**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure allegations of potential abuse were thoroughly investigated for one of three residents (R) (R4) who had an injury of unknown origin.Finding included:A review of the facility policy, last revised on 12/27/2024, titled Abuse Prohibition - Reporting and Investigating, documented that interviews will be conducted with pertinent parties. Written signed statements from any parties involved will be obtained if possible . a signed interview would be an appropriate alternative. Information regarding the event will be gathered from the suspect, the person making accusations, the patient involved, reliable patients who may have witnessed the incident, and any other persons who may have credible, pertinent information. Identify any possible conflicts between witnesses.A review of the electronic medical record (EMR) revealed that R4 was admitted to the facility on [DATE] and was discharged on 6/16/2025 with medical diagnoses that included, but were not limited to, hypertensive heart disease with heart failure, difficulty in walking, gout, and Type 2 diabetes mellitus with diabetic neuropathy.A review of the Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/4/2025 revealed that R4 was assessed to present with a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R4's cognition was moderately impaired. A review of the facility report revealed that R4 had an unwitnessed fall on 6/13/2025 and was assessed at that time to have no injuries following the fall. It was documented that on 6/16/2025, R4 reported pain in the lower right extremity. An order was obtained on 6/16/2025, and the results revealed the right femoral neck fracture. A review of the facility follow-up report, documented by the Director of Nursing (DON) and Administrator, revealed that they reviewed the documents from the fall and interviewed staff involved. It was reported that R4 reported he had fallen when trying to get up and that R4 had a moderate impairment that affects his safety awareness. It was further documented that he was cognitively aware enough to provide an accurate account of what happened.A review of the facility follow-up investigations revealed no written staff interviews for employees who worked with R4 from 6/13/2024 through 6/19/2024 regarding leg pain and unknown injury.During an interview on 9/3/2025 at 2:02 pm with the Director of Nursing (DON), she stated that the Administrator was responsible for the reportable investigations, and she would assist if any assistance was needed. The DON stated Licensed Practical Nurse (LPN)1 was the nurse working that Friday (6/13/2025) when R4 fell, and she believed she talked to her about the incident. She stated that LPN1 said that R4's pain was stable, and then he had an acute change in pain, but she couldn't recall when that acute change in pain was. The DON stated she knows it wasn't that Friday or Saturday after the fall. The DON confirmed that R4's pain levels should have been documented in his medical record.During an interview on 9/3/2025 at 2:29 pm, the administrator stated she was the Abuse and Neglect Coordinator and responsible for conducting all facility investigations. The administrator stated R4 fell on 6/13/2025, and no injury or pain was noted at that time. The administrator stated that on 6/16/2025, R4 started reporting increased pain. She stated that the nurse practitioner was in the facility, saw him, and ordered X-rays. The administrator stated R4 was at the hospital during their investigation, but they did interview staff who were assigned to R4 on 6/13/2025. The administrator stated she did not get statements from any of the staff; she just verbally interviewed them due to the written statements being very lengthy.During a follow-up interview on 9/3/25 at 2:44 pm, the DON stated they followed up with LPN1 on 6/16/2025 to see if R4 had any pain over the weekend, and LPN1 stated there was no increase in pain during her shifts over the weekend. The DON denied following up with other staff regarding R4's pain but stated that pain is monitored on medication administration records.A review of the electronic medical record (EMR) revealed that there was no pain documented for R4 from 6/13/2025 until 6/16/2025.

