**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of hospital records, review of Medscape medical reference information, policy review, and interviews, the facility failed to protect Resident #64's right to be free from neglect. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on [DATE] when the facility failed to provide timely and appropriate goods and services to meet Resident #64's total care and medical needs and failed to ensure the resident received timely and necessary care and treatment to prevent serious illness and death. On [DATE] Resident #64 returned from the hospital with orders for Lasix (diuretic) 20 milligrams (mg) daily and basic metabolic profile (BMP) laboratory test to be completed on [DATE]. The orders for Lasix and the BMP were not initiated or completed per the hospital discharge orders. On [DATE], Resident #64 was ordered additional laboratory testing, including thyroid stimulating hormone (TSH), Vitamins B1, B6, and B12, plasma, folate, and Vitamin D and D3 levels that were not completed. Resident #64 was hospitalized from [DATE] to [DATE] for hypoglycemia, hyperkalemia with EKG changes, hyponatremia, and encephalopathy. On [DATE], the resident was ordered Lasix 80 mg upon discharge from the hospital that was not implemented. On [DATE], the resident was ordered to have laboratory testing including a complete blood count (CBC) and BMP completed STAT (immediately) to determine if the resident's Lasix was appropriate to continue. On [DATE], a one-time order for Lasix 40 mg and Potassium 20 milliequivalents (meq) was ordered and not administered. The STAT CBC and BMP lab results ordered on [DATE] and completed on [DATE] were not reported timely to the provider, resulting in the resident being hospitalized from [DATE] to [DATE] with edema requiring a Bumex (diuretic) continuous intravenous infusion. Additionally, upon re-admission on [DATE], Resident #64 was ordered Lactulose 15 mg/milliliter (ml), 45 ml four times daily. On [DATE], Resident #64 reported to the telehealth Nurse Practitioner (NP) that she had been on Lactulose and would like to restart it again to treat her cirrhosis. The telehealth NP inadvertently ordered a duplicate dose of Lactulose 30 ml, and the resident started the dosage on [DATE]. Resident #64 received duplicate doses of Lactulose, 45 ml and 30 ml doses, from [DATE] until [DATE] (with the exception of [DATE] and [DATE] when the medication was not administered). On [DATE], the resident's progress notes referenced the resident had left calf pain and was ordered an unspecified scan, which was not completed. Resident #64 continued to decline, could not stand, and requested to go the emergency room (ER) on [DATE]. However, Resident #64 was not transferred to the ER, nor was the nurse practitioner (NP) notified. On [DATE], Resident #64 again requested to go to the ER because she could not stand, which was abnormal for her. In the ER, the resident was diagnosed with hyperkalemia (elevated potassium level), acute kidney injury, and encephalopathy (a condition that affects brain function or structure and can lead to changes in mental state, behavior, or cognitive abilities). The resident subsequently went into acute respiratory arrest (in the ER) and expired in the hospital on [DATE]. This affected one resident (#64) of three residents reviewed for abuse and neglect. The facility census was 63. On [DATE] at 2:07 P.M., the Administrator, Interim Director of Nursing (IDON) #600, Assistant Director of Nursing/Registered Nurse (ADON/RN) #179, and Regional Nurse #601 were notified Immediate Jeopardy began on [DATE] when the facility failed to provide timely and appropriate goods and services to meet Resident #64's total care and medical needs and failed to ensure the resident received timely and necessary care and treatment to prevent serious illness and death. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 3:00 P.M., Regional Director of Clinical Services #601 educated the Interim Director of Nursing #600 and Director of Nursing #179, LPN #135 and LPN #107 on the facility Abuse Neglect and Misappropriation, Residents Rights, Laboratory and Radiologic Services Reporting, Medication Administration, and Notification of Change in Condition policies, with emphasis on residents receiving the care and treatment needed to prevent serious illness and/or death, including medications needed to treat serious medical issues, providing ordered lab work and diagnostic tests that could identify medical issues, identifying serious changes and decline in a resident's condition. On [DATE] all new admissions (Resident #18, #28, #33, #43, #59 and #66) from [DATE] to current were audited and reviewed from 3:00 P.M. to 6:00 P.M., by Licensed Practical Nurse (LPN) #135 and LPN #107 to ensure all new admission orders were identified and implemented at time of admission. On [DATE], all 63 residents from [DATE] to current, were audited and reviewed from 3:00 P.M. to 8:00 P.M., by LPN #135 and LPN #107, to ensure all lab work was completed as ordered. Eight residents (Resident #4, #27, #28, #43, #50, #52, #59, #66) labs were re-scheduled due to the orders were not entered into lab portable. The physician was notified. On [DATE], all 63 residents from [DATE] to current were audited and reviewed from 3:00 P.M. to 3:30 P.M., by Registered Nurse (RN) #179, to ensure all lab results were identified and reported to the provider. On [DATE], all 63 residents from [DATE] to current were audited and reviewed from 3:00 P.M. to 3:30 P.M. by RN #179, for duplicated orders including lactulose orders awaiting clarification. On [DATE], all 63 residents from [DATE] to current were audited and reviewed from 3:00 P.M. to 3:30 P.M. by RN R#179, to ensure all diagnostic testing orders were identified and reported to the provider. One resident's (Resident #1) diagnostic tests were re-scheduled, and physician notified. On [DATE], all residents with a Brief Interview for Mental Status (BIMS) score of 13 or higher, total of 35 residents (Resident #3, #4, #8, #9, #10, #11, #12, #15, #17, #18, #20, #22, #28, #29, #32, #33, #35, #36, #41, #42, #43, #44, #45, #46, #47, #50, #51, #54, #55, #57, #58, #60, #61, #62, and #63) were interviewed by Social Service Designee (SSD) #116 and Director of Admissions #120, from 6:00 P.M. to 8:00 P.M., to ensure the residents were receiving goods and services as ordered such as medications, labs, and diagnostics. Three residents (Resident #3, #17, and #50), with concerns noted were addressed and MD notified. On [DATE], all 28 residents (Resident #1, #2, #5, #7, #13, #14, #16, #21, #23, #24, #25, #26, #27, #30, #31, #34, #37, #38, #39, #40, #48, #49, #52, #53, #56, #59, #64, and #66) with a BIMS less than 13 were assessed from 5:00 P.M. to 8:00 P.M. by LPN #135 and LPN #107 for potential neglect as a result of needed goods and services not being provided. Assessment included head to toe to assess for change of condition. Beginning on [DATE] the facility implemented a plan that upon hire, any new RN or LPN would receive education by the Assistant Director of Nursing/designee on Policies titled Abuse Neglect and Misappropriation, Residents Rights, Laboratory and Radiologic Services Reporting, Medication Administration, and Notification of Change in Condition, and verifying and confirming telehealth orders in a timely manner with emphasis on residents receiving the care and treatment needed to prevent serious illness and/or death, including medications needed to treat serious medical issues, providing ordered lab work and diagnostic tests that could identify medical issues, identifying serious changes and decline in a resident's condition. On [DATE] between 4:00 P.M and 10:00 P.M DON #600 and RN #179 educated all licensed nurses, (10 RNs and 9 LPNs) on the Abuse Neglect and Misappropriation, Residents Rights, Laboratory and Radiologic Services Reporting, Medication Administration, and Notification of Change in Condition policies, and verifying and confirming telehealth orders in a timely manner with emphasis on residents receiving the care and treatment needed to prevent serious illness and/or death, including medications needed to treat serious medical issues, providing ordered lab work and diagnostic tests that could identify medical issues, identifying serious changes and decline in a resident's condition. On [DATE] at 6:00 P.M, the Administrator presented the Quality Assessment and Performance Improvement (QAPI) Team with investigation and all findings for discussion and review. Discussion included abatement plan from incident regarding Resident #64, ensuring residents were receiving the care and treatment needed to prevent serious illness and/or death, including medications needed to treat serious medical issues, providing ordered lab work and diagnostic tests that could identify medical issues, identifying serious changes and decline in a resident's condition. Staff in attendance included the Administrator, Interim DON #600, LPN #107, Medical Records Director #188, SSD #116, LPN #135, Human Resource Director #155 and Regional Director of Clinical Operations #601. Via phone included the Medical Director #700, Regional Director of Operations (RDO) #701, Diversional Director of Clinical Operations (DDCO) #203, [NAME] President (VP) #702. A root cause analysis was performed on [DATE] by the interdisciplinary team with oversight by the Administrator. In review of the facilities non-compliance at Data Tag F600 current policies and procedures, documentation and staff interview, the root-cause analysis determined a need for improved clinical education and comprehensive oversight by clinical managers. Beginning on [DATE], the Administrator and DON or designee would conduct an audit on 3-5 residents/week for four weeks, and randomly thereafter to ensure residents were receiving the care and treatment needed to prevent serious illness and/or death, including medications needed to treat serious medical issues, providing ordered lab work and diagnostic tests that could identify medical issues, identifying serious changes and decline in a resident's condition, to prevent the same actions, situations, and/or practices from occurring in the future and to ensure on-going compliance. The audit would include reviewing new orders in the daily clinical meeting to ensure labs and diagnostics have been scheduled, results have been received, medications have been administered, and MD follow-up was complete. Three residents would be interviewed a week to identify if there were concerns. All findings of concern would be immediately addressed and reported to the QAPI committee for further review and prompt response and resolution. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings included:Review of the closed medical record for Resident #64 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, cirrhosis, asthma, encephalopathy, bipolar, epilepsy, anxiety, falls, hypertension, depression, sleep disorder, post-traumatic stress disorder, hyperlipidemia, type 2 diabetes, left leg deep vein thrombosis, peripheral artery disease, and anemia. Review of Resident #64's plan of care initiated [DATE] revealed the resident used anti-anxiety medications and was encouraged to voice feelings, discuss coping skills, provide a calm environment, and limit over-stimulation. A care plan focus initiated [DATE] revealed Resident #64 was at nutritional risk due to acute renal failure, depression, diabetes, bipolar, morbid obesity, hypertension, fatty liver cirrhosis, diuretic therapy, large weight fluctuations related to fluid shifts from advanced disease process, and the resident doesn't want a therapeutic diet. The interventions included establishing a baseline weight, notify the medical provider and resident representative of unplanned weight changes, obtain labs per medical provider orders, obtain weekly weights if unplanned loss was identified, and provided diet as ordered. A care plan focus initiated [DATE] revealed Resident #64 had renal failure with interventions including to administer medication per orders and to observe for side effects and effectiveness. Report abnormal findings to medical provider. Observe for signs and symptoms of complication of renal disease (decrease urine output, increased BUN/creatine, edema, dyspnea, elevated blood pressure and heart rate, decreased peripheral pulses, fatigue, weight gain, confusion, and distended jugular veins). Notify medical provider, resident/resident representation of abnormal findings. Obtain and monitor labs/diagnostic studies, as ordered. Report abnormal findings to medical provider. Obtain weight as ordered and report abnormal fluctuations to medical provider. Provide diuretics as ordered. A care plan focus initiated [DATE] revealed Resident #64's activity of daily living (ADL) listed Resident #64 as independent with toileting and toileting hygiene. A care plan focus dated [DATE] revealed Resident #64's was at risk for altered bowel elimination related to medication side effects. Interventions included to administer medication per medical provider's order, monitor bowel movements, monitor medication for side effects of constipation. Keep medical provider, resident/resident representative of any problems. A care plan focus initiated [DATE] revealed Resident #64's had cirrhosis of the liver. Listed interventions included administering medication as ordered, providing emergency care for excessive bleeding, observing for signs and symptoms of liver disease (malaise, fatigue, anorexia, weight loss, edema, bleeding, constipation, diarrhea, ascites, confusion, and jaundice). Notify the medical provider of abnormal findings. Obtain and monitor labs/diagnostic studies as ordered. Obtain weight as ordered. A care plan focus initiated [DATE] revealed Resident #64 utilized anti-platelet medication. Interventions included providing medication as ordered and obtaining labs per orders. A care plan focus initiated [DATE] revealed Resident #64 occasionally had urinary incontinence related to urgency but was continent of bowel. The resident tended to wait too long to summon assistance and was noted to rush to the bathroom. Resident #64 was noted to toilet herself independently but was alert and able to ask for assistance if needed. A care plan focus initiated [DATE] revealed Resident #64 had behaviors related to bipolar disorder (verbal/physical outburst and delusions). Interventions included ensuring the resident felt safe and was able to express feelings and encouragement from family. Review of Resident #64's quarterly Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. The resident's height was 65 inches, and she weighed 343 pounds. The assessment revealed the resident had delusions, but no behaviors towards others or rejection of care. The resident was always continent of urine and bowel and only required supervision of touching assistance with toileting. The resident's active diagnoses included renal failure, diabetes mellitus, hyperlipidemia, epilepsy, anxiety disorder, depression, asthma, cirrhosis of liver, stage 3 chronic kidney disease, and sleep disorder. The resident had no condition or chronic disease that may result in life expectancy of less