the incident; and, Resident #3 was placed in a separate wing of the facility. The police report revealed a statement from Resident #3 who reported that both Resident #3 and Resident #444 went into the bathroom in another resident's room; and that, Resident #3 reported that she performed oral sex for approximately 2 minutes on Resident #444, who had asked for it. The report also included that Resident #3 reported knowing how old Resident #444 was prior to engaging in sexual acts in the restroom. Further, the police report revealed Resident #444 reported he and Resident #3 were watching a movie in another resident's room. According to the report, Resident #444 asked Resident #3 for oral sex, proceeded to the bathroom, closed the door, and then Resident #3 conducted oral sex. Further, the police report revealed that the offense for Resident #3 included 1 count of completed statutory rape and sexual conduct with minor.A facility 5-day investigation report was signed by the former DON (Staff #66) and dated May 21, 2025 submitted to the State Agency revealed that on or about May 19, 2025 at approximately 6:15 p.m., Resident #444 who was alert and oriented to person, place, time, and event was overheard by a staff making statements that he allegedly had received sexual acts from Resident #3. According to the report, a comprehensive investigation was immediately initiated; and, both Residents #444 and #3 were instructed to refrain from spending time together or having any physical contact to mitigate the risk of further occurrence. It also included that visual safety monitoring was implemented for both residents while the investigation was ongoing. According to the report, both residents were determined to be cognitively intact and had a BIMS score of 15. The report revealed that an interview was conducted on May 19, 2025 at approximately 6:26 p.m. with Resident #444 who confirmed that a sexual encounter occurred between and mutually consented by him and Resident #3. Per the documentation, Resident #444 reported that the incident occurred one time on May 18, 2025, and was interrupted by staff; and that, both Resident #444 and Resident #3 put their clothes on before staff entered the restroom.Continued review of the facility 5-day investigation revealed an interview was conducted on May 19, 2025 at 6:45 p.m. with Resident #3 who initially denied any incident; however, retracted and acknowledged that she and Resident #444 voluntarily engaged in the act; and that, Resident #444 requested for it. Per the documentation, Resident #3 reported that the encounter was interrupted by a staff.Further review of the facility investigation revealed an interview conducted on May 18, 2025 with the nurse on duty (LPN/Staff #312), who stated she observed Residents #444 and #3 together in one of the resident rooms, but, there was no inappropriate behavior noted at that time. The LPN reported that both residents reported that they were watching videos together and denied any misconduct; and, both were directed to return to their respective rooms. The report concluded that the facility was unable to substantiate that abuse occurred, and the incident occurred between two consenting individuals.Despite knowledge of Resident #444's minor status, the facility failed to include this information in its initial and 5-day reports to the State Agency. Moreover, the facility did not identify the incident between Resident #444 and Resident #3 as sexual abuse, instead describing it as an encounter between consenting individuals. As a result, the facility did not take appropriate corrective actions to protect residents from possible abuse such as assessment and monitoring of other residents at risk, and any interventions/supervision put in place to protect other residents at risk.There was no evidence found that the facility reported this incident to DCS despite knowing that Resident #444 was a minor.The APS (Adult Protective Services) investigative report dated August 19, 2025, revealed that the allegation against the facility was neglect of a vulnerable adult, identified as Resident #3, and that the allegation was verified. The report revealed that Resident #3 was identified as a vulnerable adult due to having serious mental illness (SMI); and that, Resident #3 sexually assaulted Resident #444 while at the facility, and the case was verified because the sexual assault occurred.A phone interview was conducted on March 4, 2026, at 1:35 p.m. with another LPN (Staff #85) who stated that she was working on the night shift on May 18, 2025 when the incident occurred. She stated that earlier in the evening, Residents #3 and #444 were spending time together with another resident and were walking the halls together. The LPN said that while she was in the middle of evening medication pass, sometime around 7:00 p.m. - 9:00 p.m., a nurse (Staff #312) from another unit came and asked her if either Resident #444 or Resident #3 was one of her assigned residents. She told the nurse (Staff #312) one of the residents was; and, the nurse (Staff #312) told her that there was an incident. The LPN said that the nurse (Staff #312) reported that when the nurse (Staff #312) walked into the room of another resident, the nurse (Staff #312), found Residents #444 and #3 together in the bathroom; and that, Resident #3 was on her knees in front of Resident #444 who was standing and had his pants down. The LPN said that the nurse (Staff #312) reported that Resident #444 quickly pulled his pants up when he saw the nurse (Staff #312); and that, the nurse told her that it looked like Resident #3 was performing oral sex on Resident #444. The LPN said that both she and the nurse (Staff #312) went to the room where both Residents #3 and #444 were found. The LPN stated that upon arriving to the room, the resident who stays in that room was very upset and told both nurses that he had no idea what was going on, and had no idea that a sexual encounter was going on in his bathroom. The LPN stated that Residents #3 and #444 were separated and reported the incident to the DON (staff #66) at that time. The LPN further stated that the police came to the facility the following day.During a phone interview with a Department of Child Services (DCS) staff conducted on March 4, 2026, at 2:58 p.m. the DCS staff stated that DCS only became involved with the incident when Resident #444 was discharged to the hospital; and the hospital reported the incident to them. The DCS staff stated that the facility did not inform DCS of the incident. The DCS staff said that Resident #444 reported that he was caught by a facility staff having oral sex with another resident. Further, the DCS staff stated that based on the resident's age, Resident #444 was not able to give consent.In another telephone interview with a DCS child safety specialist who was assigned to the case of Resident #444 was conducted on March 5, 2026, at 9:03 a.m. The DCS child safety specialist stated that Resident #444 reported that Resident #3 had performed oral sex on him; and they had been caught by a nurse at the facility. The DCS child safety specialist stated that the incident at the facility, including the ripple-effect aftermath, had a negative psychosocial effect on Resident #444.During a phone interview conducted with the former administrator (Staff #38) on March 5, 2026, at 12:46 p.m., the former administrator stated it was important for facility staff to be able to recognize possible instances of sexual abuse in order to prevent abuse from occurring; and, if staff sees/observes/has knowledge of an instance of possible sexual abuse, staff were expected to report the allegation to supervisors immediately, and then the facility would report to mandated entities within 2 hours. Regarding the incident between Resident #3 and Resident #444, the former administrator stated that he was informed that Resident #3 had taken care of Resident #444 in a sexual way. The former administrator said that the former DON (Staff #66) had reported the incident right away, and led investigation of the incident; however, he stated that he could not answer questions related to discrepancies on when it was reported to him as the incident happened long time ago. Regarding the outcome of the investigation, the former administrator said that he knew the incident was involving an adult and a minor, and that we assumed it happened. He further stated that he saw it as a crime, but did not know if it was sexual abuse. During a phone interview with the former DON (Staff #66) conducted on March 6, 2026, at 10:48 a.m., the former DON stated that the facility staff investigated the incident between Residents #444 and #3. The former DON said that a thorough investigation included conducting staff interviews during and surrounding the incident, and from staff who were familiar with the residents involved. She further stated that she conducted an interview with the other resident present in the room of the restroom where both Resident #3 and Resident #444 were found; however, the interview was not documented in their facility investigative report.An interview was conducted with the facility's current Director of Nursing (DON/Staff #212) on March 6, 2026, at 11:29 a.m. The current DON stated that she reviewed the facility's investigation on the incident between Resident #444 and #3 and based on the investigation, the incident involved a minor and an adult and it appeared to be a crime. However, she stated that she could not speak directly to the details of the incident because she was not employed by the facility at that time; but, this kind of incident required immediate reporting and investigation. She said that based on the facility investigation, she could not determine details of the incident such as what room the incident happened, whether or not there was anyone else was present during the incident, if assessments were conducted for Residents #444 and #3 and whether or not DCS was notified since the incident involved a minor. During an interview conducted with the facility's current administrator (Staff #170) on March 6, 2026, at 1:43 p.m., the current administrator stated that it was extremely important for staff to be able to recognize possible instances of abuse or crimes within the facility in order to protect the residents. He said that if a staff failed to recognize abuse or crimes, then the abuse could be ongoing and detrimental to the health and wellbeing of the residents. The current administrator also said that if an allegation of abuse or a crime were suspected by staff, it was his expectation that staff would move the residents out of harm's way and to notify the administrator immediately. He said that the facility would then report the allegation to mandated entities within 2 hours. He stated that sexual abuse was any unwanted or non-consented sexual act from one person to another. Further, the current administrator stated that it was not acceptable for an adult to sexually touch or have sex with a minor who could not legally consent because the minor could experience psychological harm.

Based on clinical record review, staff interviews, resident interviews, facility documentation, and policies and procedures, the facility failed to protect one resident's (#2) right to be free from physical abuse by another resident. The census was 110. The deficient practice could result in continued abuse, and further abuse of other residents Findings include:-Resident #2 (alleged victim) was admitted to the facility on [DATE] with diagnoses of cognitive communication deficit, need for assistance with personal care, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, alcohol use, dizziness and giddiness, and anxiety.The cognition care plan initiated on September 14, 2023 revealed that the resident was at risk for impaired cognitive function/dementia. Interventions included to monitor, document, and report any changes to physician.The communication care plan initiated on September 26, 2023 revealed that the resident is at risk for communication problems due to hearing deficit. Interventions indicated to provide a safe environment and anticipate/meet needs.The Medicare Five-day MDS (Minimum Data Set) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The assessment documented that the resident required extensive two-person assist with cares due to upper and lower extremity impairment on both sides. Per the MDS, the resident utilized a walker and wheelchair as mobility devices. The diagnoses included non-Alzheimer's dementia, and depression.A psychosocial care plan which was initiated September 30, 2023, revealed that the resident has a potential for psychosocial well-being problem related to an assault. The goal was identified as resident will have no indication of psychosocial well-being problem through review date. Interventions included removal of resident to a calm and safe environment when conflict arose.A Nursing progress note dated September 30, 2023, documented a Change of Condition pertaining to an altercation with another resident. Per the note, another resident approached Resident #2's bedside and hit resident in the face. According to the note this resulted in a raised bump to the forehead and small cuts to the upper and lower lips of Resident #2. Residents were immediately separated and the alleged perpetrator was placed on 1:1 supervision to prevent further altercations. Resident #2 reported to staff that he felt safe with the interventions in place.A skin assessment on September 30, 2023 documented small lacerations to upper and lower lips, and a bump on the forehead. No other bruises or lacerations were noted.The Order Summary Report revealed a physician order dated September 30, 2023, which prescribed the following:-Changes of Condition for the lacerations to lips and forehead bump. The order indicated to check every shift for three days;-Change of Condition for psychosocial well-being. The order indicated to check every shift for three days.A Psychiatric Note dated October 2, 2023 documented a follow-up consultation due to resident's depressive symptoms. However, further review of the note did not reveal that the resident's recent resident to resident altercation was discussed.A Psychiatric Note dated October 4, 2023, documented that the resident was seen due to depressive symptoms. The note indicated that the resident was physically assaulted by another resident. Per the note, the resident reported he felt safe and denied any suicidal ideations/self-harm or homicidal ideations.A Social Services Note dated October 9, 2023, documented that resident was doing well and felt safe in the facility. -Resident #4 (alleged perpetrator) was admitted on [DATE] with diagnoses of alcohol abuse, and need for assistance with personal care.A cognition care plan which was initiated July 20, 2023, indicated risk for impaired cognitive function/dementia or impaired thought process. Interventions included monitoring cognition for changes.A behavioral care plan initiated on September 30, 2023, revealed that the resident had a potential to demonstrate physical behaviors towards others related to history of harm to others, and poor impulse control. Interventions included psychiatric consultation, document behaviors and attempt interventions, and observe for side effects of medication. Interventions also directed to guide resident away from distress when agitated and engage calmly in conversationAn admission MDS assessment dated [DATE], revealed a BIMS score of 15 indicating resident was cognitively intact. The MDS documented that the resident was negative for psychosis and behavioral symptoms during the assessment period.A Nursing progress note dated September 30. 2023, stated that Resident #4 was placed on a Change of Condition for an altercation with his roommate. Staff immediately separated the two residents, and placed Resident #4 in another room with a 1:1 sitter. Per the note, a skin assessment was completed and revealed a laceration on the middle finger of the right hand. No further injuries were documented.A subsequent Nursing note also dated September 30, 2023, documented that resident was transferred to the hospital.Further review of the resident's progress notes from the date of admission did not reveal any indication of aggressive behavior prior to the incident.A review of the Order Summary Report revealed physician orders dated September 30, 2023 for the following: Change of Condition for laceration to finger and psychosocial well-being. The order indicated to check every shift for three days.The orders also indicated for resident to have 1:1 sitter at all times every shift due to physical aggression; Resident was medically cleared for discharge.A telephonic interview with a Certified Nursing Assistant (CNA/staff #20) was attempted on March 31, 2026 at 1:25 p.m. The CNA could not be reached. A telephonic interview with CNA (staff # 21) was attempted on March 31, 2026 at 1:32 p.m. The CNA could not be reached.A telephonic interview with Registered Nurse (RN/staff #22) was attempted on March 31, 2026 at 1:36 p.m. The RN could not be reached. A second attempt at a telephonic interview with staff #20 was made on March 31, 2026 at 2:16 p.m. The CNA could not be reached.A second attempt at a telephonic interview with staff #21 was made on March 31, 2026 at 2:18 p.m. The CNA could not be reached. A second attempt at a telephonic interview with staff #22 was made on March 31, 2026 at 2:20 p.m. The RN could not be reached.An interview resident #3 was conducted on March 31, 2026 at 1:54 p.m. The resident stated she felt safe in the facility, and had no concerns with staff or other residents. If some type of incident ever occurred, this resident would push the call light and report to the nurse.An interview with resident #5 was conducted on March 31, 2026 at 1:57 p.m. The resident stated that she felt safe in the facility. Additionally the resident indicated no concerns with other residents or staff, but would report it to staff if it ever occurred.An interview with resident #7 was conducted on March 31, 2026 at 1:59 p.m. Per the resident, he felt safe in the facility, had no concerns with other residents or staff, and would report any issues to staff.In an interview with the Administrator (staff #10) on March 31, 2026 at 2:40 p.m., the Administrator stated that the current practice is to hopefully avoid resident to resident altercations. If physical contact occurs, staff are to separate the residents and make sure they are safe. If abuse occurs, staff report the abuse to the required state agencies and investigates within five business days. Staff #10 was unable to verify that the Abuse policy dated October 2022 was still in effect, and recommended to speak with the Director of Nursing (DON).An interview with the DON (staff #12) was conducted on March 31, 2026 at 2:43 p.m. The DON verified that the October 2022 policy was the correct policy being used by the facility. Clinical Resource (staff #11) was also present and concurred that the policy is in effect.A follow-up interview with the Administrator (staff #10) was conducted on March 31, 2026 at 3:09 p.m. The Administrator stated that staff should report suspected abuse to him and the DON. They then investigate and write the five-day report. Per the Administrator, they provide staff with abuse trainings upon hire and annually. The Administrator said that staff have his direct number to call any time day or night. According to the Administrator, his expectation is that staff ensure that residents involved in altercations are safe. They are separated and have room changes if they had been roommates. A clinical assessment is done, and then initial reports submitted to state agencies, the physician, and law enforcement. The written report must be completed in five days. They determine if the incident occurred or did not occur. They do not include a substantiated or unsubstantiated determination in their report.The DON was interviewed on March 31, 2026 at 3:16 p.m. The DON stated that abuse could be described as any kind of verbal, physical, or neglect that creates harm or intent to create harm. It can be resident to resident, staff to staff, or staff to resident. All staff are trained at hire and annually, plus in-serviced throughout the year. When an incident occurs, procedure is for staff to assess scene safety first, then report to their supervisor who reports to the Abuse Coordinator (Staff #10). Any allegation of resident to resident altercation is taken seriously and investigated. They ensure resident safety by separating the residents, removing one from the room if roommates, and sending to the emergency room if needed. Additionally, the incident is reported to the police, and all other required reporting agencies. Per the DON, assessments for any propensity to abuse are done upon admission to screen for possible triggers like PTSD (Post-traumatic Stress Disorder) or other behavior triggers. Supervision of residents with a potential for abuse to other residents depends on the individual person. Every care plan is tailored to that resident. They identify triggers and tailor the care plan to that individual. Care plans are also updated as needed.A review of the FRI (Facility-reported Incident) report dated September 30. 2023 revealed a resident to resident altercation between Residents #2 and #4. According to the report Resident #2 refused care from a CNA, who left the room to get a male CNA. When the CNAs returned, Resident #4 stated He didn't want to comply with care so I took care of it for you guys. The report documented that blood was noted on the floor and on the bed sheet of Resident #2. Resident # 4 was immediately removed from the room and placed in another room with a 1:1 sitter. Resident #4 had a small laceration to the middle finger of the right hand. Resident #2 had a small hematoma in the center of the forehead and cut to the inner lower lip. The FRI noted that reports were made to the state agencies, Sheriff's office, Ombudsman, the provider and the responsible party. The report did not indicate whether the allegation of abuse was verified or not verified. However, the report indicated that Resident #4 was sent to the hospital and will not be accepted back into the facility.The Abuse policy last reviewed in October 2022, revealed the policy of the facility is that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Per the policy residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

Based on clinical record review, observations, staff interviews, and policies and procedures, the facility failed to ensure that a request for a modification of a health care institution was approved by the state agency prior to establishing a dialysis center and provided dialysis treatment(s) from March 1, 2024 through March 07, 2025 to 9 residents (#17, 10, 13, 15, 8, 20, 4, 6, and 11) inside the facility. The deficiency may result in non compliance with federal, state, and local laws and professional standards. Findings include: During the complaint survey conducted March 7, 2025 through March 7, 2025, an initial request for documentation was made which included copies of dialysis contracts, the facility's modified license for in-house dialysis services, license for the contracted dialysis provider, and a list and schedule for all residents receiving in-house dialysis services from the contracted dialysis provider. On March 7, 2025 at 11:18 a.m. an interview was conducted with Administrator/Staff #8 who provided the dialysis contracts for the partner dialysis provider. Staff #8 stated that upon the remodeling the dialysis unit, the building plans were submitted to the state; and that, the facility's approval letter was received. Review of the document revealed an approval of architectural plans and specifications, however further review of the document revealed that a multipurpose room [ROOM NUMBER] had been used for inpatient dialysis services. Staff #8 stated the start date for the actively contracted in-house dialysis services started March 1, 2024. Staff #8 stated that a different dialysis company previously provided in-house dialysis services for the patients in their rooms- they went room to room - which started in 2010 - however the presently active dialysis provider started their in-house services March 2024. Staff #8 stated, I thought the plans were the approved plans to perform dialysis in the building. On March 7, 2025 at 11:58 a.m. a follow-up interview was conducted with Administrator/Staff #8. Staff #8 provided resident dialysis lists and stated that he had requested the dialysis' providers' license, but was still waiting for the documentation. Staff #8 stated that as far as modifying the license, he had assumed that the modification plans provided initially were the modification for the facility license to provide dialysis in the facility. Staff # 8 provided on letterhead statement that the facility is unable to acquire licensure from the contracted dialysis provider nor was the facility able to provide a copy of their modified license. A review of the list of residents receiving in-house dialysis services with the actively contracted dialysis provider included the following residents: Resident #17 was admitted to the facility December 07, 2024 with diagnosis including end stage renal disease, dependence on renal dialysis Onset date for renal dialysis December 12, 2024 . Dialysis days are scheduled Mondays, Wednesdays and Fridays. Resident #13 was admitted to the facility December 05, 2024 with diagnosis including end stage renal disease, dependence on renal dialysis Onset date for renal dialysis February 05, 2024 . Dialysis days are scheduled Tuesday, Thursdays and Saturdays. Resident #15 was admitted to the facility December 11, 2024 with diagnosis including acute renal failure, dependence on renal dialysis Onset date for renal dialysis December 11, 2024 Dialysis days are scheduled Tuesday, Thursdays and Saturdays. Resident #8 was admitted to the facility March 06, 2025 with diagnosis including end stage renal disease, type 2 diabetes mellitus with diabetic chronic kidney disease. Onset date January 29, 2025. Dialysis days are scheduled Tuesday, Thursdays and Saturdays. Resident #20 was admitted to the facility December 21, 2021 with diagnosis including end stage renal disease, dependence on renal dialysis. Onset date for renal dialysis January 15, 2024. Dialysis days are scheduled Mondays, Wednesdays and Fridays. Resident #4 was admitted to the facility June 07, 2024 with diagnosis including acute renal failure, dependence on renal dialysis Onset date for renal dialysis June 07, 2024. Dialysis days are scheduled Tuesday, Thursdays and Saturdays. Resident #6 was admitted to the facility November 12, 2024 with diagnosis including end stage renal disease, dependence on renal dialysis. Onset date for renal dialysis November 12, 2024. Dialysis days are scheduled Mondays, Wednesdays, Fridays and Saturdays. Resident #11 was admitted to the facility June 14, 2024 with diagnosis including end stage renal disease, dependence on renal dialysis Onset date for renal dialysis June 14, 2024 Dialysis days are scheduled Tuesday, Thursdays and Saturdays. A review of the facility assessment updated August 1, 2024 revealed there is an average of approximately 55 residents with a degree of end stage renal disease, with an average of 16 on hemodialysis. Further review of the facility assessment revealed an average daily census of 16 residents receiving dialysis services. An interview was conducted March 7, 2025 at 12:50pm with the dialysis nurse (RN/Staff # 42). Staff #42 stated the facility can accommodate four beds dialysis unit. Observation revealed six dialysis machines and two dialysis residents' bedside receiving dialysis treatment. Staff #42 stated the process for residents who receive dialysis in-house is that residents are brought in by the certified nursing assistants. Staff #42 stated the resident is assessed and the nurse will review the orders upon the resident's arrival. Staff #42 stated the run depends on the resident's blood work. The residents blood work is completed weekly and reviewed before dialysis runs which includes a post and pre-blood urea nitrogen (BUN) and tells them about the BUN number. The normal BUN ranges 14-17. Abnormal dialysis BUN ranges 40's-70's. Staff #42 stated the residents always receive their dialysis on time. If the resident has an appointment, the nurse work with them, but generally the resident has a schedule. The runs depend on the schedule and census. Review of the Arizona Administration Code S R9-10-426, titled, Physical Plant Standards revealed, an administrator shall ensure that: a nursing care institution complies with: the applicable physical plant health and safety codes and standards, incorporated by reference in R9-10-104.01, that were in effect on the date the nursing care institution submitted architectural plans and specifications to the Department for approval according to R9-10-104. Review of the Arizona Administration Code S R9-10-104, titled, Approval of Architectural Plans and Specifications revealed, for approval of architectural plans and specifications for the construction or modification of a health care institution that is required by this Chapter to comply with any of the physical plant codes and standards incorporated by reference in R9-10-104.01, an applicant shall submit to the Department an application packet including: An application in a Department-provided format provided by the Department that contains: - For modification of a licensed health care institution that requires approval of architectural plans and specifications: The health care institution's existing licensed capacity, licensed occupancy, respite capacity, or number of dialysis stations; and the requested licensed capacity, licensed occupancy, respite capacity, or number of dialysis stations for the health care institution; etc.

