Every finding on record at Auburn Oaks Care Center

Based on observation, interview, and record review, the facility failed to obtain an informed consent for a dental procedure from one of three sampled residents (Resident 1's) Responsible Party (RP) in a census of 96.This failure compromised the resident's right to make informed decision regarding their care and resulted in Resident 1 receiving a dental procedure they had not agreed to or fully understood. Findings:Resident 1 was readmitted to the facility in the winter of 2026 with diagnoses which included subarachnoid hemorrhage (a type of stroke), cognitive communication deficit (a communication problem) and encephalopathy (any disease, damage, or malfunction that alters brain function which causes mental state changes, such as confusion, and memory loss) and long term use of anticoagulants (blood thinning medication).During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/5/26, the MDS indicated Resident 1 had moderate memory impairment.During a review of Resident 1's face sheet, the Responsible Party was indicated as Family Member (FM) 1.During a review of the physician's orders (PO), the PO indicated Resident not capable.During a review of Resident 1's Nurse Practitioner Note (NPN), dated 3/31/26, the NPN indicated She is awake, has periods of confusion.During a review of the DENTIST VISIT LIST [DVL], dated 4/7/26, the DVL indicated Resident 1 was scheduled for surgical extraction requiring bone removal [of teeth number] 2, 3, 4, 5, 6, 7, 8, 9,10,11,12,13,14,15,18,19, 21, 28, 29, 30, 31.During a review of the Post-Operative Instructions for Extractions, dated 4/7/26, indicated Oral Surgery Date Completed: April 7, 2026.During a telephone interview on 4/15/26 at 9:19 a.m. with FM 1, FM 1 said, I am her RP. They did not ask my consent for taking out [Resident 1's] teeth. They took out 21 in the facility. They said they got consent from [Resident 1] but she's confused at times.During an observation of Resident 1 on 4/15/26 at 1:37 p.m., when questioned, Resident 1 had a memory problem and could not answer all questions asked by the Nurse Surveyor.During a concurrent interview and record review on 4/15/26 at 3:35 p.m. with the Director of Nursing (DON), the DON was asked her expectations for getting RP consent for dental extractions and said, According to the face sheet, [FM 1] is the RP. For any procedure that requires consent, [FM 1] should have been contacted and consent obtained. We go by the physician's order that shows capacity.Her capacity fluctuates. The DON verified the PO indicated Resident 1 had no capacity and that a consent from the RP for the extraction of 21 teeth could not be found.During a telephone interview on 4/15/26 at 4:25 p.m. with the Registered Dental Hygienist (RDH), the RDH said, If they have an RP, we normally call the RP. We didn't realize it had changed.I've never actually spoken to [FM 1].If it's a patient who is not her own RP, we definitely have a signature for those patients.A facility policy and procedure was requested but not provided.

Based on observation, interview, and record review, the facility failed to follow physician orders for two of 24 sampled residents (Resident 41 and Resident 31), when:1. Resident 41's administered oxygen amount did not match the physician's order, and 2. Resident 31 received tramadol (an opioid analgesic for pain) on 12/6/25, 12/7/25, 12/27/25, and 12/28/25 without having scheduled physical therapy (PT) sessions as per physician order.These failures decreased the facility's potential to follow the residents' physician orders as prescribed.Findings: 1. A review of an admission record indicated Resident 41 was admitted to the facility in the winter of 2025 with diagnoses including chronic obstructive pulmonary disease (COPD, a lung condition which makes it harder to breathe out because the airways become narrowed, inflamed, or damaged, trapping air and making you feel short of breath) and respiratory failure. During an observation on 1/5/26 at 10:49 a.m., Resident 41's oxygen concentrator was observed to be at 3.5 liters (L; a unit of volume measurement) per minute. A review of Resident 41's physician order, dated 8/25/25, indicated an order for oxygen at two liters per minute via nasal cannula (a thin tube connecting the oxygen source to the resident's nose for administration) for COPD. A review of Resident 41's care plan, dated 11/18/25, indicated Resident 41 required the use of oxygen continuously at two liters via nasal cannula related to COPD. During a concurrent observation, interview, and record review on 1/5/26 at 11:01 a.m. with Licensed Nurse (LN) 1, Resident 41's physician order was reviewed. LN 1 confirmed Resident 41's oxygen concentrator was set at 3.5 liters per minute and stated as per physician order, oxygen was supposed to be at two liters per minute. LN 1 further stated she did not check Resident 41's oxygen during morning round and should have checked it. During a concurrent interview and record review on 1/7/26 at 12:38 p.m. with the Director of Nursing (DON), Resident 41's physician order was reviewed. DON confirmed Resident 41's oxygen order was two liters per minute for COPD. DON stated staff should have set the oxygen condenser based on Resident 41's physician order. A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised 10/24, indicated, Adjust the oxygen delivery device so . the proper flow of oxygen is being administered . 2. A review of an admission record indicated Resident 31 was admitted to the facility in October 2025 with diagnoses including fracture of the thigh bone and difficulty in walking. A review of Resident 31's Order Summary Report (OSR), dated 11/21/25, indicated, 50 milligrams (mg; a unit of measure) of tramadol hydrochloride oral tablet to be given by mouth one time a day for pain management prior to therapy. OSR further indicated Resident 31 was scheduled to receive PT five times a week for four weeks. A review of the facility's document titled, Service Log Matrix . PT, dated 1/6/26, indicated Resident 31 did not receive PT sessions on the following dates: 12/6/25, 12/7/25, 12/13/25, 12/14/25, 12/20/25, 12/21/25, 12/26/25, 12/27/25, and 12/28/25. During a concurrent interview and record review on 1/6/26 at 2:24 p.m. with the Director of Rehabilitation (DR), DR confirmed Resident 31 did not have scheduled PT sessions on the dates indicated in the Service Log Matrix, dated 1/6/26. A review of Resident 31's Electronic Medication Administration Record (EMAR), indicated tramadol 50 mg was administered on the following dates without any scheduled PT: 12/6/25, 12/7/25, 12/27/25, and 12/28/25. On 12/7/25, 12/27/25, and 12/28/25 Resident 31's pain level was zero (indicating no pain). The EMAR further indicated Resident 31 was offered tramadol 50 mg and refused it on 12/13/25, 12/14/25, 12/20/25, 12/21/25, and 12/26/25. Resident 31's pain score was zero and had no scheduled PT. During a concurrent interview and record review on 1/6/26 at 2:08 p.m. with LN 1, Resident 31's EMAR was reviewed. LN 1 confirmed the findings documented in Resident 31's EMAR and stated nurses were required to follow the physician's orders. LN 1 further stated failing to follow physician's order could result in harm to residents. During a concurrent interview and record review on 1/6/26 at 2:42 p.m. with DON, Resident 31's EMAR and Service Log Matrix, were reviewed. DON confirmed Resident 31 had an order for tramadol to be administered prior to her PT sessions. DON also confirmed the findings documented in Resident 31's EMAR and the Service Log Matrix. DON stated nurses must ensure they were administering the correct medication to the right resident, at the appropriate dose, and frequency. DON also stated nurses need to make sure they follow exactly what the physician's order indicate. A review of the facility's P&P titled, Administering Medications, revised 10/24, indicated, . Medications are administered in accordance with prescriber orders, including any required time frame . The individual administering the medications checks the label to verify . right dosage, right time.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for a census of 93 residents, when:1. Resident bowls and food containers were found stacked upright in the drying area;2. Unsealed bags of food were found in the refrigerator and freezer; and3. Unlabeled food items were found in the refrigerator.These failures decreased the facility's potential to prevent foodborne illness among vulnerable residents eating facility prepared food.Findings:1. During a concurrent observation and interview on 1/5/26 at 8:20 a.m. with the Registered Dietitian (RD) and the Dietary Manager (DM), several resident bowls and containers were observed stacked upright in the air-drying area. RD confirmed the observation.A review of the Food and Drug Administration (FDA) Food Code 2022, Section 4-901.11, indicated, After cleaning and sanitizing, equipment, and utensils: (A) Shall be air-dried . The guidance further indicated, Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow.A review of the FDA Food Code 2022, Section 4-903, indicated, Cleaned Equipment and Utensils . shall be stored . where they are not exposed to splash, dust, or other contamination; The guidance further indicated, (1) In a self-draining position that allows air drying; and (2) covered or inverted.2. During a concurrent observation and interview on 1/5/26 at 8:29 a.m. with the DM, a bag of chopped onions was found stored in the refrigerator unsealed. DM stated the bag of chopped onions should have been properly sealed.During a concurrent observation and interview on 1/5/26 at 8:50 a.m. with the RD and DM, frozen pot stickers were stored unsealed with freezer burn (in which frozen food dehydrates due to air exposure, creating tough, discolored spots which can affect taste) in the freezer. RD stated the bag should have been well sealed.A review of the facility's policy titled, Labeling and Dating of Foods, dated 2023, indicated, all food items in the storeroom, refrigerator, and freezer . should be closed A review of the United State (US) FDA 2022 Food Guide, section 3-305.11 on Food Storage, indicated in bullet (A) . food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. The guide further indicated, Pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate and drafts of unfiltered air can be sources of microbial contamination for stored food.3. During a concurrent observation and interview on 1/5/26 at 8:31 a.m. with the DM, a bag of Danish pastries was found unlabeled in the refrigerator. DM stated the Danish pastries should have been labeled.During an interview on 1/8/26 at 9:15 a.m. with the Director of Nursing (DON), DON stated food should be properly closed and labeled because failure to do so had the potential to cause gastrointestinal (stomach and intestinal) issues for residents.A review of the facility's policy titled, Labeling and Dating of Foods, dated 2023, indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.