than six months. The assessment revealed the resident wanted to talk to someone regarding returning to the community. Review of the resident's medical record revealed beginning on [DATE] the facility failed to provide timely and appropriate goods and services to meet Resident #64's total care and medical needs resulting in resident neglect. The facility failed to ensure comprehensive and individualized systems were in place to prevent resident neglect and to ensure Resident #64 received timely and necessary care and treatment to prevent serious illness and death. The following concerns were identified: a. Review of Resident #64's hospital records revealed the resident was hospitalized from [DATE] to [DATE] with diagnoses including acute kidney injury, hyperkalemia, volume overload/edema, hypertension, and anemia. Resident #64 was discharged from the hospital with new orders to increase Lactulose to 45 ml four times daily and to continue Lasix 40 mg twice daily. Review of Resident #64's progress note authored by NP #803 and dated [DATE] revealed the residents' blood pressure was low, her speech was slurred, and she was slow to respond. The resident has a history of encephalopathy with elevated ammonia levels and acute kidney injury. The note stated to send Resident #64 to the emergency room for evaluation and STAT labs. Review of Resident #64's hospital record dated [DATE] to [DATE] revealed the resident was transferred to the emergency room for altered mental status. The resident was diagnosed with acute kidney injury. The resident's discharge instructions included to decrease Lasix to 20 mg daily and listed an order for a BMP laboratory test to be completed on [DATE]. Review of Resident #64's medical record revealed no evidence a medication reconciliation was reviewed with a provider following the resident's re-admission on [DATE]. Review of Resident #64's Medication Administration Record (MAR) and orders dated 05/2025 revealed the Lasix 40 mg twice daily was discontinued. However, the new order for Lasix 20 mg was not initiated upon the resident's return from the hospital on [DATE]. Review of Resident #64's medical record revealed no evidence a BMP was completed on [DATE] as ordered. Review of Resident #64's weights revealed no evidence the resident was weighed on re-admission on [DATE]. On [DATE], the resident weighed 315 pounds and on [DATE], the resident weighed 340 pounds (reflecting a 25-pound weight gain in a seven-day period). Review of Resident #64's progress note dated [DATE] authored by RN #103 revealed Resident #64 had orders for laboratory testing including thyroid-stimulating hormone (TSH), Vitamin B1, B6, and B12, plasma, folate, and Vitamin D2 and D3. Review of Resident #64's medical record revealed no evidence the laboratory testing order on [DATE] for TSH, Vitamin B1, B6, and B12, plasma, folate, and Vitamin D2 and D3 was done. Review of Resident #64's progress note dated [DATE] authored by LPN #163 revealed the resident was on her way to an appointment with the liver doctor and she got very lethargic and felt like she was about to black out. The residents' blood sugar was 57 (hypoglycemic) and she was transferred to the emergency room. The aide that accompanied the resident reported the hospital was discussing admitting the resident. Review of Resident #64's hospital records dated [DATE] to [DATE] revealed the resident was admitted for hypotension, hypoglycemia, and altered mental status and was found to have acute kidney injury, hyperkalemia, and acute anemia and was transferred to interventive care unit (ICU) due to hypotension. The resident was also managed for acute on chronic anemia, acute encephalopathy, cirrhosis, sub-occlusive deep vein thrombosis, and lactic acidosis. The resident was re-admitted to the facility on [DATE]. Interview on [DATE] at 3:14 P.M., with the Administrator, IDON #600, and Corporate Nurse #601 confirmed the hospital records dated [DATE] indicated to decrease Lasix to 20 mg daily, however the order was not implemented. IDON #600 and Corporate Nurse #601 confirmed there was no documented evidence that the re-admission orders were reconciled with the resident's physician. IDON #600 confirmed the resident was re-admitted to the hospital on [DATE] and noted the resident had a 25-pound weight gain. During the interview the Administrator, IDON #600, and Corporate Nurse #601 confirmed there was no evidence the TSH, Vitamin B1, B6, and B12, plasma, folate, and Vitamin D2 and D3 laboratory testing was completed on [DATE] as ordered. Interview on [DATE] at 9:06 A.M., with Corporate Nurse #802 confirmed Resident #64 did not have a BMP on [DATE] per the hospital orders on [DATE]. b. Review of Resident #64's re-admission weight dated [DATE] revealed the resident weighed 391.8 pounds. Review of Resident #64's re-admission orders dated [DATE] revealed the resident was ordered Lasix 80 mg daily until appropriately diuresed and in one week ([DATE]) follow up with (laboratory testing) iron panel, TIBC, ferritin, CBC, and BMP. Review of Resident #64's MAR and orders revealed no evidence the Lasix 80 mg was implemented per the hospital discharge orders dated [DATE]. Review of Resident #64 progress note dated [DATE] at 1:36 P.M. authored by LPN #107 revealed it was reported to the nurse manger Resident #64 had increased edema in her abdomen and pelvis. A call was placed to the facility NP who consulted with the physician. New orders were obtained for a STAT CBC and BMP laboratory test, and a one-time dose of Lasix 80 mg was ordered. Review of Resident #64 laboratory results dated [DATE] revealed Resident #64's CBC and BMP were collected on [DATE] at 12:26 P.M., received at 2:22 P.M., and resulted at 2:28 P.M. The residents' glucose, BUN, and creatine were high and red blood cells, hemoglobin and hematocrit were noted to be low. Review of Resident #64's NP #905 note dated [DATE] revealed the resident was seen for edema. The resident had requested Lasix. The nurse reported the facility had not received the laboratory testing that was completed on [DATE] due to it being sent to the hospital. The nurse would call the hospital to try to get renal function test to determine if routine Lasix was ordered. A one-time order of Lasix 40 mg and Potassium 20 meq was ordered until renal function could be evaluated. The note included to please call back with any changes in conditions. Further review of Resident #64's 05/2025 MAR revealed no documented evidence the one-time order for Lasix 40 mg or Potassium 20 meq was administered per the NP's order on [DATE]. Review of Resident #64's progress note dated [DATE] authored by LPN #178 revealed the nurse attempted to call the hospital, however an automated system indicated laboratory requests were only available Monday through Friday and if there was a holiday, you could not get results until the following day. Review of Resident #64's progress note dated [DATE] authored by LPN #163 revealed laboratory results were received. The resident potassium was 4.9, BUN was 38, and Creatinine was 2.4. There was no documented evidence that the provider was notified of laboratory results. Review of Resident #64's weight dated [DATE] revealed the resident weighed 407.2 pounds (reflecting a 15.4-pound weight gain from the [DATE] weight of 391.8 pounds). Review of Resident #64's progress note dated [DATE] authored by RN #902 revealed Resident #64 was requesting a water pill due to her feet swelling up. Upon checking orders, the resident was not on any Lasix. The resident insisted she wanted it back. The provider called and said she could only give a stat order as she was waiting for the resident's labs. Resident #64 stated the labs were already drawn. The note included the provider couldn't trace her recent labs and said they had to wait for the results to determine if the resident could continue to take the Lasix. STAT order for a one-time dose of Lasix 40 mg and Potassium 40 mEq were placed and administered. Resident #64 later complained of shortness of breath, but her oxygen saturation levels were withing normal limits. Review of Resident #64's progress note dated [DATE] authored by LPN #178 revealed during skin assessment the resident was noted to have plus three pitting edema (a moderate amount of swelling where an indentation remains on the skin after pressure is applied for a short period of time) in her bilateral lower extremities. The resident was swollen from her abdomen to her toes. Resident #64's abdomen was tight, bumpy and dimpled like an orange peel. The physician was previously notified, and new orders were received. Review of Resident #64's progress note dated [DATE] at 1:30 P.M. authored by RN #158 revealed the resident complained of not feeling well. On examination, the resident had a distended abdomen that was pitting to the touch, with clear fluid oozing from the left side. The resident had edema of both lower extremities that were pitting to the touch. The resident complained of pain with touch to both the abdomen and lower extremities. The note referred to a new order to transfer the resident to the hospital. Review of Resident #64's hospital record dated [DATE] to [DATE] revealed the resident was seen for swelling and weight gain. The resident was profoundly edematous and was symptomatic with shortness of breath from volume (fluid) overload. The records indicated Resident #64 likely required a trial of aggressive diuresis. The resident reported gaining over 100 pounds over the past few weeks. The resident had increased peripheral edema as well as shortness of breath associated with weight gain. Due to these symptoms, she was brought to the emergency department for evaluation. Laboratory studies in the emergency department revealed the resident had an acute kidney injury with her creatine (a waste product indicative of kidney health, with elevated levels indicating kidney issues) elevated at 3.73. The last known creatine was on [DATE] and it was 2.40. Resident #64's potassium was elevated at 5.6 (normal level 3.5 to 5.0 (when levels get too high it can cause problems such as muscle weakness, irregular heartbeat, and can become life-threatening). The notes indicated Resident #64 also had anemia, with a hemoglobin level of 7.9 (normal values between 10.5 to 12.5). A chest x-ray was completed with findings of vascular congestion. The resident was admitted to the intensive care unit (ICU) for further evaluation and management. Nephrology (kidney specialist) was consulted due to renal failure and hyperkalemia. Resident #64 was started on a Bumex (diuretic) continuous intravenous infusion. Review of Resident #64's hospital record dated [DATE] to [DATE] revealed Resident #64 was ordered 45 ml of Lactulose four times daily and Bumex 2 mg daily. Interview on [DATE] at 3:14 P.M., with the Administrator, IDON #600, and Corporate Nurse #601 confirmed there was no documented evidence the provider was notified of the STAT laboratory results that were collected and resulted on [DATE]. There was no documented evidence on the MAR the Lasix 40 milligram (mg) and Potassium 20 milliequivalent (meq) were administered on [DATE] per NP #905 progress note dated [DATE]. Corporate Nurse #601 confirmed the resident was hospitalized from [DATE] to [DATE]. Interview on [DATE] at 9:06 A.M., with Corporate Nurse #802 confirmed the resident's Lasix 80 mg was not implemented per the discharge orders dated [DATE]. c. Review of Resident #64 bowel history records dated 05/2025 revealed the resident was hospitalized on [DATE] and returned on [DATE] and had one large soft bowel movement (BM) on night shift. On [DATE] one large loose BM, on [DATE] no BM, [DATE] one medium loose BM, no BM on [DATE], on [DATE] one medium formed BM on day shift and one large loose BM on nights. On [DATE] and [DATE], one medium soft BM on nights, [DATE] and [DATE] large soft BM on nights, and [DATE] one medium formed BM on days. The resident was hospitalized from [DATE] to [DATE]. On [DATE], the resident had one medium formed BM on nights, [DATE] one large form BM on days, [DATE] one large loose BM on nights. The resident was hospitalized on [DATE] to [DATE]. Review of Resident #64's re-admission orders dated [DATE] revealed an order for Lactulose 10 grams (gm) per 15 ml, give 45 ml four times day. Review of NP #200's telehealth note dated [DATE], which was not part of the medical record, revealed NP #200 completed a telehealth visit on [DATE] for monthly rounds. Resident #64 reported she was previously on Lactulose and would like to restart back on Lactulose for history of cirrhosis. The resident denied nausea, vomiting, abdominal pain, constipation, and diarrhea. The resident was having regular bowel movements without bleeding. The plan was to restart the Lactulose and obtain laboratory testing to check ammonia, prealbumin, CBC, and BMP. There was an addendum added after the surveyor noted concerns with the Lactulose order on [DATE]. The addendum was dated [DATE] at 11:37 A.M., indicating that Lactulose had been previously increased due to lack of stools and a listed goal was for the resident to have two to three stools a day. Review of Resident #64's MAR dated 06/2025 revealed from [DATE] to [DATE], the resident received 45 ml of Lactose four times daily. From [DATE] to [DATE], the resident received 30 ml of Lactose four times a day except for the 10:00 P.M. doses on [DATE] and [DATE] which were not given as the nurse questioned the duplicate orders and noted she was awaiting clarification. Review of Resident #64's progress note dated [DATE] authored by RN #902 revealed the resident's blood glucose was 91. The resident reported her stomach felt full and she had not been able to eat well for two days. Review of Resident #64's bowel record dated 06/2025 revealed the resident did not have a bowel movement (BM) on [DATE], one large, formed BM on [DATE] and [DATE] and one medium BM on [DATE]. Interview on [DATE] at 10:00 A.M., with LPN #135 revealed she had reached out to NP #200 to send his telehealth visit note as it was not contained in Resident #64's medical record. Interview on [DATE] at 3:14 P.M., with the Administrator, IDON #600, and Corporate Nurse #601 reported the NP visits were all telehealth visits, and the NPs were available 24/7 to verify/clarify all orders. They indicated they were not sure why the Lactulose order was not clarified on [DATE]. Interview on [DATE] at 11:50 A.M., via telephone with Corporate Nurse #601 confirmed NP #200 had increased the dose (of Lactulose) on [DATE], however his progress note was not in the medical record. The resident's ammonia level on [DATE] was 45 (normal range 9-33) and the prior ammonia level dated [DATE] was 114 in the hospital. A telephone interview on [DATE] at 12:05 P.M., with NP #200 revealed he did a telehealth visit on [DATE] which was not in the medical record due to a glitch in the system. NP #200 reported he added an order for an additional 30 ml of Lactulose due to Resident #64 not having two to three bowel movements a day, which was the goal. Resident #64 had just been re-admitted on [DATE] after being hospitalized from [DATE] to [DATE]. NP #200 could not recall how many bowel movements the resident was having prior to increasing the dose. NP #200 reported he did not consult with the resident's physician or specialist because he felt 75 ml was safe dose for a short period of time. The NP confirmed he did not put a stop date on the new order because he stated he knew Resident #64 would be seen again in a week for a follow-up. Interview on [DATE] at 12:30 P.M., via email with the Administrator confirmed NP #200 had added a late addendum, dated [DATE], to his progress note from [DATE] to include the Lactulose was increased due to Resident #64's lack of stools and the goal was two to three stools daily. Interview on [DATE] at 7:03 A.M., with Certified Nursing Aide (CNA) #113 reported Resident #64 toileted herself and reported the resident had three BM's daily. The CNA reported she had provided care to the resident the last few weeks before she had expired and she had intermittent confusion. Interview on [DATE] at 9:25 A.M., with CNA #190 revealed Resident #64 usually toileted herself, however the last few weeks she started [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, facility policy and procedure review, and interview, the facility failed to provide timely, necessary and adequate care and services following an acute change in condition involving Resident #63. The facility failed to ensure changes in the residents' medical condition were comprehensively assessed, the resident change in condition, including abnormal vital signs, was communicated to the medical health provider, and individualized interventions were implemented for Resident #63 when the resident was identified by therapy staff to have a decline in health including tachycardia, hypoxemia, and excessive daytime sleepiness and lethargy. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on [DATE] at approximately 12:30 P.M. when Resident #63 had hypoxemia, increased sleepiness, lethargy, and tachycardia while sitting at rest in therapy without adequate intervention. On [DATE] following an inability to complete therapy, Resident #63 returned to his room with no evidence the resident was comprehensively assessed by nursing staff (including Assistant Director of Nursing (ADON) #164 who had been notified by therapy staff) or the on-site nurse practitioner related to the identified decline and change in condition. On [DATE] at 8:10 P.M. Resident #63 was found absent of vital signs. Staff initiated cardiopulmonary resuscitation (CPR) and called first responders from the local fire and rescue; however, the resident was subsequently pronounced deceased by first responder staff. On [DATE] at 12:01 P.M. the Administrator, Regional Director of Clinical Operations Registered Nurse (RN) #171, and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at approximately 12:30 P.M. when the therapy staff identified Resident #63 exhibited a decline and a change in condition which included hypoxemia, increased sleepiness/somnolence, lethargy, tachycardia with an inability to continue therapy without evidence of timely or adequate interventions/medical treatment being provided. Resident #63 remained in his room with increased somnolence, sleepiness, lethargy, and loud snoring that was not comprehensively addressed and without necessary and individualized interventions provided to the resident. On [DATE] at approximately 8:10 P.M. Resident #63 was found absent of vital signs when Licensed Practical Nurse (LPN) #86 entered the room to administer medication. Cardiopulmonary Resuscitation was initiated, 911 was called with local fire and rescue responding, and the resident was pronounced deceased at 8:40 P.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following actions: • On [DATE], audits were completed by Licensed Practical Nurse (LPN) #75 and LPN #169 for all 62 current residents from [DATE] to current to ensure timely identification and adequate and necessary medical care and intervention was provided following an acute change in condition. • On [DATE] LPN #65 reviewed the nursing notes and care plans for all 62 residents from [DATE] to current for change of condition. • From [DATE] to [DATE] all residents with a Brief Interview for Mental Status (BIMS) score of 12 or higher were interviewed during daily ambassador rounds, to see if they had any concerns that needed to be addressed health or otherwise. This was completed by all department heads and would be an ongoing process. • From [DATE] to [DATE] all residents who were not able to be interviewed had a skin assessment completed by the DON/Designee. • On [DATE] the DON, Unit manager LPN #169 and MDS LPN #75 reviewed the last two weeks of residents who had been transferred to the hospital and/or who had expired in the facility to ensure adequate medical interventions were provided. • On [DATE] at 10:00 A.M., Regional Director of Clinical Services RN #171 re-educated the Director of Nursing on the policies Clinical Documentation Standards and Notification of Change in Condition to include ensuring timely identification of a resident acute change in condition and adequate and necessary medical care and intervention were provided following an acute change in condition. • On [DATE] from 10:00 A.M. to 4:00 P.M. the Director of Nursing re-educated all nurses either in person or via phone (including 10 RNs and 12 LPNs) on the Policies Clinical Documentation Standards and Notification of Change in Condition which included: Verbal communication with attending nurses. Ensuring timely identification and adequate and necessary medical care and intervention following an acute change in condition. If at any time staff felt a resident needed a higher level of care, call 911. • On [DATE] the Director of Rehabilitation (DOR) #173 educated 16 therapists either in person or via phone on the Notification of Change policy which included: Verbal or written communication to the nursing department. Communication with the nurse responsible for the resident. • Beginning on [DATE], upon hire any new nurse practitioner (NP) would receive education on the facility Clinical Documentation Standards and Notification of Change in Condition policies by the DON/Designee. • On [DATE] at 5:00 P.M., the Administrator presented the facility Quality Assessment and Performance Improvement (QAPI) Team with investigation and all findings for discussion and review. Discussion included an abatement plan from incident regarding Resident #63, to ensure timely identification and adequate and necessary medical care and intervention is provided following an acute change in condition. Staff in attendance included the Administrator, DON, Infection Control Preventionist LPN #169, Medical Records Director #107, SSD #168, MDS # 75, HR Director #74 and Regional Director of Clinical Operations #171 and (RDCO) #172. Via phone included the Medical Director, Regional Director of Operations #174 (RDO), Diversional Director of Clinical Operations #175 (DDCO), and [NAME] President (VP) of Risk #176. • Beginning on [DATE], the facility implemented a plan for the Administrator and/or designee/DON to conduct an audit on three to five residents/week for four weeks, and randomly thereafter to ensure timely identification and adequate and necessary medical care and intervention was provided following an acute change in condition. All findings of concern would be immediately addressed and reported to the QAPI committee for further review and prompt response and resolution. In addition, nurse's notes would be reviewed daily in the clinical A.M. meeting Monday through Friday ongoing. Any concerns noted would be directed to the medical providers. Although the Immediate Jeopardy was removed on [DATE] the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #63 revealed an admission date of [DATE] with diagnoses of cellulitis, morbid severe obesity (410 pounds (lbs.) on [DATE]), cor pulmonale (right sided heart failure), congestive heart failure, sleep apnea, hypertension, respiratory failure, acute and chronic renal failure, adult failure to thrive, psychoactive substance abuse, Stage 3 chronic kidney disease, chronic venous insufficiency, iron deficiency anemia, and lymphedema. Review of the facility physician's order dated [DATE] revealed Resident #63 was admitted to the facility for skilled level of care with therapy and/or nursing services (including antibiotic use for cellulitis to right posterior lower leg). Review of Resident #63's medical record revealed the resident was a full code (advance directive status) indicating the resident wished to receive all possible life-saving measures in the event of a cardiac or respiratory arrest. Review of Resident #63's physician's orders dated [DATE] revealed an order for physical and occupational therapy to evaluate and treat. Review of the physician orders dated [DATE] revealed the resident would receive occupational therapy services five times a week for 30 days with treatment including therapeutic exercises, therapeutic activities, neurologic reeducation, activity of daily living (ADL) training, and group therapy. Additionally, there was an order for the resident to receive physical therapy five times a week for 30 days for therapy exercise, therapy activities, neurological re-education, gait training and group therapy. A plan of care dated [DATE] revealed the resident had Bilevel Positive Air-way Pressure (BiPAP) Therapy for Obstructive Sleep Apnea. (A breathing device that delivers pressurized air through a mask, helping to open the airways an assist with breathing; often used to sleep apnea, chronic obstructive pulmonary disease (COPD) or other respiratory problems). The goal was for the resident to adhere to BiPAP regimen. Interventions included to educate resident/representative on the importance of BiPAP Therapy and encourage resident's use of BiPAP. There was not a general respiratory or oxygen plan of care for Resident #63. Review of the admission Minimum Data Set Assessment (MDS) assessment dated [DATE] revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score that reflected he was cognitively intact and independent for daily decision making. The resident exhibited no behaviors, and the assessment included the resident rejected care one to three days in the look back period. Review of a Functional assessment dated [DATE] revealed Resident #63 had no upper or lower body functional impairment. The resident used a walker and wheelchair, was (staff) dependent for toileting, shower, upper and lower body partial moderate assistance with dressing, and personal hygiene. The resident was receiving physical and occupational therapy. The assessment revealed the resident required partial/moderate (staff) assistance to move from sitting position to lying position, required substantial/maximal (staff) assistance to move from lying position to sitting on the side of the bed, and required substantial/maximal (staff) assistance to transfer from a bed to a wheelchair. On [DATE] a physician order included oxygen at three liters per minute via nasal cannula as needed for shortness of breath or sign and symptoms of hypoxia/respiratory failure. Review of Nurse Practitioner (NP) #163's note dated [DATE] at 1:00 A.M. revealed the resident denied any chest pain or shortness of breath and had no other complaints. Review of Nurse Practitioner (NP) #163's note dated [DATE] revealed Resident #63 had been seen in the emergency department (ED) for a wound infection on [DATE] but had not been admitted . Upon assessment, the resident was sleeping in his bed with his legs dependent off of the bed. The resident was not wearing his BiPAP and noted to have loud snoring respirations. The NP note revealed she was able to wake the resident easily and upon asking why he wasn't wearing his BiPAP the resident reported he wore it when he could. Staff had frequently reported the resident refused the BiPAP. While in the ED venous blood gas testing showed a PCO2 of 87 which compared to one year prior was 84 and noted to be associated with hypoventilation due to obesity. The NP note revealed the resident had a diagnosis of sleep apnea and was supposed to be wearing a BiPAP, however he had been noted to be sleeping often without the BiPAP. The resident's vital signs included pulse of 76 beats per minute (BPM), blood pressure 130/64 mm/Hg, and oxygen saturation 98 percent on room air. The note included recommend using BiPAP all night and even throughout the day. Recommend follow up with pulmonology. Monitor respiratory status and vitals. Record review revealed there was no evidence of an appointment made with a pulmonologist as recommended by NP #163. Review of a nurse's note dated [DATE] at 3:00 A.M. and completed by LPN #77 revealed Resident #63 was pleasant. The resident took all evening medications as ordered without difficulty and had been medicated for generalized pain. The note included the resident refused to use BiPAP and had refused dressing changes to bilateral lower legs for this nurse, stating he was too tired. Review of the nurse's note dated [DATE] at 11:25 A.M. and completed by LPN #78 revealed the resident was alert and oriented to person, place and time. Receiving Occupational Therapy, receiving Physical Therapy and psychiatric consults. The note included the resident makes poor decisions; cues/supervision required. Review of Resident #63's occupational therapy note completed by Occupational Therapist (OT) #83 dated [DATE] and signed 12:58 P.M. revealed Resident #63's oxygen saturation at resting fluctuated between 75 and 89 percent (%) with an inability to recover with purse lip breathing (PLB). The resident came to the therapy room on three liters of oxygen. Increasing oxygen to four liters per minute via nasal cannula resulted in the resident's oxygen saturation fluctuating 82% to 95% PLB with inability to maintain greater than 90% consistently. The resident's resting heart rate was fluctuating between 86 and 116 beats per minute. The note revealed consult with nursing regarding this resident inappropriate for therapy at this time. Review of Resident #63's physical therapy note by Physical Therapy Assistant (PTA) #147 dated [DATE] at 1:24 P.M. included the resident was seen supine in bed with wound nurse removing intravenous therapy. The note included the nurse stated she had put the resident's oxygen on him while he was sleeping. The resident woke up and sat on the edge of bed (with) minimum assist times one. The resident remained on the edge of bed for 10 minutes to dress sitting unsupported. Resident edge of bed transfer to wheelchair with moderate assist times one, with cueing for sequencing and safety. Unable to reposition in wheelchair without momentum and required therapy behind wheelchair or it would tip. The resident wheeled halfway down to therapy and then requested be pushed the rest of the way. Resident's oxygen saturation checked upon arrival to therapy room and was 77%. Resident cued to breathe properly to increase oxygen saturations. Resident's oxygen was unable to stabilize at three liters increased to four liters, nursing aware. The resident was not appropriate for treatment on this date and returned to his room. Encouraged to keep oxygen on. The resident was also encouraged to sleep with a C-PAP (Note: this documentation identified