Based on observation, clinical record review, staff and resident interview, and facility policy review, the facility failed to ensure medication were not left at bedside for two residents (#62 and #71) who were not assessed to be clinically appropriate to self-administer medications. The deficient practice could result in medication not administered correctly or medication not taken by the resident. Findings include: -Resident #62 was readmitted on [DATE] with diagnoses of acute respiratory failure with hypoxia, pleural effusion, and pneumonia. The comprehensive care plan included that the resident was at risk for adverse reaction related to polypharmacy black box warning, was prescribed with an opioid, required anticoagulant therapy for atrial fibrillation, was on diuretic therapy. Intervention included to administer medication as ordered. Review of the quarterly minimum data set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The clinical record revealed no evidence found that the resident was assessed and determined to be clinically appropriate for self-administration of medications. In an observation conducted on September 15, 2024 at 8:50 a.m., there was a small plastic medication cup containing a large oblong capsule that was left on the resident's bedside table. The resident stated that the medication was a vitamin he preferred to take after his other medications, since it was large. At this time, a certified nursing assistant (CNA) and a registered nurse (RN/staff #20) entered the resident room; and both staffs saw the medication cup on the resident's bedside table. An interview with the RN (staff #20) was conducted on September 15, 2024 at 8:59 a.m. The RN stated that she administered the resident's morning medications. At this time, resident #62 became upset and stated that he had spat the medication out and planned to take it. In another interview with the RN (staff #20) conducted on September 17, 2024 at 10:25 a.m., the RN stated that she was not aware of any residents that were permitted to self-administer medication. She stated that the risks of leaving medications unattended with residents include the medications would not be administered correctly, and, the residents may not take the medications at all. During an interview with the Director of Nursing (DON/staff #115) conducted on September 18, 2024 at 8:45 a.m., the DON stated that medications were not to be left at the resident's bedside; and if found, should be discarded. She stated that only residents who have an order for self-administration of medications can have medicines left at bedside. 51158 -Regarding Resident #71 Resident #71 was admitted on [DATE] that included a diagnosis of end stage renal disease. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) Assessment score of 15 which indicated intact cognition. Review of the clinical record revealed the following medication orders: - Ativan Oral Tablet 1MG for anxiety -Carvedilol Oral Tablet 12.5 MG for blood pressure >140 -Zoloft Oral Tablet 50 MG for depression Review of the clinical revealed no evidence of medication self administration assessment. Further review revealed no evidence of physician orders regarding self-administering medications. Review of the care plan initiated, revealed no evidence of a focus regarding self administration of medications. During an observation conducted on September 16, 2024 at 9:45 AM, revealed a clear medication cup with 5 medications tablets on Resident #7 ' s bedside table. It was observed that Resident #71 removed a white pill from the cup and threw it into the garbage can located at the bedside. An interview was conducted on September 16, 2024 at 9:43 am with Resident #71, who stated that nurses leave his medications at the bedside and do not stay to watch him take them. He further stated that if he does not want to take a medication he throws it out in the trash can located at the bedside. Resident #71 confirmed this had been going on since his admission. An interview was conducted on September 16, 2024 at 9:55 AM with Staff #96, who stated that nursing staff need to observe residents take the medication. Staff #96 stated he did not stay and observe Resident #71 take him morning medications. Staff #96 stated that the facilities protocol is to document the refusal of a medication and let the provider know, and to throw away the medication in the sharps container located in the room. The RN (staff #96) then located the white pill in the garbage can next to Resident #71 ' s bed. Staff #96 then discarded the medication in the sharps container located in the residents room. The RN (staff #96) stated that the risk could result in medication hoarding and/or can be given to someone else. The RN (Staff #96) stated he was unaware the resident was disposing of his medications. An interview was conducted by surveyor #50553 on September 18, 2024 at 9:45 AM with the Director of Nursing (DON, staff #115), who stated that the facility allows medications at bedside if they have an order to do so. Staff #115 further stated that medications are not to be left at bedside and to be discarded if they were not administered. The risk could result in missed medications and improper dosage. Review of facility policy titled, Medication Administration: Administration of Drugs, revealed that medications must be administered in accordance with the written orders of the attending physician. As well as, if a medication is withheld, refused, or given other than at the scheduled time, the documentation will be reflected in the clinical record. Review of facility policy titled, Care and Treatment: Self Administration of Medications, revealed that if the resident is a candidate for self-administration of medications, a physician ' s order for self-administration of medications or for specific medications to be administered (example inhalers) will be obtained. Self-administration of medications will be care planned.

Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure that care and services was provided to related to a change in condition for one resident (#168); and, failed to ensure failed to ensure the leg rests for tilt-in-space mobility device was put on for one resident (#31) as recommended. The deficient practice could result in the resident's medical needs not being met/treated appropriately and in a timely manner. Findings nclude: -Resident #168 was admitted on [DATE] from the hospital with diagnoses that included urinary tract infection, pneumonia, type 2 diabetes mellitus (DM), urinary tract infection, and pneumonia. Review of a care plan initiated on February 9, 2023, revealed the resident was at risk for impaired cognitive function/dementia or impaired thought processes related to new environment and recent hospitalization and had an ADL (activities of daily living) Self Care Performance Deficit related to limited mobility. Interventions included to monitor/document /report to MD as needed any changes in cognitive function, specifically changes in: level of consciousness, mental status, any potential for improvement, reasons for self-care deficit, expected course, declines in function. The physician order dated February 9, 2023 included for the following: -Insulin Glargine (antidiabetic agent) subcutaneous solution 100 unit/ml (milliliter) inject 70 units subcutaneously every 12 hours for DM; and, -Metformin (antihyperglycemic) 1000 mg (milligram) by mouth every 12 hours for DM. The physician order dated February 10, 2023, revealed the following orders: -To monitor/document report to the physician signs/symptoms of anticoagulant complications that included frank blood in urine, lethargy, shortness of breath, loss of appetite, sudden changes in mental status and significant or sudden changes in vital signs every shift; -Blood sugar checks before meals and at bedtime, notify provider for Blood sugar <70 or >200;. -Dextrose Solution 50%, use 50 ml intravenously as needed for blood glucose less than 70. Administer 50 ml push over 5 minutes, recheck blood glucose in 10 minutes, may repeat x1 if blood glucose remains less than 70; and, -Glucose 30 gm, give 1 dose by mouth as needed for blood glucose less than 70. Recheck blood glucose in 10 minutes, may repeat x 1 if blood glucose remains less than 70. Review of a care plan that was initiated on February 10, 2023 to include interventions to monitor/document/report to MD PRN (as needed) any signs/symptoms of malignant hypertension and anticoagulant complications such as headache, visual problems, confusion, disorientation, lethargy, difficulty breathing (dyspnea), lethargy, shortness of breath (SOB), sudden changes in mental status, significant or sudden changes in vital signs. The resident's oxygen saturation record for February 10, 2023 were following: -At 5:26 p.m., oxygen saturation was 82% via nasal cannula; and, -At 6:16 p.m., oxygen saturation was 87% via nasal cannula. A physician order dated February 10, 2023 included to discontinue foley catheter. A Social Service assessment dated [DATE], revealed that the resident was alert and oriented x 3, had appropriate responses, and there were no concerns at this time. Per the documentation, the resident will be monitored for changes as needed. The progress note dated February 11, 2023 revealed that the foley catheter had been removed and bladder scans were conducted every 6 hours. It also incuded that resident was having wet briefs and PVR's (post void residuals) were within normal range. Review of a vitals report dated February 12, 2023 revealed the resident had the following blood sugar levels: -42mg/dl at 10:24 a.m.; -50 mg/dl at 11:54 a.m.; -43 mg/dl at 4:52 p.m.; and, -57 mg/dl at 8:47 p.m. The clinical record revealed that the resident was receiving oxygen via nasal cannula despite no documentation that the resident had shortness of breath from February 9 through February 12, 2023. The physician order dated February 12, 2023 included for for Glucagon (glycogenolytic agent) 1 mg, inject for blood glucose less than 70 and recheck blood glucose in 10 minutes. Review of the February MAR, revealed that Glucagon had been administered on February 12, 2023 for a blood glucose of 43 mg/dl. The nursing progress note dated February 12, 2023 included that the resident's blood sugar recheck after glucagon shot was 155 mg/dl. The nursing progress note dated February 13, 2023 revealed that on February 12, 2023 at 8:35 p.m., Lantus (brand name for Insulin Glargine) was held due to blood glucose of 56 mg/dl. Per the documentation, at approximately 11:00 p.m. the blood glucose was up to 98 mg/dl. It also included that on February 13, 2023 at 5:00 a.m., the resident's blood glucose was 34 mg/dl and the resident had 2 rounds of glucagon along with nursing interventions; and that, the resident's blood glucose increased to 105 mg/dl. Per the documentation, the provider was notified, orders were received to hold Lantus until February 14, 2023 and to change Lantus to 35 units twice a day. The daily skilled note dated February 13, 2023, revealed the resident was alert and oriented and vital signs do not show any fluctuations from baseline that require interventions. Per the documentation, the resident had a BP of 91/60. The physical therapy note dated February 13, 2023, revealed that the resident was breathing heavily, and moaning in obvious distress with resident's family reporting that the resident's current status was far below the resident's baseline. Per the documentation, the registered nurse (RN) was aware and had informed spouse that the physician will provide assessment within the hour. The occupational therapy note dated February 13, 2023, revealed that the therapist attempted to see the resident, but the resident was too lethargic, very shaky, and with labored breathing. Per the documentation, the resident's family was present and reported that the resident was not being himself, had increased confusion and decreased focus. The documentation included that nursing was consulted and that nursing reported that the resident's blood sugar levels were low earlier. It also included that the provider was notified/consulted about the resident's condition. Review of a speech therapy (ST) note dated February 13, 2023, revealed that the resident was seen sitting upright in bed on 6L of oxygen O2, via nasal cannula, had decreased alertness and arousal. Per the documentation, the resident's family was present and reported concerns regarding the resident's change status. The documentation also included that nursing staff were notified. Review of a vitals report dated February 13, 2023, revealed the resident had the following blood sugar levels: -34 mg/dl at 5:36 a.m.; -40 mg/dl at 11:36 a.m.; and, -33 mg/dl at 7:58 p.m. The medication administration note dated February 13, 2023 at 11:36 a.m., revealed that the resident was alert and had a blood sugar level was 40 mg/dl. Per the documentation, glucagon was administered, the provider was aware and there were pending new orders. The physician order dated February 13, 2023 included the following: -Humalog subcutaneous solution (Insulin Lispro) inject per sliding scale; an, -Insulin Glargine Subcutaneous solution 100 unit/ml, inject 35 units subcutaneously every 12 hours for DM. A care plan initiated on February 13, 2023, revealed an additional focus of oxygen therapy related to ineffective gas exchange, with interventions that included to monitor signs and symptoms of respiratory distress and report to provider as needed, and oxygen settings as ordered. The clinical record revealed no evidence that the provider was notified or made aware of the change in the resident's condition such as lethargy, increased confusion or labored breathing. Another physician order dated February 13, 2023 revealed an order for a STAT CMP (comprehensive metabolic panel) and ammonia and chest x-ray related to congestion. The Xray results dated February 13, 2023 included patchy opacity in both lungs, likely secondary to pulmonary edema, atelectasis and/or pneumonia. There was no evidence that the provider was notified with the x-ray report results. Review of a vitals report dated February 14, 2023 at 1:22 AM, revealed the following blood sugar levels of 56 mg/dl. Review of a nursing progress note dated February 14, 2023 included a blood sugar level of 56 mg/dl was reported to the provider with orders to try to get the resident to eat, if not start dextrose 5%. Per the documentation, the resident consumed 360 ml of supplement and med pass drink and ice cream; and that, the provided was notified that blood glucose will be rechecked at approximately 2:00 a.m. The documentation also included that the provider instructed to recheck blood sugar between 4:00 a.m. and 5:00 a.m. However, there was no evidence found in the clinical record that the resident's blood sugar was rechecked on February 14, 2023 at 2:00 a.m., or between 4:00 a.m. and 5:00 a.m. as documented. Review of a provider's history and physical note dated February 14, 2023 included chief complaints of physical deconditioning, catheter associated UTI, and diabetes mellitus type 2. Per the documentation, since admission the resident had episodes of hypoglycemia, looked like he was not eating well, was having hematuria, and was not behaving well. The documentation also included that the resident appeared acutely ill, had physical deconditioning, confused metabolic encephalopathy etiology unclear, hematuria likely due to recent foley catheter discontinuation. A Daily Skilled Note dated February 14, 2023 revealed the resident was confused and family was at bedside and reported that the resident was not at his baseline a couple of days ago. Assessment included acute encephalopathy. It also included that the resident continued on 5 liters of oxygen via nasal cannula. The admission Minimum Data Set (MDS) dated [DATE], revealed a Staff Assessment for Mental Status indicating memory problems, moderate impairment and altered level of consciousness that comes and goes. Review of the State Agency complaint tracking system revealed that February 16, 2023, a complaint was filed by the resident's family who reported that the resident got sick the day after he was admitted at the facility; and that, the resident had a bad episode and confusion. Per the report, the family asked the facility to call 911 but was told that the paramedics cannot come into the facility and the facility's doctor would come; but, that the facility doctor did not come. An interview was conducted on September 16, 2024 at 09:45 AM with the resident's family who stated that on February 14, 2023 she observed that the resident was more confused, was groaning, and as the time progressed he became non-responsive, and that this occurred approximately 2 days after the catheter was removed due to blood clots. The family stated that there was no provider who came in to evaluate the resident and the catheter was not replaced. The family stated that the resident was unconscious in the hospital for almost 30 days, was still recovering; and that, the resident now has as short term memory loss. She further stated that the hospital told her that the resident became sick from toxins that got into his body related to the catheter being removed, and not replaced. In another interview with the resident family conducted on September 16, 2024 at 10:20 a.m., the family stated that when she went into see the resident in the morning of September 13, 2023, the resident was already sick; and that, an occupational therapist conducted a cognitive test on February 13, 2023. The family said that the resident did not know what state he was currently living in, and this was unusual for him. An interview was conducted on September 16, 2024 with the Assistant Director of Nursing (ADON/staff #91), who stated that when a resident representative would ask a nurse to send a resident out to the hospital, the provider would be notified and the resident would be sent to a higher level of care. She stated that it would not meet her expectations that a nurse would tell a family member, that the paramedics cannot come in and that the provider would come see them. She stated that paramedics were able to come into the facility during February 2023. She stated that the nurse should document per family request that they requested the resident to be sent to the hospital. Further, the ADON stated that the expectation was that the nurse would follow standing orders for glucose and notify the provider for further orders, and not impede a resident being sent out if the family requested. A telephone interview was conducted with a Licensed Practical Nurse (LPN/staff #149) on September 17, 2024, who stated that when physical therapy or a resident's representative informs nursing of a resident health concern the resident should be immediately assessed, the provider should be notified, and it should be documented in progress notes. The LPN also stated that a change of condition would include an increase in a resident's oxygen needs, uncontrolled blood glucose, and observations of the resident shaking; and, this should be documented in the progress notes. An interview with a ST (staff #118) was conducted on September 17, 2024 at 11:52 a.m. The ST stated on February 13, 2023, she spoke with the resident's family who was concerned about the resident's medical status. The ST stated that she notified the nurse approximately at 11:00 a.m. - 12:30 p.m. on February 13, 2023. The ST stated that the resident had a change in condition from her initial evaluation on February 10, 2024; and that, the resident was The ST also stated that the resident demonstrated decreased alertness and was not easily arousable. She stated that the facility's policy on change of condition related to cognition and not eating would include notifying the nursing staff. An interview was conducted on September 17, 2024 at 12:06 p.m. with an OTA (occupational therapy assistant/staff #68), who stated that he treated the resident on February 13, 2024; and that, the resident was too lethargic to treat that day. Further, the OTA stated that he reported the resident's status to nursing staff. An interview was conducted on September 17, 2024 at 12:24 p.m. with a Licensed Practical Nurse (LPN/staff #6), who stated that if therapy or resident family notifies her of a resident's change in condition or health concern she would immediately observe the resident, take vitals, talk to the resident and notify the provider. She also stated the nurse should be familiar with the resident and have caught the change earlier. She stated that if the provider had been notified earlier regarding a blood glucose concern or if the resident's representative or therapist reported concerns about a resident's change in health status, she would notify the provider and documented the concerns and provider notification in a progress or change of condition (COC) note. She further stated that for a change in cognition, or blood glucose concern would also be documented in a change of condition note. A review of the clinical record was conducted during the intervew with the LPN who stated that there was no evidence that the nurse contacted the provider regarding the reports made by the therapist/s or resident representative regarding the resident's change in cognition or health status such as lethargy or confusion or not easily arousable. The LPN stated that the clinical record only showed that the provider was notified only of the resident's blood sugar (BS) level. She further stated that for a COC note, they document what was done to address the concern, recheck the blood sugar levels, when the provider was notified, and the times that he was notified. The LPN stated that nursing should notify the provider after each BS check to see if the BS was improving. She also said that nursing should have started a new COC assessment/charting for the new changes in cognition and blood glucose control, and document the findings on the MAR. During the review of the clinical record, the LPN stated that there was a change in cognition monitoring/documentation for the resident's new admission; however, there was no evidence that change of condition assessments/vitals had been provided to the provider regarding the reports from the therapist and the resident's family related to the resident's lethargy, confusion and not easily arousable. The LPN stated that a STAT lab and stat X-ray were ordered and completed; but, there was no evidence in the clinical record that the provider was notified of the X-ray results. The LPN also stated that the risk in not notifying the provider of x-ray results could result in respiratory distress or death. The LPN also stated that an infection could cause a fluctuation in blood sugar levels, as well as some antibiotics; and, a low oxygen saturation and an increased oxygen need could also be a change in the resident's condition. The LPN stated that if the resident's family requested that a resident be sent to the hospital, the provider would be notified; and that, the resident's representative and resident have overall decision and there was no physician that would disagree. Regarding resident #168, during February 2023 there was no reason why EMS could not have entered the facility to transfer the resident to a higher level of care. An interview was conducted on September 18, 2024 at 8:32 a.m. with the Director of Nursing (DON/ staff #115), who stated that the expectation was for nurses to assess a a resident when therapy informs them of a resident health concern. She also stated that if the nurse feels that there was a decline in the resident's condition, the provider would be notified, and it would be documented in the clinical record. The DON also stated that when a resident's representative requests that the resident be transferred to another facility, they would follow what the family requested, contact the provider and document in the clinical record. The DON stated that anything outside of baseline should be documented as a change of condition and could include an increase in oxygen needs, shortness of breath, increased temperature, uncontrolled blood glucose. The DON also stated that nursing should inform the provider regarding the representative's and therapist's concerns about a resident's decline that included being shaky, and increased oxygen needs. The DON stated that she had previously reviewed Resident #168's clinical record and knew that there were 3 days with hypoglycemia. She further stated that it did not meet her expectations that nursing did not complete an assessment after therapy reported concerns about the resident #168's status. The DON stated that there was no evidence in the clinical record that that an assessment had been conducted; and that, the resident's change of condition had not been addressed as quickly as it should have been. The DON further stated that the resident's provider was no longer at the facility, and she did not feel like he acted or addressed things promptly. The DON also stated that the clinical record revealed that the provider saw resident #169 on February 14, 2023 at 6:37 a.m.; and that, a late entry note for this encounter was dictated by the provider on February 18, 2024. She further stated that the risk of not addressing a change in condition could result in sepsis leading to death. In another interview conducted with the DON on September 18, 2024 at 12:51 p.m., the DON stated that the clinical record revealed no evidence that the provider was notified of the chest X-ray results; and that, the results had been marked as reviewed by the provider. She stated that the physician progress note dated February 14, 2023 that was a late entry on February 18, 2024, may have been mis-dated and should have been dated February 13, 2024. A policy titled, Change of Condition Reporting, relayed that all changes in resident condition will be communicated to the physician and resident representative and documented. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse will notify the physician. All nursing actions will be documented in the licensed progress notes as soon as possible after resident needs have been met. Routine medical change: unusual signs and symptoms will be communicated to the physician promptly. Routine changes are minor changes are minor changes in physical and mental behavior, abnormal laboratory and X-ray results that are not life threatening. The nurse is responsible for notification of physician prior to end of assigned shift when a significant change in resident's condition is noted. Document resident change of condition and response in nursing progress notes and update resident care plan as indicated. All attempts to reach the physician will be documented in the nursing progress notes, and will include time and response. The comprehensive care plan will be updated/revised accordingly. 51124 -Resident #31 was readmitted on [DATE], with diagnoses of acute respiratory failure, stroke, hemiplegia and hemiparesis affecting the right side, and unspecified psychosis. A review of the Quarterly MDS (minimum data set) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete the interview for cognitive screening. The assessment included that the resident was dependent for toileting, dressing, and rolling in bed.; and that, the resident had impairments in functional range of motion in both of her lower extremities. Review of the care plan initiated May 18, 2022 revealed the resident was at risk for falls. Intervention included for physical, occupational, and speech therapy services per physician orders. The Wheelchair and Seating Evaluation dated December 28, 2022 revealed that the resident spends all waking hours, 12-15 hours in the wheelchair. The goals of obtaining a custom tilt-in-space manual wheelchair were to be able to tolerate sitting in a chair all day, to facilitate pressure relief to reduce the risk of pressure ulcer formation, and to facilitate postural control. Additionally, it was documented that the Assistive Technology Professional (ATP) from the contracted wheelchair company along with the physical therapist (PT/ Staff #16) were present for the evaluation. Per the documentation, the resident required the use of a tilt-in-space mobility device to meet the needs of her medical condition and address her mobility impairments; and that, the resident was unable to maintain her sitting balance without support. The documentation also included that the recommended parts for the custom chair included manual elevating swing away leg rests with a foot box for proper lower extremity positioning and decrease risk of wounds. A physical therapy evaluation dated June 4, 2024 revealed that the resident had impaired range of motion in both of her ankle joints, had a 45 degree deficit in the right ankle and a 40 degree deficit in the left ankle. The therapy goals included for Resident #31 to improve her bilateral ankle dorsiflexion (ability to bend the ankle to move the foot upward/toward the body). The occupational therapy treatment encounter notes dated June 10 and June 25, 2024 revealed the resident presented to therapy in her custom chair without the foot rests in place. A therapy progress note dated September 15, 2024 revealed that the resident required maximum to total assistance for completion of activities of daily living (ADLs) and mobility, had a custom tilt-in-space wheelchair, and had a slight decline in the range of motion of both of her ankles. An observation was conducted on September 15, 2024 at 11:46 a.m. and revealed that the resident was sitting in a custom tilt-in-space wheelchair reclined approximately 30 degrees, with no leg rests on. The resident's legs were dangling from the chair unsupported. and her feet were pointed downward from the ankle joints. There was no evidence of the resident's leg rests were in the room. In another observation conducted on September 16, 2024 at 9:24 a.m. the resident was in the hallway next to the nurse's cart, sitting in a custom tilt-in-space wheelchair reclined approximately between 30 to 45 degrees, with no leg rests on, and her legs were dangling from the chair unsupported. The resident's feet continued to point downward from the ankle joints. The staff at the nurse's cart then pushed resident #31 down the hall and stated that they were going to activities. An observation conducted on September 16, 2024 11:15 a.m. The resident was positioned in the same wheelchair with no leg rests and the chair's tilt was positioned so that the resident was sitting almost fully upright. The resident's legs continued to dangle without support as they did not reach the floor. Both feet continued to point downward from the ankle joints. On September 17, 2024 at 9:37 a.m., the resident was in the same custom tilt-in-space wheelchair with no leg rests. The tilt was reclined to approximately 30 degrees. The resident's legs dangled in the air with the feet pointed downward from the ankles. In an interview conducted on September 17, 2024 at 9:37 a.m., a certified nursing assistant (CNA/Staff #55) stated that she was very familiar with Resident #31 and worked with her daily. The CNA stated that the resident's custom wheelchair leg rests had been missing for the past approximately 2 weeks; and that, she had told someone from therapy about it 2 weeks ago, but could not recall which therapist she had notified. An interview with the Director of Rehab (DOR/Staff #16) was conducted on September 17, 2024 at 9:57 a.m. The DOR stated that a resident should be properly positioned in a wheelchair with arms and legs supported and with adequate back support. The DOR said that most people do not like their feet dangling and therapy does not want the resident's feet positioned downward for positioning. The DOR stated that prior to this date, there was no staff who reported to him that the leg rest for the resident's (#31) wheelchair were missing. However, the DOR said that the leg rests were missing approximately a month ago and were then found. The DOR stated that the CNA (staff #55) reported that the leg rests of the resident's wheelchair were missing; and that, he was able to locate them and put them on the resident's wheelchair. An interview was conducted on September 17, 2024 at 1:01 p.m. with a physical therapist (PT/staff #2) who stated that when positioning a resident in a wheelchair, it was important to have proper support, including armrests, leg rests if needed, and a wheelchair cushion. However, the PT stated that types of equipment and recommendations were resident-specific. The PT stated that a benefit of utilizing leg rests for a resident for whom it was recommended would be comfort and to keep the legs in neutral positioning. The PT also said that the risks of not having leg rests would be the potential for legs to catch on something or a soft tissue injury during transportation if a resident's legs were hanging down. Regarding resident #31, the PT said that the resident had tightness in her ankles that could be from prolonged bedrest or a position in which the feet point downward from the ankle joints. She further stated that she had been aware of Resident #31 having missing leg rests for her wheelchair however could not specify when. In another interview with the DOR (staff #16) conducted on September 17, 2024 at 1:13 p.m., the DOR stated that the resident's leg rests had been missing on and off; and, at times, the resident refuse putting on her leg rests. A review of the therapy notes was conducted with the DOR who stated that he could find no evidence of documentation that resident #31 refused her leg rests. Further, the DOR stated that the care plan was revised to add that the resident can refuse her leg rests. The DOR also said that proper positioning was important for contracture management. Another interview with the DOR (staff #16) was conducted on September 18, 2024 at 9:10 a.m. The DOR stated that the purpose of getting a resident a custom wheelchair would include to decrease risk of wounds, increased participation in activities, contracture management, accommodate specific residents' positioning, and to allow residents to spend more time out of their room. The DOR stated that part of the process for getting a resident a custom wheelchair was that a physician provides a signature certifying that the custom wheelchair is medically necessary for the resident. In an interview on September 18, 2024 at 9:25 a.m., the social services director (SSD/staff #88) stated that she receives reports of missing items; but, she had not received any missing item report for Resident #31 for the past month. On September 18, 2024 at 10:33 a.m., an interview was conducted with the Director of Nursing (DON/staff #115) who stated that proper positioning and comfort are important parts of positioning a resident in a wheelchair. Further, the DON stated that there could be a risk of injury if a limb was dangling down unsupported. The DON also said that if a resident had a custom wheelchair and was not seated or positioned as recommended the risk would be improper positioning that could lead to contractures, falls, or pressure ulcers. Further, the DON stated that it was the staff's responsibility to ensure that equipment was not misplaced for a resident who is dependent for care; and, if an equipment was missing, staff should attempt to locate it as soon as possible and notify social services if it cannot be found. Review of the facility's policy titled Quality of Care: ADL, Services to Carry Out, revised July, 2015, revealed that residents are to be given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Mobility aids, such as wheelchairs, will be provided according to the resident's assessed needs. Review of the facility's policy titled Personal Property, Resident's, revised May, 2007, revealed that the facility is to provide space and safety for resident's personal property, and that the facility is to store all items in appropriate place. The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property.