Based on observations, staff interviews, and record review the facility failed to ensure that the care plan for one (1) of 13 residents (R) R#17 was followed related to oxygen (O2) therapy not being administered in accordance with the Physician's order. Specifically, the facility failed to ensure that the plan of care was followed related to the administration of oxygen therapy for R#17 by not ensuring oxygen settings were maintained as ordered by the physician. Findings include: Review of R#17 diagnoses included but not limited to acute respiratory failure with hypoxia, congestive heart failure (CHF), obstructive sleep apnea, and dependence on other enabling machines and devices. Review of R#17 Quarterly Minimum Data Set (MDS) revealed: Section C (Cognitive Pattern) Brief interview of Mental Status (BIMS) score of 15 indicating no cognitive deficit. Review of #17 Care Plan revealed respiratory changes related to CHF and respiratory failure and the need for O2. Interventions include administer medications and/or treatment as ordered and O2 at 4 L via nasal canula. Review of R#17 Physician's orders revealed: Oxygen: nasal cannula at 4 L per minute nasally check every shift. Observation on 6/20/2023 at 2:36 p.m., revealed R#17 was asleep in bed with O2 per nasal cannula at 5L. Observation On 6/21/2023 at 8:33 a.m. revealed R#17 was in the bed and had just finished breakfast and his call light was on. R#17's O2 concentrator was set on 5L per minute. The Licensed Practical Nurse (LPN) LPN AA checked his O2 concentrator and verified the O2 concentrator was set at 5L per minute and changed it to 4L per minute. Interview on 6/21/2023 at 11:38 a.m. with Director of Nursing (DON) revealed it is the nurse's responsibility to check the Physician's orders on the MAR on every shift to verify that the O2 is at the right setting. Interview on 6/21/2023 2:56 p.m. with MDS Registered Nurse (RN) RN DD and MDS RN EE revealed they would expect the nurses to follow the Physicians orders and follow the care plan.

Based on observations, staff interviews, record review, and review of the facility policy titled Use of Oxygen Therapy , the facility failed to ensure that one (1) of 13 residents (R) R#17 was administered oxygen (O2) therapy in accordance with the Physician's order. The deficient practice had the potential to affect the overall respiratory status for residents receiving oxygen therapy. Findings include: Review of the facility policy titled Use of Oxygen Therapy review date 12/30/2022, revealed: Under Intent: To ensure that patients maintain optimal oxygenation via the proper oxygen device and concentration when appropriate and medically indicated. Under Guideline: Physician's order for oxygen should be obtained and include: oxygen with liter (L) flow or percentage ordered. Review of R#17 diagnoses included but not limited to acute respiratory failure with hypoxia, congestive heart failure (CHF), obstructive sleep apnea, and dependence on other enabling machines and devices. Review of R#17 Quarterly Minimum Data Set (MDS) revealed: Section C (Cognitive Pattern) Brief interview of Mental Status (BIMS) score of 15 indicating no cognitive deficit. Review of #17 Care Plan revealed respiratory changes related to CHF and respiratory failure and the need for O2. Interventions include administer medications and/or treatment as ordered and O2 at 4 L via nasal canula. Review of R#17 Physician's orders revealed: Oxygen: nasal cannula at 4 L per minute nasally check every shift. Review of R#17 Medication Administration Record (MAR) revealed: MAR checked 6/23/2023 and the MAR showed R#17's O2 concentrator was checked on day shift and night shift. Observation on 6/20/2023 at 2:36 p.m., revealed R#17 was asleep in bed with O2 per nasal cannula at 5L. Observation On 6/21/2023 at 8:33 a.m. revealed R#17 was in the bed and had just finished breakfast and his call light was on. Certified Nursing Assistant (CNA) came in at 8:35 a.m. R#17 had on BiPAP and his O2 had not been taken off and changed to his O2 concentrator. R#17's O2 concentrator was set on 5L per minute. The Licensed Practical Nurse (LPN) LPN AA checked his O2 concentrator and verified the O2 concentrator was set at 5L per minute and changed it to 4L per minute. Interview on 6/20/2023 at 9:00 a.m. with Medication Technician (Med Tech) Med Tech BB revealed O2 concentrators are maintained every shift, if a nasal cannula hits the floor, it is thrown away and replaced with a new one, tubing is stored in a plastic bag. Interview on 6/21/2023 at 9:10 a.m. with LPN CC revealed O2 machines are checked for O2 flow per MAR, scheduled tube changes per MAR, O2 tubes are changed monthly or as needed (PRN). Interview on 6/21/2023 at 11:38 a.m. with Director of Nursing (DON) revealed it is the nurse's responsibility to check the Physician's orders on the MAR on every shift to verify that the O2 is at the right liter.