the resident was using a C-Pap but Resident #63 was ordered and was using a BiPAP machine) machine on to increase patients' alertness during the day. The note included the resident still continues to spontaneously fall asleep no matter what he is doing. Review of Resident #63's medical record revealed no evidence a comprehensive nursing assessment or individualized interventions were initiated following this identified decline and change in condition per therapy notes on [DATE] at 12:58 P.M. and 1:24 P.M. respectively. Record review revealed documentation on Resident #63's treatment administration record that the resident refused to have vital signs taken by LPN #78 on [DATE] at 4:50 P.M. On [DATE] at 5:08 P.M. LPN #78 documented completion of a wound treatment to the resident's bilateral lower extremities. Review of the local Fire and Rescue Patient Care Record revealed a call came in to dispatch on [DATE] at 8:11 P.M. for a resident (#63) in cardiac arrest. Emergency responders were dispatched to the facility, arriving onsite at 8:15 P.M. and to the resident at 8:16 P.M. Upon arrival, the resident was found lying supine on the floor with cardiopulmonary resuscitation (CPR) in progress by facility staff. Staff reported to responders the resident had been lying in bed at 7:00 P.M., sleeping and snoring. Making rounds at 8:10 P.M., they found Resident #63 pulseless and apneic. The resident was in asystole (the complete absence of electrical and mechanical activity in the heart). Resuscitation efforts continued for over 20 minutes with the resident's skin becoming colder, and his color becoming more pale and cyanotic with lividity noted to his back. The resident's pupils were non-reactive. The resident was pronounced deceased on [DATE] at 8:40 P.M. Review of a nurse's note dated [DATE] at 9:10 P.M. revealed Resident #63 was found at 8:10 P.M. by Licensed Practical Nurse #86 (LPN) with no pulse or respirations. The note included the resident was last talked to at 7:15 P.M. by Certified Nurse Aide (CNA) #105. Staff quickly got help from a Curriculum Practicum Training (CPT) Intern (a nurse licensed in another country waiting to take the Ohio State Nursing Boards) RN #140 and CPT Intern RN #138 to call 911. LPN #86 grabbed the crash cart, and Automatic External Defibrillator (AED). The resident was lowered to the floor being especially careful not to hit his head. After which chest compressions started. An oxygen bag was obtained. The AED was put on scanned and no shock was advised. After about two to three minutes of chest compression, the resident started foaming out of the mouth and had blood come out of his nose. Staff went to get a suction kit. CNA's #116 and #162 were in the room assisting. Ambulance staff arrived at 8:16 P.M. and after a quick briefing of the situation they took over chest compressions, hooked the resident to a monitor, put in an oral air way and pushed epinephrine. At 8:40 P.M. emergency medical staff pronounced the resident deceased after contacting their physician. Review of Resident #63's Certificate of Death revealed the immediate cause of death was acute hypoxic respiratory failure and hypercapnic respiratory failure leading to the immediate cause. Interview on [DATE] at 3:03 P.M. with Occupational Therapist (OT) #83 revealed she called Assistant Director of Nursing (ADON) #164 into the therapy room on [DATE] when Resident #63 was in therapy. PTA #147 was also in the therapy room. OT #83 revealed she was unable to increase Resident #63's oxygen saturations. She had ADON #164 come into the therapy room to see him. The ADON was told they were unable to get the resident's vital signs to stabilize and could not continue therapy. The resident would fall asleep and wake up. They had to constantly get his attention. The resident would keep the oxygen on for therapy, per nasal cannula. Nurse Practitioner (NP) #163 was in the hall outside the therapy. The ADON went out to inform the nurse practitioner of the Resident #63's condition. However, the nurse practitioner did not come into the therapy room to assess the resident. OT #83 revealed therapy staff were shocked nothing happened. She believed she recalled the resident wheeling himself out of the therapy room when they could not continue therapy due to his oxygen saturations being low and pulse elevated. OT #83 revealed she signed her documentation of the therapy session at 12:58 P.M. She indicated that it would have been close to the time she would have seen him. Interview [DATE] at 3:44 P.M. with Nurse Practitioner (NP) #163 revealed on [DATE] she was talking to Licensed Practical Nurse #169 at her door which was across the hall from the therapy room. ADON #164 walked down the hall and in general passing told her Resident #63 keeps falling asleep in therapy. She asked if he had a follow up scheduled with an infectious disease doctor and was informed it was the following day. NP #163 stated she told ADON #164 to have the resident go to his appointment and do a telehealth visit if he changed and if it was needed that day. NP #163 indicated she saw the back of the resident's head while he was in therapy on [DATE]; but denied actually assessing the resident on this date. The NP revealed she felt like the resident had been falling asleep easily and refusing his BiPAP since admission and did not think this was any type of change for the resident over the past week. Interview on [DATE] 4:43 P.M. with PTA #147 revealed she went to Resident #63's room on [DATE]. The wound nurse was in there and told her she put oxygen on him when he was sleeping because of his loud snoring. PTA #147 revealed on [DATE] she was monitoring his vital signs; his pulse was erratic, and his oxygen saturation would go low and high. ADON #164 was walking past the room, and she asked ADON #164 to come in. The ADON stood and watched Resident #63 in therapy; his pulse and oxygen were erratic all over the place. OT #83 and PTA #147 then saw ADON #164 talk to NP #163 thinking the NP would then come in and assess the resident, but she did not. PTA #147 left the therapy room and upon her return, the resident was not in the therapy room. She stated she did not know how he got back to his room and denied taking him to his room. PTA #147 revealed this was the first date the resident had been unable to participate in therapy and was deemed not appropriate for therapy. PTA #147 revealed Director of Rehabilitation #173 told therapy staff she had reported in morning meeting the day after the resident passed away that he had not been appropriate for therapy the morning prior. Interview on [DATE] at 5:14 P.M. with Director of Rehabilitation (DOR) #173 revealed she was not working on [DATE]. However, on [DATE] her staff mentioned to her Resident #63 passed away. They informed her his oxygen saturations were all over (up and down), his heart rate was high, and he was inappropriate for therapy the previous day. DOR #173 revealed her staff told her they notified nursing. She mentioned in morning meeting the therapy staff said the resident's oxygen saturations were up and down the day prior. They increased his oxygen a liter, his pulse was high, and he was not appropriate for therapy. Interview on [DATE] at 5:36 P.M. with ADON #164 revealed on [DATE] one of the therapy staff called her into the therapy room and said Resident #63 did not look well. ADON #164 stated she saw the resident was in the therapy room, and verified he did not look well. She stated she went to get the NP (#163) and the NP said the resident had an infectious disease appointment the next day and to keep it and to do a telehealth visit if needed. The ADON verified she did not complete a head-to-toe comprehensive assessment on the resident. She thought the resident wheeled himself to his bedroom. The ADON denied recalling anyone else reporting anything new the rest of that day related to Resident #63. The ADON said she did not remember if she told the floor nurse on his hall that day ([DATE]) what happened in therapy. She said she probably should have documented therapy calling her in to see Resident #63 and what she saw that day in therapy, but she did not. A subsequent interview on [DATE] at 9:11 A.M. with ADON #164 occurred when the ADON called with additional information. She said (on [DATE]) Resident #63 was tired in the therapy. She stated she did speak to LPN #78, the nurse on his hall, and LPN #78 said this was the resident's normal. The ADON revealed she did not recall what exactly she reported to LPN #78 regarding the resident and therapy on this date. ADON #164 revealed Resident #63 was not doing well on [DATE]; he was not chatty like a normal day. An additional interview on [DATE] at 2:10 P.M. with ADON #164 included Resident #63 was falling asleep in therapy and did not look well. His head was falling down, and he was supporting it by holding it up with hand. ADON #164 included the resident was nodding off but easily arousable. When he was sleeping, he looked sick like he didn't feel well. She included she went to NP #163 to decide if they should transfer the resident to the emergency room. ADON #164 indicated she asked the NP if she (the NP) could look at the resident. However, the NP told her the was going to see the infectious disease physician the next day and to have staff do a telehealth visit if needed. Interview on [DATE] at 9:47 A.M, with LPN #86 revealed he was the night nurse who came in at 7:00 P.M. on [DATE]. He stated Resident #63's call light was on during report, and he thought CNA #105 answered the call light but said the resident did not want anything that he had just bumped it. LPN #86 revealed during shift change report he was not told of any episode in therapy related to Resident #63. He was told the resident was extremely tired throughout the day. LPN #86 revealed the first time he saw the resident was when he took in his medications at 8:10 P.M. at which time he found the resident's skin cool to touch, and he was not breathing. The resident's oxygen was up by his head and not in his nose. LPN #86 stated he ran out of the room and grabbed the crash cart and had a nurse call 911. A nurse supported the resident's head, they lowered him to the floor, and they began cardiopulmonary resuscitation. Interview on [DATE] at 9:27 A.M. with CNA #110 revealed on [DATE] she was assigned to Resident #63's hall. The resident had been very lethargic, and his lips were cyanotic, but he did go to therapy. CNA #110 revealed she had not assisted the resident back to bed after therapy and was unsure who had helped him get into bed. The CNA revealed she was not real familiar with Resident #63 but indicated the resident had not eaten any breakfast, or just a bite or two, indicating he was not hungry. However, she did have another staff enter he had eaten 26-50 percent of breakfast (she did not have access to enter the documentation). The CNA denied collect the resident's lunch tray, so she stated she did not write down a percentage eaten down, but revealed it was entered that he had eaten 76-100 percent (the accuracy of this could not be verified). The resident did not eat any dinner; however, the TASK kiosk included the resident consumed 51-75 percent of the dinner meal. CNA #110 revealed she told the aide coming in during shift report the resident had been lethargic, had not eaten. The resident's lips looked bluish, and he was taking gasps of air laying on the bed. The CNA stated it looked like he was going septic. She said she told the nurse (LPN #78) what she was seeing. She said the nurse reporting checking the resident's vital signs after lunch and they were fine. Interview on [DATE] at 10:07 A.M. with LPN #78 revealed on [DATE] the resident was asleep every time she went in his room, but she was able to wake him up. She stated she did not recall Resident #63 eating breakfast on this date. At lunch she tried to wake him up to eat lunch and he said OK. The LPN didn't recall if the resident ate supper on this date. The LPN revealed residents were not required to have vital signs taken every day and denied obtaining vital signs for the resident on this date. The LPN denied recall of ADON #164 saying anything to her or therapy saying anything to her about Resident #63's condition on [DATE]. LPN #78 revealed if she knew the resident's oxygen saturations were low and pulse fast, she would have obtained a set of vital signs every 20 minutes, turned on his oxygen and made sure he wore it. LPN #78 stated she thought Resident #63's face was flushed that day ([DATE]). The LPN then indicated Resident #63 refused his vitals to be taken at 4:50 P.M. as part of his daily orders. Interview on [DATE] at 10:39 A.M. with RN #149 revealed on [DATE] Resident #63 was difficult to arouse; however, the RN did not believe this was uncommon for the resident. The RN indicated she had discontinued the resident's intravenous antibiotic this morning and did not feel there was anything off about him at that time. Interview on [DATE] at 11:39 A.M. with the Director of Nursing revealed on [DATE] she documented Resident #63's supper meal percentage as 51-75 percent. She included someone would have had to tell her that percentage for her to write it. Interview on [DATE] at 11:53 A.M. with CNA# 162 revealed when she came in for night shift on [DATE] Resident #63 was asleep on walking rounds. She went out to her car and when she came in, they (staff) had started a code (for Resident #63). Interview on [DATE] at 10:28 A.M. with NP #163 revealed she was not provided any vital signs by ADON #164 to review from [DATE] for Resident #63. The NP stated if she knew the resident's oxygen saturation was 76 percent, pulse 118 and he was unable to complete therapy, she would have had the nurses keep the resident's BiPAP on him and would have transferred him to the emergency room if he continued with the elevated pulse and lower oxygen saturation. She stated she would have assessed him if she would have been aware of the change in condition. Interview on [DATE] at 5:04 P.M. with CNA #105 revealed on [DATE] Resident #63's call light was on at 6:53 P.M. when she arrived to work on this date. She stated she clocked in and put her stuff behind the nurse's station and then started answering lights (there were five resident call lights on). Resident #63's call light was the second light she answered. The resident way laying sideways in bed with his feet hanging down off the side of the bed and his head touching the mattress and propped up just a little bit. The CNA stated she asked the resident if he was alright or needed anything. The CNA stated the resident sort of sat up partially and his eyes were opened but he did not say anything. The CNA stated she took this as him not needing anything and left the room. Review of the facility undated Notification of Change in Condition policy revealed it was the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs, concerns of the residents. Changes may include but are not limited to changes in overall health status, significant medical changes and therapy services changes. The policy included the facility must inform the resident, consult with the resident's medical practitioner and/or notify the residents' representative, authorized family member, or legal power of attorney/guardian when there was a change requiring such notification. Circumstances requiring notification included but were not limited to significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status including but not limited to life-threatening conditions or clinical complications. Review of the facility's Oxygen-Medical Gas Use policy (dated 2014) included a licensed nurse, or respiratory personnel would provide respiratory assessments as indicated. This deficiency represents non-compliance investigated under Complaint Number OH00165450.