Based on observations, staff interviews, and facility documentation and policy review, the facility failed to ensure food items were dated when opened; failed to ensure food readily available for resident use were not expired; and, failed to ensure that the ceiling air vents above the food tray line and the kitchen ice machine were clean. The deficient practices increase the potential for foodborne illness. Findings include: -Regarding food storage and expired food items: A kitchen observation was conducted on [DATE] at 8:24 a.m. and revealed the following food items found in the refrigerator were beyond their use by date: -A bag of grated parmesan cheese with a use by date of [DATE]; -An opened bag of lettuce salad secured with a tie, with a use by date of [DATE]; and, -Two additional bags of lettuce salad with a use by date of [DATE]. An observation of the first unit refrigerator was conducted on [DATE] at 8:48 a.m. There were 7 small cartons of milk with a use by date of [DATE]. The following food items were found in the refrigerator, opened but not dated or had no use by date: -An opened bottle of orange juice with a resident's name; -An opened turkey deli meat package with a resident's name marked; and, -A piece of pizza wrapped in paper towel with no resident room number. An observation of the second unit resident refrigerator was conducted on [DATE] at 9:03 a.m. There was a bottle of salad dressing with a use by date of [DATE]. The following food items were found in the refrigerator, opened but not dated or had no use by date: -Cheesecake with a resident's room number marked; -Tortilla chips and salsa in a bag with a resident's room number; and, -A piece of cake stored in a Styrofoam bowl with another upside-down Styrofoam bowl on top to cover it, with a resident's room number marked. An observation of the third unit resident refrigerator was conducted on [DATE] at 9:10 a.m. and revealed the following food items found in the refrigerator were beyond their use by date: -A Danish pastry with a use by date of [DATE]; and, -An opened container of orange juice with a date marked as [DATE]. An interview was conducted on [DATE] at 8:54 a.m. with a certified nursing assistant (CNA/staff #33) who stated that for food brought in by resident's visitors, the CNAs/staff would check with the nurse to ensure the food brought in aligned with the resident's diet orders, ensure the food was in a sealed container, and was marked with the resident's room number. In an interview with a dietary aide (staff #78) conducted on [DATE] at 8:55 a.m., the dietary aide (staff #78) stated that there was a 3-day limit for food brought in for residents from outside sources to be stored in the unit refrigerators, and that it must be disposed of after the three days. An interview was conducted on [DATE] at 9:03 a.m. with the Dietary Manager (staff #144) who stated that food brought in by visitors would be kept for 3 days, and marked so that it can be disposed of on the correct date. The dietary manger stated that if the food was a condiment such as bottled salad dressing, it can be kept for 30 days or the manufacturer's use by date, whichever comes first. An interview was conducted with the Administrator (staff #101) on [DATE] at 1:34 p.m. The Administrator stated that it was his expectation that staff follow the facility's policies to ensure safe food storage. Review of the facilities policy on Food Storage, dated 2013, revealed that potentially hazardous foods and time/temperature control for safety (PHF/TCS) foods should be covered, labeled, and dated. All foods will be checked on to ensure that foods will be consumed or discarded by their use by dates. -Regarding the ceiling vents: An observation was conducted in the facility's kitchen on [DATE] at 10:32 a.m. The ceiling vent located above and between the sink and the tray line was coated with a layer of dust and debris that extended from the vent onto the surrounding ceiling and onto the light fixture that was next to the vent. An interview was conducted with the Dietary Manager (staff #144) on [DATE] at approximately 10:40 a.m. The dietary manager stated that the ceiling vents were to be cleaned monthly; and that, she thinks that the ceiling vent between the sink and the tray line previously observed got overlooked. In an interview conducted on [DATE] at 11:35 a.m., the Maintenance Director (staff #171) stated that the vents in the kitchen were last cleaned in [DATE]. The facility policy for Cleaning Vent Fans issued by the facility's electronic maintenance log revealed that the Maintenance Department is to inspect exhaust fans for proper operation and clean if necessary and monthly. The policy included to clean vents using vacuum and air compressor to remove all dust. -Regarding the ice machine: A kitchen observation was conducted with the dietary manager (staff #144) on [DATE] at 10:32 a.m. On the side of the ice machine was a paper cleaning log for the ice machine which was labeled as monthly; and, there were weekly spaces on the log for employees to initial. Review of the log for the third week in [DATE] revealed that it was marked that a deep clean occurred from a contracted company. There were no markings present on the log for the last week in [DATE], and for any of the weeks in August or [DATE]. Continued observation of the ice machine revealed that the inside of the ice machine had a gray plastic shroud that had a black-brown discoloration on the bottom edge. During the observation, a clean, white cloth was provided by the dietary manager and the edge of the plastic shroud in the ice machine was wiped to reveal a residue that appeared brown on the white cloth. An interview was conducted with the dietary manager (staff #144) on [DATE], at 10:34 a.m. The Dietary Manager stated that the ice machine gets deep cleaned every three months by an outside contracted company; and, it was supposed to be wiped down weekly. Staff #144 stated weekly cleaning of the ice machine involved taking a clean cloth and wiping the inside of the ice machine with soapy water. In an interview conducted on [DATE] at 11:35 a.m., the maintenance director (staff #171) stated that there was a deep cleaning for the ice machine from a contracted company that occurred in [DATE]; and that, the maintenance department has not cleaned the ice machine since then. The facility's policy for the Ice Machine issued by the facility's electronic maintenance log revealed that the Maintenance Department is to wipe clean the ice machine monthly. Review of the facility's policy titled Cleaning Instructions: Ice Machine and Equipment revealed that the ice machine is to be cleaned on a regular bases to maintain a clean, sanitary condition. The steps include to remove the ice, wash the interior thoroughly with a detergent solution, to sanitize, and to allow to air dry.

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 contamination. Findings: During the Medication Administration observation with the Licensed Practice Nurse (LPN/staff #6) conducted on September 17, 2024 at 7:58 a.m., the LPN dropped a used plastic vial of normal saline on the floor. The LPN then picked the vial up off the floor with her bare hands, and placed the empty vial in the sharps container on the medication cart. The LPN proceeded to open medication cart drawers and started preparing medications to be administered without sanitizing her hands. In another observation was conducted the LPN (staff #6) on September 17, 2024 at 8:25 a.m., the LPN dropped a packet on the floor from her pocket. She picked up the packet off the floor with her bare hands and placed it back in her pocket. Without sanitizing her hands, she locked the medication cart, picked up the prepared medications and entered the resident's room with the prepared medications. An interview was conducted on September 17, 2024 at 8:40 a.m. with the LPN (staff #6) who stated that the hand hygiene included sanitizing hands after picking items up off the floor. She stated she did not sanitize her hands after picking both items up off the floor; and that, the risk could include contamination. An interview was conducted on September 18, 2024 at 10:14AM, with Director of Nursing (DON/staff #115) who stated that the hand hygiene included for a staff to use sanitizer or wash their hands after picking items off the floor with bare hands. She further stated that the risk of not perfroming hand hygiene could include contamination. Review of the facility policy titled, Hand Hygiene, revealed that hand washing/hand hygiene is generally considered the most important single procedure for preventing the transmission of infection.

Based on clinical record review, observations, interviews, and policy review, the facility failed to ensure one resident (#72) was treated with dignity and respect. The deficient practice could result in resident's self-esteem and self-worth not maintained, honored and valued. Findings include: Resident #72 was admitted on [DATE] with diagnoses of muscle disuse atrophy, dysphagia, cognitive communication deficit, and need for assistance with personal care. The care plan initiated on January 13, 2023 included that the resident had a potential for nutritional problems, required adaptive equipment to assist with independent feeding and had self-care performance deficit. Intervention included to encourage participation to the fullest extent possible, promote dignity by ensuring privacy, and required staff assistance for ADLs (activities of daily living). The nutrition-quarterly evaluation dated September 9, 2024 included that the resident preferred dining location preference was his room; and that, the resident needed meal tray set-up, and limited assistance, but was otherwise able to self-feed. The MDS (minimum data set) assessment dated [DATE] revealed resident was assessed by staff as severely impaired on cognitive skills for daily decision making. The MDS included that the resident coughs or chokes during meals or when swallowing medications and required a mechanically altered diet. The physician progress note dated September 15, 2024 included that there was a regression in the resident's ability to swallow. Recommendation included proper positioning during meals, and feeding the resident when less lethargic from anxiety medications. An observation was conducted on September 15, 2024 at 8:35 a.m. The resident was lying supine in bed with pureed-like substance caked around resident's mouth and beard. The resident was wearing a red short sleeved shirt which was also saturated with pureed-like substance, his legs exposed and he had one sock on and the other off. The resident's bed was placed in lowest position with a visibly soiled blue fall mat on floor; and the side table with the meal tray was elevated and placed on the right side of the resident's bed. In an interview conducted with a licensed practical nurse (LPN/staff #6) conducted on September 15, 2024 at approximately 9:00 a.m., the LPN stated that breakfast trays were usually picked up around 9:30 a.m. An interview with a certified nursing assistant (CNA/staff #58) was conducted on September 15, 2024 at approximately 9:50 a.m. The CNA stated that staff conducts resident rounds every two hours, or more frequent if needed to check on resident needs. However, in another observation conducted on September 15, 2024 at 11:01 a.m. (approximately 2 1/2 hours after the initial observation), the resident was sleeping in bed with pureed-like substance caked still around resident's mouth and beard. The resident was still wearing the red short sleeved shirt which was saturated with pureed-like substance. According to facility policy entitled ADL, Services to carry out, if the resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, and grooming will be provided by qualified staff.

Based on observation, record review, interviews, and facility policy review, the facility failed to ensure there was physician order for the oxygen use for two sampled residents (#219 and #168). The deficient practice could result in unnecessary oxygen use for the resident. Findings include: -Resident #219 was readmitted on [DATE] with diagnoses of that included end stage renal disease (ESRD) with dependence on renal dialysis, respiratory failure and type 2 diabetes mellitus. The care plan dated January 28, 2023 included that the resident had altered respiratory status and difficulty breathing related to hypertension and ESRD. Intervention included to maintain a clear airway by encouraging resident to clear own secretions with effective coughing. A review of the oxygen summary from February 17 through March 15, 2023 revealed the resident was documented to be on oxygen via nasal cannula on February 20, March 3, 8, 9, 10, 13, 14 and 15, 2023. The daily skilled note dated March 13, 2023 included that resident had an oxygen saturation (O2 sat) of 98% and was on oxygen via nasal cannula. A late entry physician progress note dated March 13, 2023 revealed the resident had chronic hypoxic respiratory failure with hypoxia and OSA (obstructive sleep apnea) with CPAP (continuous positive airway pressure) during the night. Despite documentation that the resident was on oxygen via nasal cannula, there was no physician order for the use of oxygen found in the clinical record from February 17 through March 15, 2023. The physician order dated March 16, 2023 included for oxygen at 1-3 liters/minute via NC continuously and may titrate to maintain O2 sats greater than 90%. the start date for this order was March 17, 2023. An additional order was present dated March 17, 2024 for O2 at 1-3 liters per minute via nasal cannula to maintain O2 saturation greater than 90%. There was no evidence of any other oxygen orders to cover the timeframe from when Resident #219 re-entered the facility on February 17, 2023 until March 16, 2023. The care plan dated March 17, 2023 revealed the resident had oxygen therapy related to ineffective gas exchange. Interventions included oxygen settings as ordered, give medication as ordered by physician and monitor/document side effects and effectiveness. In an interview with the Assistant Director of Nursing (ADON/staff #91) conducted on September 17, 2024 at 8:42 a.m., the ADON stated that according to facility policy, oxygen therapy would require a physician order in place. A review of the clinical record was conducted with the ADON who stated that she could find no evidence of any physician order for oxygen use for resident #219 from February 17 through March 16, 2024. An interview was conducted on September 17, 2024 at 9:03 with the respiratory therapy director (RTD/staff #59) who stated that respiratory therapy was following and providing care to Resident #219 when he was initially admitted to the facility in December 2022. The RTD said that when the resident went to the hospital in February 2023, respiratory services were discontinued. The RTD said that when the resident was readmitted on [DATE], there was no referral or order for respiratory therapy for resident #219. During the interview, the RTD reviewed the clinical record and stated that there was no evidence of any oxygen orders and respiratory care plan in place for resident #219 from in February until March 16, 2023. In an interview with the Director of Nursing (DON/staff #115) conducted on September 18, 2024 at 10:52 a.m., the DON stated that it was the facility's policy that oxygen administration has a physician order; and that, the risk of administering oxygen without an order could be over delivery of oxygen for a resident. The DON said that this would not align with the facility's policy. 43863 -Resident #168 was admitted on [DATE] with diagnoses of urinary tract infection (UTI), pneumonia and type 2 diabetes mellitus The physician order dated February 10, 2023 revealed to document the following: -Temperature and oxygen saturations and monitor for symptoms: fever, cough, shortness of breath, chills, shaking/chills, headache congestion every shift; -Shortness of breath at rest every shift for 10 day; -Shortness of breath lying flat every shift for 10 days; and, -Shortness of breath with exertion every shift for 10 days. The resident's oxygen saturation record for February 9, 2024 was 92%. The resident's oxygen saturation record for February 10, 2023 were following: -At 5:26 p.m., oxygen saturation was 82% via nasal cannula; and, -At 6:16 p.m., oxygen saturation was 87% via nasal cannula. A medication administration note dated February 11, 2023 included that a new admission change of condition assessment was done; and that, the resident was receiving 4 liters of oxygen via nasal cannula. The resident's oxygen saturation record for February 11, 2023 were following: -At 12:12 a.m. - 87% via nasal cannula; -At 5:23 a.m. - 94% via nasal cannula; -At 5:46 p.m. - 93% via nasal cannula. A daily skilled note dated February 11, 2023 revealed the resident had an oxygen saturation of 94% with oxygen via nasal cannula. The resident's oxygen saturation record for February 12, 2023 were following: -At 8:43 a.m. - 93% via nasal cannula; and, -At 7:21 p.m. - 95% via nasal cannula. The daily skilled note dated February 12, 2023 included an oxygen saturation at 93%, with oxygen via nasal cannula. The Medication Administration Record (MAR) for February 2023 also revealed no evidence that the resident was administered oxygen from February 9, 2023 through February 12, 2023. Despite documentation that the resident was receiving oxygen via nasal cannula, there was no evidence of a physician order for oxygen use and administration for resident #168 from February 9 through February 12, 2023. The care plan was revised on February 13, 2023 reveal to include an additional focus of oxygen therapy related to ineffective gas exchange. Interventions included to give medications as ordered by physician, monitor/document side effects and effectiveness, monitor signs and symptoms of respiratory distress and report to provider as needed, and oxygen settings as ordered. The daily skilled note dated February 13, 2023 revealed the resident was alert and oriented and had oxygen saturation at 92%, with oxygen via nasal cannula. The resident's oxygen saturation record for February 13, 2023 were following: -At 6:35 a.m. - 92% via nasal cannula; -At 7:07 p.m. - 94% via nasal cannula. The speech therapy (ST) note dated February 13, 2023 revealed the resident was sitting upright in bed on 6L (liters) of oxygen via nasal cannula. A pulmonary consult note dated February 13, 2023 included the resident was discharged from the hospital on 5 liters oxygen via nasal cannula; and that, to wean oxygen to maintain SpO2 (oxygen saturation) >90%. However, the physician order dated February 13, 2023, included to administer oxygen at 2 liters/minute via nasal cannula continuously; may titrate to maintain oxygen saturations greater than 90%. Review of the clinical records dated February 11 through February 14, 2023 revealed no evidence that the provider was notified of the increase in oxygen from 2 liters to up to 6 liters. Continued review of the MAR revealed that an order for oxygen was transcribed onto the MAR with order date of February 13, 2023. And had a discontinued dated of February 15, 2023. It also included that oxygen was administered to the resident on February 13 and 14, 2023. The admission Minimum Data Set (MDS) dated [DATE], revealed a Staff Assessment for Mental Status indicating memory problems, moderate impairment and altered level of consciousness that comes and goes. The provider's history and physical dated February 14, 2023 included a chief complaint of recent influenza along with COVID-19 infection with acute hypoxic respiratory failure; and that, the resident was stabilized at an acute care hospital and was transferred to the facility on 2 liters of oxygen for ongoing rehabilitation. Per the documentation, the resident appeared acutely ill; and had acute respiratory failure with hypoxemia due to underlying pneumonia/influenza. It also included that the resident remained on oxygen. The vitals report for February 14, 2023 revealed the resident had 91% oxygen saturation at 8:05 a.m. and 12:51 p.m. A Daily Skilled Note dated February 14, 2023 revealed an oxygen saturation of 91% at 8:05 a.m.; and that the resident received oxygen via nasal cannula. Per the documentation, the resident was confused and family was at bedside and reported that the resident was not at his baseline a couple of days ago. Assessment included acute encephalopathy. It also included that the resident continued on 5 liters of oxygen via nasal cannula. A Case Manager progress note dated February 14, 2023 included that the resident was alert and oriented and was currently on 4 liters of oxygen. Per the documentation, cognitive symptoms were described as able to answer minimal questions, able to answer to name being called. An interview was conducted on September 17, 2024 at 12:24 p.m. with a Licensed Practical Nurse (LPN/staff #6), who stated that if a resident has a low oxygen saturation she would notify the provider for orders, and that this would be a change in condition. She stated she would assess the resident, check the vitals, talk to the resident, notify the provider, and document in the clinical record. The LPN stated that she would expect that the provider was notified of the resident's increased need for oxygen; and that, a new oxygen order was received from the provider for administration if oxygen was increased from 2 to 6 liters. A review of the clinical record was conducted with the LPN who stated that there was no evidence of a physician order to administer oxygen at 4-6 liters to resident #168. An interview with the with the Director of Nursing (DON/staff #115), was conducted on September 18, 2024 at 8:32 a.m. The DON stated that anything outside of the resident's baseline should be documented as a change in condition and that could include an increase in oxygen needs, or shortness of breath. She further stated her expectation was that the provider would be notified regarding the changes in a resident's condition, and, the change would be documented in the clinical record. The DON also stated that nurses may titrate oxygen up or down, but if there was continuous increase the nurse should notify the provider, especially if there was still shortness of breath, and document in the clinical record. She further stated that she would expect nursing to notify the provider using SBAR (situation, background, assessment, recommendation) regarding an increase in oxygen needs. Review of the facility's policy on Oxygen Administration, revised in July 2013, revealed that oxygen therapy is administered as ordered by the physician or as an emergency measure until the order can be obtained. It also included a purpose to provide sufficient oxygen to the blood stream and tissues. The policy included that oxygen therapy is administered as ordered by the provider or as a nursing measure until the order can be obtained. The clinical record will include charting and documentation related to oxygen use.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure the resident representative (RR) was notified in writing of a transfer to the hospital for one resident (#6). The deficient practice could result in the RR not being informed of changes in resident status. Findings included: Resident #6 was admitted on [DATE] with diagnoses of respiratory failure, diabetes mellitus, quadriplegia, and seizure disorder. The physician order revealed an order for a blood draw for a complete blood count (CBC) on October 23, 2023. Review of the laboratory report dated October 23, 2023 included the resident had a critically low hemoglobin of 5.7 grams per deciliter (g/dl). The nursing note dated October 23, 2023 revealed the doctor was contacted regarding the critical laboratory value and the nurse received the order to discharge the resident to the hospital. The physician order dated October 23, 2023 revealed an order to discharge the resident to the hospital. The Discharge Minimum Data Set assessment dated [DATE], the resident was discharged to an acute care hospital. Further review of the clinical record revealed no evidence that the resident representative was provided with a written notice of the resident's transfer/discharge to the hospital on October 23, 2023. During an interview with the assistant director of nursing (ADON/staff #94) conducted on November 9, 2023, the ADON was not able to provide notification to the resident representative of the transfer to the hospital for resident #6 on October 23, 2023. Review of the facility policy on Admission, Transfer, and discharge date d May, 2022 revealed that when a facility transfers or discharges a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to receiving health care institution or provider.

Based on documentation, staff interviews, and facility policy and procedures, the facility failed to ensure bed-hold policy or notice was provided to resident or resident representative prior to or upon transfer to hospital for one resident (#6). The deficient practice may result in residents and/or their representatives not being able to return to the facility. informed of the bed-hold policy. Findings include: Resident #6 was admitted on [DATE] with diagnoses of respiratory failure, diabetes mellitus, quadriplegia, and seizure disorder. The physician order revealed an order for a blood draw for a complete blood count (CBC) on October 23, 2023. Review of the laboratory report dated October 23, 2023 included the resident had a critically low hemoglobin of 5.7 grams per deciliter (g/dl). The nursing note dated October 23, 2023 revealed the doctor was contacted regarding the critical laboratory value and the nurse received the order to discharge the resident to the hospital. The physician order dated October 23, 2023 revealed an order to discharge the resident to the hospital. The Discharge Minimum Data Set assessment dated [DATE], the resident was discharged to an acute care hospital. Further review of the clinical record revealed no evidence that the bed hold policy was provided to the resident or resident representative prior to or upon transfer to the hospital on October 23, 2023. During an interview with the assistant director of nursing (ADON/staff #94) conducted on November 9, 2023, the ADON was not able to provide Bed Hold Notification to the resident or resident representative prior to or upon resident transfer to the hospital on October 23, 2023. The facility's policy on Admission/Discharge/Transfer revealed that when a facility transfers or discharges a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to receiving health care institution or provider. The policy did not include notification regarding bed hold.

