**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including retention of urine, personal history of traumatic brain injury, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The Quarterly Minimum Data Set (MDS) dated [DATE], documented R1 had impairment on both sides of upper and lower extremities and always incontinent with bowel and bladder (urinary). R1 required extensive assistance, two persons physical assist with toilet use, and total dependence, two persons physical assist with personal hygiene. Resident 84 (R84) R84 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, pressure ulcer of sacral region (Stage 3), metabolic encephalopathy, and major depressive disorder, recurrent, severe with psychotic symptoms. The Quarterly MDS dated [DATE], documented R84 had impairment on one side of upper and lower extremities and always incontinent with bowel and bladder. R84 required extensive assistance, one person physical assist with toilet use and personal hygiene. The final Facility Reported Incident (FRI) dated 07/18/2023, documented the following: - An allegation of neglect which occurred on 07/12/2023 was investigated. A Certified Nursing Assistant (CNA) did not go into the room to provide care to two total care residents (R1 and R84) until seven hours or more after the start of the shift. - The CNA substantiated the allegation and admitted to not caring for either resident for several hours during the shift. - The CNA was terminated at the conclusion of the investigation on 07/18/2023. - The allegation against the CNA was verified (substantiated) by the facility and the State Board of Nursing (BON) was notified. On 09/01/23 at 2:17 PM, the Director of Nursing (DON) revealed the CNA was scheduled to work on day shift, from 6:00 AM to 6:00 PM, on 07/12/2023. The DON confirmed the CNA admitted R1 and R84 were not changed or not provided with incontinence care from 6:00 AM to 2:00 PM. The DON indicated the two residents were incontinent and required total care. The DON revealed the CNA was suspended pending investigation then terminated upon the conclusion of the investigation. The CNA was reported to the State BON regarding the incident. The DON explained the CNAs were expected to do check and change (incontinence care) every two hours. The licensed nurses were expected to supervise the CNAs and made sure the residents were provided with incontinence care. During the onsite investigation on 08/30/2023 through 09/01/2023, the facility's correction of the past non-compliance related to the incident occurred as evidenced by: - Observation of grooming and physical appearance of residents, including the residents of concern, revealed there were no residents observed with foul-smelling odor. Residents who were interviewed, including R84, acknowledged the staff attended to their needs. - A CNA and a Licensed Practical Nurse (LPN) explained the residents who were incontinent with bowel and bladder were checked and changed every two hours. The nurses and CNAs would have done the rounds alternately at least every one to two hours to ensure the residents were safe, comfortable, and not wet. The CNA and the LPN indicated the facility provided continuing education regarding resident rights and prevention of abuse and neglect. Facility Reported Incident #NV00068924, #NV00068455, and #NV00068988. Based on interview and record review, the facility failed to ensure 1) a resident was kept safe from physical abuse for 1 of 31 sampled residents (Resident 159); 2) nursing staff followed up on physician orders and monitored a resident who experienced a change in condition for 1 of 31 sampled residents (Resident 309) ; and 3) incontinence care was provided to 2 of 31 sampled residents (Resident 1 and 84) for seven hours. The deficient practice had the potential for the residents to not receive adequate care. Findings include: Resident #159 (R159) R159 was admitted on [DATE] and discharged on 04/25/2023 with diagnoses including right lower extremity deep venous thrombosis, chronic kidney disease stage III, hypertension, history of non-sustained ventricular tachycardia, chronic low back pain with sciatica, diabetes mellitus type 2, history of COVID-19 viral infection, history of bronchitis due to COVID-19, and bilateral eye blindness, status post retinal detachment repair. A Nursing Progress Note dated 04/25/2023 at 9:12 PM, documented CNA (certified nursing assistant) reported resident was hard to arouse writer entered room noted that patient was non responsive when his name was called during assessment resident noted with carotid pulse and in distress using all accessory muscles with an oxygen saturation of 87% pulse of 189/128 with a heart rate of 28 writer called for a cash cart and for another nurse to call 911 non breather applied with 10 liters of oxygen patient is a full code blood sugar 220 paramedics arrived and took over care. A Nursing Progress Note dated 04/25/2023 at 11:57 PM, documented Spoke with ER (emergency room) charge nurse stated patient has a diagnosis of encephalopathy and systemic inflammatory response syndrome and is going to be transferred to another hospital that can accommodate his needs as of now transfer hospital has not been confirmed. A Nursing Progress Notes dated 04/26/2023 at 3:19 PM, written by the Director of Nursing (DON) documented .Police Department arrived this morning at (name of facility) at 8:15 AM to investigate the injuries sustained by (R159) last night. DON not aware that he had been injured, was aware of COC (change of condition). (The police) informed DON of the severity of the injuries. At that time an internal investigation