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

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

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