Based on clinical record review, staff interview, and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure that an MDS (Minimum Data Set) assessments for two residents (#105 and #50) were accurate. The deficient practice has the potential to affect continuity of care. Findings include: -Resident #105 was readmitted on [DATE] with diagnoses of ESRD (end stage renal disease), type 2 diabetes mellitus with foot ulcer, and dependence on renal dialysis. Review of physician order dated [DATE] revealed an order for cardiopulmonary resuscitation/full code The progress note dated [DATE] at 10:33 p.m. included the resident had a blood pressure of ,d+[DATE] and was placed on Trendelenburg position; and that, the blood pressure was ,d+[DATE] after 30 minutes. The documentation also included that the provider was informed and the nurse received orders for hydration and midodrine and the resident was monitored every ,d+[DATE] minutes. A progress note dated [DATE] at 10:52 p.m. revealed 911 was called and the resident transported to the hospital at 11:08 p.m. There was no evidence that resident was in cardiac or respiratory arrest while at the facility prior to discharge to the hospital. Review of a notice of proposed transfer/discharge revealed resident was transferred to a hospital for hypotension on [DATE]. The clinical record revealed no evidence that the resident died at the facility on [DATE]. However, review of the MDS assessment dated [DATE] revealed resident was coded for death in the facility. An interview was conducted on [DATE] at 11:58 a.m. with an MDS resource nurse, (staff #110) who stated that a discharge MDS was completed based on nursing notes and assessments. During the interview, a review of the clinical record was conducted with staff #110 who stated that resident #105 was discharged to the hospital; and that, there were no documentation found to support resident's death in the facility. Staff #110 stated that if the resident died on route to the emergency room or died in the emergency room prior to being admitted to the hospital, it would be coded as death in the facility. However, staff #110 was unable to find in the electronic health record evidence to support that resident died on route to the hospital or while in the emergency department. In a follow-up interview conducted with staff #110 on [DATE] at approximately 1:00 p.m., staff #110 stated there were no documentation to support death in the facility and that she would not have coded death in the facility. Further, she stated that the resident may not have died on the 23rd of June; thus, it was inaccurately documented. An interview was conducted on [DATE] at 1:57 p.m. with the director of nursing (DON/staff #100) who stated that the expectation was that the MDS assessments were accurate; documentations from staff for various reasons such as Medicare reimbursement and repayments were timely; and, staff were to follow guidelines. The DON said she expected the MDS coordinator to find clinical records or inquire for documentation to accurately provide accurate assessment for discharges. Regarding resident #105, the DON stated that resident #105 left for the hospital around 11:00 p.m. on [DATE]; and, she does not know whether resident received a work-up or the resident was admitted to the hospital. The DON said that she knew resident #105 had passed either on the [DATE] or 25 because their marketers followed up with the hospital. Further, the DON stated the documentation in the MDS assessment dated [DATE] for resident #105 was inaccurate. On [DATE] the DON provided a discharge summary report from the hospital that included that an intensive care registered nurse updated a family member on the resident's status; and that, resident #105 was pronounced dead on [DATE] at 2:58 a.m. The RAI (Resident Assessment Instrument) manual refers to death in the facility when the resident dies in the facility or dies while on a leave of absence; and, leave of absence as therapeutic leave of at least one night; or hospital observation stay less than 24 hours and the hospital does not admit the resident. -Resident #50 was admitted to the facility on [DATE] with diagnoses of ESRD, dependence on renal dialysis, heart failure, and chronic obstructive pulmonary disease. The physician order dated February 9, 2023 revealed an order for palliative care. The quarterly MDS assessment dated [DATE] revealed resident had a BIMS (Brief Interview for Mental Status) score of 15 indicating resident was cognitively intact. The assessment included the resident had a condition or chronic disease that may result in a life expectancy of less than six months; and that, the resident was on hospice. Review of a quarterly MDS assessment dated [DATE] revealed resident had a BIMS score of 14 indicating resident was cognitively intact. The assessment included the resident had a condition or chronic disease that may result in a life expectancy of less than six months; and that, the resident was on hospice. The care plan dated [DATE] revealed resident had a terminal prognosis related to end-stage renal disease and was on palliative care. Interventions included consult with physician and social services to have hospice care for resident in the facility and work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. An interview was conducted on [DATE] at 11:34 a.m. with resident #50 who stated she was not on hospice and was never on hospice. An interview was conducted on [DATE] at 10:10 a.m. with an assistant to the social services coordinator (staff #5) who stated palliative care was comfort care and was not hospice because resident does not have a terminal illness, a life expectancy of within six months. Staff #5 stated that palliative care allow resident to receive dialysis; and that, residents who were on palliative were followed by hospice but the resident were not receiving full hospice care. In an interview with social service coordinator (staff #10) conducted on [DATE] at 10:15 a.m., staff #10 stated that resident #50 was on palliative care and not hospice. An interview was conducted on [DATE] at 10:20 a.m. with the MDS resource (staff #110) who stated residents who were on palliative care were not coded as hospice on MDS. Staff #110 stated resident #50 had a physician order dated February 9, 2023 for palliative care; and that, this would not trigger hospice on the MDS. Staff #110 also stated that the quarterly MDS assessments dated [DATE] and [DATE] revealed resident #50 was on hospice. Staff #110 stated that this was coded by an MDS staff who no longer worked at the facility. Staff #110 said that she had made corrections on these MDS assessments on [DATE]; however, there was no record of the modification done. An interview was conducted on [DATE] at 10:30 a.m. with the DON (staff #100) who stated she was unsure if hospice were coded in the MDS assessments for resident who has a physician order for palliative care. Regarding resident #50, the DON stated that the physician order dated February 9, 2023 was for palliative care; and, in the quarterly MDS assessments dated [DATE] and [DATE], resident #50 was coded for hospice. The DON stated that resident should not have been coded as being on hospice. Review of the facility's policy on Accuracy of Assessment (MDS 3.0) with a review date of [DATE] revealed that it is their policy to ensure that the assessment accurately reflect the resident's status. The RAI Manual included an instruction to review the medical record to determine whether the resident is receiving hospice services; and, to select the code that corresponds to the prognosis: -Code 0, no: if the medical record does not contain physician documentation that the resident is terminally ill and the resident is not receiving hospice services. -Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. The RAI Manual for the MDS assessments included, The importance of accurately completing and submitting the MDS cannot be overemphasized. The MDS is the bases for the development of an individualized care plan. In addition, Federal regulations require that the assessment accurately reflects the resident's status.

Based on review of resident records, National Center for Biotechnology Information, facility documentation, State Agency Database, staff interviews, and facility policy and procedures, the facility failed to ensure care and services was provided to 3 of 3 sampled residents (#18, #22 and #36) to prevent unexpected death. Findings include: -Resident #18 was readmitted on [DATE] with diagnoses that included pleural effusion in other conditions classified elsewhere, urinary tract infection and cognitive communication deficit. A care plan dated February 3, 2023 revealed the resident had hypotension. The goals were that the resident will maintain BP (blood pressure) within an acceptable range as determined by the Medical Doctor (MD) and will be free of signs and symptoms of hypotension. Interventions included medications as ordered and monitor side effects and effectiveness; and, to monitor labs, radiologic studies, cardiac testing results and other studies to determine causative factors of hypotension and report abnormal findings to the physician. A provider order dated February 3, 2023 revealed midodrine HCl (alpha-adrenergic agonist) 10 milligrams (mg) give one tablet with meals for hypotension for 10 days. A provider order dated February 4, 2023 included the resident was a full code and required CPR (cardiopulmonary resuscitation). The daily skilled note dated February 12, 2023 included the resident had a regular pulse at 99 beats per minute with a heart rate and rhythm at baseline; and that vital signs did not show any fluctuations from baseline that require interventions. Per the documentation the resident was alert and oriented x 3 with no active symptoms or treatments affectine level of consciousness, cognition, sleep, mood or behavior. A provider note dated February 13, 2023 included the resident was alert and oriented and had a regular cardiovascular pattern and rhythm with a normal rate. Assessment included acute hypoxic respiratory failure secondary to recurrent bilateral pleural effusions due to stage IV lung cancer and hypertensive heart disease with heart failure. Plan was to continue with current medication, and to monitor BP and weights. The psychiatric progress note dated February 13, 2023 revealed resident was alert and oriented to person, place and time. Review of the discharge planning note dated February 14, 2023 included that the discharge planner spoke with resident's family via the phone; and that, the NOMNC (Notice of Medicare Non-Coverage) form was issued with discharge date of [DATE]. The daily skilled note dated February 14, 2023 at 12:46 p.m. revealed the resident was alert and oriented x 3 with no active symptoms or treatments affectine level of consciousness, cognition, sleep, mood or behavior. It also included that vital signs did not show any fluctuations from baseline that require interventions. Further, the documentation included that resident continued on Plavix (generic name clopidogrel, anticoagulant) and Lasix (generic name furosemide, diuretic) and required cardiovascular system monitoring. The physician progress note dated February 14, 2023 included resident denied any chest pain, shortness of breath fever and chills. It also included that the resident had mild pleuritic chest pain when she coughs. Per the documentation, based on the IDT (interdisciplinary team) meeting, the resident likely discharging home later this week under the care of her family. A progress note dated February 14, 2023 at 4:50 p.m. included resident had a past medical history of hypertensive heart disease with heart failure, a cardiac ejection fraction of ,d+[DATE]% with a grade 1 diastolic dysfunction and recent hospitalization for increased weakness and shortness of breath. The daily skilled note dated February 15, 2023 revealed the the resident was alert and oriented x 3 with no active symptoms or treatments affectine level of consciousness, cognition, sleep, mood or behavior. It also included that vital signs did not show any fluctuations from baseline that require interventions. Further, the documentation included there were no cardiovascular and respiratory changes observed. A physician order dated February 15, 2023 included for a STAT (immediate) chest x-ray for shortness of breath. A physician order dated February 16, 2023 included for a change of condition order for hyperkalemia 6.6 every shift for three days. (Normal range falls between 3.5 - 5.0 for adults/elderly). The physician order dated February 16, 2023 included for Levaquin (generic name levofloxacin, antibiotic); give one tablet by mouth every 48 hours for pneumonia for 7 days. Review of the daily skilled note dated February 16, 2023 at 1:16 p.m. included resident was alert and oriented x 3 with no active symptoms or treatments affectine level of consciousness, cognition, sleep, mood or behavior. It also included that vital signs did not show any fluctuations from baseline that require interventions. It also included that resident has current treatment that required cardiovascular system monitoring and had no respiratory changes observed. A provider progress note dated February 16, 2023 at 3:11 p.m. included that the resident was alert and oriented, not in acute distress, lungs clear to auscultation, respiration non-labored and had a normal rate and regular heart rhythm. The note included that at 8:05 a.m. on February 16, 2023 the resident had a potassium level of 6.6 and for the staff to continue to monitor blood pressure. The documentation also included that the resident's chest Xray had significant findings of marked degree of consolidating infiltrate in the right lower lobe; and the impression was marked right lower lobe pneumonia. Plan was to monitor BP, give kayexalate for hyperkalemia, recheck laboratory in the morning and resident may need gentle hydration and at bedtime. A change in condition (COC) note dated February 16, 2023 included that the resident was started on change of condition related to hyperkalemia and new orders was received for kayexalate (potassium binder). Another COC note dated February 16, 2023 included that new order for Levaquin related to pneumonia was received. Review of the Medication Administration Record (MAR) for February 16, 2023 revealed the resident received sodium polystyrene sulfonate oral suspension (potassium-removing agent), 15 GM/60 mL (Grams per milliters), by mouth for hyperkalemia at 6:32 pm. A physician order dated February 17, 2023 included for the following: -Antibiotic therapy related to pneumonia every shift for 3 days; and -IV (intravenous) fluids related to hypotension for 3 days. The MAR documentation for February 17, 2023 revealed that the resident received 1 liter of IV fluids; and that, an additional dose of sodium polystyrene sulfonate oral suspension, 15 GM/60 mL for hyperkalemia was administered at 11:04 a.m. Review of the clinical record for February 17, 2023 revealed the following vital signs: -At 6:34 am: BP ,d+[DATE] mmHg (millimeters of mercury); HR (heart rate) 76 beats per minute (bpm) -At 6:34 pm: BP ,d+[DATE] mmHg; HR 69 bpm -At 7:22 pm: BP ,d+[DATE] mmHg; HR 80 bpm A COC note dated February 17, 2023 included that new orders was received for IV fluids related to hypotention. A nursing note dated February 18, 2023 included that staff were monitoring the resident for hyperkalemia and that the last potassium level was 5.8. A physician order February 18, 2023 revaled an order for Dextrose-NaCl (sodium chloride) ,d+[DATE].45% 50 ml/hr (milliliter/hour) one time a day for lab value result for 1 day. An eMAR note dated February 18, 2023 at 5:20 p.m. included that the resident continued to receive fluids for hypotension and hydration; and that the most recent potassium level was 5.5. The weight and vital summary dated February 18, 2023 at 7: 17 p.m. revealed that the resident's BP was ,d+[DATE]. The documentation also included a warning that read, diastolic low of 60 exceeded. The daily skilled note dated February 18, 2023 at 9:41 p.m. indicated that the resident's blood pressure was ,d+[DATE] at 7:17 pm. with a regular pulse rate of 91 beats per minute. A COC note dated February 18, 2023 at 10:09 p.m. revealed the resident continued to have IV fluids and was started on po (oral) antibiotic for pnuemonia. Per the documentation, BP was ,d+[DATE] and that BP will be rechecked. Further, the documentation included that there were no signs of distress and the HOB (head of bed was elevated to 35 degrees. However, review of the clinical record provided no evidence that the resindet's blood pressure was rechecked; and that, the provider was notified of the change in clinical status. A Change of Condition note dated February 19, 2023 at 6:02 a.m. included that the resident's potassium level was 5.4 and that the IV fluids were running as ordered. The weights and vitals summary dated February 19, 2023 at 6:04 a.m. revealed the following vital signs: pulse = 56 bpm (beats per minute) RR = 20 breaths/minute, Oxygen saturation 90% The nursing note dated February 19, 2023 at 9:25 a.m. by a Licensed Practical Nurse (LPN/staff #94) included that the nurse was at the bedside to administer medications and found the resident unresponsive with no pulse. The note included that code blue protocol was initiated and EMS (emergency medical services) was on site at 9:35 a.m. Further, the documentation included that despite all the efforts the resident expired at 10:00 a.m. and that provider and family were notified. An eMAR note dated February 19, 2023 included that the resident was transferred to the emergency department. A Documentation Survey Report for February 3 through February 19, 2023 revealed the last documentation of care had been provided to the resident was on February 18, 2023 at 10:33 p.m. Review of the National Library of Medicine's National Center for Biotechnology Information Stat Pearls dated February 19, 2023, hyperkalemia was defined as serum or plasma potassium levels in the blood of greater than 5.5 mEq/L (millEquivalent per Liter). The Stat Pearls included that symptoms usually develop at higher levels, greater that 6.5 mEq/L, and complications include cardiac arrest and weakness. An interview was conducted on [DATE] at 11:49 am with a certified nursing assistant (CNA/staff #17) who stated that vitals are documented in the electronic medical record. Staff #17 stated that the nurse will let her know if the blood pressure or heart rate is too high or low and if they want to recheck it. Staff #17 stated that residents are repositioned or looked in on every two hours or more if needed. During a telephone interview conducted on [DATE] at 1:31 pm with a Licensed Practical Nurse (LPN/staff #94), he stated that providers are notified if vital signs are outside of protocols. He stated that blood sugars should be performed ,d+[DATE] minutes before meals. Staff #94 stated that if he notifies a provider of a change of condition it was usually by a text message and if there are no new orders the provider will send back a thumbs up emoji. However, if there were orders, the provider will text them or call. Staff #94 stated that communication with the provider is documented in the electronic medical record; and that, if something is not documented that it was not done. Regarding resident #18, the LPN said that the resident had a lot of comorbidities such as cancer. Staff #94 stated he did not recall specifically what time he saw the resident prior to her being unresponsive but he believes it was ,d+[DATE] minutes before. Staff #94 stated the resident was resting last time he saw her. Further, he stated that he did not recall any notification of the resident having a heart rate of 56 the morning of February 19, 2023. An interview was conducted on [DATE] at 2:08 p.m. with a nurse practitioner (staff #110) who stated that he would expect staff to notify him immediately if a resident's vital signs were outside parameters. Staff #110 stated he would order a full set of current vitals, get a complete report of the residents current condition, and update the orders as needed. Staff #110 stated he can access the resident records electronically remotely if needed. Staff #110 stated that if it was not emergent the staff can send a text message but if it was an emergency the staff should call. During an interview conducted on [DATE] at 4:32 p.m. with the Director of Nursing (DON/staff #11) and a Clinical Resource (staff #190), the DON stated that she only reports suspicious deaths in the facility to the State Agency; and that, if the resident has comorbidities, or it could be age related and if hospice has been discussed, but not necessarily ordered, she does not report the death. The DON stated that vitals signs are obtained every shift and there are different standards of vital sign ranges for each resident. The DON stated that depending on the resident's condition, the provider may be aware of vitals outside of range. The DON stated that if the vital signs trigger on the electronic record, the clinical staff should review them and CNAs should notify the nurse right away if the vitals are elevated or too low. The DON stated the expectation was that the clinical staff would notify the provider and document the notification in the medical record. Further, the DON stated that if something was not documented it was not done. -Resident #22 was readmitted on [DATE] with diagnoses that included tracheostomy status, chronic respiratory failure, anoxic brain damage, essential hypertension, muscle spasm, major depressive disorder, anxiety disorder, chronic pain syndrome, gastro-esophageal reflux disease without esophagitis, morbid (severe) obesity due to excess calories, mild protein-calorie malnutrition, other schizophrenia, bipolar disorder, and peripheral vascular diseases. A provider order dated [DATE] included that the resident was a full code. A care plan initiated on [DATE] for prescribed opioids for pain included a goal that the resident would be free from adverse reactions and that the resident would be free from pain or would maintain a level of acceptable pain. The interventions for these goals included to administer opioids as prescribed, assess for risk of substance abuse, and to educate the resident on alternatives to prescribed opioids. A care plan initiated on [DATE] for ventilator dependence related to respiratory failure included a goal that the resident would not experience episodes of respiratory distress during the weaning process. The interventions for this goal included to maintain ventilator settings as ordered, respiratory therapy to follow, and monitoring. Another care plan initiated on [DATE] for tracheostomy related to impaired breathing mechanics included a goal that the resident would have no signs or symptoms of infection. The interventions for this goal included to provide care per facility protocol, monitor, and keep tracheostomy secure. Review of the clinical record revealed a new onset of an irregular heart rate of 93 bpm (beats per minute) on February 16, 2023 at 6:26 am. Review of the clinical record revealed no documenation of a provider notified of a new onset of an irregular heart rhythm on February 16, 2023. A Respiratory Flow Sheet dated February 16, 2023 included an assessment at 6:20 am. The assessment included that the resident's heart rate was 77. The assessment did not include if the rate was regular or irregular. The assessment included that the breath sounds were diminished. A Respiratory Flow Sheet dated February 16, 2023 included an assessment at 10:55 am. The assessment included that the resident's heart rate was 75. The assessment did not include if the rate was regular or irregular. The assessment again included that the breath sounds were diminished. A Nursing note dated February 16, 2023 at 2:45 pm included that the resident was resting comfortably in bed watching a tablet device. A Respiratory Flow Sheet dated February 16, 2023 included an assessment at 2:50 pm. The assessment included that the resident's heart rate was 76. The assessment did not include if the rate was regular or irregular. The assessment included that the breath sounds continued to be diminished. Review of the clinical record revealed a regular heart rate of 90 bpm on February 16, 2023 at 8:28 pm. A Transfer form dated February 17, 2023 at 1:30 am included that the resident had an unplanned transfer to the hospital for being unresponsive. The transfer form included a set of vital signs dated February 16, 2023 at 8:28 pm. The vitals included a blood pressure of ,d+[DATE], pulse of 90 and regular, respirations of 12, temperature of 98.6, and oxygen saturation of 94%. The vial signs included a blood glucose level of 97.0 mg/dL (milligrams per deciliter) dated [DATE] at 5:30 am. Review of the clinical record revealed no documented heart rate, respiratory rate or rhythm, or blood pressure after February 16, 2023 at 8:28 pm. Review of the Documentation Survey Report dated February 2023 revealed that resident received care at 12:06 am and 4:43 am. A Nursing note dated February 17, 2023 at 5:57 am included that the nurse entered the resident's room at 12:45 am and found the resident unresponsive. The note included that the resident was assessed and found to have no vital signs. The note included that at 12:53 am CPR (cardiopulmonary resuscitation) was started and a call was placed to 911. The note included that the staff did two (2) rounds of CPR with no shock advised and on the next round shock was advised and done. The note included that the staff continued to do compressions until the paramedics arrived at 1:07 am. The note included that the paramedics continued CPR and administered three (3) total dose of epi (epinephrine). The note included that the paramedics reported that the resident went from asystole (no heart beat or rhythm) to EPA (eicosapentaenoic acid) at 1:21 am. The note included that the resident had a pulse and was taken to the hospital at 1:24 am. Review of a medical dictionary revealed PEA (Pulseless electrical activity is characterized by unresponsiveness and impalpable pulse in the presence of sufficient electrical discharge. A Discharge note dated February 17, 2023 at 6:37 am included that the staff called the ER (emergency room ) and was informed that the resident had passed. During an interview conducted on [DATE] at 11:49 am with a Certified Nursing Assistant (CNA/staff #17), staff #17 stated that when a resident is found unresponsive the will get a manual set of vital signs and enter them into the electronic record. Staff #17 stated that if they are not breathing a code blue or rapid response is called either by yelling out or on the radios. Staff #17 stated that resident checks are done all the time. Staff #17 stated that historically the resident was calm but after a change in medication the resident had been anxious at nights pulling at her tracheostomy tube and disconnecting the vent. An interview was conducted on [DATE] at 1:15 pm with another CNA (staff #71). Staff #71 stated that if a resident is unresponsive he would call a code blue and get the vital cart. Staff #71 stated the resident had a shower and wasn't really being herself. They stated she was not being herself. During an interview conducted on [DATE] at 3:05 pm with another CNA (staff #61), staff #61 stated that on February 17, 2023 they were grabbing supplies for their resident when they heard the page for a code blue in resident #22's room. Staff #61 stated that when they got there one nurse was performing CPR and two or three other staff members were just standing on the side watching. Staff #61 stated that one nurse did CPR through the entire code blue. Staff #61 stated that the staff did not perform a shock for awhile because they did not have any AED (automated external defibrillator) pads. Staff #61 stated they asked if they were going to get pads and after two or three minutes later the staff returned without an AED or pads. Staff #61 stated they even went to the emergency cart to find pads. Staff #61 stated that there was a lag in CPR and finding the pads to attach the AED. Staff #61 stated that the first shock was not given until the paramedics arrived. Review of code cart checks for February 2023 for the unit resident #22 was on revealed that from February 16, 2023 at 8:00 pm through February 22, 2023 at 8:00 pm the AED check was marked as no, N/A, or battery. An interview was conduced on [DATE] at 2:00 pm with a Respiratory Therapist (RT/staff #90). Staff #90 stated that when the code blue was called for resident #22 he entered the room and one of the nurses had started CPR. Staff #90 stated that the resident had been on the ventilator and was fine at last check. Staff #90 did not recall anything related to the AED but did state that the paramedics provided a shock and gave rescue breaths. Staff #90 stated they believed that the resident had a pulse when they left but was being given breaths by the paramedics. During an interview conducted on [DATE] at 3:39 pm with the Materials Manager (staff #41), staff #41 stated that the staff had notified them in February that there weren't any pads but staff #41 was able to get them. An interview was conducted on [DATE] at 4:32 pm with the Director of Nursing (DON/staff #11) and a Clinical Resource (staff #190). The DON stated that the expectation of staff is to complete an assessment of an unresponsive resident and call a code or rapid response if there is no pulse. The DON stated that the nurse in charge would delegate who calls 911 and most of the staff respond to the code. The DON stated that the expectation is that staff should swap out doing CPR after a round or couple per CPR Guidance. The DON stated that the expectation is that code carts are assessed every shift to ensure they are complete. The DON stated she was never made aware of any issues with not having AED supplies on the carts and that there are two other machines in the building accessible to staff. The DON stated that vital signs should be obtained during a code if there is time and documented in the electronic record. The DON stated if something is not documented it is not done. -Resident #36 was admitted to the facility on [DATE] with a diagnosis that included Hypertensive heart disease with heart failure. Heart failure, unspecified. Essential (primary) hypertension and cognitive communication deficit. Review of the resident's vital signs record was conducted on [DATE] and revealed the that on [DATE] @ 06:58 the resident had a pulse of 44 bpm (beats per minute), Irregular - new onset. Continued review of the resident record did not reveal that the facility notified the provider or that any nursing interventions were initiated. Vital signs documentation revealed the following vital signs: [DATE] @ 6:31pm: Pulse of 63 bpm Irregular - new onset [DATE] @ 6:29pm: Pulse of 39 bpm Irregular - new onset [DATE] @ 6:43am: Pulse of 42 bpm irregular - new onset The vital signs for the [DATE] daily skilled note reveal that the BP was not taken and that the BP noted is from actually from [DATE] @10:29pm. Further review of the resident medical record revealed that there are no documented vital signs until the event that lead to the resident being transferred to the ER. A review of a daily skilled progress note, dated [DATE], [DATE] and [DATE] all revealed Vital signs do not show any fluctuation from baseline that require interventions. A discharge note dated [DATE] revealed resident was unresponsive with no vital signs and was discharged to the hospital. Per the documentation, 911 was called, CPR was started and left via ambulance with a pulse. An interview conducted with a Certified Nursing Assistant (CNA/staff #17) on [DATE] at 12;40 p.m., the CNA stated that upon resident admission, the CNA would introduce themselves to the resident, take vitals, obtain supplies; and then, the nurses will give the CNA care directions. Vitals are done per shift. The first set is done in the morning and then as needed by order or need. The CNA stated that vitals taken will be documented in the clinical record. The CNA also said that the nurse was responsible for actions needed related to the VS results; and that, the CNA will let nursing staff know if a BP was high or low . The CNA said that the nursing staff will then dictate follow up. Further, the CNA said that if a resident is not responsive or not at baseline and the CNA was not able to obtain the VS, the CNA will let the nurse know. The CNA said that if the resident was unresponsive, the CNA will activate a code blue/rapid response communicated through the walkie talkie. An interview conducted with another CNA (staff #71) on [DATE] at 1:15 p.m., staff #71 said that if a resident has abnormal (out of range) vital signs, the CNA will document the vital signs and notify the nurse. Staff #71 stated that the machine will always alarm if the vitals are out of range; and, the CNA documentation software will prompt the CNA that the vital signs were out of range and the CNA will notify the nurse. An interview was conducted with the Director of Nursing (DON/staff #110 on [DATE]. The DON stated that the vitals machine does not alarm if the blood pressure or pulse are out of range and that the expectation was that the CNA will be able to recognize if any vital signs were out of range. A review of the facilities policy for vital signs, weight and height was conducted and revealed that Vital signs shall be taken and recorded in accordance with the resident's condition and current treatment plan, and as prescribed by the attending physician. This may vary with certain factors such as residents on cardiac medications may warrant daily pulses, those on blood pressure medications may warrant daily or weekly blood pressures, residents involved in a possible head injury incident may warrant neuro-checks.