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of hospital records, review of an emergency medical service (EMS) report and EMS staff statements, review of facility Self Reported Incidents, review of a facility investigation, review of the facility dialysis policy and procedure, review of the facility Abuse/Neglect policy and procedure and interviews with staff, the coroner, and resident, the facility failed to prevent an incident of neglect when Resident #72 did not receive timely and necessary care to prevent major blood loss from his hemodialysis fistula site. This resulted in Immediate Jeopardy and Actual Harm with subsequent death beginning on [DATE], when Resident #72, who had intact cognition and required hemodialysis, was seen by dialysis staff, picking at his fistula site. The resident was educated not to pick at it and the resident stated he was a picker. Dialysis staff submitted a communication to the nursing home staff regarding the picking incident. The night shift nurse noted the resident asked for a band aid to cover the scabbed areas and the area was covered with a two by two (2x2) dressing with no further assessment or intervention at that time. On [DATE] at 11:25 A.M. Resident #72 was found by staff unresponsive, hemorrhaging a large amount of blood from his hemodialysis fistula in his left upper arm. The resident's call light had been activated (for an undetermined period of time) at the time he was found unresponsive. Resident #72 subsequently passed away on [DATE]. On [DATE] at 11:20 A.M., the Administrator, Director of Nursing (DON) and Divisional Director of Risk #223 were notified Immediate Jeopardy began on [DATE] when dialysis staff notified nursing home staff Resident #72 was picking at his dialysis fistula site. Nursing home staff failed to implement adequate and effective measures and interventions after identifying the resident was picking at his fistula site to prevent complications. On [DATE] at 11:25 A.M., Resident #72 was found by Certified Nursing Assistant (CNA) #267 with his call light on (for an undetermined amount of time), hemorrhaging a large amount of blood from his hemodialysis fistula. Resident #72 was subsequently pronounced deceased on [DATE] at 12:09 P.M. In addition, a concern that did not rise to the level of Immediate Jeopardy was identified when the facility failed to prevent staff to resident potential abuse when a staff member was identified engaging in an inappropriate romantic relationship with Resident #71. This affected two residents (#71 and #72) of three reviewed for abuse and neglect. The facility census was 71. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] at 11:45 A.M., the DON began collecting statements from all staff who worked on Resident #72's unit in last 24 hours. All statements were collected by [DATE]. • On [DATE] at 1:00 P.M., the Director of Human Resources #260 gave the DON all cardiopulmonary resuscitation (CPR) cards of the nurses completing CPR. • On [DATE], Licensed Practical Nurse (LPN) Unit Manager (UM) #208 completed assessments on residents who had dialysis ports or fistulas. The assessments included checking for any signs of infection, any bleeding, dry and intact dressings, and bruit and thrill for Resident #71's arteriovenous (AV) fistula and Resident #64's right upper cervical (RUC) hemodialysis (HD) port. • On [DATE], the DON initiated education to all 24 licensed nurses which was completed by [DATE]. The education pertained to the policy titled Hemodialysis Care and Monitoring with emphasis on the assessment of ports and shunts, pre and post assessments on dialysis residents, all dialysis orders, and on dialysis monitoring orders. The education also included communication between the facility and dialysis center every dialysis day and to initiate immediate dialysis interventions. New licensed nurses would be educated by the DON or designee during new hire orientation. • On [DATE] the DON initiated education of the facility's Abuse, Neglect, and Misappropriation Policy. The education was completed by [DATE] for all 24 licensed nurses and all 29 CNA's. New nurses and CNAs would be educated during new hire orientation. • On [DATE], the DON initiated an audit on all dialysis residents to validate dialysis orders to monitor residents' dialysis sites. Orders were corrected for Resident #71's left upper arm fistula and added to the treatment record. A physician order to check Resident #71's dialysis graft site for bruit and thrill every shift was initiated on [DATE]. • On [DATE], the DON reviewed and revised care plans for dialysis residents to ensure accuracy and Resident #71's was updated to ensure accuracy related to the type of fistula he had. • On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, Regional Director of Operations (RDO) #217, Regional Director of Clinical Operations (RDCO) #218, Diversional Director of Clinical Operations (DDCO) #219, [NAME] President (VP) of Risk #220, VP of Operations #221, and VP of Clinical Operations #222. • On [DATE], a Root Cause Analysis was completed by the DON, Administrator, Assistant Director of Nursing (ADON) #213, Divisional Director of Risk #223, and LPN UM #208. Licensed nurses CPR licenses were verified. The analysis determined the problem to be cardiac arrest secondary to hypovolemic shock due to hemorrhage from AV fistula per hospital documentation. Care plans, orders, and code statuses were reviewed for accuracy, dialysis patients were assessed, and nurses received education on Hemodialysis Care and Monitoring and medication administration. • On [DATE], the facility initiated audits for neglect through Angel Rounds (monitoring completed by department heads Monday through Friday on the residents) through observation and interviews of three staff and three residents, five days a week for four weeks. • Beginning on [DATE], the DON/designee would audit three dialysis residents, three times a week for four weeks then randomly thereafter to ensure dialysis orders were in place to monitor the shunt site with the schedule, pre/post dialysis forms were completed, and care plans and orders reflected dialysis recommendations, and any monitoring needed. The DON/designee will validate that the facility received communication forms from the dialysis center three days a week for four weeks then randomly thereafter. • On [DATE], education to all staff on answering call lights in a timely fashion was completed by the DON/designee. New staff would be educated during new hire orientation. • On [DATE], the ED/designee would initiate call light audits on three call lights, three days a week and interview five residents a week on call light response times for four weeks then randomly thereafter. • The results of audits will be forwarded to the facility QAPI committee for further review and recommendations until substantial compliance is maintained. The Medical Director will give input into any data presented and plans proposed by the Committee. Although the Immediate Jeopardy was removed on [DATE] the deficiency remained at a Severity Level II (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Included: 1. Review of the closed medical record for Resident #72 revealed the resident was admitted to the facility on [DATE] with diagnoses including hypertensive heart, end stage renal disease with hemodialysis, diabetes, hypothyroidism, dementia, major depressive disorder, hydronephrosis, benign prostatic hyperplasia, and mood disorder. The resident was discharged to the hospital on [DATE] where he expired. Review of the physician order dated [DATE] revealed Resident #72 had an order for staff to check his dialysis graft site for bruit and thrill every shift. Review of the hemodialysis care plan dated [DATE] revealed Resident #72 was receiving hemodialysis therapy related to renal failure and he had an AV fistula to the left upper extremity. Interventions included to administer medications per medical provider's order, observe for side effects and effectiveness, on dialysis days administer medications before, during, or after dialysis according to the medical providers orders, report abnormal findings to the medical provider, nephrologist, dialysis center, resident, and resident representative, communicate with the dialysis center regarding medication, vital signs, weights, restrictions, diet orders, nutrition or fluid needs, laboratory results, and who to notify with concerns, coordinate resident care in collaboration with dialysis center, evaluate the AV fistula for bleeding and if bleeding occurred, apply continuous direct pressure to the site for at least five minutes, if unable to stop the bleeding call 911, evaluate the resident following dialysis treatment, fluid restriction per orders, do not complete blood draws/blood pressure in the same arm as AV fistula, listen for bruit and thrill, do not remove dressing applied by dialysis center, and evaluate the AV fistula for bleeding. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had intact cognition and received dialysis. The assessment revealed the resident required (staff) set-up assistance or supervision for all activities of daily living (ADL) and mobility. Review of the [DATE] and February 2025 Medication Administration Records (MAR) and Treatment Administration Records (TAR) revealed no documented evidence of staff checking the dialysis graft site for bruit and thrill every shift for Resident #72 as ordered. Review of a Dialysis Hand Off Communication Report document dated [DATE] revealed Resident #72 had been picking at scabs on his fistula and the plan was to try to keep a band aide on the sites. The communication was signed by Dialysis Registered Nurse (RN) #225. Further review of the report revealed Facility Registered Nurse #261 signed the form indicating she checked Resident #72's bruit and thrill. She documented the resident's dialysis catheter dressing was dry and intact and the resident had no signs or symptoms of infection at that time. Review of a nurse's note dated [DATE] at 11:25 A.M. revealed the nursing assistant notified the nurse that Resident #72 was bleeding. Upon entering the room, Resident #72 was unresponsive with a large amount of blood noted. 911 was called immediately and a code blue (a universal emergency code indicative of a medical emergency, usually cardiac or respiratory arrest) for the staff was called. CPR was initiated at 11:26 A.M. with the arrival of other clinical staff. An intravenous (IV) access line was unable to be obtained. Resident #72's physician and family were notified. The ambulance arrived at 11:33 A.M. and the resident was transferred to the emergency room (ER). Review of an Emergency Medical Service (EMS) report dated [DATE] revealed at 11:23 A.M. EMS was called for an emergency at the facility. The primary impression was Resident #72 had a cardiac arrest and the secondary (impression) was hemorrhage. The report included barriers of care that the resident was left unattended or unsupervised and he had a sharp object penetrating injury or a cut laceration at the nursing home on [DATE]. EMS was dispatched to the facility for a hemorrhage from an unknown origin and the resident was lethargic. Upon arrival, and after applying standard precautions, the staff were found at the door, holding the doors open, and reported the resident's fistula was bleeding and he was bleeding out. A large stack of four-by-four gauze along with a pressure dressing was gathered from the truck and the crew reported to the resident's bedroom. The resident was found supine in bed with active CPR being performed. The staff did not report active CPR to EMS until the crew was at the bedroom door. A crew member was sent to the truck to obtain supplies for the updated situation. Additional resources were immediately requested with one staff member reporting they did not know what happened because Resident #72 was not their resident. When asked for the patient's information and history they stated, Why don't you go get your paperwork, and another staff member provided his first and last name however, no birth date was given. Another staff member stated, talk to her (indicating to the staff member preforming CPR) she would know more. This staff member reported, He was just fine a moment ago when I checked on him and then I came in and he was bleeding. Upon assessment, there was a large amount of blood loss and the (resident's) dialysis fistula, located in the anterior portion of the upper left arm, was no longer bleeding. The assumed site where the hemorrhage occurred was clotted and mostly hardened at the site. The site was closely monitored so as not to disrupt the clot. The site appeared to have been self-controlled for a considerable time as there was a large amount of dried blood to the area and no signs of active hemorrhaging. There were pools of cold blood under the resident as well as on the floor and next to the bed he was in. There was blood splatter on the headboard of the bed. There were many clots of varying size and in various stages of forming, including bright red arterial blood that was coagulating with pools of dark dried blood clots. Estimation was difficult, but total blood loss appeared to be around two to four liters. The resident had no easily visible veins including the jugular veins and his dialysis fistula was flattened. The resident's pupils were non-reactive, round and equal. He did not show signs of rigor mortis, dependent lividity, or an injury incompatible with life. The resident's skin displayed pallor and was dry to the touch. The resident had signs of cyanosis around the mouth and slight mottling of the skin in various areas. Resident #72 also did not have a Do Not Resuscitate (DNR) order, the decision to continue attempted resuscitation was made. The automated external defibrillator (AED) was attached by nursing home staff, when prompted for analysis it provided no shock advised, and CPR was resumed. While CPR was continuing, the resident's shirt was cut to allow for access to the chest. At the next pulse check the resident was moved to allow for the [NAME] University Cardiopulmonary Assist System (LUCAS) back plate (an automated chest compression machine) to be applied. Due to the size of the resident and the conditions of the bed, the LUCAS was not able to be attached to the back plate. The resident was moved to the cot and secured to the cot. CPR continued with the LUCAS device now applied. When the resident was moved to the cot, a large amount of additional blood and blood clots were found underneath the resident on the bed including a