Based on observation, interview, and record review, the facility failed to maintain a safe environment for one of 24 sampled residents (Resident 112), when a transition strip (a narrow piece of material [often metal, wood, or vinyl] used to cover and protect the seam where two different types of flooring meet) between Resident 112's bedroom and bathroom was not securely affixed.This failure decreased the facility's potential to prevent Resident 112 from a fall, injury or harm due to tripping hazard.Findings:A review of an admission record indicated Resident 112 was admitted to the facility in late 2025 with a diagnosis of difficulty in walking.A review of Resident 112's Minimum Data Set (a standardized assessment tool used in nursing homes), dated 12/30/25, indicated Resident 112 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognitive function. MDS also indicated Resident 112 used a walker and wheelchair for ambulation.During a concurrent observation and interview on 1/5/26 at 8:54 a.m. with Resident 112, a transition strip between the bedroom and bathroom was loose and could be easily lifted off the floor. Resident 112 had a two-wheeled walker with two rear legs capped with rubber tips. Resident 112 stated the transition strip between the bedroom and bathroom was not properly secured and she might fall when using the walker. Resident 112 also stated the transition strip catches on the rubber tips when moving in and out of the bathroom and she had to remember to lift the back of walker when passing over the transition, which was not safe too. Resident 112 further stated she reported this issue to staff in December of 2025, but no corrective action was taken.A review of Resident 112's care plan, dated 12/28/25, indicated Resident 112 was at risk for falls due to history of falls, unsteady gait, and visual impairment. Care plan further indicated Resident 112 will not experience fall related to risk factors.A review of the facility's Maintenance Repair Log, dated December 2025, indicated no records of a loose transition strip inside Resident 112's room.During an interview on 1/6/26 at 3:24 p.m. with Licensed Nurse (LN) 2, LN 2 stated the transition strip located inside Resident 112's room was not properly secured and may cause accidents.During an interview on 1/6/26 at 3:45 p.m. with the Maintenance Supervisor (MS), MS confirmed the transition strip was not properly secured and stated, It would be a trip hazard if it was not fixed.During an interview on 1/6/26 at 3:49 p.m. with the Director of Nursing (DON), DON stated the loose transition strip inside Resident 112's room could be a trip hazard and maintenance should have been notified so they get it fixed. DON expected staff to report anything that needs repair promptly to ensure resident safety.A review of the facility's policy and procedure titled, Physical Environment and Accommodation Policy, revised in 2024, indicated, The facility shall be clean, safe, sanitary and in good repair always . Maintenance shall include provision of maintenance services and procedures for the safety and well-being of resident, employees and visitors.

Based on interview and record review, the facility failed to prevent an elopement (the act of leaving a facility unsupervised and without prior authorization) for one resident (Resident 5) of a census of 96, when Resident 5 was found by a family member walking down the street outside the facility and standing at a traffic light intersection.This failure decreased the facility's potential to maintain Resident 5's safety.Findings:A review of Resident 5's admission Record, indicated he was admitted to the facility in 2024 with diagnoses including moderate dementia (a decline in mental ability severe enough to interfere with daily life, involving memory loss and reasoning issues) with behavioral disturbance, post-traumatic stress disorder (PTSD-a mental health condition associated with experiencing an event that was traumatic, terrifying, or life-threatening), and difficulty in walking. The record further indicated Resident 5's spouse was his responsible party.A review of Resident 5's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 10/2/25, indicated Resident 5's Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was four out of 15 with severe memory impairment. MDS further indicated a wander alarm device was not in use on Resident 5.A review of Resident 5's progress notes, dated 10/22/25 at 5:35 p.m., indicated Resident 5's family member notified a licensed nurse that she saw Resident 5 outside the facility walking down the street. The licensed nurse and an aide ran outside the facility to search for Resident 5. Resident 5 was found standing at the red light at an intersection and was escorted back to the facility. The facility's medical director was notified and a wander guard was placed on Resident 5's right foot.A review of Resident 5's Care Plan Report, revised on 10/22/25, indicated Resident 5 had an episode of elopement on 10/22/25 and was at risk for elopement related to dementia, forgetfulness, and PTSD.A review of Resident 5's Elopement and Wandering Risk Assessment, dated 4/7/25, indicated Resident 5 . has exhibited unsafe wandering [and] has made one or more attempts to elope . in the last year. The document further indicated a wander alarm was required for Resident 5.A review of the facility's Order Summary Report, dated 4/8/25, indicated the facility's physician ordered a wander guard for Resident 5 due to elopement risk.A review of Resident 5's nursing progress note, dated 4/19/25, indicated the wander guard order was discontinued and the device was removed.A review of Resident 5's Care Plan Report, revised on 8/28/25, indicated Resident 5's elopement risk and need for a wander guard were resolved.During an interview on 12/9/25 at 1:56 p.m. with the Director of Nursing (DON), DON stated on 10/22/25 Resident 5 left the premises until his family member spotted him on a road and alerted staff.During a concurrent interview and record review on 12/9/25 at 5:41 p.m. with the Administrator (ADM) and DON, Resident 5's care plan, elopement risk assessment, and MDS were reviewed. ADM and DON confirmed Resident 5 eloped from the facility on 10/22/25 and was at risk for elopement. DON stated Resident 5's care plan did not indicate the elopement risk between 8/28/25 and 10/22/25 and expected staff to prevent elopement incidents. ADM stated he did not know what time Resident 5 left the facility and for how long he was wandering outside the facility until a family member saw him. ADM and DON further stated Resident 5's elopement was a safety issue since he had dementia and PTSD which increased Resident 5' potential for injury if he fell or was hit by a vehicle.A review of the facility's policy titled, Wandering and Elopements, dated October 2024, indicated, If identified as at risk for wandering or elopement, the resident's care plan will include strategies and interventions that will be provided to maintain the resident's safety.

Based on interview and record review, the facility failed to protect the right to be free from abuse for one of three sampled residents (Resident 1) when Resident 2 pushed Resident 1's plate of food onto her chest and landed in her lap which affected Resident 1's emotional well-being. This failure resulted in Resident 1 not free from abuse by Resident 2. Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted in July 2017 with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular diseases (stroke) affecting left non-dominant side (decreased ability to move and muscle weakness on left side), dementia (a progressive state of decline in mental abilities) and anxiety disorder (any group of mental conditions characterized by excessive fear of real or perceived threats). Review of Resident 1's Minimum Data Set (MDS-A federally mandated resident assessment too), dated 6/13/25 indicated Resident 1 had moderately impaired cognition. Review of Nurse's note for Resident 1 dated 7/7/25 indicated, .around 1850H [6:50 p.m.] when CNA [ Certified Nursing Assistant] reported another resident [ 2] swung resident [1] and was hit at the chest area. During an interview on 7/9/25 at 11:34 a.m. with Resident 1, Resident 1 stated that she was eating, and Resident 2 was trying to get her food. Resident 1 stated Resident 2 pushed her plate onto her lap. Resident 1 stated, It made me mad. Review of Resident 2's admission Record indicated Resident 2 was admitted [DATE] with diagnoses including metabolic encephalopathy (a change in how a brain works due to an underlying condition which can cause confusion and memory loss) and Alzheimer's Disease (a disease characterized by progressive decline in mental abilities). Review of Resident 2's MDS indicated Resident 2 had severely impaired cognition. During an interview on 7/9/25 at 12:36 p.m. with CNA 3, CNA 3 stated she witnessed the altercation between Resident 1 and Resident 2. CNA 3 stated that there were three CNAs in the room and these two residents were in the dining room at that time. Resident 2 was being touchy with Resident 1. Resident 2 took a swing at Resident 1 and her plate of food hit her chest and landed in her lap. During an interview on 7/9/25 at 2 p.m. with the Director of Nursing (DON), the DON stated that residents do have the right to be free from abuse in the facility. Review of the facility's policy and procedures (P&P) titled, Abuse and Prevention Program, dated December 2016, the P&P indicated, .our residents have the right to be free from abuse . Protect our residents from abuse by anyone including but not necessarily limited to facility staff, other residents .