Based on closed record review, staff interviews, and facility policy and procedures, the facility failed to ensure one resident (#7) received wound assessments in accordance with professional standards of practice. The sample size was 3. The deficient practice could result in pain, infection and/or rehospitalization . Findings include: Resident #7 was readmitted on [DATE] with diagnoses that included cellulitis of right lower limb, sepsis, type 2 diabetes mellitus without complications and Methicillin resistant staphylococcus aureus infection. An anticoagulant therapy care plan initiated on October 29, 2022 related to DVT (deep vein thrombosis) prophylaxis and dialysis included a goal that the resident would remain free from discomfort or adverse reactions. Interventions included daily skin inspection and reporting abnormalities to the nurse. A potential for impaired skin care plan initiated on October 29, 2022 included goals that the resident's wounds would show signs of improvement without signs and symptoms of infection and that the skin would be free from redness, blisters, or discoloration. Interventions included to assess wound healing, monitor dressings and complete a weekly head to toe skin assessment. The care plan included that the resident frequently declined treatments. Further review revealed the resident had actual impairment to the following areas: -Sacrum -Left lateral thigh superior -Right flank -Left Hip -Right medial thigh -Left medial thigh -Right lower abdomen However, the care plan did not include documentation of wounds on the resident's toes. Review of eMAR (electronic Medication Administration) notes revealed the resident preferred to have wound care completed on the night shifts. Provider orders written December 22, 2022 included to: -Cleanse left great toe with NS (normal saline) or wound cleanser, and pat dry. Apply calcium alginate to top of toe, [apply] betadine (topical antimicrobial) to eschar [on] bottom [of] toe, cover with ABD (abdominal) pad, wrap with kerlix and secure with tape, daily and p.m. PRN (as needed). -Cleanse left great toe with NS or wound cleanser, pat dry. Apply calcium alginate to top of toe, [apply] betadine to eschar [on] bottom [of] toe, cover with ABD pad, wrap with kerlix and secure with tape daily and p.m., every day shift. Review of the clinical record revealed the following provider orders written on October 29, 2022: -Encourage the resident to float heels every shift. -Podiatry consult as needed. -Cleanse left great toe with NS or wound cleanser, pat dry. Paint with betadine and leave open to air daily, PRN. -Cleanse left great toe with NS or wound cleanser, pat dry. Paint with betadine and leave open to air daily, every day shift A provider order dated January 19, 2023 included for the resident to have a podiatrist consult. A provider order dated January 25, 2023 included for the resident to have a wound care consult. A podiatry note dated January 30, 2023 included that the resident had hair growth on right foot with decreased on the left foot. The noted included that the resident had decreased pedal (foot) pulses on the left, with edema (swelling in the tissue) and the nails were discolored, thickened and enlarged. The note included that the toenails had onychomycosis (fungal nail infection). The note included that wound care was treating the left foot. Review of a provider progress notes dated February 1 and 2, 2023 at 3:44 pm revealed no documentation of the resident's toes. An eMAR note dated February 2, 2023 at 5:53 pm included that the resident allowed the nurse to do wound treatments except to the right toe. A Weekly Skin Evaluation dated February 3, 2023 at 8:34 am included that the resident had wounds present and that the wound care team was following. However, further review revealed no documention of wounds on the resident's toes. A Daily Skilled note dated February 6, 2023 at 1:33 am included that the resident's integumentary was normal for ethnicity and there were no active symptoms affecting the integumentary system observed. A Skin Ulcer Non-Pressure weekly assessment dated [DATE] at 1:59 pm included an assessment of a right lower abdomen, right medial thigh, and left medial thigh wound. The assessment indicated that a podiatrist had been consulted for the resident. Review of the Skin Ulcer Non-Pressure weekly assessment dated [DATE] at 1:59 pm did not included any documentation of an assessment of the left great toe. A Weekly Skin Evaluation dated February 10, 2023 at 12:54 am included that the resident had no new skin issues noted and that wound care was refused at that time. Review of the Weekly Skin Evaluation dated February 10, 2023 at 12:54 am revealed no documentation of wounds on the resident's toes. A progress note dated February 10, 2023 at 2:15 pm included that the resident's integumentary was warm and dry. The note included that the resident had necrotic toes/wounds and wound care and podiatry were to follow. However, review of the clinical record revealed no evidence of orders, care plan, change in treatment, or notification to the wound care provider for the necrotic toes documented on February 10, 2023 at 2:15 pm. Another progress note dated February 13, 2023 at 10:20 am included that the resident's integumentary was warm and dry. The note included that the resident had necrotic toes/wounds and wound care and podiatry were to follow. Review of the clinical record revealed no orders, care plan, change in treatment, or notification to the wound care provider for the necrotic toes documented on February 13, 2023 at 10:20 am. A Skin Ulcer Non-Pressure weekly assessment dated [DATE] at 12:49 pm again included an assessment of a right lower abdomen, right medial thigh, and left medial thigh wound. The assessment included a podiatrist consulted for resident. Review of the Skin Ulcer Non-Pressure weekly assessment dated [DATE] at 12:49 pm did not included any documentation of an assessment of the left great toe. A Weekly Skin Evaluation dated February 17, 2023 at 12:39 am included that the resident had no new skin issues noted and that wound care was refused at that time. No documentation of wounds on the resident's toes was identified. A Daily Skilled note dated February 20, 2023 at 1:02 am included that the resident's integumentary was normal for ethnicity and there were no active symptoms affecting the integumentary system observed. A Skin Ulcer Non-Pressure weekly assessment dated [DATE] at 1:01 pm revealed an evaluation of the left great toe which included wound measurements of 4 cm (centimeters) in length and 4.5 cm in width with no depth, described as a partial thickness with a small amount serosanguineous drainage. The wound bed was noted with 26-50% eschar, 26-50% pink granulation [tissue] and was odorless. The assessment indicated that the injury was trauma from nail falling off and that the assessment was a follow-up. The documentation included that osteo (sic) had been consulted. However, the assessment did not include and evaluation of the wound edges or surrounding tissue. Daily Skilled notes dated February 21 and 23, 2023 included that the resident's integumentary was normal for ethnicity and there were no active symptoms affecting the integumentary system observed. A Physician Progress note dated February 23, 2023 at 8:34 pm included that the resident had pulses that were present and equal in 4 limbs and no peripheral erythema was noted. A Weekly Skin Evaluation dated February 24, 2023 at 9:44 pm included that the resident had multiple open areas to RLQ (right lower quadrant), left inner thigh, right inner thigh, left lateral thigh, right hip, and sacrum. The evaluation indicated that wound care followed the resident. Review of the Weekly Skin Evaluation dated February 24, 2023 at 9:44 pm revealed no documentation of wounds on the resident's toes. Daily Skilled notes dated February 25 and 26, 2023 am included that the resident's integumentary was normal for ethnicity and there were no active symptoms affecting the integumentary system observed. A Skin Ulcer Non-Pressure weekly assessment dated [DATE] at 12:28 pm revealed an evaluation for the left great toe. The assessment indicated that the wound measured 4 cm in length and 4.5 cm in width with no depth documented. The assessment indicated that the injury was trauma from nail falling off and that the assessment was a follow-up. The wound was identified as a partial thickness with a small amount serosanguineous drainage. The wound bed was described with 26-50% eschar, 26-50% pink granulation [tissue] and was odorless. The wound edges were defined and the surrounding tissue was normal for skin. The assessment included that osteo had been consulted. Further review of the TAR for February 1 through 27, 2023 revealed the resident received a weekly skin check on Fridays 4 out of 4 times. Review of the Treatment Administration Record (TAR) for February 1 through 27, 2023 revealed the resident received a cleaning of the left great toe 25 out of 27 times. A Physician Progress note dated February 27, 2023 at 4:52 pm included that the resident had pulses that were present and equal in 4 limbs and that no peripheral erythema was noted. A nursing note dated February 27, 2023 at 9:21 pm included that the writer was notified by the Director of Nursing (DON/staff #11) that the resident went to a podiatry appointment and was transfer from there to the hospital. An interview was conducted on March 14, 2023 at 1:15 pm with a Certified Nursing Assistant (CNA/staff #71). Staff #71 stated that the facility beds are equipped with adjusters for the width but he was not sure if there was an adjustment for the footboard. Staff #71 stated that he would use a pillow or something to create a barrier at the footboard to protect the feet. Staff #71 stated he monitors larger residents closely because the way the bed's footboards are, they can be too close and can make the toes bleed or the toe nails can get injured. Staff #71 stated that resident #7 had some wounds on his feet and they were discolored. Staff #71 stated that resident #7 would always slide down and the pain was so intense the resident needed regular repositioning. During an interview conducted on March 14, 2023 at 2:08 pm with a Nurse Practitioner (staff #110) stated that resident #7's toes became necrotic during the admission. Staff #110 stated that the wound care staff identified them and he ordered in-house podiatry to see the resident. Staff #110 stated that the in-house podiatry recommended for the resident to see outside podiatry, so an order was made and the resident was sent out. Staff #110 stated the wound team was tracking and monitoring the toes. An interview was conducted on March 14, 2023 at 4:32 pm with the Director of Nursing (DON/staff #11) and a Clinical Resource (staff #190). The DON stated that the expectation was that if a provider puts an order in for a consult it will be set up the next day. The DON stated that if the consult is related to a wound, the wound nurse will go straight to the medical record and communicate the information to the provider. The DON stated that sometimes consults take two to six weeks waiting for the health plans approval. The DON stated that if something was not documented then it was not done. A facility policy titled Care and Treatment - Wound Management - documentation (revised 5/2021) included that it is the policy to have a flow sheet to enable medical staff to evaluate the status of wounds. A wound is identified as an arterial ulcer, diabetic neuropathic ulcer, pressure ulcer, venous insufficiency ulcer, surgical wound and lacerations. A weekly skin assessment will be completed on all residents and documented in the resident's medical record. The policy included that each wound will be measured in centimeters weekly. Treatment orders by the physician will be used and if no improvement, the physician will be called for an evaluation. A facility policy titled Resident Assessment - Skin Assessment (revised 5/2007) included that it is the policy of this facility to assess all residents upon admission, when a comprehensive assessment is required and quarterly thereafter to identify risk of skin breakdown.

Based on observations, closed and current clinical record reviews, staff interviews and policy and procedures, the facility failed to ensure that least restrictive measures were attempted and were ineffective, prior to implementing physical restraints for residents who exhibited agitation, restlessness and combative behaviors, failed to provide ongoing re-evaluation for the need and safe use of the restraints despite these behaviors, and failed to document the condition of the resident's skin when the restraints were removed and skin breakdown was identified, resulting in Substandard Quality of Care involving six residents (#'s 12, 11, 6, 13, 3 and 9). The deficient practice resulted in residents being physically restrained without least restrictive measures being attempted first, and a lack of re-evaluating for the ongoing safe use of these restraints, placing residents at risk for possible injury. Findings include: -Resident #12 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed an admission nursing note dated June 5, 2020 that the resident was admitted from the hospital and was unable to follow direction. The note included the resident had soft wrist restraints in place due to pulling at his [MEDICAL CONDITION] while hospitalized and that the PEG (percutaneous endoscopic gastrostomy) tube was in place. The note also included consent was obtained from the family but did not include what the consent was for. The physician orders [REDACTED]. Review of Resident/Family Consent for use of Physical Restraints did not reveal a consent for the use of soft wrist restraints. Review of a physician progress notes [REDACTED]. The note did not address why the resident no longer had a sitter. A behavior nursing note dated June 13, 2020 revealed the resident was combative toward nursing staff and the nurse attempts to console the resident were not successful. The note included the resident pulled out [MEDICAL CONDITION] times and that [MEDICAL CONDITION] able to be replaced by the respiratory therapist. Another behavior nursing note dated June 15, 2020 revealed the resident became agitated with staff when he got himself out of the wrist restraints and was scooting himself naked across the mattress on the floor next to the bed. The note included the resident made a swing at the nurse. A quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment, had physical behavioral symptoms and verbal behavioral symptoms directed at others, and behavioral symptoms not directed toward others. The assessment included the resident was always incontinent of urine and bowel and was totally dependent on staff for toilet use. The assessment also included limb restraint was used daily. The nursing note dated June 19, 2020 revealed the resident remained in restraints due to physical aggression and pulling at devices. A nursing wound note dated June 25, 2020 included the resident was unable to assist with repositioning in bed. Staff to turn and reposition. The note also included the resident often repositions himself choosing not to remain as positioned by staff. A MAR (Medication Administration Record) note dated July 2, 2020 revealed the resident remained in restraints, due to pulling at devices. Skin was clean, dry and intact. A follow-up psychiatric consultation note dated July 9, 2020 revealed the resident had shown some agitation, restlessness, and pulling at life-sustaining devices when not restrained. The note included the resident required soft restraints. The daily skilled nursing note dated July 12, 2020 included the resident had a skin tear to the right wrist. The note did not include how the resident obtained the skin tear or an assessment of the skin tear. A physician order [REDACTED]. Review of the resident's care plans revealed there was no care plan regarding the use of soft wrist restraints from June 5 to July 13, 2020. The facility was unable to produce a care plan for soft wrist restraints for this time period. Review of the Treatment Administration Record (TAR) for July 2020 revealed the physician's orders [REDACTED]. On the TAR, staff initialed on the day and night shift that this order had been implemented through July 13, 2020. However, there was no corresponding documentation regarding the skin condition of the resident's wrists and circulation, when the 2 hour skin checks were documented as being done on the TAR. Review of a nursing note dated July 13, 2020 at 11:55 a.m. revealed the resident was very aggressive and agitated, was administered [MEDICATION NAME] (antianxiety) with mild relief and calmness. The note included the resident became aggressive again, was able to wiggle off the restraints, and threw himself on the floor causing a laceration to the left orbital area. The note also included the resident had pulled out the PEG tube and that a new PEG was replaced. The incident report dated July 13, 2020 at 12:54 p.m. revealed that predisposing physiological factors included confusion, impaired memory, and recent change in medications/new. The report included the resident had 1-2 falls in the past 3 months. The report stated immediate action taken included restraint reinforced, 15-minute rounds being done, and provider adjusted medications. Another nursing note dated July 13, 2020 at 1:15 p.m. revealed a Certified Nursing Assistant (CNA) saw the resident sitting on the edge of the bed as he was walking in to check on the resident. The note included the resident jumped off the bed to the floor and hit his head leaving a small cut on the left eyebrow. The note also included the resident had pulled out his PEG tube. A nursing note dated July 13, 2020 at 3:15 p.m. revealed a nurse had walked into the resident's room to check on him and found the resident out of the restraints laying in the bed. That nurse called for assistance with reapplying restraints. The note included the resident began kicking and scratching staff and tried to hit the nurse writing this note with his head twice. A nursing note dated July 13, 2020 at 3:29 p.m. revealed the resident was found sitting on the floor mattress out of the restraints during a 15-minute walking round. The resident was assisted back to bed. Steri strips were reapplied to the eyebrow, due to the resident removing the steri strips. The note included the provider was called and ordered the resident be sent to the hospital for medication adjustment. Review of the fall committee IDT (interdisciplinary team) note dated July 15, 2020 revealed the resident had a witnessed fall, that a CNA witnessed the resident falling to the floor as he approached the resident's room. The resident had bilateral wrist restraints but was able to wiggle himself free. The resident hit his head on the floor causing a laceration to the left orbital area and had pulled out the PEG tube with the balloon intact. The resident denied pain and stated he was trying to get up to fix the TV. The resident remained combative and kicking and assistance of 5 was used to subdue the resident and put the resident back to bed. Restraints were reapplied, skin check completed, steri-strips applied to left orbital area, and neuro checks were initiated per protocol. The note included orders were obtained from the provider to send the resident to the hospital for psych hold related to uncontrolled combative behavior. Further review of the clinical record revealed there was no documentation of any least restrictive measures which were attempted, prior to using bilateral soft wrist restraints (e.g. hand mitts, 1:1 supervision). In addition, despite documentation that the resident exhibited agitation, physical aggression, got out of the soft wrist restraints, pulled out the PEG tube and trach, sustained a fall with a laceration, and continued to be combative and kicking after the fall, the only interventions were to reapply the soft wrist restraints and 15 min checks on the day of the fall. There was no documentation of any ongoing less restrictive measures that were implemented to address these behaviors, such as 1:1 supervision. In addition, there was no documentation that the resident was reassessed for the ongoing safe use of the soft wrist restraints, despite exhibiting agitation, combativeness and was able to get out of the restraints. Review of the clinical record revealed the resident was admitted back to the facility on [DATE]. A physician order [REDACTED]. Remove every 2 hours to assess skin integrity and circulation every shift. The restraint evaluation dated July 24, 2020 included the identified medical condition requiring the restraint was [MEDICAL CONDITIONS], pulling at life-sustaining devices and resistant to care. Associated health issues which contribute to potential for falls or need for safety/enabling devices included poor impulse control, history of falls, antipsychotics, weakness and incontinence. A measure that had been tried before implementing the restraint included low bed. Per the evaluation, bilateral soft wrist restraints were the device recommended to prevent the resident from pulling at life-sustaining devices. The section regarding the benefits/reasons for the restraint device with the question What does this device enable resident to do? (check all that apply) revealed nothing was checked. The evaluation included the risks and benefits which may occur as a result of a restraint device had been discussed with the resident's representative and that consent was obtained via telephone from the resident's representative. A nursing note dated July 24, 2020 revealed the resident was readmitted to the facility in bilateral soft wrist restraints for being combative with staff and pulling at life sustaining devices. Skin tear to right forearm with dressing in place. Consents signed by telephone with emergency contact. The note did not include what consents were obtained. There was no clinical record documentation that upon readmission, any least restrictive measures were attempted prior to implementing the soft wrist restraints upon admission. A change of condition note dated July 25, 2020 revealed the resident was compliant with meds and treatments. The note included bilateral wrist restraints were intact and released for skin integrity and circulation, and that the resident will pull at life sustaining devices. A care plan regarding bilateral soft wrist restraint use was initiated on July 25, 2020. The goals were to minimize/eliminate restraint use and for the resident to be free from complications including skin breakdown. Interventions included anticipating and intervening for potential causes which have precipitated prior falls or accidents, the need to have the restraints released every two hours and document the release per facility protocol, ensure the resident is positioned correctly with proper body alignment while restrained, and monitor, document and report changes to the physician regarding the effectiveness of the restraint and any negative or adverse effects including skin breakdown and falls/accidents/injuries. A behavior note dated July 26, 2020 revealed the resident failed the restraint reduction, as once the restraints were released and skin integrity and circulation were assessed, the resident attempted to pull at life sustaining devices. Despite attempting a restraint reduction, there was no documentation that other less restrictive measures such as; 1:1 supervision was attempted and was ineffective. The psychiatric note dated July 29, 2020 stated that staff reported the resident's agitation, restlessness, and pulling at life-sustaining devices has improved. A nursing note dated August 3, 2020 revealed the resident yelled at the nurse incoherently and tried to grab the nurse's arm, despite being in restraints. A behavior note dated August 7, 2020 revealed the wrist restraints were released and the resident pulled at the trach. The skin was assessed for circulation and integrity. Review of a nursing note dated August 14, 2020 revealed a staff member noted the resident sitting on the edge of the bed and that before he could reach the resident, the resident slid to the floor, sitting on his butt. The restraints were discovered untied. No injury noted and the resident was assisted into bed by three staff. The note included that staff were educated on restraint application. An addendum nursing note dated August 14, 2020 at 11:55 p.m. included the fall on August 14 occurred at 8:45 p.m. and was witnessed by a CNA. The resident only slid to the floor and sat on his butt and that no other part of his body came in contact with the floor or any objects in the room. No injury noted and no change in mental status. The IDT team fall review note dated August 15, 2020 revealed the resident had a witnessed non-injury fall on August 14. A CNA reported to the nurse that the resident was sitting on the side of the bed and before he could get to the resident, the resident slid onto the floor on his buttocks, with the bed in the lowest position. The note included that safety measures were in place and staff were educated on restraint application. A nursing daily skilled note dated August 15, 2020 revealed the resident was confused and combative at times. A MAR indicated [REDACTED]. Further review of the clinical record revealed there was no documentation that any other least restrictive measures were attempted in August 2020 such as 1:1 supervision, until September 10, 2020. There was also no documentation that the resident was re-evaluated for the ongoing safe use of the restraints, despite exhibiting agitation, restlessness and combative at times. A nursing note dated September 10, 2020 now included that a sitter was at the resident's bedside as of September 10 at 6:00 p.m., for safety monitoring and measures related to resident's behaviors. Restraint reduction attempted. A physician order [REDACTED]. Ask sitter each shift if any episodes have occurred or any other behaviors and document them in a progress note every 6 hours until September 12, 2020 at 8:00 a.m. Review of the TAR for September 2020 revealed the bilateral soft wrist restraints were on hold for the night shift on September 10 through the night shift on September 11. A MAR indicated [REDACTED]. A consent for the use of bilateral wrist restraints was obtained on September 12, 2020. A skilled daily nursing note dated September 14, 2020 now included the resident had bilateral restraints related to pulling at life sustaining devices. Review of the TAR from July 23-31, August 2020 and September 2020 revealed the order for bilateral soft wrist restraints to prevent the resident from pulling out life sustaining devices and to remove every 2 hours to access skin integrity and circulation every shift. Staff initialed on the day and night shift that the order had been implemented. However, there was no corresponding documentation regarding the condition of the resident's wrists and circulation, when the 2 hour skin checks were documented as being done. During an observation conducted on September 16, 2020 at 2:45 p.m. with a LPN (staff #249), the resident was observed with bilateral wrist restraints in place. At this time, the nurse removed the right wrist restraint. Under the right wrist restraint, there was an area of scarred tissue to the right anterior medial wrist that measured approximately 1 cm x 2.5 cm. The nurse then reapplied the restraint. The LPN stated she was unable to say what the healed injury was caused from. According to the facility's policy, a resident requiring physical restraints will be checked by a staff member at least every 30 minutes. However, there was no documentation that the 30-minute checks were done, when the resident was in physical restraints. -Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician order [REDACTED]. Review of the clinical record revealed a Resident/Family Consent for use of Physical Restraints form dated August 26, 2020 for bilateral soft wrist restraints. The form contained a checkmark in the box which acknowledged that the restraining device had been explained and agreed to. The form included verbal consent from a family member was obtained on August 26, 2020 and two facility representatives signed the consent. The sections that an evaluation had been obtained, the reasons a physical restraint would be in the best interest of the resident, and the recommended times to be applied were not completed. A daily nursing skilled note dated August 27, 2020 revealed the resident was alert and oriented times two, had a [MEDICAL CONDITION], oxygen, and was receiving enteral nutrition via a PEG (percutaneous endoscopic gastrostomy) tube. The note included the resident was totally dependent on staff for transfer, bed mobility and toilet use, and was incontinent of urine and bowel. A care plan dated August 27, 2020 included for physical restraints (bilateral soft wrist restraints) related to pulling at life sustaining devices (life sustaining devices were not listed). The goal was to minimize or eliminate the need for restraints and to keep the resident free from complications related to restraint use. Interventions included ensuring a valid consent is on the chart prior to initiating restraints, ensuring the resident is positioned correctly with proper body alignment while restrained, monitor, document and report to the provider any changes regarding the effectiveness of the restraint, any negative or adverse effects noted, including contracture formation, skin breakdown, falls/accidents/injuries and agitation. The interventions did not address to remove the restraints every two hours to assess skin integrity. Review of the physical medicine and rehabilitation initial evaluation dated August 28, 2020, revealed the resident had bilateral soft wrist restraints in place. The evaluation included that when the resident's limbs were moved, the resident mildly grimaced in pain with range of motion. Bilateral soft wrist restraints in place. The evaluation also included the resident was at severe risk for developing contractures. The endocrinology physician progress notes [REDACTED]. The note also included the resident had unrestricted PROM (passive range of motion) in all four extremities with grimacing. The TAR for August 2020 revealed the physician's orders [REDACTED]. The TAR included staff initials on the day shift and night shift that indicated the order had been implemented. However, there was no corresponding documentation regarding the condition of the resident's wrist, when the 2 hours skin checks were documented as being done or if the resident experienced any pain when the restraints were removed. In addition, there was no clinical record documentation of the least restrictive measures that were attempted, prior to implementing the bilateral soft wrist restraints upon admission, such as 1:1 supervision. A nursing note dated September 1, 2020 revealed the resident was going to be trialed without bilateral soft wrist restraints for 24 hours for possible restraint reduction. Staff to monitor the resident closely for any episodes of pulling at life sustaining devices. A MAR indicated [REDACTED]. An admission MDS assessment dated [DATE] included the resident had a BIMS score of 8, indicating the resident had moderate cognitive impairment. The MDS included the resident was totally dependent for bed mobility, transfers, toilet use and was always incontinent of bowel and bladder. The MDS also included the resident had oxygen therapy, suctioning, [MEDICAL CONDITION] care, ventilator, tube feeding and limb restraints. A nursing note dated September 2, 2020 stated the staff reported that during the evening while the resident was being trialed without bilateral wrist restraints, the resident continuously used her left hand to pull at the [MEDICAL CONDITION], which required restraints to be placed back on the left hand only, related to right sided weakness. The resident to be trialed with mitt to left hand for 24 hours to possibly reduce restraint. The restraint safety device review dated September 3, 2020 revealed recommendations to discontinue the bilateral soft wrist restraints. The review included that at that time, the resident was no longer pulling at the life sustaining devices. An IDT (Interdisciplinary Team) note dated September 3, 2020 revealed that after a trial without restraints, the resident was no longer displaying pulling at life sustaining devices as of September 3. The note included that bilateral soft wrist restraints will be discontinued and that bilateral hand mitts were not needed either. Will continue to monitor. The care plan for the bilateral soft wrist restraints was resolved on September 3, 2020. The MAR indicated [REDACTED]. The resident complained that it felt like she was getting shocks all over her body. The note included the resident was medicated with an antianxiety medication and a narcotic pain medication. Another MAR indicated [REDACTED]. The note included the resident was medicated with an antianxiety. Review of a behavior note dated September 5, 2020 revealed the resident was found with the inner cannula of [MEDICAL CONDITION] her pillow and was struggling with breathing, asking for help. The cannula was replaced and the respiratory therapist assessed the resident. The resident denied pulling it out. The safety mitts were placed to bilateral hands to prevent the resident from pulling out life sustaining devices. A physician order [REDACTED]. Remove every 2 hours to check skin integrity and circulation every shift. A consent dated September 6, 2020 included for the use of a left-hand mitt (the order was for mitts to both hands). The section regarding an evaluation being conducted was blank. In addition, there was no care plan that was developed regarding the use of safety mitts to both hands. The TAR for September 2020 included the physician's orders [REDACTED]. Staff initials indicated on the day and night shift that this order was implemented on September 6, 7, and 8. However, there was no corresponding documentation regarding the condition of the resident's wrists and circulation, when the 2 hours skin checks were documented as being done. Review of the physical medicine and rehabilitation follow-up evaluation dated September 8, 2020, revealed the resident had unrestricted PROM in all four extremities and was at moderate to severe risk for developing contractures, if not receiving adequate therapy and pain control. The physician's orders [REDACTED]. A physician order [REDACTED]. The order included removing the mitt every 2 hours to check skin integrity and circulation every shift. A care plan dated September 9, 2020 revealed the resident had a safety mitt to the left hand related to pulling life sustaining devices. The goal was to minimize or eliminate the need for restraints and to keep the resident free from complications related to restraint use. Interventions included anticipating and intervening for potential causes which have precipitated prior falls or accidents, have safety mitt applied to left hand and release every two hours, and document the restraint use and release, as per facility protocol. A nursing MAR indicated [REDACTED]. The note included the resident was not compliant with keeping the mitt on. The resident has been getting it off several times throughout the day. No attempts to pull at life sustaining devices. An IDT note dated September 11, 2020 stated the resident was to have a restraint reduction trial for the mitt to the left hand, related to a decline in pulling at life sustaining devices. The resident was to be monitored closely for pulling at life sustaining devices. Resident will not have left a soft hand mitt on for 24 hours. A nursing MAR indicated [REDACTED]. The MAR indicated [REDACTED]. An IDT note dated September 14, 2020 at 6:32 a.m. stated the soft hand mitt was to be discontinued related to the resident not pulling at life sustaining devices. Review of the restraint safety device review dated September 14, 2020 at 6:34 a.m. revealed recommendations to discontinue the safety hand mitt to the left hand, due to the resident no longer pulling at life sustaining devices at this time. Although there was a restraint reduction from soft wrist restraints to hand mitts, there was no documentation of any 1:1 supervision that was provided, as a less restrictive measure. An observation was conducted on September 16, 2020 at 2:50 p.m. of resident #11. The resident was awake and was not restrained at this time. The resident was not pulling at any lines or tubes during the observation. The resident's skin was clean, dry and intact around the hands and wrist areas. An interview was conducted with the DON on September 17, 2020 at 11:40 a.m. She stated that restraints are applied when a resident is pulling at life sustaining devices. She stated that if the resident is admitted from the hospital with restraints, staff will re-evaluate to ensure the resident still needs restraints upon admission and will document the evaluation in the clinical record. Staff #77 stated the expectation is for staff to release the restraints every two hours and document any changes in the resident's condition. She further stated that for any changes, the resident would be put on change of condition charting, and the physician and family would be notified. She stated that when obtaining a consent, staff will address alternatives to restraints, identify the best type of restraint to use on the resident, and notify the resident or family of the rationale for restraining the resident. The DON said the consent is kept in the electronic record or in medical records. She said when the order is obtained for a restraint, the consent is completed prior to the restraint being applied to the resident. She stated it is the expectation that the consent is completely filled out by the nurse. The DON said that she was not sure why there was not a consent for the use of bilateral mitt restraints for resident #11 or why consents were not fully completed. In an interview conducted with a LPN (staff #138) via telephone on September 18, 2020 at 2:27 p.m., the LPN stated when a resident is in restraints, a skin assessment is conducted every two hours and as needed. She stated that if there is a change or an issue with the skin, change of condition charting will be initiated and the physician would be notified. The LPN said that she documents the 2 hour monitoring of restraints, one time during the shift on the TAR. Although the facility policy regarding restraints included for 30 minute checks by staff for residents requiring physical restraints, there was no documentation that the 30 minute checks were done. -Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Initial Admission Record dated August 4, 2020 included the resident was alert, confused, oriented to person only and his speech was not clear (i.e. slurred, mumbled words). The record stated that the resident had a [MEDICAL CONDITION] and was on a ventilator. The record also included the resident exhibited a behavior or medical symptom that required assessment of a physical restraint and was currently being restrained, and had a physical restraint within the last 3 days. The specific behavior requiring a restraint was not documented. A physician's orders [REDACTED]. Review of a Restraint/Enabling Safety Device Evaluation dated August 4, 2020 revealed the resident was a new admission. The evaluation identified the medical condition/symptom requiring a restraint/enabling device as COVID-19. The rationale for the restraint was that bilateral hand mitts prevented the resident from pulling at life sustaining devices (no specific life sustaining devices were listed), thus potentially protecting the resident from injury. The documentation also included that no other less restrictive measures had been attempted, prior to implementing bilateral hand mitts. Also, in the section to document if the facility had obtained an evaluation for least restrictive means by physical therapy (PT), occupational therapy (OT) or another source, the section was left blank. A Resident/Family Consent for the use of Physical Restraints dated August 4, 2020 included the resident had been identified as requiring a physical restraint. The type of restraint recommended was bilateral hand mitts to prevent pulling at life sustaining devices (the specific life sustaining device was not mentioned). On the form there was a check mark in the box which acknowledged that the use of the restraining device had been explained and agreed to. The consent form contained documentation of a verbal consent on August 4 from the resident's family