singular mass of coagulated/clotted blood that was several inches wide in diameter. The now revealed blood and blood clots had also varied stages of clotting and drying. This increased the suspicion of a prolonged down time due to the different dryness of blood and changes in color across the collective fluid, however the approximate downtime was not-clear due to history gathering and findings on scene. Once loaded into the ambulance, intraosseous (IO) (bone marrow) access was obtained via 25 millimeter (mm) IO needle which gave positive bone marrow return. Endotracheal intubation was successfully achieved with a 7.5 tube and stylet. Direct visualization was achieved and the endotracheal tube (ETT) was placed at 22 centimeters (cm) at the teeth line. ETT was secured with a [NAME] (a device used to secure an ETT tube). Upon arrival at the hospital the resident was transferred to the bed and care was transferred to the hospital staff with a full report given to the nurse and physician on duty. Due to the nature of the call and the circumstances that occurred, a police report was filed with the local police department and adult protective services were contacted after the call. Review of a hospital ER report dated [DATE] revealed Resident #72 presented to the ER in cardiac arrest and they noted a large amount of blood on the sheets. It noted that the resident came from the nursing facility after an unwitnessed cardiac arrest with concerns of a fistula rupture and an unknown downtime. The note also stated upon arrival, the resident had no active bleeding from the fistula and [the fistula] was flat with overlying scabs with no palpable pulsation or hum. Resident #72 arrived at the ER at 11:57 A.M. with a diagnosis of cardiac arrest and hypovolemic shock due to hemorrhage from AV fistula. The residents time of death was 12:09 P.M. Review of a handwritten Police Department Statement from Paramedic #216 dated [DATE] revealed upon arrival to the scene, Resident #72 was found lying in a pool of his own blood and the blood was beginning to clot. The resident was bleeding from his fistula. Paramedic #216 noted that once they arrived on scene staff had begun CPR. The statement revealed they were originally dispatched for a resident bleeding and lethargic. The staff stated the resident's downtime was unknown and they did not have any idea when the bleeding started. The fire department took over CPR efforts and moved the resident to the ambulance. The resident was transported to the hospital where the resident was pronounced deceased . Paramedic #216's statement included staff stated they were going to lose their jobs because of this, but the statement did not elaborate as to why the staff made the statement. Review of a handwritten Police Department Statement from Paramedic #215 dated [DATE] revealed when responding to an emergency call, Resident #72 was found supine in bed with an obvious injury to his dialysis fistula. The wound appeared to have been self-controlled for a significant amount of time. The wound had bleeding in various stages of clotting, there was dried blood found in significant amounts on the wound and arterial blood was found all around the resident in bed and on the headboard of the bed. There were large clots found under the resident and around various areas such as the floor and the bed sheets. Paramedic #215 noted there were no first aid supplies, such as dressings or a tourniquet found in the room, and the staff members could not provide an account of the events. No staff members could provide a name or birth date for the resident. Paramedic #215 further revealed that most of the blood found was either cool or cold and had begun to darken, and this was a cause for concern as it appeared the resident had been deceased for a substantial amount of time, and that the blood hemorrhaging had occurred as a substantial amount of time had passed prior to the nursing home calling and reporting. The resident appeared to have been bleeding to death and laid in a pool of his own blood unnoticed for an abnormally long time. Review of the facility investigation revealed the only documents present pertaining to an investigation into the incident related to Resident #72 from [DATE] included 31 different staff members' statements about the last time they saw Resident #72 and if he was picking at his fistula site. The statements revealed the last staff to see Resident #72 alive was RN #204 on [DATE] at 9:00 A.M. The statements revealed no facility staff observed the resident picking at his fistula site, besides Dialysis RN #225. The facility also conducted a timeline of the code blue for Resident #72 stating who was present and the sequence of events after the resident was found unresponsive. On [DATE] at 11:53 A.M. an interview with Dialysis RN #225 revealed on [DATE] Resident #72 had numerous small scabs on his fistula and he was picking at them. She stated there was no active bleeding when she saw him and she told him to stop, but he stated he was sorry and that he was a picker. She stated he did not have a dressing or band aid on prior to dialysis. She stated there were no concerns with his fistula and it was assessed and accessed fine for her that day. She stated she placed a pressure dressing over his fistula prior to him leaving the dialysis center. On [DATE] at 12:15 P.M. an interview with Visitor #226 revealed she had been visiting her family member on [DATE] and stated the call light for Resident #72 had been on for a long period of time that morning when she was in the facility. On [DATE] at 1:00 P.M. an interview with the Director of Nursing confirmed Resident #72 had an order for his dialysis fistula bruit and thrill to be checked every shift. However, there was no documentation this was completed. On [DATE] at 2:31 P.M. an interview with the DON confirmed an aide did leave at 8:00 A.M. on [DATE], leaving three aides and one restorative aide for four halls. No additional information was provided related to the activation of Resident #72's call light or the length of time it had been on before the resident had been found unresponsive. On [DATE] at 2:32 P.M. an interview with the Administrator revealed she did not know what they facility could have done differently regarding the circumstances of in the incident with Resident #72 on [DATE]. On [DATE] at 9:20 A.M. an interview with CNA #241 revealed she was in the dining room when the code blue was called for Resident #72. She revealed the staff had been working short on the units on [DATE] because they had an aide go home sick. On [DATE] at 9:46 A.M. an interview with CNA #286 revealed she had been working the day Resident #72 coded (indicating when the code blue was called), but stated she was not working his hall. She stated they had an aide go home sick, so they had three aides for four units. She stated CNA #241 did not help on the floor or help answer call lights, she only completed her restorative programs. She stated she did not know how long Resident #72 had his call light on, but confirmed the resident's call light was on when she went into the room to help with the code. On [DATE] at 9:55 A.M. an interview with CNA #244 revealed she was not working on Resident #72's unit on [DATE], however when they called the code she ran into the resident's room. She stated she did not notice the call light on when she went into the room, but it was on when she came out of the room. She stated she saw Resident #72 at breakfast when she took his tray to him at around 7:30 A.M., but you could not see his fistula because it was higher up on his arm and his gown covered it but she stated she did not see any blood on his gown at that time. She stated she also heard him talking to Director of Public Relations #249 when she (Director of Public Relations #249) picked up his breakfast tray (at approximately 8:10 A.M.), but she (CNA #244) did not see him at that time. On [DATE] at 12:16 P.M. an interview with CNA #267 revealed he was the only aide working on Resident #72's unit. He stated he was in the shower room giving a shower to a different resident. After the shower, he took that resident back to her room to get her dressed and then took her down to the dining room. When he came back to the unit, the lunch cart was sitting in the hallway outside Resident #72's room. He stated he got Resident #72's tray off the meal cart, went to take it in the room, saw all of the blood, immediately put the tray down, and went to get help. He stated Resident #72's call light was on when he went into the room. He stated he had not been in Resident #72's room for a little while and he indicated no other staff were on the unit when he was in the shower room. On [DATE] at 7:25 A.M. an interview with RN #261 revealed on [DATE] Resident #72 had a couple scabbed areas to his fistula site and she applied a dressing to it. However, the RN revealed she did not document this or write any new orders because the dialysis sheet (from the treatment on this date) already indicated they placed a band aide on it earlier. She stated she did not see any concerns with his fistula site at that time and she did not personally see the resident picking at his fistula site, but stated he had been picking at his forehead. There was no evidence any new interventions were implemented at that time to prevent the resident from picking or to prevent complications with the resident's dialysis fistula site. On [DATE] at 12:10 P.M. an interview with Coroner #214 revealed she knew about Resident #72. She stated she did not handle the resident's body and she did not know what the resident's official cause of death was on the death certificate, but she remembered the nurses in the ER calling her to tell her about Resident #72. The nurses told her the resident had been bleeding profusely from his left upper arm fistula as it had ruptured. She stated the nurses explained the resident had passed away from cardiac arrest, but Coroner #214 stated that would have been considered cardiac arrest secondary to hypovolemic shock secondary to a ruptured fistula based on the circumstances. She further revealed the nurses told her there was so much blood that they had to clean the resident up completely before they allowed the family in to see him. Review of the undated facility policy titled, Ohio Abuse, Neglect and Misappropriation, revealed neglect occurred when the facility was aware of, or should have been aware of, goods or services a resident required but the facility failed to provide them to the resident resulting in, or which may result in, physical harm, pain, mental anguish, or emotional distress. Review of the undated facility policy titled, Hemodialysis Care and Monitoring, revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical, and emotional needs and concerns of the residents and that safety was the primary concern for the residents, staff and visitors. It noted that resident may require hemodialysis in the event of critically low kidney function, usually 12-15 percent to less, that allowed the buildup of lethal toxins in the blood. Hemodialysis may be required due to renal damage attributable to long term uncontrolled diabetes and/or hypertension or for acute episodes due to physical or chemical injury to the kidney. Residents would be individually evaluated by a nephrologist or physician for hemodialysis and would have a vascular access device placed specific to their needs. It was important that the nurse understand the type of venous access device each resident had, signs and symptoms to monitor, was pruritus or itchy skin present and if lotion could relieve, aneurysm which may rupture, bleeding, lack of bruit and thrill palpated at the site. General care was to monitored for infection, thrill and bruit. 2. Review of the medical record for Resident #71 revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease, diabetes, neuropathy, hepatitis C, hypertension, anxiety disorder, major depressive disorder, complete traumatic amputation between the elbow and wrist of the left arm and phantom limb syndrome. Resident #71 was his own responsible party. Review of the plan of care dated [DATE] revealed no documentation of inappropriate sexual behaviors being exhibited by the resident. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #71 had intact cognition and had no behaviors. Review of the signed handwritten statement from Certified Nursing Assistant (CNA) #287 dated [DATE] revealed she had called the Director of Human Resources #260 on [DATE] to let her know about an incident that occurred on Tuesday ([DATE]) morning in the parking lot, directly after working. Resident #71 walked to her (CNA #287's) car with CNA #227. CNA #227 got into the car and Resident #71 leaned down and thanked her (CNA #287) for giving CNA #227 a ride home, they both giggled then Resident #71 leaned in and kissed CNA #227. CNA #287 stated she turned her head away because she did not want to see it. Resident #71 then walked away. Review of the signed, typed statement for Director of Human Resources #260 revealed she had received a call from CNA #241 stating she spoke to a coworker and the coworker reported to her that CNA #227 and Resident #71 kissed in the parking lot after CNA #227's shift on the morning of [DATE]. CNA #241 stated to her that she received a call from CNA #287 stating she was taking CNA #227 home the morning after her scheduled shift on [DATE]. She stated Resident #71 walked to her [CNA #287's] car with a crutch and kissed CNA #227 in the car in the parking lot. Review of the facility Self Reported Incident (SRI) investigation dated [DATE] revealed a State surveyor called the facility Administrator and asked if she was aware of an allegation of sexual activity between a resident and staff. The investigation noted that the facility had been working on an investigation regarding a staff member and resident and possible romantic involvement that did not include allegations of sexual activity. Both the resident and staff member had previously denied the allegations of romantic involvement. The investigation further revealed CNA #227 was previously suspended upon arrival to work [DATE], pending the investigation of a suspected kiss with Resident #71. CNA #287 reported to the Director of Human Resources #260 on [DATE] that in the evening, she had driven CNA #227 home and Resident #71 walked them to the car and kissed CNA #227. CNA #227 denied that the resident kissed her. CNA #287's interview and statement indicated that CNA #227 was in the car, Resident #71 leaned in the window, and CNA #287 assumed the resident was going to kiss CNA #227, and CNA #287 looked away. Resident #71 was interviewed and stated he did not kiss CNA #227 but only walked her to the car. CNA #227 was interviewed via phone on [DATE] and she denied any sexual interactions with Resident #71. Resident #71 was interviewed on [DATE] and he denied any sexual interactions with CNA #227. The investigation noted Resident #71's psychosocial care plan was updated with new interventions and he would continue to see the facility psychiatric nurse practitioner and the facility counselor. Review of the facility investigation revealed the following text