Based on observation, interview and record review, the facility failed to provide safe supervision and assistance to prevent accidents for one of three sampled residents (Resident 1) when Resident 1 fell on the ground while being transferred from bed to shower chair by 2 Certified Nursing Assistants (CNA 1 and CNA 2) who failed to follow the proper maneuvering and operation of a Hoyer lift (a mechanical device used to lift and/or transfer a person from one surface to another) during the transfer and when CNA 2 was behind the shower chair away from the Hoyer lift. This failure resulted in Resident 1 sustaining a right ankle sprain (a soft tissue injury that occurs when ligaments are stretched or torn), back pain, and developed fear of being moved out of bed using a lift. Findings: During a review of Resident 1's admission records, the records indicated Resident 1 was admitted to the facility in December 2023 with diagnoses that included morbid obesity (having too much body fat), muscle weakness, fibromyalgia (pain and tenderness throughout the body), and difficulty in walking. Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had moderate cognitive impairment. A review of Resident 1's MDS Section GG - Functional Abilities, dated 1/2/25, indicated Resident 1 was dependent on staff with toileting hygiene, transfers and showering which indicated Resident 1 put no effort to complete the activities, and needed the assistance of two or more staff to complete the activities. During a review of Resident 1's Fall Risk Observation/Assessment, dated 1/2/25, the assessment indicated Resident 1 scored 16 which indicated Resident 1 was at high risk for falls. During a review of Resident 1's undated Care Plan, the care plan indicated, Falls: [Resident 1] is at risk for falls with or without injury related to .in need of assistance with ADLs [Activities of Daily Living], decreased mobility, difficulty walking, generalized muscle weakness .Will minimize risk for falls to extent possible .Will not experience a fall related to risk factors .2/12/25: IDT [Interdisciplinary Team is a group of professionals who collaborate and plan resident care] recommends room change once available to accommodate for bariatric bed [big bed that supports overweight clients], belongings and maneuvering Hoyer [lift] in the room with ease to minimize risk for unsafe transfer technique thus minimizing risk for falls . During a review of Resident 1's Change in Condition (CIC) evaluation, dated 2/11/25, the evaluation indicated Resident 1 had a fall in the morning of 2/11/25. The evaluation further indicated Resident 1 had 8 out of 10 level of pain [severe pain on a numeric pain scale of zero to 10, zero being no pain and 10 being the worst pain possible, classified as mild 1-3, moderate 4-6 and severe 7-10] on the back due to the fall and the primary clinician recommended to perform x-ray (imaging of the body parts) and to send Resident 1 to the hospital. During a review of Resident 1's imaging results, dated 2/11/25, the results indicated, XR [Xray] ANKLE 3 OR MORE VIEWS RIGHT .CLINICAL INDICATION: Injury. Pain status post [after] fall .FINDINGS: 3 views of the right ankle and 4 views of the right foot .IMPRESSION: Possible avulsion fracture of the lateral talar process [a small break in the ankle bone where it attaches to a ligament or tendon] . During a review of Resident 1's Emergency Department Note, dated 2/11/25, the note indicated, .[Resident 1] presents after mechanical fall [fall associated to an external cause e.g. an object or force] .Describes discomfort near her ankle. May have a tiny avulsion fracture of the talus but no other need for orthopedic [medical specialty that deals with treatment of bones, joints, muscles, ligaments and tendons] emergent intervention. Placed in a postoperative boot [designed to protect and support the foot while healing from injuries) and will be prescribed pain medication . During a review of Resident 1's IDT (Interdisciplinary team is a group of health care professionals who coordinate and plans patient care) Notes, dated 2/12/25, the notes indicated, .Per nursing note Writer was notified by staff that [Resident 1] had sustained a fall while attempting to transfer [Resident 1] to the shower chair for her shower. Upon initial entry of [Resident 1's] room, [Resident 1] was found on her bottom right next to her bed. Hoyer lift was on standby next to her. Resident showing non verbal signs of pain such as grimacing and rapid breathing. Pain assessment performed and pain was noted to be worse at her ankle .Asked CNAs [Certified Nursing Assistants] how [Resident 1] fell and said that the lift had tipped over while they were attempting to get [Resident 1] into the shower chair. NP [Nurse Practitioner] informed and ordered xray to ankle. Later on during the shift [Resident 1] started reporting she was experiencing back pain. Asked [Resident 1] to rate the pain and [Resident 1] rated the pain to be 8/10 [8 out of 10, severe pain] NP informed and added lower back xray. [Resident 1] also experiencing bad pain when moving and elevating head of bed .Suspected root cause: .During the process of moving the [Resident 1] from bed to shower chair the lift tilting laterally leading to [Resident 1] making contact with the ground . During a review of Resident 1's Nurse Practitioner Note,dated 2/12/25, the note indicated, On 2/11/25, nurse assigned reported that [Resident 1] had sustained a fall [on 2/11/25] while attempting to transfer [Resident 1] to the shower chair for her shower. [Resident 1] was found on her bottom right next to her bed and Hoyer lift was on standby next to her. Upon assessment, [Resident 1] complained of pain in the back and most on the right ankle and in tears when telling me that [Resident 1] is in pain .Hours later, [Resident 1] informed the nurse assigned that [Resident 1's] pain is 8/10 and wanted to be sent to hospital for further evaluation and management. Late at night, [Resident 1] came back with new diagnosis of right ankle sprain .I went to see [Resident 1] today, [Resident 1's] right leg elevated on the pillow and has complaints of pain on the right ankle. [Resident 1] is in pain . During a review of Resident 1's Care Conference Meeting notes, dated 2/20/25, the notes indicated, DOR [Director of Rehabilitation] explained how [Resident 1] fell in the most recent fall [on 2/11/25], and that inservicing [in-service is training given to employees] was completed with the staff following the fall regarding use of the hoyer [lift] .and recommendation for a potential room change when a room becomes available. [Resident 1's family members] expressed concerns of [Resident 1] feeling now fearful of the lift d/t [due to] the falls .[Resident 1] expressed she has been having back spasms and is having difficulty sitting up to eat, writer informed NP .of the back pain. During a concurrent observation and interview on 2/26/25 at 10:57 a.m. with Resident 1 in her room, Resident 1 was observed alert, calm, lying in bed, and wearing a boot on her right foot. Resident 1 stated, I did have a fall, I was in that lift .the whole machine tripped .my back and my foot hurts .I have a little boot thing on my right foot .It still hurts .I don't like the lift, no more lift .Feels safe [in the facility] except for the lift and I will not use it anymore. During an interview on 2/26/25 at 11:30 a.m. with CNA 1, CNA 1 stated she was one of the CNAs assisting Resident 1 when the incident happened on 2/11/25. CNA 1 stated, I was transferring [Resident 1] to the shower chair .now [Resident 1] won't [use the lift] because she's afraid .I was by the feet .The other CNA [CNA 2] was at the back of the shower chair .[CNA 2] was away from the lift .[CNA 2] should have been closer . During an interview on 2/26/25 at 11:47 a.m. with the Director of Staff Development (DSD), the DSD stated, Expectation for safe transfer would be to make sure staff follow proper transferring techniques, both for resident and staff safety .We don't want the resident or the staff to get hurt. During an interview on 2/26/25 at 12:09 p.m. with CNA 2, CNA 2 stated, I was asked by [CNA 1] to assist with a lift, I went with [CNA 1] .[CNA 1] was guiding [Resident 1] to the shower chair .the lift was not maneuvered properly by [CNA 1] that's why it tipped .there was no pivot, she went to the left side of it [the lift] instead of pivoting it .[CNA 1] moved the Hoyer sideways instead of backwards . CNA 2 further stated Resident 1 fell on the ground followed by the Hoyer lift and the lift fell on Resident 1's right ankle. CNA 2 added that instead of opening the base of the lift, and pivoting and then moving forward, CNA 1 came to the side of the lift and held the left side handle and the hydraulic pump (part of the lift that creates the power to lift). CNA 2 stated, .not both handles . CNA 2 stated Resident 1's back hit the foot of the bed, and the tip of the lift hit Resident 1 on her right ankle. CNA 2 further stated, The legs of the Hoyer were not open or extended, if it was open, it would have been more stable .according to what was taught to us, it was not the proper maneuvering of the Hoyer [lift]. During an interview on 2/26/25 at 12:29 p.m. with the Maintenance Director (MTD), the MTD stated, .To get it [the lift] to where it's going, the staff should hold both handles, lock the wheels, and spread the feet [base of the lift] .If not done, the biggest problem is stability, it can slide either way .it could tip to one side . During an interview on 2/26/25 at 1:15 p.m. with the Assistant Director of Nursing (ADON), the ADON stated, From what I was told, it could be something that happened with the equipment [lift] .If the lift was not maneuvered correctly, it can cause the lift to fall .[Staff] should be holding both handles . The ADON stated staff should not be holding the hydraulic pump and should be holding both handles because the lift might not be balanced. The ADON further stated, Expectation is to do two-person transfer and follow right protocol .and use the appropriate lift too .follow correct usage and maneuvering . During an interview on 2/26/25 at 1:37 p.m. with the Director of Rehabilitation (DOR), the DOR stated, .[Resident 1] should not be falling and not be fearful .Staff should hold both handles, stay as close as you can [to the resident], the other person guide the resident to the desired position .The legs should be open so it can have a wider base support . During a review of the Hoyer lift's operation manual, dated 12/2019, the manual indicated, .Transfer from a Bed or Stretcher .11) Move the [brand name of Hoyer lift] into position .Open the base to its widest position .14) Leaving the caster brakes [packing brakes] unlocked, lift the patient about 2 inches off of the bed or stretcher and back the [brand name of Hoyer lift] away. Leaving the brakes unlocked will allow the lift to walk forward to center itself over the patient's center of gravity as it raises. This increases the stability of the lift. The only time the brakes should be locked is if the patient is being lifted from a ramp or some other sloping surface .15) When the patient is away from the bed or stretcher, lower the patient so his or her feet are at the top of the base of the lift and, slowly turning the lift, move the patient to the desired location . During a review of the facility's policy and procedure (P&P) titled Safety and Supervision of Residents, revised 10/2023, the P&P indicated, Our facility strives to make the environment as free from accident hazards as practicable as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Systems Approach to Safety .1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly .Resident Risks and Environmental Hazards .1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards may include .b. Safe Lifting and Movement of Residents; c. Falls . During a review of the facility's P&P titled Lifting Machine, Using a Mechanical, revised 7/2022, the P&P indicated, General Guidelines .1. The nursing assistant will assist to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for tasks that require: .b. Transferring a resident from bed to chair .d. Toileting or bathing .Steps in the Procedure .4. Make sure the lift is stable and locked .

Based on observation, interview and record review, the facility failed to ensure needed care or services were provided for one of three sampled residents (Resident 1) when Resident 1's use of postoperative boot (designed to protect and support the foot while healing from injuries) after a fall for right ankle sprain (a soft tissue injury that occurs when ligaments are stretched or torn) was not monitored and evaluated. This failure decreased the facility's ability to evaluate Resident 1's response to intervention and had the potential to result in Resident 1's increased risk for skin breakdown related to the use of the boot. Findings: During a review of Resident 1's admission records, the records indicated Resident 1 was admitted to the facility in December 2023 with diagnoses that included morbid obesity ( having too much body fat), muscle weakness, fibromyalgia (pain and tenderness throughout the body), and difficulty in walking. Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had moderate cognitive impairment. During a review of Resident 1's MDS Section GG - Functional Abilities, dated 1/2/25, the section indicated Resident 1 was dependent on staff with toileting hygiene and showering, indicating Resident 1 put no effort to complete the activities and needed the assistance of two or more staff to complete the activities. During a review of Resident 1's Fall Risk Observation/Assessment, dated 1/2/25, the assessment indicated Resident 1 scored 16 which indicated Resident 1 was at high risk for falls. During a review of Resident 1's Change in Condition (CIC) evaluation, dated 2/11/25, the evaluation indicated Resident had a fall in the morning of 2/11/25. The evaluation further indicated Resident 1 had 8 out of 10 level of pain [severe pain] on the back due to the fall and the primary clinician recommended to do x-ray (imaging of the body parts) and to send Resident 1 to the hospital. During a review of Resident 1's imaging results, dated 2/11/25, the results indicated, XR [Xray] ANKLE 3 OR MORE VIEWS RIGHT .CLINICAL INDICATION: Injury. Pain status post [after] fall .FINDINGS: 3 views of the right ankle and 4 views of the right foot .IMPRESSION: Possible avulsion fracture of the lateral talar process [a small break in the ankle bone where it attaches to a ligament or tendon] . During a review of Resident 1's Emergency Department Note, dated 2/11/25, the note indicated, [Resident 1] presents after mechanical fall .Describes discomfort near her ankle. May have a tiny avulsion fracture of the talus but no other need for orthopedic emergent intervention. Placed in a postoperative boot and will be prescribed pain medication . During a concurrent observation and interview on 2/26/25 at 10:57 a.m. with Resident 1 in her room, Resident 1 was observed alert, calm, lying in bed, and wearing a boot on her right foot. Resident 1 stated, I did have a fall, I was in that lift .the whole machine tripped .my back and my foot hurts .I have a little boot thing on my right foot .It still hurts . During a concurrent observation and interview on 2/26/25 at 2:46 p.m. with the Assistant Director of Nursing (ADON) in Resident 1's room, Resident 1 was observed lying in bed with eyes closed, wearing a boot on right foot. The ADON confirmed the observation. During a concurrent interview and record review on 2/26/25 at 2:49 p.m. with the ADON, the ADON confirmed Resident 1's xray indicated possible avulsion fracture on ankle and new diagnosis from the hospital indicated right ankle sprain. The ADON stated she cannot find any documentation about Resident 1's use of the boot and stated, Expectation is staff should be aware about it, make sure no skin breakdown and good circulation. The ADON verified there were no physician orders and no monitoring for Resident 1's use of boot in the clinical record. The ADON stated, If it's in the discharge orders, it should be carried out. The ADON confirmed there were no treatment notes nor care plans in place for the use of the boot and stated, Every intervention should be care planned. During a concurrent interview and record review on 2/26/25 at 3:04 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated she was aware that Resident 1 was wearing a boot on the right foot. LN 1 confirmed there was no order for the boot in the clinical record and stated, .supposed to have one .to monitor boots, if legs need to be evaluated, we monitor for skin integrity and circulation . During a concurrent interview and record review on 2/26/25 at 3:26 p.m. with the ADON and the Director of Rehabilitation (DOR), the DOR confirmed Resident 1 came back from the hospital on 2/11/25 with the boot on the right foot for right ankle sprain. The ADON and the DOR verified there was no order for the boot and no care plan in place specific to the use of boot in Resident 1's clinical record. The ADON stated the boot should be checked by the wound nurse and confirmed that Resident 1 was not seen by the wound care team because Resident 1 had no active wound. During a review of the facility's policy and procedure (P&P) titled Safety and Supervision of Residents, revised 10/2023, the P&P indicated, Individualized, Resident-Centered Approach to Safety .3. Implementing interventions to reduce accident risks and hazards may include the following .d. Ensuring that interventions are implemented .e. Documenting interventions .f. Modifying or replacing interventions as needed .g. Evaluating the effectiveness of new or revised interventions .