Based on observations, clinical record review, staff interviews, and policies, the facility failed to ensure that two residents (#1 and #2) received adequate hydration and one resident (#3) maintained acceptable parameters of nutritional status. The deficient practice could result in residents being dehydrated and not maintaining acceptable parameters of nutritional status. Findings include: -Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing Initial Admission Record dated December 24, 2019 revealed the resident was alert and oriented to time, place, and person. The Record included the resident had no difficulty swallowing and no vomiting or complaints of heartburn within the last 3 days. The resident's blood pressure was 147/71, pulse 85, respirations 18, temperature 97.8 F (Fahrenheit), and her oxygen saturation was 97%. The care plan initiated December 24, 2019 revealed the resident had the potential for skin breakdown related to limited mobility. Interventions included encouraging good nutrition and hydration in order to promote healthier skin. Review of the physician orders [REDACTED]. The Mini Nutritional assessment dated [DATE] revealed the resident's weight was 113.6 pounds, height was 66 inches, and Body Mass Index (BMI) was less than 19. The assessment included the resident's food intake had not declined over the past 3 months and the resident did not have weight loss during the last 3 months. The score for the assessment was 10 which indicated the resident was at risk of malnutrition. The admission nutrition evaluation dated December 26, 2019 revealed a mighty shake nutritional supplement three times a day had been ordered and the resident was on a full liquid diet. The evaluation included the resident's weight was 113.6 pounds and that the desirable weight range/ideal weight range was 130 pounds +/- 10%. The evaluation included labs were reviewed and the resident had an elevated creatinine of 1.58. The evaluation also included the resident was underweight with potential for weight loss fluctuation related to fluid shifts related to recent hospitalization . The goal was that the resident would tolerate the diet with no complications and would have 70% intake of meals and supplements. The evaluation also included the resident's EEN (estimated energy need) was around 1500 to 1800 kcals/day and EFN (estimated fluid need) was 1ml/kcal or as tolerated, indicating 1500 to 1800 cc (cubic centimeters) fluid intake daily. Review of the Nutrition/Hydration Risk Evaluation dated December 26, 2019 revealed the resident's intake was fair, that she eats 25% to 50% of most meals, her fluid intake was 1000 - 2000 cc daily, and she took snacks/supplements less than 50% and her [MEDICATION NAME] less than 2.9. The score for the evaluation was 9 (if score is 10 or greater, a prevention protocol should be initiated immediately and documented in the care plan). Review of the care plan initiated December 26, 2019 revealed the resident had nutritional problem or the potential for nutritional problem related to underweight, BMI of 18.3 and the potential for weight loss/fluctuation related to fluid shifts related to recent hospitalization . The goals included the resident would maintain adequate nutritional status as evidenced by maintaining weight with no sign or symptoms of malnutrition and will have 70% intake of meals and supplements. Interventions included obtaining and monitoring lab/diagnostic work as ordered and reporting results to the physician as needed, providing and serving the diet as ordered, providing the mighty shake three times a day as ordered, the RD (Registered Dietician) to evaluate and make diet change recommendations as needed, and weekly weights times 4 weeks and then monthly if stable. Review of the lab report dated December 26, 2019 revealed the abnormal values included the creatinine 1.58 (0.60-1.40 mg/dl), glomerular filtration rate (GFR) 31 (greater than or equal to 60 mL/min/1.73m2), total protein 4.8 (6.0-8.0 g/dL), [MEDICATION NAME] 2.7 (3.4-4.9 g/dL), and calcium 8.4 (8.8-10.4 mg/dL). The weight summary record revealed the resident's weight was 129.2 pounds on December 29, 2019. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact. The assessment included the resident was independent for eating and required setup help only, did not have dehydration, and was on a mechanically altered diet. The Nutrition note dated December 31, 2019 revealed the resident was consuming around 64% of meals and that the labs were reviewed. The note included EEN around 1500 to 1800 kcals/day and EFN 1ml/kcal or as tolerated. A review of the MAR (Medication Administration Record) for December of 2019 revealed the resident was medicated with [MEDICATION NAME], Milk of Magnesia, and a Fleet Enema on December 31 for Bowel Care. A Daily Skilled nursing note dated December 31, 2019 included the staff offered fluids as a non-pharmaceutical approach for constipation and that the resident's abdomen was hard and distended due to constipation. The note included the resident had not had a bowel movement for 6 days. Review of daily fluid intake for December 2019 revealed the following: December 25 - 2500 cc; December 26 - 1000 cc; December 27 - 2240 cc; December 28 - 1440 cc; December 29 - 2520 cc; December 30 - 2600 cc; December 31 - 480 cc. A physician order [REDACTED]. Review of the weight summary revealed the resident weighed 130.2 pounds on January 5, 2020. A Nutrition note dated January 6, 2020 included the resident was showing weight gain since admission, diet intakes were around 52%, taking 100% of the mighty shakes, and that intakes were within estimated needs and appropriate as evidenced by weight gains. The Weights and Vitals Summary revealed the resident's pulse was 100 or greater on January 11 and 12, 2020. The resident's pulse was 112 on January 11, 2020 at 2:13 p.m., 112 on January 12 at 5:31 a.m., and 117 on January 12 at 6:22 a.m. Review of the MAR indicated [REDACTED]. Review of the nursing Daily Skilled Note dated January 12, 2020 revealed the resident's pulse was 113 and blood pressure was 121/81 at 8:41 p.m The note included the vital signs did not show any fluctuations from baseline that required interventions. The MAR for January 2020 also revealed the resident was administered Milk of Magnesia for bowel care on January 11 and was administered a [MEDICATION NAME] suppository and a Fleets enema for bowel care on January 12. Review of the daily fluid intake for January 2020 revealed the following: January 1 - 480 cc; January 2 - 2400 cc; January 3 - 480 cc; January 4 - 660 cc; January 5 - 240 cc; January 6 - 960 cc; January 7 - 660 cc; January 8 - 360 cc; January 9 - 860 cc; January 10 - 360 cc; January 11 - 890 cc; January 12 - 480 cc. Further review of the clinical record revealed no nursing and/or dietary clinical notes addressing the decrease in daily fluid intake or the elevated pulses. Nursing notes dated January 12, 2020 revealed the family requested the resident be transferred to another facility and that the resident was discharged to another facility on January 12, 2020 at about 9:00 p.m. A hospital emergency room note dated January 13, 2020 revealed the admitting facility assessed the resident and immediately transferred the resident to a hospital for a distended abdomen and sharp abdominal pain. A review of the hospital emergency room laboratory results dated [DATE] revealed the following results: sodium 132 mEq/L (135 to 145 mEq/L), potassium 5.8 mmol/L (3.6 to 5.2 mmol/L), BUN 35 mg/dL (7 to 20 mg/dL), and creatinine 2.54 mg/dL (0.84 to 1.21 mg/dL). The emergency room physician note dated January 13, 2020 revealed the resident was in acute [MEDICAL CONDITION] with dehydration. An interview was conducted with the Dietetic Technician (staff #16) on September 15, 2020 at 11:12 am. She stated that she obtained the resident's height and weight upon admission. Staff #16 also stated that she reviewed the medications and identified whether the resident was high risk for malnutrition. Staff #16 stated she did not know why the oral fluid intakes were documented so low. She stated that she did not feel the resident needed a follow up assessment because her vital signs and weight did not show signs or symptoms of dehydration. An interview was conducted with the Director of Nursing (DON/staff #77) and the Clinical Resource (staff #84) on September 15, 2020 at 2:08 pm. Staff #84 stated resident #1 did not have any changes in her vital signs to indicate dehydration. She stated that if the resident had a high heart rate and a low blood pressure, the staff would have notified the provider. The DON stated the provider would have been able to order labs and assess the hydration status at that time. The DON also stated there was nothing in any of the nursing assessments to indicate the resident was dehydrated. An interview was conducted with the Registered Dietitian (RD/staff #76) on September 16, 2020 10:30 am. She stated that when she reviewed resident #1's chart, her hospital weight was closer to 130 pounds, which showed stability. She stated that she didn't want to comment regarding if the 113-pound weight was documented in error. She stated based on her review of the documentation, the resident was taking all of her mighty shakes. The RD stated that she would only address hydration if there were other symptoms such as an elevated temperature or heartrate. She stated the volume the resident was eating and drinking was acceptable based on the information provided. The RD stated, The Intake & Output is a CNA thing and does not capture everything. I believe they are streamlining it to get rid of it. She stated the resident's weight was stable, blood pressures were not low, and no vomiting, so there were no issues noted with this resident. -Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A potential for fluid volume deficit care plan dated October 1, 2019 had a goal for adequate fluid balance to be restored as evidenced by normal skin turgor, moist mucous membranes, vital signs and labs within normal limits, and balanced intake and output. Interventions included to infuse the fluids and/or medications as ordered and to monitor for adverse reactions such as change in level of consciousness, respiratory rate of less than 10, [MEDICAL CONDITIONS] constipation, rash, nausea, and vomiting. A physician's orders [REDACTED]. An additional order dated October 2, 2019 revealed medications may be crush/combine for administration if not contraindicated and mixed with 4 ounces (118.29 mL) of water; may use slow push to facilitate consumption. A tube feeding care plan dated December 23, 2019 related to dysphagia included a goal to be free from aspiration. Interventions included monitoring/documenting/reporting to MD as needed (PRN) signs or symptoms which included abnormal lab values and dehydration; resident is dependent with tube feeding and water flushes - see Medical Doctor (MD) orders for current feeding orders, and obtaining and monitoring lab and diagnostic work as ordered, reporting results to MD and follow up as indicated. The annual MDS assessment dated [DATE] revealed the resident was assessed to be comatose. The resident required 2-person total physical assistance for all activities of daily living, received 51% or more proportion of total calories through [MEDICATION NAME] or tube feeding and 501 cc a day or more average fluid intake. Additionally, the Care Area Assessment (CAA) indicated that dehydration/fluid maintenance had been triggered and addressed in the resident's care plan. On March 30, 2020 at 12:42 p.m., a nursing progress note stated that the NP had been notified that the resident's peg tube had dislodged. The note stated that nursing had received orders for a replacement and a stat KUB, peg tube in place. The note stated that nursing had received verbal orders for a wound culture at the peg site related to copious bloody/brown drainage, the lab was called, and the resident continued feeding at the current setting. The note said that nursing would continue to monitor the resident's vital signs. A nursing progress note dated March 30, 2020 at 3:23 p.m. revealed the nurse practitioner had been notified that the mobile x-ray service had requested to hold the resident's feeding until 5:00 p.m. for the ultrasound. On April 1, 2020 at 3:43 p.m. a Nurse Practitioner/Physician's Assistant (NP/PA) progress note included that the nurse had reported that the resident had a low-grade fever of 99.1 Fahrenheit (F) that morning. Other vital signs documented for the resident included a heart rate (HR) of 87, respiratory rate (RR) of 18, and a blood pressure (BP) of 129/84. Upon assessment, the NP noted that the resident was assessed to be agitated, restless, and had symptoms of nausea and vomiting. The plan included obtaining labs immediately to include a complete blood count and complete metabolic panel (CBC/CMP). However, review of the resident's clinical record did not reveal that additional hydration intervention had been put into place. Review of a Lab Report dated April 1, 2020 reported at 9:54 p.m. included for a blood glucose level of 302 milligrams per deciliter (mg/dL) (normal range is 65-99), blood urea nitrogen (BUN) of 28 milligrams per deciliter (mg/dL) (normal range is 8 -25), and BUN/Creatinine Ratio of 29.5 (normal range is 10.0 - 28.0). An NP/PA progress note dated April 2, 2020 at 2:46 p.m. revealed the resident had been seen and examined as follow-up regarding hypertension and abdominal [MEDICAL CONDITION]. The note stated the resident had no fevers. Vital signs included for a temperature (T) of 98.5 F, HR of 77, RR of 18, and BP of 149/84. The resident was assessed to be agitated and restless, and had nausea and vomiting. The plan included to consult the Registered Dietician related to tube feeding via PEG tube, and to monitor labs. However, no additional hydration was added to the resident's orders. Review of the Point of Care (POC) Certified Nursing Assistant (CNA) documentation dated April 1 through 10, 2020 included for 44 occasions when urinary incontinence care was provided to the resident which was an average of 4.4 wet briefs per 24-hour period. On April 13, 2020 at 6:00 p.m. an NP/PA progress note revealed for a T: 98.0, HR: 60, RR: 16, BP: 140/66, and blood glucose (BG) of 148 (high). The plan included to consult the Registered Dietician and to monitor labs. Review of a nutrition progress note dated April 18, 2020 included that the resident received tube feedings of [MEDICATION NAME] 1.5 at 65 mL per hour for 20 hours daily, auto water flushes at 30 mL per hour for 20 hours (1950 kcals, 82 grams protein, 1046 mL free water, total free water tube feedings plus all flushes equaled about 2000-2100 mL per day). The note stated the resident's estimated energy needs (EEN) was about 1800-2000 kcals per day, estimated protein needs (EPN) was about 76-85 grams per day, and estimated fluid needs (EFN) was about 2000 mL per day or more. The note included the resident had increased needs remaining related to skin integrity/healing of recent abdominal abscess and intermittent elevated temperatures. The recommendation was to continue tube feeding as tolerated pending chest x-ray and new labs. The note stated that the resident may benefit from additional free water related to elevated temperatures, will monitor. However, no additional free water was added to the resident's orders. A nursing progress note dated April 18, 2020 at 10:41 a.m. stated the resident was noted with an episode of emesis one time that morning. The note stated that the resident's tube feeding had been turned off for an hour with effective results. The note included that the respiratory therapist reported that she had suctioned tube feeding out of the resident's trach, and that the provider had ordered labs and a chest x-ray for the following morning. A lab report dated April 19, 2020 returned results at 8:33 a.m. The report revealed the resident had a white blood cell (WBC) count of 15.2 million per cubic millimeter (k/mm3) (normal is 4.0 - 11.0), RDW 52.6 fL (normal is 38) a blood glucose level of 283 mg/dL (high), a glomerular filtration rate (GFR) Non-African American of 55 milliliters per minute (mL/min) (normal range is greater than 60), chloride 90 millimoles per liter (mmol/L) (normal is 95-108), protein, total 8.5 grams per deciliter (g/dL) (normal is 6.0-8.0), and [MEDICATION NAME] 4.6 g/dL (normal is 1.9 - 3.7). The resident's blood urea nitrogen (BUN) was 24 mg/dL (within normal limits), her creatinine level was 1.08 mg/dL (within normal limits), and her BUN/Creatinine Ratio was 22.2 (normal range is 10.0 - 28.0). An eMAR medication administration note dated April 19, 2020 at 12:34 p.m. included for a change of condition. The note stated that nursing had received the resident's labs that morning and the resident's WBC was 15.2. The note stated the provider had been notified and that new orders [MEDICAL CONDITION] protocol and intravenous antibiotics had been received. In addition, a 500 cc (mL) normal saline bolus was administered per provider's orders. However, review of the resident's clinical record did not reveal the initiation of IV fluids in response to the [DIAGNOSES REDACTED]. A [MEDICAL CONDITION] NP/PA progress note dated April 20, 2020 at 6:51 p.m. revealed the resident had been started [MEDICAL CONDITION] protocol over the weekend. The note stated that the resident had a fever of 100.0 F, WBC of 15.4, and HR of 106. The note stated that the nurse reported the resident may have had an aspiration event and that cultures were pending. However, no change was made to the resident's hydration order in response to the [DIAGNOSES REDACTED]. Review of CNA POC documentation dated April 11 through 20, 2020 included for 43 occasions when urinary incontinence care was provided to the resident. This was an average of 4.3 wet briefs per 24-hour period. On April 21, 2020 at 12:48 p.m. an NP/PA progress note stated that the resident had been seen and examined for follow-up regarding hypertension. The note stated the resident was assessed to have fever and [MEDICAL CONDITION] and that she was started [MEDICAL CONDITION] protocol. Further assessment included agitation and restlessness, nausea and vomiting. The plan included monitoring closely. Review of a NP/PA progress note dated April 22, 2020 at 2:41 p.m. revealed the resident had been seen and examined for follow-up regarding hypertension, fever, and [MEDICAL CONDITION] The resident was assessed to have agitation and restlessness, nausea and vomiting. The resident's vitals were listed as: T: 98.4, HR: 78, RR: 18, BP: 138/98, and BG: 148. Additionally, the note stated the resident's Creatinine level was 1.25, that labs were pending, and the plan included monitoring the resident closely. However, no additional interventions were put into place to address the resident's hydration status. On April 22, 2020 at 3:55 p.m. a lab report included for blood glucose levels of 382 (high), BUN of 28 mg/dL (high), BUN/Creatinine Ratio 30.8 (high), chloride 91 mmol/L (low), carbon [MEDICATION NAME] 33 mmol/L (high) (normal range is 19-31), and [MEDICATION NAME] 4.4 g/dL (high). Review of a nursing progress note dated April 23, 2020 at 6:40 a.m. stated the lab results had been reported to the provider. The note stated there were no new orders thus far. Lab results dated April 23, 2020 at 10:56 a.m. revealed for blood glucose levels of 385 (high), BUN of 26 mg/dL (high), BUN/Creatinine ratio 31.0 (high), and chloride 92 (low). A nursing progress note dated April 23, 2020 at 4:39 p.m. revealed the provider and infectious disease had been notified of the resident's results. The note stated there were no new orders thus far. On April 23, 2020 at 3:52 p.m., an NP/PA progress note stated that the resident had been seen and examined for follow-up regarding hypertension, fever, and [MEDICAL CONDITION] The resident assessment continued to include agitation and restlessness, nausea and vomiting. The plan was to monitor closely. On April 24, 2020 a change of condition progress note stated that the resident was noted with an open area on left buttocks. The note stated the area had been cleaned, the resident positioned, MD and case management notified, unable to reach family, and unit nurse would notify wound team to evaluate. Review of an NP/PA progress note dated April 27, 2020 at 5:23 p.m. revealed the resident had been seen and examined for follow-up regarding hypertension and pneumonia. Agitation and restlessness, nausea and vomiting were also listed on the assessment. The resident's vitals were noted as: T: 98.4, HR: 78, RR: 18, BP: 138/98, and BG: 148. An NP/PA progress note dated April 29, 2020 at 1:45 p.m. stated that the resident was in no apparent distress, that she was doing well, and that there were no concerns at that time. The note stated that the resident was at risk for recurrent infection and rapid decompensation, will monitor closely. Review of the April 1 through 30, 2020 Medication Administration Record [REDACTED]. Further review of the April 2020 MAR indicated [REDACTED]. Also included on the MAR indicated [REDACTED]. The POC CNA documentation dated April 21 through 30, 2020 included for 45 occasions when urinary incontinence care was provided to the resident. This was an average of 4.5 wet briefs per 24-hour period. A [MEDICAL CONDITION] NP/PA progress note dated May 4, 2020 at 11:43 a.m. included a BP: 136/76, HR: 110, RR: 20, and T: 98.9. However, there was no nursing progress note to indicate that the resident's vitals had been reported to the provider. On May 4, 2020 at 9:31 p.m. lab results were reported and included for a blood glucose level of 1462 mg/dL (critically high), BUN 93 mg/dL (high), Creatinine 2.43 mg/dL (high), GFR Estimated (Non-African-American) 18 mm/min (low), GFR Estimated (African-American) 21 mm/min (normal is greater than 60), BUN/Creatinine Ratio 38.3 (high), and sodium 156 mmol/L (normal range is 134-147), and anion gap 27 (high). A NP/PA progress note dated May 4, 2020 at 9:48 p.m. stated the resident was seen and examined, and was in no apparent distress. The note stated the resident was doing well, that she was better today. The note stated the resident had a low-grade temperature and [MEDICAL CONDITION] The resident's vital signs were listed as: T: 100.4, HR: 115, RR: 20, BP: 107/75, and BG: 148. The plan included obtaining stat labs. Review of CNA POC documentation dated May 1 through 4, 2020 included for 15 occasions when urinary incontinence care was provided to the resident. This was an average of 3.75 wet briefs per 24-hour period. A nursing progress note dated May 4, 2020 at 11:09 p.m. stated the lab had called with a critical BG of 1482. The note stated that the provider had been called and that an order was obtained to send the resident to the emergency room (ER). Review of an eMAR medication administration note dated May 4, 2020 at 11:39 p.m. revealed that [MEDICATION NAME] (antipyretic, non-opioid [MEDICATION NAME]) 325 mg, 2 tablets, had been administered enterally for a temperature of 100 F or above. Review of a nursing progress note dated May 5, 2020 at 1:35 a.m. included nursing had called the hospital and it was reported that the resident's BG was 1745 when she arrived and that she would be admitted . Hospital records dated May 5, 2020 revealed the resident was admitted to the intensive care unit at 2:07 a.m. for diabetic ketoacidosis (DKA). Admitting labs included a serum glucose level (BG) of greater than 1500, serum sodium of 131 mmol/L (low), potassium 4.4 mmol/L (normal range is 3.6 - 5.3mmol/L), lactic acid of 8.1 mmol/L (normal range is 0.5 - 1), beta [MEDICATION NAME] 7.6 mmol/L (normal range is less than 1.5 mmol/L), and elevated creatinine 22.97. Further [DIAGNOSES REDACTED]. Further review of the resident's clinical record revealed she was readmitted to the facility on [DATE]. An interview was conducted on September 15, 2020 at 9:40 a.m. with an LPN (staff #11). She stated that some signs and symptoms of dehydration might include skin tenting, low blood pressures, elevated heart rate, dry mouth, and decreased output. She stated that incontinent residents would usually be wet every 2 hours and that it would be unusual if they were only wet 2-4 times in a 12-hour shift. She stated that she would anticipate that dehydration would be reflected in the resident's labs as well. She stated she would expect to see low potassium, elevated sodium, white blood cells, BUN and creatinine levels. She stated that the protocol is for the desk nurse on the unit to notify the provider of abnormal labs. She stated that the floor nurse could also notify the provider. She stated that she would absolutely make recommendations. On September 15, 2020 at 10:03 a.m,. an interview was conducted with an LPN (staff #260). She stated that the floor nurse is ultimately responsible for her residents and for notification of all abnormal labs. However, she stated that on the unit in which resident #2 resides, the desk nurse may also notify the provider. She stated that on that unit, it is part of the desk nurse's job, to watch for abnormal labs. She stated that if a resident had a critical set of findings, such as elevated sodium, low potassium, and elevated BUN and creatinine, the provider would be notified immediately. She stated that would be an emergent situation. She stated that the medical director could be notified if the NP or provider did not answer or was unavailable. She stated that someone is always available 24/7. She stated that if critical labs are reported to the provider and the provider gives no new orders, they may follow the chain of command and contact the next provider. The LPN stated that if the nurse is not comfortable with something, there is always an open field of communication and ultimately, the nurse is responsible for that patient. The LPN stated they always have that option to call 9-1-1, even if a provider does not give you an order to call. She said they are able to contact the DON if they feel the provider did not give them adequate orders, and the DON can reach out to the provider. An interview was conducted on September 15, 2020 at 11:12 a.m. with the Dietary Technician (staff #16). She stated that caloric needs are based upon the resident's weight 20-25 kilocalories (kcals) per pound. She stated that fluid is calculated 1 mL to 1 kcal. She reviewed the resident's nutrition/hydration order and stated that yes, that would meet the resident's needs. She said she could not say whether or not that would be reflected in the resident's labs. On September 23, 2020 at 11:33 a.m., an interview was conducted with the DON (staff #77). She stated she spoke with the provider and asked if he knew about the resident's labs. She stated he told her yes, but said it was related to the resident's infection. She stated she pulled up the resident's chart and reviewed it. The DON stated the floor nurses are primarily responsible for monitoring. She stated that she noticed the nurses on the floor were reporting abnormal results to the provider, but he was not giving them any new orders. She stated she brought the issue up to QAPI and they came up with a plan regarding abnormal labs. The action plan included to in-service all the unit managers along with the nurses to look at the labs and make sure they were reporting them. She said that if they noticed something was high or abnormal to make sure the physician was notified, that they documented the notification, and if there was no new orders or if there were new orders, they would notify the unit managers as well, just to make sure there was a second double-check. She stated that every day during stand-up meetings they go through all the labs to ensure they are being addressed. She stated that since then, they have not had any further issues. The facility's policy titled Hydration included that it is the policy that this facility will provide each resident with sufficient fluid intake to maintain proper hydration and health. The purpose is to ensure that the resident receives sufficient amount of fluids based on individual needs to prevent dehydration. The policy defines sufficient fluid as the amount of fluid needed to prevent dehydration and maintain health. The amount needed is specific for each resident and fluctuates as the resident's condition fluctuates (e.g., increase fluids if resident has fever or diarrhea). Risk factors for dehydration include fluid loss and increased fluids needs. The nursing staff will encourage each resident to consume all fluids provided on their meal trays. Fluids will be encouraged. The policy included the staff would educate residents, as needed, regarding the importance of fluids, especially water, in maintaining body functions. -Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Another physician's orders [REDACTED]. The Initial admission nursing assessment dated [DATE] included the resident had a [MEDICAL CONDITION], and that he received [MEDICATION NAME]/enteral feedings via a percutaneous endoscopic gastronomy (PEG) tube. The Initial Admission Nursing assessment did not include the resident's admission weight. A nutritional problem/potential nutritional problem care plan dated June 9, 2020 related to weight below ideal weight range, dysphagia, altered blood glucose levels, increased nutrient needs and had goals to maintain adequate nutritional status as evidenced by (AEB) maintaining weight with no signs or symptoms of malnutrition, and to tolerate tube feeding diet without complications, and controlled blood glucose. Interventions included diet: NPO on tube feeding Glucerna 1.5 and hydration via PEG tube, monitor for tolerance, monitor, document, and report to Medical Doctor (MD) as neede(TRUNCATED)