message exchange between CNA #227 and CNA #287 on [DATE]: • CNA #287 stated, Did you find a ride home? • CNA #227 replied, Nope • CNA #227 then stated, Mister man says he loves you But not the way he loves me • CNA #287 replied, Lol I hope not • CNA #227 stated, Girl . maybe I should just find a different job • CNA #287 replied,[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, emergency room record review, review of a facility Self-Reported Incident (SRI), review of the facility investigation, review of the news broadcast at https://wtov9.com/news, employee code of conduct review, staff interviews, resident interview and review of facility policy, the facility failed to prevent staff to resident sexual abuse. This resulted in Immediate Jeopardy and the potential for actual physical and psychosocial harm on 08/08/24 at approximately 11:10 A.M. when Hospitality Aide (HA) #286 witnessed an incident of potential sexual abuse between Maintenance Director (MD) #300 and Resident #1, a resident with a court appointed legal guardian due to mental incapacity with a known history of hypersexual tendencies. On 08/08/24 HA #286 observed Resident #1 sitting in her room on the floor, with the door closed and Maintenance Director (MD) #300 standing in front of the resident. Upon entry to the room, HA #286 observed MD #300 pulling down his shirt and his pants appeared to have been unbuttoned. The incident was reported to nursing staff and the Administrator and MD #300 was suspended pending an investigation of alleged sexual abuse. The local police department was notified of the alleged incident. On 08/08/24 at 3:45 P.M. Police Chief (PC) #306 contacted the facility Administrator and reported MD #300 confessed to receiving oral sex from Resident #1 on 08/08/24 when discovered in the resident's room. The PC also reported MD #300 confessed to having sexual interactions with Resident #1 for the last nine to 12 months (while he was employed at the facility). MD #300 was arrested and charged with sexual assault of Resident #1. This affected one resident (#1) of two residents reviewed for abuse. The facility census was 75. On 08/15/24 at 4:30 P.M. the Administrator and Regional Director of Clinical Operations (RDCO) #304 were notified Immediate Jeopardy began on 08/08/24 when Resident #1 was observed on the floor in her room with MD #300 standing in front of her. MD #300 was adjusting his shirt, and his pants appeared to be unbuttoned when discovered by HA #286. MD #300 was suspended pending an investigation and later confessed to receiving oral sex from Resident #1 and being in a sexual relationship with Resident #1 for the past nine to 12 months (while employed at the facility). The MD was arrested by police and charged with the sexual assault of Resident #1. Based on Resident #1's diagnoses and mental incapacity, there was no evidence Resident #1 was able to consent to this relationship. The deficient practice was corrected on 08/10/24 when the facility implemented the following corrective actions: • On 08/08/24 between 11:10 A.M. and 11:20 A.M., Hospitality Aide (HA) #286 entered Resident #1's room (the door was closed) and observed Resident #1 sitting on the floor and Maintenance Director (MD) #300 standing in front of her, adjusting his clothing. HA #286 ensured the resident's safety by instructing MD #300 to immediately leave the room and reported the incident to Licensed Practical Nurse (LPN) #238. • On 08/08/24 at 11:30 A.M. LPN #238 reported the incident to the Administrator. • On 08/08/24 at 11:33 A.M. LPN #238 completed a head to toe and pain assessment on Resident #1. • On 08/08/24 at 11:34 A.M. the Administrator interviewed MD #300, who initially denied anything sexual was occurring and stated he was helping Resident #1 up off the floor. MD #300 was suspended pending the results of the investigation for suspicion of sexual abuse and escorted out of the facility by Human Resource Manager (HRC) #256. MD #300's timecard reflected an 11:45 A.M. time punch to end his shift MD #300's employment was subsequently terminated on 08/08/24. • On 08/08/24 at 11:40 A.M. the Administrator notified Regional Director of Operations (RDO) #308 of the suspicion of sexual abuse by MD #300. • On 08/08/24 at 11:45 A.M. the Administrator interviewed HA #286 regarding her observations. HA #286 remained with Human Resource Manager (HRM) #256 to provide a statement and then went home at 12:30 P.M. per her request. • On 08/08/24 at 12:06 P.M. the Director of Nursing was notified of the incident by the Administrator. • On 08/08/24 at 12:25 P.M. the Administrator notified the local police department of the incident HA #286 had reported involving MD #300. • On 08/08/24 at 12:30 P.M. the Administrator asked Social Service Designee (SSD) #225 to speak with Resident #1 to determine if the resident would share any information. The resident was unable to provide meaningful information at that time, indicating MD #300 had been fixing her television. • On 08/08/24 at 12:40 P.M. Police Chief #306 arrived at the facility and interviewed Resident #1. The Police Chief asked Resident #1 if she would like to go to the hospital and get checked out. Resident #1 declined at first but then stated it may be nice to get out for a little bit. The Police Chief explained to Resident #1 the hospital may complete a rape kit. Resident #1 stated she was familiar with rape kits. The resident returned to the facility on [DATE] at 5:57 P.M. No rape kit had been completed due to the resident's refusal at that time. • On 08/08/24 at 1:30 P.M. Resident #1 was transported to the emergency room (ER). • On 08/08/24 at 3:45 P.M. Police Chief #306 called the Administrator and reported during the interview with MD #300, MD #300 admitted to receiving oral sex from Resident #1. MD #300 was being arrested and taken to jail. • On 08/08/24 at 5:12 P.M. the Administrator initiated a self-reported incident to report the incident of sexual abuse to the State agency. • On 08/08/24 at 8:30 P.M. the DON/Designee interviewed 26 female residents (Resident #1, #2, #4, #5, #7, #8, #17, #21, #25, #26, #27, #33, #35, #38, #45, #46, #54, #58, #59, #62, #65, #68, #70, #71, #74 and #75) with a Brief Interview of Mental Status (BIMS) score of nine or higher (results range from 0-15) regarding MD #300. Skin sweeps were completed for 12 female residents (#3, #6, #20, #24, #32, #36, #37, #39, #40, #53, #69 and #74). unable to be interviewed Three residents (#16, #31 and #34) received both a skin sweep and interview due to their questionable BIMS score. • On 08/09/24 at 9:00 A.M. the DON/Designee interviewed 28 male residents (#10, #11, #12, #14, #15, #16, #18, #19, #28, #29, #30, #41, #42, #43, #44, #47, #48, #49, #50, #55, #56, #57, #61, #64, #66, #67, #72 and #73) and skin sweeps were completed for eight non-interviewable residents (#9, #13, #22, #23, #51, #52, #60 and #63) to identify any additional sexual abuse concerns. • On 08/09/24 by 1:00 P.M. the DON/Designee interviewed all 52 interviewable residents regarding abuse. Questioned asked included: Has staff, a resident or anyone else here abused you-this includes verbal, physical or sexual abuse? • On 08/09/24 by 1:00 P.M. the DON/Designee interviewed 97 staff (five housekeeping staff, 35 STNAs, eight dietary staff, seven registered nurses (RN), 16 licensed practical nurses (LPN), 15 therapy staff, seven administration staff, two activity staff, one maintenance staff, and one hospitality aide) regarding MD #300 and inappropriate activity with residents. Employees were interviewed either by phone or in person. STNA #200, #219, #220, and #250 were interviewed in-person or by phone by 08/13/24 due to approved leave, leave of absence (LOA) or beginning employment. STNA #230 remained on LOA and will be interviewed on her first shift upon her return. Questions asked included: Have you witnessed or heard any inappropriateness between MD #300 and a resident? If yes, what did you hear and when? HA #286 stated she had observed Resident #1 naked in her bathroom with MD #300 present a few months prior, but this was not reported. • On 08/09/24 at 3:13 P.M. Resident #1 was evaluated by Psychiatric Nurse Practitioner #307. • On 08/09/24 by 2:00 P.M. the Administrator/Designee completed education with 97 staff (five housekeeping staff, 35 STNAs, eight dietary staff, seven registered nurses (RN), 16 licensed practical nurses (LPN), 15 therapy staff, seven administration staff, two activity staff, one maintenance staff, and one hospitality aide). Employees were educated either by phone or in person regarding facility's abuse policy as well as identifying residents at risk for boundary violations and recognizing warning signs of inappropriate behavior. In addition, employees were also educated via text through On-Shift. STNA #200, #219, #220, and #250 were educated in-person or by phone by 08/13/24 due to approved leave, leave of absence or beginning employment. STNA #230 remains on LOA and will be educated on her first shift upon her return. Education was related to the facility abuse policy, identification of potential/actual abuse situations and abuse reporting. • On 08/09/24 at 11:30 A.M. an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held. Members of the meeting included the Administrator, DON, Regional Director of Operations (RDO) #308, RDCO #304, Divisional [NAME] President of Risk #309, Medical Director #301, and Divisional President #310. As a result of the meeting, the facility-initiated interventions to have no male caregivers for Resident #1, no male staff in the resident's room without a witness and to encourage Resident #1 to leave the door open. • Beginning on 08/10/24, the DON/Designee began interviewing all interviewable residents, then implemented a plan to interview five residents weekly for four weeks regarding any abuse concerns. After four weeks, random interviews would be conducted. • Beginning on 08/10/24 the Administrator/Designee began interviewing five staff members which would be done weekly for four weeks regarding any abuse concerns. • Beginning on 08/10/24 Social Services and in-house counseling services would continue offering support to Resident #1 as needed. Additional residents would be identified as needed in morning clinical meeting by reviewing resident nurse's notes, discussion of grand rounds prior to morning meeting, recap from resident meetings from the therapeutic behavior specialist and psych services. • On 08/10/24 the facility implemented a plan for all self-reported incidents to be reviewed by the DON/Designee within 24 hours to ensure no other residents were affected. The DON/Designee would address issues with reported incidents immediately upon identification. • The facility implemented a plan for any additional staff training/re-education to be completed by the DON/Designee as needed on the facility Abuse and Neglect policy. • The facility also implemented a plan for the DON/Designee to educate all new staff on the abuse policy. This would be ongoing as part of new hire orientation. • Beginning in September 2024, the Administrator or DON would monitor compliance in the facility monthly QAPI meetings for three months. Then as needed for one year. • The facility identified Regional Director of Clinical Operations would monitor compliance during monthly visits times beginning 08/09/2024 for three months then on an as needed basis. Findings include: Review of the Final Decree of Adjudication of Incapacity and Appointment of Plenary Guardian of the Person and Estate document dated January 15, 2003, revealed Resident #1 was adjudged and decreed an incapacitated person and her parents were appointed as guardians. Review of Resident #1's medical record revealed an admission date of 08/04/21 with diagnoses including schizophrenia, adjustment disorder, anxiety, unspecified psychosis not due to a substance or known physiologic condition, depression, unspecified lack of coordination, difficulty walking and sleep disorder. Record review revealed the facility developed a care plan (initiated 03/09/22 and revised 04/22/24) for Resident #1 related to behaviors. The care plan noted the resident had diagnoses of schizophrenia, adjustment disorder, anxiety, and psychosis as evidenced by verbal outbursts, physical outbursts, hallucinations, restlessness, irritability, disturbance in sleep patterns, inappropriate/false statements, sexual behaviors/ comments (i.e. father), taking others belongings, yells loudly throughout the building, prefers to sleep on the floor at times stating its cooler. Interventions included administer medications as ordered; Observe and document signs and symptoms of effectiveness and side effects; Educate resident/resident representative to medication effectiveness and side effects; Assist with cosmetic routine; Behavioral health consults as needed; Communicate with resident/resident representative regarding behaviors and treatment; Consult with pastoral care, Psych services and/or support groups; Encourage active support by family/resident representative; Encourage resident to express feelings; Encourage resident to participate in activities of choice; Encourage to maintain as much independence and control/decision making as possible; Intervene as necessary to protect the rights and safety of others; Minimize potential for disruptive behaviors by offering tasks that divert attention; Monitor behavioral episodes and attempt to determine underlying causes; Music of resident's choice; Offer activity of choice, offer chocolate or pop (caffeine free when possible); Notify medical provider of increase in behaviors; observe and anticipate resident's needs: thirst, food, body positioning, pain and toileting needs; Offer TV or PlayStation; Praise any indication of progress in behaviors; Send for psych evaluation if unable to redirect. A plan of care, initiated on 03/09/22 revealed Resident #1 experienced hallucinations at times related to schizophrenia as she would not answer questions appropriately at these times and might appear to have cognitive decline related to this. Interventions included administer medications as ordered, assess whether the behaviors endanger her and/or others and intervene as necessary and obtain psych consult/psychosocial therapy as needed. A plan of care, initiated on 03/09/22 revealed Resident #1 had impaired temporal orientation and recall, hallucination, disorganized thinking and poor decision-making skills related to schizophrenia. Interventions included administer medication as ordered; Discuss concerns about confusion, disease process, nursing home placement with resident/family /care giver; Keep routine as consistent as possible in order to decrease confusion; Observe/document /report to medical provider any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status; Offer two to three step instructions when competing basic tasks. Review of the resident's current physician orders revealed medications included Geodon 80 milligrams (mg) one tablet two times daily for schizophrenia, Sertraline 200 mg in the morning for depression, Wellbutrin SR 150 mg daily for depression, Amitriptyline 50 mg at bedtime for insomnia, Divalproex 500 mg in the A.M. and 1000 mg at