Based on interview and record review, the facility failed to follow their policy for pronouncing death for one resident (Resident 1) in a census of 96 when two licensed vocational nurses (LVNs) worked out of their scope of practice (services that a trained health professional is deemed competent to perform and permitted to undertake according to the terms of their professional nursing license) and pronouced the resident's death. This failure resulted in a violation of the facility's policy and had the potential to jeopardize resident health and safety. Findings: Resident 1 was admitted to the facility in 2024 with diagnoses that included Chronic Respiratory Failure and Chronic Obstructive Pulmonary Disease (COPD). A review of Resident 1's, Order Summary Report dated [DATE], indicated an order for hospice (an end-of-life service for the terminally ill) for a diagnosis of COPD. During an interview with Registered Nurse 1 (RN 1) on [DATE] at 9:47 a.m., RN1 stated, Only a physician or RN can pronounce a resident deceased . A review of Resident 1's Progress Notes dated [DATE] at 1:38 a.m., Licensed Vocational Nurse 2 (LVN 2) documented, Resident noted in bed with eyes closed, no signs of life or respiratory effort. Not responsive to verbal or tactile stimuli. No palpable pulse for one minute, checked by two LVNs on site. No heart or respiratory sounds, checked by two LVNs on site. Time of death called at 0142 by two LVNs . During an interview with the Hospice Clinical Consultant (HCC) on [DATE] at 2:06 p.m., the HCC stated the nurse's note dated [DATE] at 1:42 a.m., indicated a Non-Visit note which indicated the hospice nurse did not go to the facility and Licensed Vocational Nurse 3 (LVN 3) had pronounced Resident 1 deceased . During an interview with the Director of Nursing (DON) on [DATE] at 3:07 p.m., the DON verified Resident 1 was pronounced dead by LVN 2 and LVN 3. The DON stated, If a resident is on hospice and expires, only a physician or RN may pronounce a resident as expired. The DON further stated, An LVN cannot pronounce a resident as expired. A review of the facility policy titled, Death of a Resident, Documenting dated ,d+[DATE] indicated, A resident may be declared dead by a licensed physician or registered nurse with physician authorization in accordance with state law .

Based on observation, interview, and record review, the facility failed to protect one of 5 sampled residents (Resident 2) from physical abuse when Resident 2 ' s hands were grabbed by Resident 1. This resulted in Resident 2 sustaining a scratch to her face and felt unsafe in the room. Findings: A review of Resident 1 ' s Admission Record indicated she was admitted with diagnoses including cerebral infarction due to occlusion or stenosis of small artery (a type of stroke caused by blockage of blood flow to the brain) and schizophrenia (mental illness that can affect thoughts, mood, and behavior). A review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/3/24 indicated Resident 1 had moderate cognitive impairment. A review of Resident 1 ' s undated care plan indicated, [Resident 1] has impaired cognitive function or impaired thought processes r/t [related to] BIMS [Brief Interview of Mental Status - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident] @ 9. A review of Resident 1 ' s Social Service Note dated 11/1/24 indicated, Reported by nursing [Resident 1] was sitting in her w/c[wheelchair] in her room near the foot of the A bed when her room mate [Resident 2] wheeled into the room. [Resident 2] was wheeling past [Resident 1] and touched her foot which irritated her and she grabbed [Resident 2 ' s] wrists inan [sic] upward motion and shook them and swiped [Resident 2 ' s] right side of her face with her hands . A review of Resident 2 ' s Admission Record indicated she was admitted with diagnoses including postconcussional syndrome (symptoms may persist after a concussion or mild traumatic brain injury that affects brain function) and mild cognitive impairment. A review of Resident 2 ' s MDS dated [DATE] indicated she had short term and long-term memory problems. A review of Resident 2 ' s SBAR (Situation, Background, Assessment, Recommendation- a communication tool used by healthcare workers when there is a change of condition among the residents) dated 11/1/24 at 15:31 [3:31 p.m.] indicated, .Altercation between room-mates in which roommate [Resident 1] was witnessed holding on to [Resident 2 ' s] arms, residents assessed and scratch was noted on right side of face. A review of Resident 2 ' s Social Service Note dated 11/1/24, indicated, .[Resident 2] had a room change .[Resident 2] stated she feels safe with changing her room. In an observation on 11/15/24 at 11:15 a.m., Resident 1 was up in a reclining wheelchair inside her room and her eyes were closed. In an interview on 11/15/24 at 12:52 p.m., the Licensed Nurse 1 (LN 1) stated she was sitting at her usual spot at the desk in the nurse ' s station 1 when the incident occurred between Resident 1 and Resident 2. The LN 1 further stated she heard the yelling coming from the resident ' s room. The Certified Nursing Assistant (CNA) got to the residents ' room before her. The residents were near each other. The LN 1 pulled Resident 2 ' s wheelchair back and Resident 1 was by the bathroom door facing the television. The CNA told her [LN 1] it was Resident 1 who grabbed Resident 2 ' s wrists when Resident 2 accidentally bumped into Resident 1 ' s feet. Resident 2 told LN 1 she was hit by Resident 1 and Resident 1 also knew what she did with Resident 2. In a concurrent interview and record review on 11/15/24 at 1:11 p.m., LN 1 stated Resident 2 had MoCA (Montreal Cognitive Assessment- to assess cognitive function) score of 12 out of 30 on 10/28/24 which indicated Resident 2 had moderate cognitive impairment. The LN 2 further stated Resident 2 ' s MoCA score was 7 out of 30 on 10/21/24 which indicated severe cognitive impairment. In a concurrent observation and interview on 11/15/24 at 1:21 p.m., Resident 2 was inside her room lying in bed. Resident 2 was able to sit upright in bed with assistance when a female staff delivered her lunch tray. Resident 2 stated a month ago this resident slapped her 4 times on her cheek, twice on both cheeks. Resident 2 further stated she wacked her back because she got scared. Resident 2 added she did not know if she hit her, she just swung her hand. Resident 2 stated she did not feel scared as long as she did not see her again. In a telephone interview on 11/15/24 at 1:38 p.m., the CNA stated he was sitting at the nursing station when he heard the verbal exchange between Resident 1 and Resident 2. The CNA further stated it was Resident 2 who started the conflict. Resident 1 had her feet sticking out a little and then Resident 2 rolled in and bumped into Resident 1 ' s feet. Resident 1 started arguing with Resident 2, both residents exchanged some words. Resident 2 waved her hand close to the face of Resident 1 and that was when Resident 1 grabbed the hands of Resident 2 and shook it. Resident 2 got a little scared because Resident 1 grabbed her hands. The CNA further stated things happened pretty quick. The CNA stated there was a potential for the incident not to have happened if he intervened during the verbal altercation. In a telephone interview on 11/21/24 at 11:24 a.m., the LN 3 stated Resident 1 and Resident 2 were roommates at the time of incident. Resident 1 was in the room sitting in her wheelchair. Resident 2 was at the nurses ' station and then wheeled herself inside the room. The LN 3 heard Resident 2 yelling out and the CNA rushed in the room. The CNA told LN 3 Resident 1 grabbed Resident 2. The LN 3 stated Resident 1 had behaviors such as yelling and repetitiveness. The LN 3 further stated Resident 1 would yell not so nice language and both residents (Resident 1 and Resident 2) had memory problems. In a telephone interview on 11/22/24 at 10:11 a.m., the Administrator (ADM) stated they try to keep residents free from abuse in their facility. A review of the facility ' s Policy and Procedure (P & P) revised December 2016 and titled, Abuse Prevention Program indicated, .residents have the right to be free from abuse .This includes but is not limited to freedom from .physical abuse .As part of the resident abuse prevention, the administration will .Protect our residents from abuse by anyone including .other residents . A review of the facility ' s P & P revised September 2022 and titled, Resident-to-Resident Altercations indicated, .All altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator .Behaviors that may provoke a reaction by residents or others include .screaming .grabbing .wandering into others .space .