Based on clinical record reviews, staff interviews, facility documentation and policy review, the facility failed to ensure that three residents (#1, #2 and #7) received appropriate care and treatment. Findings include; -Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was comatose and required 2-person total assistance for all activities of daily living. The assessment included the resident received all nutrition through a feeding tube. The assessment did not include a [DIAGNOSES REDACTED]. Review of a nursing progress note dated March 31, 2020 stated the resident's percutaneous endoscopic gastronomy (peg) tube had become dislodged, was replaced, and a culture of the copious bloody/brown drainage had been obtained. An antibiotic therapy care plan dated March 31, 2020 related to [MEDICAL CONDITION] and risk for adverse side effects related to antibiotics had a goal the resident would be free of any discomfort or adverse effects of antibiotic therapy. Interventions included to report pertinent lab results to the provider. A Nurse Practitioner (NP)/Physician's Assistant (PA) progress note dated April 1, 2020 revealed the resident was seen and examined for follow up regarding hypertension (HTN) and abdominal [MEDICAL CONDITION]. The note included nursing had reported a low-grade fever that morning of 99.1 degrees Fahrenheit (F). In addition, the resident was assessed to have agitation and restlessness, nausea and vomiting, and oral thrush. Per the clinical record, the resident did not have a [DIAGNOSES REDACTED]. On April 1, 2020 at 10:46 p.m., a lab report included the resident had a fasting blood glucose (BG) level of 302 milligrams (mg)/deciliter (dL) (normal range 65 - 99 mg/dL). Despite the high blood glucose level, there was no documentation that the provider had been notified, nor any interventions that were done to address the elevated BG. A nursing progress note dated April 9, 2020 revealed the peg tube had split open when it was flushed. The note included the provider was notified, the peg tube was replaced and verification was confirmed. The note also included the peg site was cleaned and a dry dressing was applied and that the tube feeding was resumed. A NP/PA progress note dated April 10, 2020 revealed the resident was seen and examined and had a BG level of 148. Review of the NP/PA progress note dated April 16, 2020 at 3:49 p.m. revealed that nursing had reported a low-grade fever of 99.2 degrees F and a BG of 148. On April 18, 2020 at 10:41 a.m., a nursing progress note stated the resident had one episode of emesis that morning. The tube feeding had been turned off for an hour with effective results. The note included respiratory therapy had suctioned tube feed out of the resident's [MEDICAL CONDITION], the provider was notified. Physician's orders dated April 19, 2020 included for an influenza A&B rapid test stat for leukocytosis, a stat complete blood count (CBC) and complete metabolic panel (CMP) one time only for leukocytosis, a stat sputum for leukocytosis, a stat urinalysis (UA) with culture and sensitivity (C&S) for leukocytosis, and [MEDICATION NAME] (antibiotic) [MEDICATION NAME] (HCl) solution 1.25 gram intravenously one time a day for leukocytosis for 4 days. The orders did not include for accuchecks to monitor the resident's BG levels. A lab report dated April 19, 2020 revealed a white blood cell count (WBC) of 15.2 per cubic millimeter (k/mm3) (normal range is 4.0 - 11.0 k/mm3) and a high fasting BG level of 283 mg/dL. A nursing progress note dated April 19, 2020 at 12:31 p.m. included the lab results had been reported to the NP, and new orders were on the medication administration record (MAR). However, there were no orders or interventions to address the resident's elevated BG level. A NP/PA progress note dated April 20, 2020 at 3:17 p.m. stated the resident had a fever and [MEDICAL CONDITION] The resident was started [MEDICAL CONDITION] protocol and the plan included monitoring labs. An intravenous (IV) access care plan dated April 20, 2020 related to antibiotics had a goal for the IV to be maintained and free of complications for successful completion of IV therapy. Interventions included to check labs as ordered and notify the MD with the results. A lab report dated April 22, 2020 revealed the WBC was normal and the fasting elevated BG level was 382 mg/dL. However, there was no clinical record documentation that the provider was notified of the lab results, nor any interventions that addressed the elevated BG level. A lab report dated April 23, 2020 included a fasting elevated BG level of 385 mg/dL and a normal WBC. A nursing progress note dated April 23, 2020 included the lab results had been reported to the NP and infectious disease. Again, there were no orders or interventions to address the elevated BG level. Review of a NP/PA progress note dated April 29, 2020 stated that the resident was at risk for recurrent infection and rapid decompensation. The note included the resident's BG level was 148. There was no clarification in the note if the BG of 148 was done on April 29 or if this reflected the BG from April 16, which was 148. A NP/PA progress note dated May 1, 2020 stated the nurse had reported an elevated blood pressure of 148/90 and the BG of 148. The plan included to monitor for recurring infections. There was no clarification in the note if the BG of 148 was done on May 1 or if this reflected the BG from April 16, which was 148. Further review of the clinical record revealed there were no physician/provider notes on May 2 or 3, 2020. There were also no nursing progress notes from April 25 through May 3, 2020. Review of a lab report dated May 4, 2020 revealed the WBC was elevated at 11.1 k/mm3 and the fasting BG level was critically high at 1462 mg/dL. The time stamp on the report indicated the results were reported to the facility at 9:31 p.m. Review of a follow up NP/PA progress note for hypertension dated May 4, 2020 at 9:48 p.m., revealed the resident was seen and was resting in bed and was doing well. The note stated the resident had [MEDICAL CONDITION] a heart rate of 115, and had a temperature of 100.4 The plan included obtaining stat labs. The note continued to state the resident's BG level was 148. A nursing progress note dated May 4, 2020 at 10:23 p.m. included a peripheral IV was started [MEDICAL CONDITION] protocol was initiated for a temperature of 100.4 degrees F and the NP was notified. A nursing progress note dated May 4, 2020 at 11:09 p.m. included the lab had called with a critical BG level of 1482. The note stated the NP was called and new orders were obtained to send the resident to the emergency room and 911 was called, and the resident was transported to the hospital. However, there was no nursing documentation of any interventions that were implemented or that an assessment of the resident was completed, despite having a BG level over 1400. A nursing progress note dated May 5, 2020 at 1:35 a.m. revealed the hospital was called regarding the status of the resident. The note included the resident's BG was 1745 when she arrived and the resident would be admitted to the hospital. Hospital records dated May 5, 2020 indicated the resident was admitted to the intensive care unit at 2:07 a.m. for diabetic ketoacidosis. The admitting labs included a serum BG level of greater than 1500. Additional [DIAGNOSES REDACTED]. On September 22, 2020 at 10:00 a.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #132). She stated that she worked the day shift on May 4, 2020. The LPN stated that if a resident spiked a fever of 100.3 or above, nursing would be expected to start [MEDICAL CONDITION] protocol. She said the provider would be notified, nursing would start IV's and antibiotics and labs would be ordered. The LPN stated the nurse would act on any additional orders and write a progress note in the resident's record. She stated that vitals would be obtained and recorded every 4 hours. In addition, she stated that a change of condition (COC) would automatically pop up on the MAR and would be documented in a progress note. She stated that the change of condition should have triggered on the evening shift for the nurse. The LPN stated that if they had started the resident on the change of condition protocol, it would be documented on the MAR and in the resident's clinical record. An interview was conducted on September 22, 2020 at 2:32 p.m., with a Registered Nurse (RN/staff #40). The RN stated that once a COC is documented, the resident would go on a 72-hour vital monitoring schedule to be completed every shift. She said if a resident's BG result was out of the normal range and the resident was not a diabetic, most likely that would spur a COC in the nursing documentation. She also said that if a resident was on a medication that caused the elevation in BG, it may not spur a COC and that the Interdisciplinary Team would decide that. The RN said that if she did have a resident that was not a diabetic, she would notify the provider if the resident's BG level was outside of the normal range, and if the BG level was over 150, she would consider it to be alarming. She further stated that for a BG level greater than 150, she would ask the provider for an order to monitor BG levels with accuchecks. She said that the nursing team, the charge nurse, and the provider would be responsible to oversee the trending of the BG levels. On September 22, 2020 at 2:54 p.m., an interview was conducted with the NP (staff #275). He stated that the resident was admitted with [MEDICAL CONDITION], and that she has been off and on with infections, including abdominal [MEDICAL CONDITION] 2-3 times. He stated the first part of April, the resident had no history of diabetes, but that she did tend to become hyperglycemic with infections. The NP stated that accuchecks were not ordered initially, as it would have been if the resident had diabetes mellitus. He stated that it was not until the resident's BG levels began creeping up with the infections, that they decided to get endocrinology involved. He said the resident did not have a history of diabetes, but higher BG levels are a common [MEDICAL CONDITION]. He stated that staff had notified him of the resident's abnormal labs. The NP stated that on May 4, 2020, the resident became hyperglycemic. He stated his concern with beginning BG monitoring a little earlier was that the resident would have actually gone into [DIAGNOSES REDACTED] a little too fast. An interview was conducted on September 23, 2020 at 9:39 a.m. with the Director of Nursing (DON/staff #77). She stated that infections, steroids, and wounds may all cause increased levels of BG. She stated that nausea and vomiting might be an indication of elevated BG levels. The DON said that she would expect nursing to continue reviewing lab results with the physician and hopefully obtain orders to address them. She stated the conversations with the physician should be documented in the resident's clinical record, including if there were no new orders. She stated that if a resident was having fever, nausea, vomiting, or new onset symptoms such as increased heart rate, even if they had a history of [REDACTED]. The DON stated that if a resident had patterns of illness, those signs and symptoms should quickly be identified and responded to. The facility policy titled Blood Glucose Monitoring stated that it is the policy of the facility to check and monitor finger stick blood glucose levels as ordered by the physician. Review of the facility's policy titled, Change of Condition Reporting stated that all changes in the resident's condition would be communicated to the physician. The purpose was to clearly define guidelines for timely notification of a change in resident condition. The policy stated that all symptoms and unusual signs would be communicated to the physician promptly. Routine changes are: a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life-threatening. The policy stated that the nurse in charge is responsible for notification of the physician prior to end of assigned shift, when a significant change in resident's condition is noted. The policy stated if nursing is unable to reach the physician, all calls to the physician or exchanges requesting callbacks will be documented on nursing progress notes. If the physician has not returned the call by the end of the shift, the on-coming nurse will be notified for follow-up. The policy stated that if unable to contact the attending physician or alternate timely, notify the Medical Director for response and follow-up to change in resident status. Document resident change of condition and response in nursing progress notes, on 24-hour report (24 Hour Report Form) and update resident care plan, as indicated. The policy stated that all attempts to reach the physician and responsible party will be documented in the nursing progress notes and include time and response. The policy stated that follow-up included the licensed nurse responsible for the resident will continue assessment and documentation every shift for at least seventy-two (72) hours or until the condition has stabilized. Residents with acute medical changes (and some routine changes) will be listed on the 24-hour report and have progress and needs clearly communicated to each shift. -Resident #7 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A physician's order dated May 17, 2020 included for insulin detemir solution (to control blood sugar/glucose) 100 units/per milliliter (u/ml), inject 10 units subcutaneously (SQ) one time a day (8:00 a.m.) for DM. Another order the same day included for insulin detemir solution 100 u/ml, inject 10 units subcutaneously at bedtime. The admission orders [REDACTED]. The order also included to call the physician if the resident's BG level was over 400. The order did not include when to call if the BG was below a certain amount. An Initial Admission Record dated May 18, 2020 included the resident had difficulty swallowing and had a fair oral intake (eats 25-50% of most meals) and occasionally took less than 50% of supplements. A physician admission progress note dated May 18, 2020 at 6:44 p.m. revealed the resident had type 2 diabetes. The plan included for aggressive sliding scale insulin therapy. The diabetes care plan dated May 19, 2020 included goals that the resident would be free from signs and symptoms of [MEDICAL CONDITION] (high BG) and [DIAGNOSES REDACTED] (low BG). Interventions were to administer diabetes medication as ordered, monitor/document for side effects and effectiveness, fasting serum blood sugar as ordered, monitor/document/report to Medical Doctor (MD) as needed (PRN) signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. According to the May 2020 Medication Administration Record (MAR), the resident received insulin detemir 10 units at 8:00 a.m. on May 19, as scheduled. However, the space on the MAR to document the resident's BG level prior to administering the scheduled insulin was left blank. A physician's order dated May 19, 2020 included for a full liquid diet with thin liquids consistency. Review of Certified Nursing Assistant (CNA) Point of Care (POC) documentation dated May 19, 2020, revealed the resident had eaten between 76 -100% of her breakfast and lunch. A daily skilled note dated May 19, 2020 at 11:29 a.m. stated that the resident's blood glucose was not being monitored. No specifics were included. The note also stated that the resident required extensive one-person physical assistance with eating. A nursing progress note dated May 19, 2020 at 6:50 p.m. included for an endocrinology consultation related to DM and tube feeding. The note stated that the provider had been notified. A note at 8:06 p.m. stated the resident was alert to person, place and time. The note also included the resident continued with puree texture foods. However, per the clinical record there was no physician's order at this time for a puree diet. The CNA POC documentation for May 19, 2020, revealed the resident had eaten 0-25% of her dinner. The documentation also stated that the resident had received a tube feeding as a snack at 7:18 p.m. However, there was no physician order for [REDACTED]. A physician's order dated May 19, 2020 included for a complete blood count (CBC) and a complete metabolic panel (CMP) to be done in the morning (May 20). On May 20, 2020 at 4:16 p.m., a physician's order included to discontinue the scheduled insulin detemir and the [MEDICATION NAME] sliding scale orders. A physician's order dated May 20, 2020 at 4:17 p.m. included for [MEDICATION NAME]per sliding scale for BG between 151-200 give 2 units; 201-250 give 4 units; 251-300 give 6 units; 301-350 give 8 units; 351-400 give 10 units; 401-999 give 12 units SQ before meals and at bedtime for diabetes. Call the physician if BG is less than 100 or greater than 200. An endocrinology progress note dated May 20, 2020 at 7:50 p.m. revealed the resident had a most recent BG of 104.0. However, the note also included that laboratory results from May 20 (the time of day was not documented) showed that the resident's BG level had been at 18 mg/deciliter (which is a critically low value). In the assessment and plan section, the physician documented that the resident was receiving insulin detemir 10 units twice daily with meals, plus moderate sliding scale coverage with [MEDICATION NAME]before meals and before bed (AC/HS). The note stated that the resident was having hypoglycemic events and was on a liquid diet. The note further included that insulin detemir would be discontinued, and that moderate sliding scale insulin coverage AC/HS would continue. Despite documentation that the resident's BG level was 18 mg/dl, there was no nursing documentation regarding the critical low BG level, nor any documentation of the resident's condition or any interventions that were implemented to address the low BG on May 20, 2020. A Nutrition Admission Evaluation dated May 21, 2020 at 11:44 a.m. included that the resident was on a full liquid diet with thin fluid consistency and that a supplement had been ordered (Nephro 3 times a day). Per the evaluation, the resident fed herself in her room and consumed about 58% of the full liquid diet. A physician's order dated May 21, 2020 revealed for blood glucose monitoring every 6 hours for [DIAGNOSES REDACTED] for three days and Nephro three times a day as a supplement. A physician's order dated May 24, 2020 included for insulin detemir 100 u/ml, inject 5 units SQ one time a day for diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 3 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The resident was assessed to have clear speech, but was rarely/never able to make self understood and rarely/never understood others. The MDS included the resident required extensive two person physical assistance for most activities of daily living, did not have a swallowing disorder, had a feeding tube, received more than 51% of her total calories through [MEDICATION NAME] or tube feeding, that her average fluid intake per day was more than 501 cc/day or more, and that she received insulin injections on a daily basis. On May 25, 2020 at 10:53 p.m., a Nutrition Note stated that the labs from May 20, 2020 had been reviewed and the resident had a decreased glucose level of 18, was on a full liquid diet consuming about 58%, Nepro three times daily and had increased needs for healing of pressure injuries and repletion of nutrients lost during [MEDICAL TREATMENT]. A goal was to tolerate liquid diet with no complications. An endocrinology physician's progress note dated May 26, 2020 at 10:42 p.m. included the resident was still on a full liquid diet. The note stated that her BG was much better controlled at about the 100's. On May 28, 2020 at 11:31 p.m., a physician's order for insulin detemir solution 100 u/ml, inject 5 units one time a day was discontinued. A physician's order dated May 28, 2020 revealed for insulin detemir solution 100 u/ml, inject 8 units SQ one time a day for diabetes. Review of the CNA POC documentation on May 29, 2020 revealed that the resident had eaten 75-100% of her breakfast and lunch that day. The May 29, 2020 MAR on May 29 indicated the resident's BG was 216 at 11 a.m. and received 4 units of [MEDICATION NAME] insulin. The MAR then showed that at 4:30 p.m., the resident's BG was low at 56. A physician's order dated May 29, 2020 included for [MEDICATION NAME]100 u/ml per sliding scale: if BG is 151-200 give 0 units; 200-250 give 2 units; 251-300 give 4 units; 301-350 give 6 units; 351-400 give 8 units; 401-999 give 10 units, SQ before meals and at bedtime. Call physician if the resident's BG is less than 100 or more than 200. However, there was no clinical record documentation of any interventions that were implemented when the resident had a low BG level of 56, nor was there any documentation of an assessment of the resident which was done when the BG was 56. On May 30, 2020 at 8:07 p.m., an endocrinology progress note stated the resident's BG was much better controlled but some variability had been noted. Further review of the May 2020 MAR revealed the resident's BG levels were below 100 as follows: May 19=89; May 20=78; May 21=98; May 22=89; May 26=98; May 30=87; and May 31=83. Despite the resident's BG levels being lower than 100, there was no documentation that the physician was notified, per the order. In addition on the MAR for May 20 and May 31, the resident's BG was documented with an x in lieu of a numeric value. A physician order dated June 1, 2020 at 4:51 p.m. included to discontinue the order for insulin detemir 8 units one time a day. An endocrinology progress note dated June 1, 2020 at 7:54 p.m. stated the resident's BG was suboptimal controlled. The note stated the resident's BG was less than 100 in the a.m. and greater than 200 during the day. Increase detemir to 13 units every morning and discontinue the HS sliding scale coverage. On June 2, 2020 at 10:02 a.m., a physician's order included to discontinue [MEDICATION NAME]per sliding scale: if BG is 151-200 give 0 unit; 200-250 give 2 units; 251-300 give 4 units, 301-350 give 6 units; 351-400 give 8 units; 401-999 give 10 units, SQ before meals and at bedtime. A physician's order dated June 1, 2020 with a start date of June 2, 2020 revealed for insulin detemir solution 100 u/ml, inject 13 units SQ one time a day for diabetes. Another order from June 2, 2020 included for [MEDICATION NAME]100 u/ml sliding scale as follows: If BG is 151-200 give 0 units; 201-250 give 2 units; 251-300 give 4 units; 301-350 give 6 units; 351-400 give 8 units; 401-999 give 10 units, SQ three times a day for DM and to call the physician if BG is less than 100 or greater than 200. Another physician's order dated June 2, 2020 included for accuchecks every evening at bedtime. An endocrinology progress note dated June 3, 2020 at 8:13 p.m. included the resident had finished her dinner and required assistance with meals. The note included the resident was eating more and was still on a full liquid diet. Additionally, the note stated that the resident's BG had been in about the 50's at noon, because she did not get breakfast. However, there was no nursing documentation that the resident had a BG in the 50's that day. Review of the CNA POC documentation for June 3, 2020 revealed the resident had eaten 0-25% of her breakfast and refused lunch. There was no documentation in the space provided for the evening meal to indicate whether or not the resident had eaten. A physician's order dated June 5, 2020 included for insulin detemir inject 10 units SQ one time a day. The June 2020 MAR included documentation that the resident's BG was 131 at 7 a.m. on June 5, and the resident received 13 units of insulin detemir, but no sliding scale insulin. At 11:30 a.m., the resident's BG was 141 and no sliding scale insulin was given. However, at 4:30 p.m., the resident's BG level was 28. Review of the CNA POC documentation dated June 5, 2020 revealed the resident had eaten 75-100% of breakfast 0% of lunch. Documentation of snacks included NA. Further review of the clinical record revealed no nursing documentation regarding the resident having a BG level of 28, nor any interventions that were implemented to address the low BG or any assessment of the resident. An endocrinology physician's progress note dated June 5, 2020 at 8:10 p.m. included the resident's BG had been in the 20's at 4 p.m. The note stated the resident had a hypoglycemic event after lunch and apparently did not eat lunch, and that the resident needs to be fed. The note included the resident was still on a full liquid diet. A physician's order dated June 8, 2020 included for insulin detemir inject 12 units SQ one time a day. Review of the June 2020 MAR revealed the resident's BG level was 49 at 8 p.m. on June 9. Despite a BG of 49, there was no documentation that the physician was notified or of any nursing interventions which were implemented. Review of the CNA POC documentation for June 9, 2020 revealed the resident had eaten 75-100% of breakfast, 25-50% of lunch, and 75-100% of the evening meal. In the space provided for snacks, the documentation included for tube feeding. The June 2020 MAR included the resident's BG level was 45 on June 15 at 8 p.m. The CNA POC documentation for June 15, 2020 revealed the resident had eaten 75-100% of breakfast, lunch and dinner on that date. The snack was documented as no. There was no clinical record documentation that the physician was notified, no documentation of any nursing interventions which were implemented and no assessment of the resident that was done at the time of the low BG level. An endocrinology progress note dated June 16, 2020 stated the resident was on mild sliding coverage before meals and at bedtime and was on Detemir 12 units every a.m. with BG in the 100's and less than 100 when not eating or not fed. Continue with same for now. A physician's order dated June 17, 2020 included for [MEDICATION NAME] Emergency Kit 1 mg (hormone/treats low blood glucose levels) inject 1 dose intramuscularly as needed for [DIAGNOSES REDACTED], unconscious, and to be administered only if the resident is unable to swallow. If the resident is able to swallow or receive tube feeding, give regular Med Pass (supplement) first. The order included to notify the doctor after medication is given the first time with current BG, and maximum of two doses to be administered. An endocrinology progress note dated June 18, 2020 at 7:29 p.m. included the resident was on mild sliding scale insulin coverage before and after meals and was receiving detemir 12 units every morning, BG was about the 100's with BG less than 100 when not eating or not fed. BG less than 100 in the morning, will cut down the detemir to 10 units instead. A physician's order dated June 18, 2020 included to discontinue the insulin detemir solution 100 u/ml,12 units SQ one time a day. A physician's order dated June 18, 2020 included for insulin detemir inject 10 units SQ one time a day. An endocrinology progress note dated June 20, 2020 at 12:56 p.m. stated the resident's BG had been in the 200's during the day. The plan included to increase detemir to 12 units. A physician's order dated June 21, 2020 included to discontinue the insulin detemir 10 units one time a day. A physician's order dated June 21, 2020 revealed for insulin detemir solution 100 u/ml inject 12 units SQ one time a day for diabetes. This order was discontinued on June 22. A physician's order dated June 22, 2020 included for insulin detemir solution 100 u/ml inject 14 units SQ one time a day. A nutrition note dated June 23, 2020 at 9:06 p.m. included for a full liquid diet consuming: 88%, Nepro three times a day and that her current intakes were within estimated needs for meals. The recommendation included to advance the resident's diet as able, and suggest swallow evaluation. A physician's order dated June 29, 2020 included to discontinue the insulin detemir 14 units one time a day and give insulin detemir 16 units SQ one time a day. According to a daily skilled note dated June 29, 2020 at 10:25 p.m., the resident's BG was being monitored and was well controlled. The note stated the resident was totally dependent with eating, and required one person physical assistance. Review of the June 2020 MAR revealed the resident's BG was 45 at 11:30 a.m. on June 30. However, there was no nursing documentation of any nursing interventions which had been implemented or an assessment of the resident at the time of the low BG. An endocrinology progress note dated June 30, 2020 at 8:43 p.m. included the resident's BG was about 100 and occasionally less than 100. Continued review of the June 2020 MAR revealed the resident's BG levels were between 71 and 99 on the following dates: 6/11 for a BG of 90; 6/13 for BG level of 98 and 84; 6/14 for a BG of 90; 6/16 for a BG of 98; 6/18 for BG of 86, 74, and 93; 6/24 for BG of 99 and 71; 6/25 for BG of 96 and 78; and 6/29 for a BG of 87. Despite the documentation that the resident's BG levels were below 100, there was no documentation that the physician was notified at the time that the low values occurred as ordered. The physician order dated July 1, 2020 revealed for insulin detemir inject 14 units SQ one time a day. Another order dated July 13, 2020 included for insulin detemir inject 16 units SQ one time a day and another order dated July 15, 2020 included for insulin detemir inject 18 units SQ one time a day. A physician's order with a start date of July 15, 2020 included for nothing by mouth (NPO) at midnight one time only for tunneled catheter removal for one day. Review of the CNA POC documentation for July 20, 2020 revealed the resident had refused her dinner that evening. A physician's progress note dated July 20, 2020 at 8:14 a.m. included that he had spoken with the endocrinologist, who was concerned about the resident's lack of nutrition. The note stated that the endocrinologist wanted the resident to have increased caloric intake. However, there was no documentation of any changes to the resident's nutrition regimen. Review of a nursing progress note dated July 20, 2020 at 9:58 p.m. revealed the resident's BG had been checked at evening medication pass and was 39. The note stated that the resident refused to take oral glucose. [MEDICATION NAME] was administered per order. After 15 minutes the resident's BG went up to 55, and took oral Nephro and BG went up to 107, after rechecking for the 3rd time. Doctor notified. A nursing progress note dated July 21, 2020 at 5:22 p.m. stated the resident had a low BG of 24. Per the note, the resident was unresponsive and one dose of [MEDICATION NAME] was given. (however, the [MEDICATION NAME] administration was not on the MAR). The note stated the resident was observed to be more responsive. Provide(TRUNCATED)