night for schizophrenia, and Junel 1/20 daily for birth control (which had been ordered since August 2021). Review of the annual Minimum Data Set (MDS) 3.0 Assessment, dated 07/05/24, revealed a Brief Interview of Mental Status (BIMS) score of 13 (a level of 13-15 indicates intact cognition). Further review revealed the resident had delusions and indicated the resident had verbal behaviors directed toward others which occurred one to three days in the seven-day assessment period. Review of Resident #1's nurse's note, authored by the DON, dated 08/08/24 at 12:31 P.M. revealed staff reported an alleged allegation regarding Resident #1. The staff immediately had Resident #1 separated from harm and made to feel safe. The note included a head-to-toe assessment was completed with no abnormalities noted. Review of Resident #1's nurse's note, authored by the DON, dated 08/08/24 at 1:30 P.M. revealed the facility nurse practitioner (NP), NP #312 was notified, and an order was given to send Resident #1 to the emergency room. Resident #1's father was notified. Review of Resident #1's nurse's note, authored by the DON, dated 08/08/24 at 1:45 P.M. revealed Resident #1 was transported to the emergency room per (name of transport company). Review of a facility self-reported incident (SRI), tracking number 250577 revealed an initial report, dated 08/08/24 at 4:21 P.M. related to an incident of sexual abuse involving Resident #1 (victim). The SRI listed the perpetrator as MD #300. HA #286 was identified to be a witness of the incident. HA #286 reported she walked into Resident #1's room and the resident was sitting on the floor and MD #300 was standing in front of her, adjusting his clothing; pulling his shirt down and it appeared to her that, under his shirt, his pants were unfastened. HA #286 remained in the room and called for help. State Tested Nursing Assistant (STNA) #285 came in the room and assisted in standing Resident #1 up. HA #286 reported the incident because the positioning (of those involved) and the clothing adjustment when she walked into the room seemed suspicious to her. The investigation of the incident revealed on 08/08/24 between 11:10 A.M. and 11:20 A.M. HA #286 entered Resident #1's room and saw Resident #1 sitting on the floor and MD #300 standing in front of her adjusting his clothing. HA #286 ensured Resident #1's safety by asking MD #300 to immediately leave the room and reported the incident to LPN #238. At 11:30 A.M. LPN #238 reported the incident to the Administrator. At 11:33 A.M. LPN #238 assessed the resident which included a head-to-toe and pain assessment. At 11:34 A.M. the Administrator immediately met and interviewed MD #300. MD #300 denied anything sexual was going on. MD #300 stated he was helping Resident #1 up off the floor. MD #300 was sent home pending investigation. At 11:45 A.M. the Administrator interviewed HA #286. HA #286 remained with Human Resource Director #256 to complete a statement and went home after. At 12:06 P.M. the DON was notified and at 12:25 P.M. the Administrator notified the police and described the scenario as HA #286 explained. PC #306 stated he would be out. At 12:30 P.M. the Administrator asked social service staff to speak with Resident #1 and see if she would share any information. At 12:40 P.M. PC #306 arrived and interviewed Resident #1. PC #306 asked Resident #1 if she would like to go to the hospital and get checked out. Resident #1 declined at first but then stated it may be nice to get out for a little bit. PC #306 explained that the hospital may complete a rape kit. Resident #1 stated she was familiar with them (rape kits). At 1:30 P.M. Resident #1 went out to the emergency room (ER) and at 3:45 P.M. PC #306 called the administrator. PC #306 reported during their interview with MD #300, MD #300 admitted to receiving oral sex from Resident #1. MD #300 was arrested and taken to jail. At 5:57 P.M. Resident #1 returned from the ER but no rape kit was performed (resident refused). A skin check was completed upon the resident's return with no issues noted. On 08/15/24 at 4:59 P.M. the facility SRI was completed. As a result of this investigation the facility substantiated the incident of sexual abuse. Review of Resident #1's nurse's note, authored by the DON, dated 08/08/24 at 5:57 P.M. revealed Resident #1 returned from the emergency department. A head-to-toe assessment was completed with no new findings. Review of the emergency room Hospital discharge date d 08/08/24 revealed the resident was seen for vaginal discharge and indicated the resident was to follow up with her primary provider. No other information relevant to the visit was provided. As part of the facility investigation, a statement was obtained from HA #286. The handwritten statement dated 08/08/24 at 12:00 P.M. revealed HA #286 was going to pick up Resident #1's lunch tray. She opened the door and Resident #1 was sitting on the floor with her back to the sink. MD #300 was facing the resident. MD #300 hurried up and pulled his untucked shirt down over the front of his pants. Resident #1 was licking her lips. MD #300 wouldn't move. He said he was trying to help Resident #1 up. MD #300 wouldn't move and kept standing in front of Resident #1. HA #286 moved over a little bit and yelled out the door that they needed help. When HA #286 looked back, MD #300 was messing with the front of his pants while his shirt was still over his pants. Through his shirt, you could see that his pants were not buttoned. STNA #285 came in to help get Resident #1 up. HA #286 stated she did not leave the room. MD #300 asked, What else do you need fixed? But MD #300 did not have any tools with him. MD #300 left the room but stood in the hallway while HA #286 was in the room. MD #300 eventually left the hall. By the time MD #300 left the room, the staff had Resident #1 off the floor. Resident #1 did not admit to anything. HA #286 tried to ask Resident #1 if MD #300 made her do something and she said no. HA #286 documented she told Resident #1 we are all human, but we are supposed to protect her. Review of a police report dated 08/08/24 and completed by Police Chief (PC) #306, incident #24-08-000247 revealed the police were contacted by the facility related to an incident of sexual abuse involving Resident #1. During the initial police investigation, MD #300 admitted to receiving oral sex from Resident #1. MD #300 stated to PC #306 sexual relations with Resident #1 had been going on for nine months to a year. The prosecutor was contacted, and MD #300 was transported to a local county jail. MD #300 was charged with sexual assault. Review of the news broadcast at https://wtov9.com/news/local/[NAME]-healthcare-worker-charged-with-sexual-assault-of-a-resident on 08/13/24 at 5:08 P.M. revealed a maintenance worker employed by [NAME] Healthcare Center had been charged with sexual assault after an incident last week at the facility. MD #300 was arrested after an investigation and had since bonded out. The PC involved with the case stated he received a call from the facility Administrator on 08/08/24 that an incident was reported to her regarding a staff member that may have sexually assaulted a resident. Allegedly, another employee witnessed MD #300 engaging in sexual activity with a patient. On 08/15/24 at 8:18 A.M. an interview with PC #306 revealed MD #300 was arrested and charged related to the above incident with Resident #1 as the result of a police investigation. PC #306 indicated Resident #1 lacked the cognitive ability to report accurately what had or was occurring (with MD #300) due to her diagnoses. PC #306 stated based on their investigation, witness, suspect confession- the incident of sexual abuse had occurred. Further interview revealed the PC was aware of some rumors that MD #300 had been engaging in sexual activity for a number of years, but stated none of the staff felt had enough evidence or had witnessed anything specific prior to this incident on 08/08/24. On 08/15/24 at 9:35 A.M. an attempted interview with Resident #1 revealed the resident was unable to describe any physical interactions with MD #300. On 08/15/24 at 11:56 A.M. an interview with the Administrator revealed she was notified of the incident involving Resident #1 and MD #300 on 08/08/24 at 11:30 A.M. The Administrator stated she immediately brought MD #300 to the office, and he was notified at that time of a suspension pending investigation (into an allegation of sexual abuse). The Administrator stated she asked MD #300 if anything sexual had occurred with Resident #1 to which MD #300 denied. At that point MD #300 became angry and threw his keys on the desk. MD #300 was escorted out of the building. During the interview, the Administrator shared about a year ago, there was report of MD #300 coming to the building at off hours frequently however, she stated the incident was investigated without findings. On 08/15/24 at 12:21 P.M. an interview with HA #286 revealed on 08/08/24 between 11:10 A.M. and 11:20 A.M. she walked into Resident #1's room. The main door to the room was closed and Resident #1 only closed the door when looking for clothing or when she was sleeping. HA stated MD #300 was in Resident #1's bathroom and Resident #1 was sitting on the bathroom floor. HA #286 stated after she entered the room, MD #300 pulled down his shirt to cover the front of himself. HA #286 stated she asked MD #300 what he was doing in the room, and he told her he was helping Resident #1 get off the floor. HA #286 shared MD #300 would never assist a resident off the floor prior to this incident but would ask staff to assist a resident. HA #286 stated, at that point, MD #300 was told to leave the room and she stated she called for help. HA #286 stated MD #300 turned away from her and adjusted his pants and left the room but stayed in the hallway outside of the door. HA #286 further revealed there was an incident with MD #300 within the last year where he was in Resident #1's bathroom with Resident #1 and the resident was without clothing. HA #286 stated she did not report the incident because she did not think anyone would do anything about her observation. HA #286 also stated Resident #1 would often call out MD #300's name. On 08/15/24 at 12:55 P.M. interview with STNA #294 revealed she was working on a different hall on 08/08/24 and HA #286 had reported concerns involving Resident #1 directly to her. STNA #294 stated HA #286 was distraught and looked like she had just seen a ghost. STNA #294 stated HA #286 told her she walked into Resident #1's room for a food tray and Resident #1 was on the floor with her back up against the sink. HA #286 described MD #300 was standing over Resident #1 and had his shirt untucked. STNA #294 was told by HA #286 MD #300 then pulled down his shirt to cover his front. STNA #294 stated this was unusual for MD #300 as he always had his shirt tucked in with a belt on. At that point they were approached by LPN #238 and HA #286 was removed from the area to talk privately with LPN #238. Further interview with STNA #294 revealed MD #300 spent a lot of time with Resident #1 behind closed doors. STNA #294 also shared Resident #1 would call out MD #300 by name in a sweet manner but would call out to other staff with anger and would curse. STNA #294 indicated in her opinion, the facility failed Resident #1 by not reporting feelings staff had that MD #300 gave a creepy vibe regarding Resident #1. On 08/15/24 at 1:52 P.M. interview with LPN # 238 revealed on 08/08/24, HA #286 pulled her into a private area and informed her of an incident between Resident #1 and MD #300. LPN #238 stated she then reported the incident to the Administrator and HRM #256. After reporting the incident, LPN #238 stated she completed an assessment of Resident #1 for injury and there were no physical or mental issues. When asked what was meant by that, LPN #238 stated Resident #1 was confused at times with delusions. LPN #238 further revealed Resident #1 could not make safe decisions which all staff were aware of. LPN #238 shared Resident #1 would call out MD #300's name but stated this did not seem suspicious to her. LPN #238 stated she had not witnessed any unusual behaviors with MD #300 prior to this incident. LPN #238 stated there was a time MD #300 was reported to be coming in early (for work) but she stated this had been investigated, and nothing was found out of the ordinary. Lastly, LPN #238 stated Resident #1 was not capable of consenting to a sexual relationship with MD #300 due to her cognition. On 08/15/24 at 2:50 P.M. an interview with Physician #301 (also the facility medical director) revealed he was Resident #1's primary care physician. Physician #301 stated Resident #1 could not make safe decisions. Physician #301 further stated Resident #1 could say something sensible at one minute then something nonsensical the next. Physician #301 stated he was aware of the incident involving MD #300 that had occurred on 08/08/24 and had participated in the facility corrective plan following the incident. On 08/15/24 at 3:52 P.M. an interview with Resident #1's mother, who was a named guardian for the resident, revealed Resident #1 could, in no way make safe decisions. Resident #1's mother further stated Resident #1 often fixated on sex and would not stop fixating. Resident #1's mother revealed she had been notified of the incident that had occurred with MD #300 on 08/08/24. On 08/15/24 at 3:52 P.M. an interview with Ombudsman #303 revealed knowledge of the incident that occurred on 08/08/24. Ombudsman #303 stated she saw Resident #1 on 08/09/24 and at that time Resident #1 had denied the incident. Ombudsman #303 further stated she interviewed staff, and many were creeped out by MD #300 and advances he had made toward staff in the past. On 08/15/24 at 3:57 P.M. an interview with Nurse Practitioner (NP) #302 revealed she saw all residents in the building for psychiatric care except for Resident #65. NP #302 stated she was made aware of the incident that occurred on 08/08/24 on the day it happened and gave the order to send Resident #1 to the emergency room to have a rape kit completed. NP #302 stated Resident #1 was unable to make safe, informed decisions. The NP stated she felt MD #300 knew the status (cognitive and behavioral) of Resident #1 (he attended morning clinical meetings) including the resident being fixated on sex, her mental status, that she was on birth control and believed MD #300 likely felt no one would believe the resident if she reported sexual incidents. The NP stated the resident was on birth control as an intervention to prevent pregnancy if she was sexually active. She described it as the perfect storm. On 08/19/24 at 12:48 P.M. an interview with Social Service Designee (SSD) #225 revealed she was notified of the incident between Resident #1 and MD #300 on 08/08/24 and attempted to speak to Resident #1 about the incident. SSD #225 revealed Resident #1 was unable to tell her what MD #300 had done or why MD #300 was in the room. SSD #225 stated during the interview, Resident #1 denied any incidents regarding MD #300. On 08/22/24 at 11:20 A.M. an attempt to reach MD #300 via phone was made. The phone number was not in s[TRUNCATED]