Based on observation, interview, and record review, the facility failed to ensure confidentiality was maintained for one of four sampled residents (Resident 2) when Resident 1 received Resident 2's labeled medication cards upon discharge by mistake. This failure resulted in Resident 2's confidential information being provided to an unauthorized recipient. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility in September 2024 with multiple diagnoses including orthopedic aftercare for fusion of spine (surgery to connect two or more bones in the spine) and spinal stenosis (narrowing of the spaces in the spinal canal). A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility in September 2024 with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke- blood flow to the brain is blocked). A review of Resident 1's Discharge Summary, dated 9/24/24, indicated .All medications reviewed including route, time, dose and indication with no questions asked .Current Reconciled Medications List was provided to Resident/Family/Caregiver at Discharge? .Yes . A review of Resident 1's Progress Note, social services note, dated 9/23/24, indicated .Resident is scheduled for discharge on 9/24/24 to home w/ [with] daughter and medications . A review of Resident 1's Progress Note, nurse's note, dated 9/24/24, indicated .Pt [patient] discharging home today with daughter .present at bedside for transport. All medications and ppwk [paperwork] reviewed, signed and sent with resident and dtr [daughter] with no questions at this time .Pt and dtr left facility approx [approximately] 12:30 [12:30 p.m.] . During a telephone interview on 10/10/24 at 8:52 a.m. with Resident 1's Family Member (FM), the FM stated Resident 1 was discharged from the facility on 9/24/24. The FM stated she noticed after she left the facility, Resident 1 was discharged with her own Norco (narcotic pain medication) but also had roommate's (Resident 2) medications. The FM was told that medications for both roommates (Resident 1 and Resident 2) were in the same drawer and Resident 2's medications were scooped up by mistake. During an interview on 10/10/24 at 10:46 a.m. with the Director of Nursing (DON), the DON stated for a scheduled discharge the medication cart nurse or desk nurse reviews medications with the resident or Responsible Party (RP). Medications that are left are given to the resident upon discharge. The DON stated on 9/24/24, the wrong medications were pulled for Resident 1. Resident 1 was given her roommate's (Resident 2) medications. The DON stated, It was a mistake from nursing. Need to verify and make sure medications are correct. During an interview on 10/10/24 at 11:39 a.m. with Licensed Nurse (LN) 1, LN 1 stated the medication cart nurse pulls the medications for discharged residents from the medication cart, places in bag, and gives to the desk nurse. LN 1 stated the medication cart nurse pulled Resident 1 roommate's (Resident 2) medications by mistake upon discharge of Resident 1. LN 1 was the desk nurse that day. LN 1 stated she briefly went through the bag and used Resident 1's Norco medication card from the bag to review with Resident 1. LN 1 stated, Did not notice the rest of meds. Did not check rest of meds to see if they were correct. During an interview on 10/10/24 at 11:53 a.m. with LN 2, LN 2 stated Resident 1 received her roommate's (Resident 2) medications at discharge. During a telephone interview on 10/10/24 at 2:13 p.m. with LN 3, LN 3 stated for resident discharges she usually obtains the medication list from the desk nurse, goes over the medications, collects the medications from the medication cart, places medications in a bag, and gives to the desk nurse. LN 3 stated when Resident 1 was discharged , Did not do this. Didn't have the list. LN 3 stated she pulled Resident1's Norco cards from the second left drawer, then picked up roommate's (Resident 2) medications from second right drawer and gave then to LN 2. LN 3 stated, Didn't look at the medications either. LN 3 stated Resident 1's FM was angry and anxious at the time of discharge, so she hurried and got the medications. LN 3 stated, Was in a hurry. LN 3 was notified later Resident 1 had been given the wrong medications. During a concurrent observation and interview on 10/10/24 at 1:35 p.m. with LN 2, observed Resident 2's medication card in the medication cart. The medication card was labeled with Resident 2's name, medication, dosage, instructions, prescription number, and expiration date. During an interview on 10/10/24 at 1:21 p.m. and a subsequent interview on 10/10/24 at 2:33 p.m. with the Director of Nursing (DON), the DON stated, Nurses need to go over medications. The DON stated the confidentiality breach was not reported to the state as far as she knows. The DON stated Resident 1 and FM were aware of incident, but the family of Resident 2 was not notified of incident. Requested policy and procedure for confidentiality breach process. The DON stated she could not find the policy. A review of the facility's Policy and Procedure (P&P) titled Confidentiality of Information and Personal Privacy, revised 10/23, indicated .Our facility will protect and safeguard resident confidentiality and personal privacy .The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records .The facility will strive to protect the resident's privacy regarding his or her .medical treatment . A review of the facility's P&P titled Resident Rights, revised 10/23, indicated .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .Privacy and confidentiality .The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues .

Based on observation, interview, and record review, the facility failed to provide a safe discharge home for one of four sampled residents (Resident 1), when Resident 1 was discharged home with another resident's (Resident 2) medications. This failure had the potential for Resident 1 to take the wrong medications causing adverse effects. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility in September 2024 with multiple diagnoses including orthopedic aftercare for fusion of spine (surgery to connect two or more bones in the sine) and spinal stenosis (narrowing of the spaces in the spinal canal). A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility in September 2024 with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke- blood flow to the brain is blocked). A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 9/13/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 15 out of 15 that indicated she was cognitively intact. A review of Resident 1's MDS, Functional Abilities and Goals, dated 9/13/24, indicated Resident 1 was independent for self-care and indoor mobility and required some assistance for stairs upon admission. A review of Resident 1's Discharge Summary, dated 9/24/24, indicated .All medications reviewed including route, time, dose and indication with no questions asked .Current Reconciled Medications List was provided to Resident/Family/Caregiver at Discharge? .Yes . A review of Resident 1's Order Summary Report, indicating medication list for discharge was signed by Resident 1 on 9/24/24. A review of Resident 1's Progress Note, social services note, dated 9/23/24, indicated .Resident is scheduled for discharge on 9/24/24 to home w/ [with] daughter and medications . A review of Resident 1's Progress Note, nurse's note, dated 9/24/24, indicated .Pt [patient] discharging home today with daughter .present at bedside for transport. All medications and ppwk [paperwork] reviewed, signed and sent with resident and dtr [daughter] with no questions at this time .Pt and dtr left facility approx [approximately] 12:30 [12:30 p.m.] . A review of Resident 1's Progress Note, nurse practitioner note, dated 9/24/24, indicated .[Resident 1] was seen in her room this morning with her daughter at bedside. They were waiting for her discharge papers and as soon as they received them, they left. Patient and daughter said they had no needs at the time of discharge . A review of Resident 1's Progress Note, nurse practitioner note, dated 9/25/24, indicated . [Resident 1] was discharged [DATE] in stable condition .meds reconciled . During a telephone interview on 10/10/24 at 8:52 a.m. with Resident 1's Family Member (FM), the FM stated Resident 1 was discharged from the facility on 9/24/24. The FM stated she noticed after she left the facility, Resident 1 was discharged with her own Norco (narcotic pain medication) but had roommate's (Resident 2) medications. Resident 1 did not have her other medications upon discharge. The FM stated she was asked by the facility to bring back Resident 2's medications but was unable to do so until the next day as she was in the emergency department with Resident 1. The FM stated Licensed Nurse (LN) 1 and LN 2 brought Resident 1's medications to the emergency department that day. The FM was told that medications for both roommates (Resident 1 and Resident 2) were in the same drawer and Resident 2's medications were scooped up by mistake. During an interview on 10/10/24 at 10:46 a.m. with the Director of Nursing (DON), the DON stated for a scheduled discharge the medication cart nurse or desk nurse reviews medications with the resident or Responsible Party (RP). Medications that are left are given to the resident. The DON stated on 9/24/24, the wrong medications were pulled for Resident 1. Resident 1 was given Resident 2's medications. The DON stated, it was a mistake from nursing. Need to verify and make sure medications are correct. The DON stated Resident 1's medications were delivered to her the same day and Resident 1's FM brought in Resident 2's medications the next day. During an interview on 10/10/24 at 11:39 a.m. with LN 1, LN 1 stated the medication cart nurse pulls the medications for discharged residents from the medication cart, places in bag, and gives to the desk nurse. LN 1 was the desk nurse that day. LN 1 stated the medication cart nurse pulled Resident 1 roommate's (Resident 2) medications by mistake. LN 1 stated she briefly went through the bag and used Resident 1's Norco medication card from the bag to review with Resident 1. LN 1 stated, Did not notice the rest of meds. Did not check rest of meds to see if they were correct. Observed with LN 1 medication cart, 1 Front. Observed second left drawer contained medication cards for narcotics in order by resident, no dividers. Observed second right drawer with medications separated by dividers labeled with room number. LN 1 stated she delivered Resident 1's medications to her that same day in the emergency room . When asked what the consequences may be of resident discharged with wrong medications, LN 1 stated, Potentially allergies, side effects. During an interview on 10/10/24 at 11:53 a.m. with LN 2, LN 2 stated Resident 1 received her roommate's (Resident 2) medications at discharge. LN 2 stated medications are pulled by the medication cart nurse, checked against the medication list, and given to the desk nurse. The desk nurse gives the discharge instructions. LN 2 stated that he went with LN 1 to deliver Resident 1's medications in the emergency department. When asked what the outcome might be if resident given wrong medication, LN 2 stated, Family may not have checked medication, can cause harm, allergic reactions, side effects. May be given the wrong dose. All sorts of consequences with wrong medications. Should be double or tripled checked, read card two times. During a telephone interview on 10/10/24 at 2:13 p.m. with LN 3, LN 3 stated for resident discharges she usually obtains the medication list from the desk nurse, goes over the medications, collects the medications from the medication cart, places medications in a bag, and gives to the desk nurse. LN 3 stated when Resident 1 was discharged , Did not do this. Didn't have the list. LN 3 stated she pulled Resident1's Norco cards from the second left drawer, then picked up Resident 2's medications from second right drawer and gave then to LN 2. LN 3 stated, Didn't look at the medications either. LN 3 stated Resident 1's FM was angry and anxious at the time of discharge, so she hurried and got the medications. LN 3 stated, Was in a hurry. LN 3 was notified later Resident 1 had been given the wrong medications. A review of the facility's Policy and Procedure (P&P) titled Discharging the Resident, revised 10/23, indicated .If the resident is being discharged home, ensure that resident and/or responsible party receives discharge instructions . A review of the facility's P&P titled Medication Regimen Review, revised 4/23, indicated .The resident's medication regimen shall be consistent with an individual's plan of care .