Based on clinical record review, staff interviews, facility documentation and policies and procedures, the facility failed to ensure one resident (#252) was provided the necessary care and services to prevent an unstageable pressure ulcer. Findings include: Resident #252 was admitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. A quarterly Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 15, (YEAR) indicated that the resident was at high risk for developing pressure ulcers. According to a quarterly Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR), the resident had severe cognitive impairment. The MDS also included that the resident was at risk for pressure ulcer development, but did not have any pressure ulcers. A care plan identified the resident was at risk for skin breakdown and slow healing related to impaired mobility. The goal was for the resident to be free from skin breakdown through the next review date. Interventions included educating family and caregivers of causative factors and measures to prevent skin injury, encourage good nutrition and hydration in order to promote healthier skin, monitor and document location, size and treatment of [REDACTED]. Review of a PRN/weekly skin evaluation dated (MONTH) 4, (YEAR) revealed the resident did not have any skin issues to the bilateral lower extremities. A physician's order dated (MONTH) 6, (YEAR) included for the resident to wear bilateral lower extremity dynasplints for neuro stretch up to 2-4 hours daily as tolerated. The goal was to increase ROM (range of motion) and prevent further contractures. The order also included for Restorative Nursing Assistant (RNA) to inform the therapy department of complaints from the resident, pressure ulcers or changes related to the dynasplints/braces. Review of the clinical record revealed there was no documentation of when the dynasplints were applied each day or when they were removed from (MONTH) 6 through (MONTH) 11. Review of a nursing note dated (MONTH) 12, (YEAR) at 10:00 a.m. revealed patient was found in room with splints on from previous shift. RNA went in room to put on splints and found that previous day shift had not removed splints. Patient was left with splints on through the night until RNA had came to see patient. Day shift staff assumed RNA had put them on at beginning of shift. Only when removing splints, was redness and blister found. No open large area, epc and sure prep applied to affected areas. Family notified and asked that splints not to be applied until area has healed. The location of the redness and blister were not documented. A nursing note dated (MONTH) 12, (YEAR) at 4:41 p.m. indicated that splints were found on the resident from the previous shift and that redness was found on the resident's inner knee and bilateral inner thighs. Provider and care manager were notified. Further review of the clinical record revealed there were no physician ordered treatments for (MONTH) 12 or 13, (YEAR). A skin ulcer non-pressure weekly assessment dated (MONTH) 14, (YEAR) identified a blister on the resident's right medial thigh. The blister measured 1.0 cm x 12.0 cm. The documentation included that the blister was identified on (MONTH) 12. A physician's order dated (MONTH) 14, (YEAR) now included to cleanse the blisters to bilateral lower extremities with normal saline, pat dry, apply xeroform to affected areas, cover with abdominal pad, wrap with Kerlix and secure with tape, change daily and as needed if soiled or dislodged. Review of the treatment administration record (TAR) for (MONTH) (YEAR) revealed the above treatment orders. However, there was no documentation that the treatments were done from (MONTH) 16 - 20. A Wound Assessment Details Report dated (MONTH) 21, (YEAR) documented the resident had a facility acquired unstageable pressure ulcer on his right medial thigh. Per the assessment, the wound was 100% slough with white [MEDICATION NAME] tissue and measured .8 cm x .7 cm x unknown depth. A physician's order dated (MONTH) 21, (YEAR) included to cleanse the right medial thigh with normal saline, pat dry, apply nickel thick layer of Santyl to wound bed, cover with [MEDICATION NAME] large dressing, change daily and as needed if soiled or dislodged. Review of a Wound Assessment Details Report dated (MONTH) 28, (YEAR) revealed the resident had a facility acquired unstageable pressure ulcer on the right medial thigh. The wound was 100% slough with white [MEDICATION NAME] tissue and measured .3 cm x .4 cm x unknown depth. A Wound Assessment Details Report dated (MONTH) 4, (YEAR) included the resident had a facility acquired unstageable pressure ulcer on his right medial thigh. The wound was 100% slough with white [MEDICATION NAME] tissues and measured .3 cm x .4 cm x unknown depth. A Wound Assessment Details report dated (MONTH) 11, (YEAR) revealed the pressure ulcer on the right medial thigh had healed. On (MONTH) 8, (YEAR) at 1:14 p.m., a Restorative Nursing Assistant (RNA/staff #161) stated that the RNA's are responsible for putting on and taking off the splints. He stated that RNA staff are informed of the physician's orders for splints. He stated that if he notices any changes to the skin, he notifies the resident's nurse and would notify the Director of Nursing, as she oversees the RNA program. Staff #161 said he went to see the resident in the morning (on (MONTH) 12) to put on the splints, but the splints were already on. Staff #161 stated he took the resident's splints off and the resident had marks. He stated when he saw the marks, he reported it to the nurse on duty. He said the resident must of worn the splints throughout the night. He stated that RNA staff are responsible for putting on and taking off the resident's splints, as physician ordered. An interview was conducted with a registered nurse (RN/staff #188) on (MONTH) 8, (YEAR) at 1:36 p.m. She stated that RNA staff put the splints on and takes them off. She stated if there is a skin issue observed after a splint is taken off, she will inform the physician. An interview was conducted on (MONTH) 8, (YEAR) at 1:56 p.m. with a Licensed Practical Nurse (LPN/staff #167). She stated the RNA department is responsible for ensuring splints are put on the resident and taken off, per the physician's orders. She stated when working with the residents who are wearing splints, she checks for skin breakdown. An interview was conducted with the Director of Nursing (DON/staff #187) on (MONTH) 9, (YEAR) at 10:15 a.m. She stated that she over sees the RNA program. She stated that RNA staff are responsible for putting splints on and taking them off, per physician orders. She stated she collaborates with the Assistant Director of Nursing (ADON/staff #14) and they meet monthly. She stated the ADON reviews orders, runs reports and puts them on the schedule for the RNA staff to see. Staff #187 said that staff #14 oversees the splints in the facility to see how they are being tolerated by the residents. She stated the splints are double checked by staff in the evening and during the day. Staff #187 stated she also conducts daily audits of the TARS (Treatment Administration Record) and that the nurses will tell her if there are any skin issues with the splints. She stated that she was informed by staff of the resident having bilateral blisters on his lower extremities. The facility provided documentation that the concern related to splints not being applied per the physician's orders and the resident developed skin breakdown was identified by their Quality Improvement Team (QIT) on (MONTH) 15, (YEAR). Their corrective action plan included the following: new process for licensed nurses to sign off that splints have been removed on the treatment administration records (TAR), random visual observation audits for the application and removal of splints; audits of TARs to ensure documentation that splint removal was being completed by licensed staff, staff in-services including RNA staff regarding physician orders for splints, application and removal of splints, the associated risks including skin breakdown with splints not being removed as ordered and the new process of nurses signing off on the TAR. The QIT documentation showed that the facility was in 100% compliance by (MONTH) 3, (YEAR). Review of the facility's policy and procedure on wound management revealed the facility will provide care and services to promote the prevention of pressure ulcer development; promote the healing of pressure ulcers that are present; and prevent the development of additional, avoidable pressure ulcers. A resident having pressure ulcers will receive the necessary treatment and services to promote healing, prevent infection and prevent new, avoidable sores from developing. Once a wound has been identified, assessed and documented, nursing shall administer treatment to each affected area, per the physician's order. All wound or skin treatments should be documented in the resident's clinical record at the time they are administered. The facility will stabilize, reduce or remove any existing risks. The policy also included to monitor impact of interventions and modify interventions as appropriate based on any identified changes in condition.

Based on clinical record and hospital record reviews, staff interviews, and review of facility policies, the facility failed to ensure that a PICC (Peripherally Inserted Central Catheter) line site was consistently assessed, and monitored, failed to ensure that appropriate care and services were provided for one resident (#107). Resident (#107) sustained actual harm. The sample size was one of two. Findings include: -Resident #107 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A nursing note entry dated May 21, 2011, included documentation that the resident had a PICC line. A continued review of the nursing note entries from May 21, through July 1, 2011, revealed inconsistent and/or absent documentation regarding the status of the PICC line and only one entry, which was dated June 19, 2011, that included documentation that the PICC line dressing had been changed. A physician's order dated June 24, 2011, now included IV (intravenous) directives for the flushing of central IV lines, however, the physician's order did not include treatment orders for the care of the PICC line site. Although the clinical record did not include any documented evidence that a physician's treatment order had been obtained for the PICC line site, the June 2011, TAR (Treatment Administration Record) included a physician's order (dated June 24, 2011) for the PICC line dressing to be changed every seven days. According to the TAR documentation, a dressing change was provided on June 25, 2011. A continued review of the resident's clinical record revealed no documented evidence that the PICC line was assessed, monitored or that care was provided after June 25, 2011. A nursing note entry dated July 1, 2011, included the following: The resident's blood pressure was 90/56 The resident's pulse was 108 The resident's respiratory rate was 22 The resident's temperature was 102.1 (axillary) The nursing note entry also included that a physician's order was obtained at this time to transfer the resident to the hospital. A review of the emergency transport record dated July 1, 2011, revealed documentation that a PICC line was present and that the dressing was dated was June 18, 2011, which was contradictory to the facility's documentation as evidenced by the June 25, 2011, TAR documentation. A review of the hospital history and physical documentation, revealed that the resident was admitted to Intensive Care, with a [DIAGNOSES REDACTED]. The hospital record documentation also included that the PICC line site looked red, was oozing yellowish material, and was subsequently diagnosed with [REDACTED]. The facility's quality improvement team tracking form dated July 6, 2011, documented that the team had identified the problem of PICC line care, dressing changes, and the line flushes were not being documented. However, the quality improvement team had not identified a problem with lack of nursing assessments of the PICC line or to monitor for infection control issues. An interview was conducted on August 15, 2011, with the DON (Director of Nursing), who stated that a physician's order for the care and services that were to be provided for the PICC line, should have been obtained upon the resident's re-admission, transcribed onto the TAR, and initialed by the licensed staff when the treatment was provided. The DON also stated that per facility policy, a PICC line dressing was to be changed every seven days and prn (as needed). Following a review of the resident's clinical record, the DON stated that she was unable to locate any additional documentation that included that the PICC line was consistently assessed, and monitored or that the PICC line site dressing had been changed from admission (May 20, to June 19, 2011, which was 30 days after re-admission to the facility). A facility policy titled, Dressing Change For Vascular Access Devices, included in the section titled purpose, the following, "...To prevent local and systemic infection related to the IV site..." The policy also included, "...Transparent membrane dressings (no gauze over site) are changed every 7 days and PRN...A dressing is changed immediately if...The dressing is non-occlusive or soiled....There is drainage or moisture under the dressing...There are signs of irritation or inflammation at the insertion site..."

Based on observations, interviews, and reviews of the clinical record and policy, the facility failed to ensure that one resident (#35) received appropriate supervision, assistance, and positioning to reduce the potential for choking and aspiration, and to facilitate proper intake of nutrition/hydration, that resulted in the Condition of Immediate Jeopardy. The facility also failed to ensure that one resident was provided with necessary safety devices (#24). Findings include: -Meal observations conducted on May 24 and on May 26, 2010, revealed that resident #35 was not positioned appropriately in her Geri-chair. The chair was reclined with the resident's head only slightly elevated and the resident would lean to the side. The resident was cognitively impaired and unable to be interviewed. The resident also could not reposition herself, and required staff assistance with eating. On May 26, 2010 at 11:53 a.m., the resident was assisted with eating her meal. At this time, the resident was noted to be reclined in a Geri-chair, and was leaning to the right side of the chair. A certified nurse aide (CNA) was observed to add some of the resident's pureed food to her glass of juice, stir this up, and give it to the resident using a straw. Due to the positioning of the resident and the manner in which the resident's food was served to her, the CNA was interviewed and stated that when the resident was moved up (repositioned), she would just slide down again. The CNA indicated that she would not move the resident because the resident was currently propped up with pillows under her legs/feet and the resident would slide down. The CNA further stated that the resident had no history of choking, and that the resident would not eat the pureed food unless it was added to fluids. The CNA stated that the resident could then drink the fluid/food. At 11:56 a.m., before a nurse could be summoned to the dining room by the surveyor, the resident choked and coughed. The resident's face became very red and she continued to cough. The CNA continued to try to feed the resident, both with a spoon and a straw. A licensed practical nurse (LPN) was retrieved by the surveyor, and informed of the concerns. When the LPN approached the resident, the resident was still coughing, and her face was a deep red color. The LPN and the CNA repositioned the resident by lifting her up in the Geri-chair and placing a pillow to her right side. The resident continued to cough. Once the resident was repositioned, the CNA immediately began giving the resident more fluids and the resident continued to cough. The CNA continued to give, or attempt to give, the resident drinks of the pureed mixture, but the resident kept coughing. The CNA was using a clothing protector to catch the liquid which the resident was coughing back out. The LPN did not intervene and allowed the CNA to continue to give the resident spoonfuls of food even after the resident was coughing. The LPN removed one of the cups of liquid and then brought a thin liquid. The feeding attempts stopped briefly and the resident's coughing slowed down to an occasional cough and her facial color became less red. The LPN then gave the resident a small amount of liquid which stimulated only a small cough. The CNA began trying to feed the resident the pureed food again, but the resident would not take more than an additional few bites. The resident was taken out of the dining room at 12:16 p.m. There was no evidence that the CNA had authorization to alter the resident's meal consistency, and had failed to stop feeding the resident when she exhibited coughing/choking. There was no evidence that the resident was provided with repositioning prior to surveyor intervention. There was no evidence that there was sufficient supervision provided during the meal by nurses in order to ensure safety. Finally, there was no evidence of a re-evaluation or new evaluation provided the resident following the choking incident until surveyor intervention. Based on these concerns, the administrator was notified of the Condition of Immediate Jeopardy on May 26, 2010 at 1:45 p.m. The facility's immediate plan was to have speech therapy and the director of nursing provide staff immediate and ongoing education and in-services, for speech therapy to re-assess the resident and other residents with modified diet textures, to counsel the two staff members involved, to notify all responsible parties, to have occupational therapy assess the resident's sitting posture (as well as that of all residents with a need for devices), and to designate staff to monitor for compliance. Based on the facility's plan of action, the immediacy of the Condition was lifted, but not abated, on May 26, 2010 at 7 p.m., pending verification that the facility was implementing their plans of action. The Condition of Immediate Jeopardy was abated on May 27, 2010 at 1:15 p.m., after it was verified that all components of the facility's plan was being implemented and resident safety was assured. Specifics regarding resident #35 include the following: Review of resident #35's medical record revealed that the resident had [DIAGNOSES REDACTED]. Review of the resident's Dietary Progress Notes revealed that the registered dietitian's last assessment of the resident was written on August 15, 2009. Documented was that the resident's 2 Cal supplement was increased, and that the resident had "more dental extractions" planned. Also documented was that the resident required a pureed diet, needed to be fed by staff, that her meal intake was usually less than 50%, and that the resident's nutritional needs were to be followed. Review of the resident's Swallow Guide with review dates of August 27, 2009 and October 28, 2009, included that the resident required puree diet texture, thin liquids, that her chin was to be in a neutral position and body positioning at 90 degrees during eating, that the resident should be given a small amount of solid food and encouraged to utilize multiple chewing cycles, to alternate a bite of food with a sip of fluid throughout the meal at slow rate, and for staff to watch for the resident to swallow prior to giving more food. On October 28, 2009, a bite of sherbet was recommended to given between bites of food. Liquids were to be controlled to a 1/2 teaspoon sip, and the resident was then to swallow. Review of the resident's Dysphagia Plan of Treatment with therapy service dates of October 28, 2009 through November 28, 2009, included the purpose "to assess pt (patient/resident) for present swallowing function secondary to weight loss. Pt not always accepting puree foods." Per the documentation, precautions were listed as aspiration with contraindications of delayed swallow reflux and decreased cognition. Therapy was discontinued due to a lack of payor authorization, but documented was the need for the resident to have a puree diet with thin liquids, and the use of sherbet between bites of solid food. Review of the January 17, 2010 speech therapy summary, included clinical impressions of "Poor oral motor control, inadequate dentition, and inability to follow compensatory strategies" that placed the resident "at risk for airway obstruction with mechanical soft textures. Recommend continuing current diet of puree with thin liquids....Risk Factors: Airway obstruction..." The May 2010 physician's orders [REDACTED]. There was no physician authorization for mixing the resident's pureed food with fluids. As part of the plan of correction following the Immediate Jeopardy condition, speech therapy conducted another evaluation of the resident. This evaluation, dated May 26, 2010, listed clinical impressions as "Severe oral phase dysphagia resulting in inability to negotiate spoon presentation of food, delayed A-P transfer of bolus, severe swallow initiation delays placing pt at high risk for malnutrition and mod risk of aspiration for diet texture greater that Blenderized. WFL management of straw presentation of thin to nectar consistency." Included were risk factors of cognitive status, contractures, choking risk, and aspiration risk. The facility forwarded additional information after survey exit, however, the information was not considered as it either supported the deficient practice or did not impact the deficient practice. -On May 26, 2010 at 10:45 a.m., during an observation of a music program in the main dining room, resident #24 was observed leaning over the side of the wheelchair with his left hand through the side bars on the wheelchair. Another resident expressed concerns about that resident (#24) was about to fall out of his wheelchair. The surveyor requested a corporate RN consultant check the resident as CNAs indicated that this was "normal" for the resident. Staff took the resident out of the room and got his hand loose after repositioning him. Staff indicated that she was going to get therapy to evaluate positioning. At the time of the observation, the resident's clip alarm was unfastened and his wheelchair seat belt was off. These devices were refastened and the resident was returned to the dining room.