was initiated by the DON and Administrator. The required state report was completed and submitted timely. The facility physician Discharge summary dated [DATE] at 10:07 PM, documented the patient had a past medical history significant for hypertension, diabetes mellitus, previous COVID-19 infection, right lower extremity deep vein thrombosis, chronic kidney disease stage III, non-sustained ventricular tachycardia and chronic low back pain who was a long-term resident at the facility. During R159's stay at the facility, the resident had been receiving physical therapy, occupation therapy, and skilled nursing services. The resident was also followed by psychiatry, podiatry, and ophthalmology. The resident remained stable with multiple comorbidities. On 04/25/2023, I was notified that the resident was found unresponsive. The resident was transferred to the hospital for further evaluation and treatment. The hospital medical record revealed the resident had encephalopathy, unspecified systemic inflammatory response syndrome, mandibular fracture, and sternal fracture. On 08/31/2023 at 9:27 AM, the Director of Nursing revealed the resident did not have a fall prior to being transferred to the hospital. The resident had a change in condition (altered mental status, but no fall). The police and facility suspected R159 was beaten by someone. The facility was not aware of the extent of the resident's injuries until the police showed up to look at the crime scene. The DON was informed the hospital records documented the resident had a recent fall at the facility. The DON revealed the nurses did not indicate the resident had a fall. The nurse on duty did not know what happened to the resident. It was possible the resident's roommate might have told the Emergency Medical Technicians (EMTs) the resident had fallen. The resident was not on the floor, as the resident was a big man, it would have taken several staff to lift him off the floor to the bed. The resident's bed was in the lowest position. The facility began their investigation after being informed by the police of the injuries and could not find proof of how the resident sustained the injuries. After the incident, the resident's roommate was placed on a 1:1 for safety and was being followed by social services. R159's roommate was not aggressive and got along well with R159. As R159's roommate did not need the services of a skilled nursing facility and had spoken of wanting to discharge from the facility, the roommate was issued a 30-day discharge notice. Social services and Ombudsman worked with the resident to find an appropriate discharge location and social services checked in the resident to see how he was handling the incident. On 09/01/2023 at 2:15 PM, the Director of Nursing (DON) and the Administrator revealed R159, and roommate (R160) had been roommates for about a year. R159 could not get out of bed and could not fight back if attacked, R160 was ambulatory. The facility staff did not see any issues with the two residents and had no reason to suspect abuse. The facility placed R160 on a 1:1 observation after the incident and issued a 30-discharge notice. The resident had already intended to discharge and had the funds to transition back into the community. The police had found a decorative walking stick hidden on R160's side of the room, it blended in with the bed frame and was difficult to notice. The DON indicated the facility would try to not admit residents with aggressive behavior or been placed on a legal hold for aggressive or violent behavior. There were times when you would not know how the resident would behave when you admitted them to the facility. After the incident, the facility educated staff to be aware of things that were out of place such as a resident acting differently or new bruises and to inform leadership. If a resident did not get along with their roommate to listen to the resident and if they wanted to change rooms to have them meet the new roommate and then decide to change rooms. Staff were trained on abuse and neglect on orientation and the facility reviews abuse training with staff at least every quarter and during staff meetings. The DON and Administrator reported no other incidents. Resident #309 (R309) R309 was admitted to the facility on [DATE] and discharged on 06/25/2023 with diagnoses including acute metabolic encephalopathy, dysphagia status post (s/p) Percutaneous Endoscopic Gastrostomy Tube (PEG) placement, bacterial urinary tract infections s/p treatment, hypothyroidism, urinary retention, cerebral atrophy, seizure disorder, and hypo osmolar hyponatremia. A Nursing Progress Note dated 06/25/2023 at 1:25 AM, by the nightshift Licensed Practical Nurse (LPN) revealed the resident was sleeping all evening. Responded to name when called, just opens her eyes, turns her head, and shuts them back. Vital signs temperature febrile, 101.7 Fahrenheit. PEG tube site was cleaned of a moderate amount of brown drainage with soap and water, patted dry and secured with a drainage sponge. Foley catheter draining clear yellow urine with no sediment or foul odor. The physician was made aware. New orders included the following laboratory orders to be done in the morning: complete blood count, complete metabolic panel, magnesium level, erythrocyte sedimentation rate (could indicated possible inflammation in the body), C-Reactive Protein (CRP), Radiology: Chest x-ray and kidney, ureter, and bladder (KUB) to check g-tube position, urinalysis with culture and sensitivity, g-tube drainage culture, blood culture x2 and to run Dextrose (D)5 ½ Normal Saline (NS) at 100 milliliters (mL)/hour until