Based on interview and record review, the facility failed to complete annual performance evaluations (PEs) for three of five sampled certified nursing assistants (CNAs; CNA 3, CNA 4, and CNA 5), for a census of 95. This failure increased the risk of residents receiving poor-quality care from the CNAs. Findings: During a concurrent interview and record review on 10/2/24 at 2:48 p.m. with the Director of Staffing Development (DSD) and the Consultant of Director of Staffing Development/Infection preventionist (CDSD/IP), the DSD and CDSD/IP reviewed CNA 3, CNA 4, and CNA 5's employee's files and found the following: CNA 3 was hired on 7/30/19, CNA 4 was hired on 12/26/20, and CNA 5 was hired on 8/31/09. All the CNAs files reviewed had no documented evidence the annual PEs were done. The DSD stated, I have not completed any employee's performance evaluations PEs in 2023 to 2024 . During a concurrent interview and record review, on 10/3/24 at 9:15 a.m. with the Administrator (ADM) and the Director of Nursing (DON), the DON stated, The PEs are completed by the DSD and are used to identify areas for improvement of residents' care and evaluate if care has been provided the correct way. The ADM stated, I found out yesterday and confirmed that no PEs were completed for 2023 to 2024. The ADM stated that if the PEs were not completed annually, the staff skills could be decreased, affecting the CNAs' competency in caring for the residents. During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations, dated 5/24, the P&P indicated, The job performance of each employee shall be reviewed and evaluated at least annually.

Based on observation, interview, and record review, the facility failed to ensure care and services in accordance with acceptable professional standards of quality were provided for four of 25 sampled residents (Resident 143, Resident 144, Resident 36, and Resident 85), when: 1. Medication and ointments were left at the nightstand of Resident 143; 2. Medication, hazardous liquids and ointments were left at the bedside of Resident 144; 3. A medication was not administered completely and left at the bedside, and oxygen tank was empty while in use for Resident 36; and 4. The oxygen (O2) saturation levels were not monitored for Resident 85. These failures had the potential risks to negatively affect the residents' health status. Findings: 1. Resident 143 was admitted in late 2024 with diagnoses which included peripheral vascular disease [decreased blood flow to the arms and legs], communication deficit, difficulty walking, and lack of coordination. During a review of Resident 143's Baseline Care Plan (BCP), dated [DATE], the BCP indicate Resident 143 had baseline confusion but able to make needs known. During a review of Resident 143's Physician Orders (PO), dated [DATE], the PO indicated, Miconazole [treatment for fungal infection] External powder .Micatin Cream .apply under breast topically . During a concurrent observation and interview on [DATE] at 9:55 a.m. in Resident 143's room, on top of the nightstand were two unlabeled plastic medicine cups half-filled with white paste-like consistency and an ointment tube. Resident 143 sat in a wheelchair, awake, alert and verbally responsive, and stated, I don't know what they are, but I think those are for me. They left it there for me. During a concurrent observation and interview on [DATE] at 9:57 a.m. in Resident 143's room with Certified Nursing Assistant (CNA) 9, CNA 9 verified the findings of the leftmedicine cup and the ointment tube, and stated, I don't know what they are. I will tell the nurse. During a concurrent observation and interview on [DATE] at 9:59 a.m. in Resident 143's room with License Nurse (LN) 7, LN 7 verified the medications on top of the night stand of Resident 143, and stated, [The medications] are not supposed to be here. They are not labeled and dated. I don't know when they left them here. 2. Resident 144 was admitted in late 2024 with diagnoses which included right arm fracture, difficulty in walking and lack of coordination. During a review of Resident 144's Minimum Data Set (MDS, an assessment tool), dated [DATE], the MDS indicated Resident 144 had mild memory impairment, hard of hearing, and needed assistance with activities of daily living. During a concurrent observation and interview on [DATE] at 9:44 a.m. in Resident 144's room, Resident 144 sat on a wheelchair, awake, alert and verbally responsive but hard of hearing. On top of the bedside table was a labeled medication inside a plastic bag with another resident's name (Resident 143). Resident 144 indicated the medication was not hers. Another opened and unlabeled container of mentholatum ointment (product use to relieve itching, minor muscle or joint pain) was on top of the bedside table, and Resident 144 stated, That's mine. I brought that from home and I use it. On top of the night stand was another unlabeled and opened large plastic container of mouthwash rinse, and Resident 144 stated, My friend gave me that. During a concurrent observation and interview on [DATE] at 9:52 a.m. in Resident 144's room, CNA 9 verified the plastic container was a medication, and stated, [The medications] are not supposed to be at the bedside. It's a prescription medication and that's not even hers. The mouth rinse should not be here, it should be placed in the bathroom and the other one is hers. Those things would be risky for the resident. I will report to the nurse. I don't understand why the medication is there. During a concurrent observation and interview on [DATE] at 9:59 a.m. in Resident 144's room with LN 7, LN 7 verified the medication on top of bedside table of Resident 144, and stated, The medication is labeled with another name [Resident 143] and that's not hers. I'm not sure if they forgot to take it, but no medications should be left at bedside because they can ingest it or give it to somebody else or someone else can come in and take it. LN 7 verified the mentholatum ointment and the big plastic bottle of mouthwash, and stated, When they receive medications from home, they're supposed to check in with the nurse and the nurse is supposed to get an order, then we're supposed to put it on our locked cart or inside our medicine cabinet or send these home with the family members. 3. Resident 36 was admitted in late 2024 with diagnoses which included asthma exacerbation (the lung airways become inflamed, narrow and swell making it difficult to breath), respiratory failure with hypoxia (low levels of O2 in the blood). During a review of Resident 36's PO, dated [DATE], the PO indicated, Ipratropium-Albuterol inhalation Solution .1 unit inhale orally three times day for SOB [shortness of breath]/Wheeze r/t [related to] asthma .Run over 15 minutes. During a review of Resident 36's MDS, dated [DATE], the MDS indicated Resident 36 had no memory impairment and required assistance with activities of daily living and needed O2 therapy. During a concurrent observation and interview on [DATE] at 11:03 a.m. in Resident 36's room, Resident 36 was in bed, awake, alert and verbally responsive in his own language, and stated, No speaking English. I speak and understand a little bit. On top of the nightstand were an unlabeled and undated nasal cannula (nasal tubing delivering O2)connected to the nebulizer machine dated [DATE], a disconnected HHN with liquid medication left in the chamber and dated [DATE], and an undated disconnected O2 mask coiled and parts of the tubing touching the floor. During a concurrent observation and interview on [DATE] at 11:05 a.m. in Resident 36's room with CNA 9, CNA 9 verified the nasal cannula, HHN and mask at the bedside, and stated, So, that's [DATE] on the machine. Today is [DATE], so it has been 10 days. The [nasal] tubing is dated [DATE]. There's no date on the other tubing .The other one that is touching the floor has no labeled date. During a concurrent observation and interview on [DATE] at 11:10 a.m. in Resident 36's room with LN 7, LN 7 verified the dates of the nasal tubings, and stated, This one here should have a date on. We change the O2 tubing weekly so that's expired and should have been changed. This one has still medication on it and the process is that they are supposed to finish it for 15 minutes .if there is something left, then they're not getting the medication. We are supposed to come and check it and I didn't. The nebulizer mask are supposed to be in a bag, labeled and dated, and these bags are not dated. When asked what happened if medication was not administered and the tubes were not changed weekly, LN 7 stated, They're not getting their medicine. When they are not changed every week, they get respiratory infections. It's all about infection. During a concurrent observation and interview on [DATE] at 1:22 p.m. in a hallway near the front lobby, Resident 36 sat in a wheelchair calling staff for help and pointed at the O2 tank hanging behind his wheelchair. Resident 36 indicated his O2 tank was empty, and stated, I'm okay, but short of breath. The O2 tank was checked and the indicator was on the red mark which indicated the tank was empty. During a concurrent observation and interview on [DATE] at 1:23 p.m. in a hallway near the front lobby, with LN 8, LN 8 verified the O2 tank was empty, and stated, We check them out to as needed and every day when the staff comes in or when the resident takes the O2 around. LN 8 verified and confirmed the tank was zeroed out, and stated, [Resident 36 is alert and oriented but he speaks a different language but understands English. He can be short of breath without the oxygen. During an interview on [DATE] at 8:20 a.m. with LN 7, LN 7 stated, Because [O2 tank] was empty, we're supposed to be checking it each shift whenever he gets out of the room .This is the first time that it was empty, but we should have checked it. During an interview on [DATE] at 8:35 a.m. with the DON, the DON stated, We usually check [O2 tanks], like if a resident is on a chair, we check intermittently to make sure that the tank has O2 on it. There's no monitoring like every day to check the tank. When the nurses come in every shift, all they want to know is the resident is using the O2 tank. The resident could potentially have respiratory distress. 4. Resident 85 was admitted in the middle of 2024 with diagnoses which included lung cancer, pulmonary fibrosis (scarred lung tissue over time causing shortness of breath), and chronic obstructive pulmonary disease (COPD). During a review of Resident 85's NCPs, dated [DATE], the NCP indicated, [Resident 85] has pulmonary fibrosis .oxygen therapy as ordered. During a review of Resident 85's MDS, dated [DATE], the MDS indicated Resident 85 had no memory impairment and needed oxygen therapy. During an observation on [DATE] at 11:30 a.m. in Resident 85's room, Resident 85 was in in bed and received O2 via nasal cannula at 4L/min. During a review of Resident 85's PO, dated [DATE], the PO indicated, Oxygen - @3 Liters/Min Via Nasal Cannula (Routine/Continuous) .Goal to Maintain 02 Sats [saturation, O2 levels in the blood] great than 90% .Monitor O2 Sats .every shift. During a concurrent interview and review of Resident 85's PO on [DATE] at 3:25 p.m. with LN 3, LN 3 verified the PO was O2 at 3L/min, and stated, It is important to follow the doctor's order .specially for residents with COPD . During an observation on [DATE] at 1:40 p.m. in Resident 85's room, Resident 85 was in bed and received O2 via nasal cannula which remained at 4 L/min. During a concurrent interview and record review on 1:42 p.m. with LN 4, confirmed Resident 85's was continuously receiving 4L/min. LN 4 verified the order at 3L per minute and titrate for O2 sat above 90% and check saturation every shift. When asked if she had checked the O2 sat for her shift, the LN stated, I have not checked the oxygen saturation in my shift. When asked to check the care plan, LN 4 confirmed the intervention to administer the medication as ordered. During a review of facility's policy and procedure (P&P) titled, Oxygen Administration, revised ,d+[DATE], the P&P indicated, Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter .The Oxygen tubing is changed at least weekly, labeled with the date it was changed, and stored in anti-microbial bag which is changed at least every 30 days. During a review of the undated document titled, Nursing Practice Act Rules and Regulations, the document indicated, Article 2. Scope of Regulation 2725 (b). The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require substantial amount of specific knowledge of the following: (2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement treatment, disease prevention, or rehabilitative regiment . ordered by and within the scope of licensure of a physician .as defined by Section 1316.5 of the Health and Safety Code. (Nursing Practice Act Rules and Regulations Issued by Board of Registered Nursing 1997 State of California Department of Consumer Affairs. pp. 5).

Based on observation, interview and record review, the facility failed to ensure: 1. Controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the medication administration record (MAR) and the Controlled Drug Record (CDR) for four of five randomly selected residents (Residents 3, 22, 75 and 78); and 2. An antibiotic emergency kit (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) was replaced timely after being opened and medications were removed. These failures resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications, the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: 1. Resident 3 had a physician's order dated 9/16/24, for hydrocodone/acetaminophen (a medication to treat pain) 5/325 milligrams (mg, a unit of measurement), one tablet every eight hours around the clock and one tablet every four hours as needed for pain. The CDR indicated 1 tablet was removed on 9/26/24 at 11:31 p.m., but the respective administration was not documented on the MAR. Resident 22 had a physician's order dated 9/11/24, for tramadol (a medication to treat pain) 50 mg, one tablet every eight hours for pain management. The MAR indicated 1 tablet was administered to Resident 22 on 9/18/24 at 3 a.m. but the removal was not documented on the CDR. Resident 75 had a physician's order dated 8/28/24, for lorazepam (a medication to treat anxiety) 0.5 mg, half tablet every four hours as needed for anxiety. The CDR indicated half a tablet was removed on 9/18/24 at 8:24 p.m. but the respective administration was not documented on the MAR. Resident 78 had a physician's order dated 7/12/24, for hydrocodone/acetaminophen 5/325 mg, one tablet every 4 hours as needed. The MAR indicated 1 tablet was administered on the following dates and times, but their removal was not documented on the CDR: 8/8/24 at 10:16 a.m., 8/8/24 at 4:02 p.m., and 8/9/24 at 3:42 p.m. During an interview on 9/30/24 at 2:14 p.m. with Licensed Nurse 2 (LN 2), LN 2 stated whenever a controlled medication was administered to a resident, the removal of the medication was to be documented on the CDR and the administration in the MAR. She stated nursing staff checked the MAR to know when a resident was last given a medication. During an interview on 10/1/24 at 10:34 a.m. with Director of Nursing (DON), DON stated nursing staff were expected to document the administration of controlled medications on both the CDR and the MAR. She stated documentation in the CDR and MAR allowed nursing staff to know what was removed from the medication cart and when a dose was last given. During a review of the facility's policy and procedure (P&P) titled, Controlled Medications, revised 10/2022, the P&P indicated, Procedures . 4. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose, completed after the medication is actually administered. 2. During a concurrent interview and inspection on 9/30/24 at 10:52 a.m. of Medication Storage room [ROOM NUMBER] with the Assistant Director of Nursing (ADON), an e-kit with a red plastic tie (indicating it had been opened) was identified. Inside the e-kit were seven e-kit logs indicating what medications had been removed. The e-kit logs indicated medications were removed on the following dates: 9/14/24, 9/19/24, 9/20/24, 9/21/24, 9/26/24, and 9/27/24. ADON confirmed the finding and stated nursing staff were expected to request a replacement e-kit as soon as it was opened and used to ensure all doses of each medication were on hand and available for use when needed. During a review of the facility's P&P titled, Emergency Kits, revised 10/2023, the P&P indicated, Procedures . 7 . opened kits are replaced with sealed kits within 72 hours of opening.

Based on interview and record review, the facility failed to develop and implement a process to ensure clinical rationale was documented when no changes were made to medications in response to identified irregularities and recommendations by the pharmacy consultant (PC) for one of 25 sampled residents (Resident 83). This failure had the potential to result in medication-related problems, errors, or irregularities identified and reported by the PC, and the potential for unnecessary medications (such as prolonged use, excessive dose, unmonitored use, duplication, etc.) for the resident. Findings: A review of Resident 83's medical record indicated she was admitted to the facility on [DATE] with multiple diagnosis including Huntington's disease (an inherited disorder that causes nerve cells in parts of the brain to gradually break down and die), anxiety, insomnia, dementia, high blood pressure, depression, and repeated falls. A review of the Resident 83's medical record indicated she had physician's orders for the following medications: aripiprazole (a medication to treat Huntington's disease), trazodone (a medication to treat insomnia), sertraline (a medication to treat depression), tetrabenazine (a medication to treat Huntington's disease), lamotrigine (a medication to prevent seizures), lorazepam (a medication to treat anxiety), and carvedilol (a medication to treat high blood pressure). During an interview on 10/1/24 at 2:59 p.m. with Director of Nursing (DON), DON stated the PC's monthly drug regimen reviews (MRR) were given to the provider for review. She stated the provider was to assess the risk versus benefit for any recommendations and to document clinical rational if they did not agree with them. During a concurrent interview and record review on 10/1/24 at 3:03 p.m. with DON the PC's MRR dated 7/11/24 for Resident 83 was reviewed. The MRR indicated, Resident's medications were reviewed for possible adverse effects or drug interactions which may have contributed to her recent falls . Combination therapy of aripiprazole sertraline, trazodone, tetrabenazine, and lamotrigine increases risk of CNS depression. Combination therapy of aripiprazole, sertraline, trazodone and tetrabenazine can increase risk of serotonin syndrome (a serious and potentially life-threatening condition that occurs when there is too much serotonin in the body); use of aripiprazole and tetrabenazine can increase risk of neuroleptic malignant syndrome (a life-threatening condition that can occur as a reaction to certain drugs used to treat mental illness) and increased risk of extrapyramidal symptoms (a group of side effects that cause involuntary movements and other motor issues that can occur as a result of taking medications used to treat mental illness). Would recommend evaluating regimen and assessing risk vs. benefits of therapy and if appropriate can consider dose reductions. She receives lamotrigine ER (extended release) 25 mg twice a day. Lamotrigine ER (extended release) is typically dosed once a day. Would recommend assessing appropriateness/necessity for resident to receive lamotrigine ER twice a day as she may be experiencing adverse effects of therapy, which may be contributing to her falls . consider changing ER therapy to once-a-day dosing or change to IR (immediate release) formulation . DON confirmed the MRR indicated the provider marked disagree with the PC's recommendations however the clinical rationale was not documented. During a concurrent interview and record review on 10/1/24 at 3:10 p.m. with DON, the PC's MRRs for Resident 83, both dated 7/12/24 were reviewed. The MRRs indicated, Resident has an order for lamotrigine ER 25 mg scheduled twice a day. Lamotrigine ER (extended release) is typically dosed once a day . should dose be changed to ER 50 mg daily? Or changed to the IR (immediate release) formulation for twice a day dosing? The DON confirmed the MRR indicated the provider marked disagree with the PC's recommendations but did not document the rationale. The second MRR dated 7/12/24 indicated, Resident is on 2 antidepressants . although combination therapy may be clinically appropriate, use of 2 antidepressants may appear as duplicate therapy. Please review the orders to assess appropriateness/necessity for resident to be on 2 antidepressant therapies as this can increase risk of adverse effects/toxicity. The DON confirmed the MRR indicated the provider disagreed with the PC's recommendations but did not provide clinical rationale. During an interview on 10/1/24 at approximately 4 p.m. with DON, a facility P&P addressing the facility's process for reviewing and acting upon the PC's MRRs was requested. The facility was unable to provide the requested P&P.