KUB results are in. Resident has no intravenous (IV) line at this time. A Nursing Progress Note dated 06/25/82023 at 1:30 AM, documented Urine collected for culture and sensitivity. A Nursing Progress Note dated 06/25/2023 at 3:55 AM, documented Resident has no IV line in place. Midline placement to be ordered in am. A Nursing Progress Note dated 06/25/2023 at 11:57 PM, documented pt (patient) send out per MD (medical doctor). WBC (white blood cell) 20.8 and gt (g-tube) malfunction. Sent to (name of hospital). Urinalysis with culture and sensitivity lab results report dated 06/25/2023 at 1:04 PM, documented abnormal test results. Handwritten on the document was to DC (discontinue) free water flush, consult ID (infectious disease) for Leukocytosis, DC D5 ½ NS and start NS at 80 cc (cubic centimeters)/hour, daily renal and mag (magnesium) panel x5 days, NP (nurse practitioner) notified as 06/25/23. The C-Reactive Protein, Magnesium lab results report dated 06/25/2023 at 1:10 PM, documented abnormal results. Handwritten on the document was NP notified as 06/25/2023. The Sedimentation Rate lab results were reported on 06/25/2023 at 2:03 PM with abnormal results. The Comprehensive Metabolic Panel lab results report dated 06/25/2023 at 1:10 PM documented abnormal results. Handwritten on the document was NP notified as 06/25/2023. The Complete Blood Count with differential lab results report dated 06/25/2023 at 2:26 PM documented abnormal results. Handwritten on the document was NP notified as 06/25/2023. The Blood Culture report was pending. A review of the orders from 06/23/2023 to 06/25/2023, documented the following orders: - D5 ½ NS at 100 mL/hour via intravenous. - Midline placement for IV fluids - Blood Culture x2, CBC, CMP, CRP, Magnesium, ESR, urinalysis with culture and sensitivity - CBC with differential, Renal Function Panel - Standard abdomen/KUB - Standard chest x-ray Vital signs taken on 06/25/2023 at 8:20 AM documented a blood pressure (BP) 119/73, pulse 79, Oxygen saturation (O2 Sat) 98, no temperature or respiratory rate was documented. Vital signs taken on 06/24/2023 at 7:59 PM, documented an O2 Sat of 95%, no other vitals were documented. The facility physician Discharge summary dated [DATE] at 10:45 PM, documented the resident was transferred to the hospital for diagnoses including altered mental status and sepsis. The resident was transferred to an acute care hospital for further evaluation and treatment. On 6/25/2023, the resident was found to have a fever of 101.7 °Fahrenheit. Stat (immediate) labs were ordered. Chest x-ray and KUB were also ordered. IVF (intravenous fluid) was also ordered. The resident's labs came back critical with a white blood cell count of 20.8. The facility was unable to establish an IV access. Therefore, the resident was transferred to the hospital for further evaluation and treatment. The clinical record lacked documentation of the resident's status from 06/25/2023 at 3:55 AM to 10:45 PM when the physician was notified, and new orders given to send resident out. On 09/01/2023 at 2:15 PM, the Director of Nursing (DON) and the Administrator revealed the LPN did not call-in radiology test request, forms were not completed, the LPN wrote more in the progress note than was carried out. The LPN did not give a full report to the oncoming LPN of the resident's status and orders which needed to be followed up on and carried out. The physician kept calling the facility requesting results of the lab work and the LPN kept indicating the results were not available. The LPN did not follow up and the 24-hour report was not updated. The nightshift nurse came in and identified a change in condition and notified the physician and the resident was sent out to the hospital. An investigation was conducted and verified the allegation of neglect. The oncoming LPN did not talk to the facility after being suspended pending the investigation of neglect. The two nurses were terminated and reported to the Board of Nursing. After the incident the facility conducted training on change of condition, carrying out physician orders, follow up on orders, LPN could not give another LPN orders to carry out, and documentation of the follow up. Leadership was out on the floor more and asking questions about resident status and ensuring the nurses were following up on residents with a change of condition and new orders. DON had provided the staff with reasons to call the on-call administrator to let them know what was going on, so follow-up could occur, the 24-nursing report was being turned in each day and reviewed in daily stand up. During the survey, the facility had educated staff and implemented the 24-hour nursing report as identified in the corrective action. There were no reported abuse/injury of unknown origin to the extent of a resident being hospitalized and staff were following up and documenting resident change of condition status. The facility policy titled Documentation - Licensed Nursing revised on 05/05/2023, documented the 24-hour report would reflect any status changes, changes in resident conditions, and notification and the verification of documentation of any changes according to the Facility Practice Guidelines, and state specific rules and regulations when indicated. The qualified nurses in each unit complete the 24-Hour Report, on each shift 7 days per week. The facility policy titled Abuse, Neglect, Exploitation, or Mistreatment (undated) documented abuse was the willful infliction of injury, unreasonable confinement intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical, harm, pain, mental anguish, or emotional distress.