Based on observation, interview, and record review, the facility failed to ensure expired medications were not available for resident use, medications with shorter expiration dates after use were labeled with an open date, single-use medications were discarded after use, medications were labeled with a pharmacy label, and medications in medication carts were stored in a clean, safe and orderly manner in accordance with the facility's policy and procedure (P&P). These failures had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration date or improper storage, and diversion or misuse of medications from not being safely stored. Findings: During an inspection on 9/30/24 at approximately 11 a.m. of the Central Supply, alongside Assistant Director of Nursing (ADON), three tubes Skintegrity Hydrogel (a topical used for wound care) expired 2/2024 and two vials EvenCare G3 blood glucose test strips (used to test blood sugar) expired 6/2024 were identified. ADON confirmed the finding and stated expired items were to be removed from facility stock. During an inspection of Medication Cart Station 2 Front on 9/30/24 at approximately 12 p.m. with Licensed Nurse 2 (LN 2), one open vial Assure Platinum blood glucose test strips was identified. LN 2 confirmed the manufacturer's labeling on the package indicated they expired six months after opening. Inspection of the cart also identified four loose tablets in the drawers, one partially used bottle sterile normal saline (used to moisten wound dressing) 0.9%, and three partially used bottles acetic acid irrigation 0.25% irrigation (used to flush tubing to prevent infection). LN 2 confirmed the loose tablets should not have been available in the cart and needed to be disposed. She acknowledged the manufacturer's labeling on the normal saline and acetic acid solutions indicated single use and agreed any unused portion was to be discarded after opening the bottles. A review of the manufacturer's labeling for acetic acid 0.25% irrigation, dated 8/2023, the labeling indicated, Description . contains no preservatives . Precautions . Use only if solution is clear and container and seal are intact . Unused portions should be discarded and a fresh container of appropriate size used for the start up of each cycle or repeat procedure . A review of the manufacturer's package labeling for sterile 0.9% normal saline indicated, Caution . No antimicrobial or other substance added . Contents sterile unless container is opened . During an inspection of Medication Cart Station 2 Back on 9/30/24 at approximately 12:40 p.m. with LN 1, three loose tablets in the drawers were identified with one vial nitroglycerin (a medication used to treat chest pain) 0.4 milligram (mg, a unit of measurement) sublingual (under the tongue) tablets in a clear, unlabeled plastic bag were identified. LN 1 confirmed the loose tablets should have been disposed of and all medications provided by the pharmacy needed labeling to identify which resident it was for. During a review of the facility's P&P titled, Storage of Medications, revised October 2023, the P&P indicated, Policy Interpretation and Implementation . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Discontinued, outdated, or deteriorated drugs or biologicals are placed on designated appropriate bins for destruction. During a review of the facility's P&P titled, Medication Labeling, revised October 2023, the P&P indicated, Policy Interpretation and Implementation . 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with . currently accepted pharmaceutical practices. 2. The medication label includes, at a minimum . d. expiration date as determined by the manufacturer e. resident's name . During an inspection of Medication Cart 2 Back on 10/1/24 at 9:57 a.m. with LN 4, two bags containing injectable medications along with a third bag containing topical patches for separate residents were identified stored with oral medications. LN 4 stated medications that required different routes of administration should have been stored separately. During an inspection of Medication Cart 2 Front on 10/1/24 at 10:04 a.m. with LN 5, one bag of transdermal patches was identified in a drawer with oral medications. LN 5 stated topical medications should have been stored separately from oral medications. During an interview on 10/1/24 at 10:46 a.m. with the Director of Nursing (DON), DON stated medications that required different routes of administration should have been stored in separate compartments in the medication carts. She stated nurses were expected to inspect their carts between shifts for loose tablets and dispose of them. DON stated medications provided by the pharmacy should have all had a resident specific label on them to correctly identify who it was for. She stated single-use medications should have been discarded after the first use since there was a risk of contamination. During a review of the facility's P&P titled, Storage of Medications, revised October 2023, the P&P indicated, Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a total of 95 residents who received facility prepared foods, when: 1. Proper food labeling was not followed; 2. Expired foods were not discarded; 3. Undated box of loose bananas with dark brown to black discoloration and leaking fluids were stored in the walk-in refrigerator; and 4. Several wet steam table pans were found stacked at the clean and ready-to-use storage areas. These failures had the potential to cause food-borne illnesses. Findings: 1. During the initial kitchen tour on [DATE] beginning at 8:40 a.m. the following items were observed not having proper labeling: Inside the dry storage: Unlabeled and opened clear plastic bag of coconut flakes with no opened or used date. Inside the walk-in refrigerator: Opened resealable plastic bag of diced onion with no opened or used by date; and Unlabeled and opened clear plastic bag of cut celery sticks with no opened or used by date. During a concurrent observation and interview on [DATE] at 9:04 a.m. with the Registered Dietitian (RD) in the dry food storage room in the kitchen, the RD confirmed the observed item did not have the proper labels and removed it from the shelf. During a concurrent observation and interview on [DATE] at 9:53 a.m. with the RD in the walk-in refrigerator in the kitchen, the RD confirmed the observed items did not have the proper labels and removed it from the shelf. During an interview with the RD on [DATE] at 10 a.m. the RD stated that food items stored in dry storage and walk-in refrigerator, should be labeled and dated before it gets in. The RD expects the staff to label the food items correctly. During a review of the facility Policy and Procedure (P&P) titled, Storage of Food and Supplies, dated 2023, the P&P indicated, . Labels should be visible .All foods will be dated- month, day, year. 2. During an observation on [DATE], within the initial kitchen tour beginning at 8:40 a.m. the following expired items were observed: Inside the dry storage room: Carton of .Oat Milk expired on of [DATE]; Box of .salad dressing packets expired on [DATE]; Box of .chocolate baking chips expired on [DATE]; and Box of .[pie] Crust Expired on [DATE]. Inside the walk-in refrigerator: Clear plastic bag with four peeled hard-boiled eggs with opened date of [DATE]. Inside the front refrigerator: Opened carton of .Soy Milk expired on [DATE]. During a concurrent observation and interview on [DATE], at 9:04 a.m. with the RD in the dry storage area of the kitchen, the RD confirmed the observations of expired products in the dry storage, and stated, Those should have been thrown away. During a concurrent observation and interview on [DATE], at 9:36 a.m. a pack of four peeled hard-boiled eggs with an open date of [DATE] were stored on a shelf in the walk-in refrigerator. The RD confirmed the observation, and stated, It should've been dumped by staff. During a concurrent observation and interview on [DATE] at 10 a.m. an opened carton of Soy Milk with an expiration date of [DATE] was found inside the front refrigerator. The RD confirmed the observation. During an interview on [DATE] at 10 a.m. with the RD, the RD indicated she expected the staff to regularly check the expirations or the use-by date and to discard expired items immediately. During a review of the facility P&P titled, Storage of Food and Supplies,dated 2023, the P&P indicated, .No food will be kept longer than the expiration date on the product. During a review of the U.S Food and Drug Administration (FDA) document titled, FOOD FACTS, Egg Safety: What You Need To Know, dated ,d+[DATE], The document indicated, Storing .Use or eat hard-cooked eggs (in the shell or peeled) within 1 week after cooking. During review of the US FDA (Food and Drug Administration) Food Code 2022, ,d+[DATE].17 (A) (B) (C) (D) discusses required food labeling and dating. The FDA code indicated, The day the original container is opened in the food establishment shall be counted as Day 1 .The date marked shall not exceed a manufacturer's use-by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. 3. During a concurrent observation and interview on [DATE] within the initial kitchen tour at 9:32 a.m. a box of undated loose bananas with dark brown to black discoloration and leaking fluids were stored on the bottom shelf of the rack inside the walk-in refrigerator. Both the RD and the Dietary Manager (DM) confirmed this observation. The DM stated that the bananas would not be served to the residents. During an interview with the RD on [DATE] at 10 a.m. the RD stated that produce stored in the kitchen should be properly sealed and labeled with the received, opened, and used-by dates. The RD also expected staff to make sure the produce remains fresh and discard any overripe produce. During a review of the facility P&P titled, STORING PRODUCE, dated 2023, the P&P indicated, Check boxes of fruit and vegetables for rotten, spoiled items .Bananas should be stored at room temperature. When fully ripe, bananas may be stored in the refrigerator for five days . 4. During a concurrent observation and interview on [DATE], within the initial kitchen tour at 8:53 a.m. several steam table pans were found stored wet. The RD and DM confirmed the observation. During an interview with the RD on [DATE] at 10 a.m. the RD stated that pans and other utensils should be air dried for sanitation reasons. During a review of the facility P&P titled, DISHWASHING, dated 20123 [sic], the P&P indicated, Dishes are to be air dried in racks before stacking and storing. During a review of the US FDA 2022 Food Code, Annex ,d+[DATE].11, titled, Equipment and Utensils, Air-Drying Required, [DATE] version, the FDA code indicated, Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program for four of 25 sampled residents (Resident 148, Resident 36, Resident 1 and Resident 3), when: 1. A hand held nebulizer (HHN, breathing treatment device) and a nasal cannula (tubing that delivers oxygen) were unlabeled and undated for Resident 148; 2. A nasal cannula and HHN with expired dates were found at the nightstand of Resident 36; 3. Resident 1's oxygen (O2) tubing and face mask was not labeled or dated; and 4. Resident 3 O2 tubing and face masks were not labeled or dated and the antimicrobial bag was labeled with an expired date. These failures increased the potential risk for respiratory infection. Findings: 1. Resident 148 was admitted in late 2024 with diagnoses which included pulmonary edema (fluid in the lung causing cough with extreme difficulty of breathing), muscle weakness and swallowing difficulty. During a concurrent observation and interview on [DATE] at 10:23 a.m. in Resident 148's room, a HHN on top of the wheelchair with no date and label was found. Resident 148 was in bed, awake, alert and verbally responsive, and stated, That is mine. On top of the nightstand was another nasal cannula tubing with no date, and a nebulizer bag dated [DATE]. During a concurrent observation and interview on [DATE] at 10:30 a.m. in Resident 148's room with Certified Nursing Assistant (CNA) 11 and Resident 148, CNA 11 verified the HHN on top of the wheelchair belonged to Resident 148, and stated, The stuff is hers .I hadn't had a chance to clean up these stuff .Sorry, the tube is a little tangled up with her. I don't see a label on this one .There's a label on that one at the nightstand but the nebulizer has no label and the bag has a label but both are dated more than a week. 2. Resident 36 was admitted in late 2024 with diagnoses which included asthma exacerbation (the lung airways become inflamed, narrow and swell making it difficult to breath), respiratory failure with hypoxia (low level of O2). During an observation on [DATE] at 11:03 a.m. in Resident 36's room, Resident 36 was in bed, awake, alert and verbally responsive in his own language. On top of the night stand were an unlabeled and undated nasal cannula connected to the nebulizer machine which was dated [DATE], a disconnected nebulizer chamber with liquid medication dated [DATE], and an undated disconnected O2 mask coiled with parts of the tube touching the floor. During a concurrent observation and interview on [DATE] at 11:05 in Resident 36's room with CNA 9, CNA 9 verified the findings on top of Resident 36's nightstand, and stated, So, that's labeled [DATE] on the machine. Today is [DATE], so it has been 10 days. The tube is dated [DATE]. There's no date on the other tubing .The other one that is touching the floor has no labeled date. During a concurrent observation and interview on [DATE] at 11:10 a.m. in Resident 36's room with LN 7, LN 7 verified the dates of the tubing, and stated, This one here should have a date on. We change the oxygen tubing weekly so that's expired and should have been changed .The nebulizer mask are supposed to be in a bag, labeled and dated, and these bags are not dated .When they are not changed every week, they get respiratory infections. It's all about infection. 48175 3. Resident 1 was admitted to the facility in early 2012 with a diagnosis that included quadriplegia (paralysis of upper and lower limbs) and a history of COVID-19. During a review of Resident 1's care plan (CP), dated [DATE], the CP indicated, [Resident 1] .receiving muscle relaxant .serious side effects .respiratory depression .and enhanced barrier precautions .MDRO [multidrug resistant organism] .PO [by mouth] ABT [antibiotic] .MD [physician] will not change this due to risk of infection. During a concurrent observation and interview on [DATE] at 8:56 a.m. in Resident 1's room, with CNA 6, CNA 6 stated, The oxygen tubing and the face mask should be dated and labeled weekly. There's someone assigned to change .otherwise, the patient can develop an infection . During a concurrent observation and interview on [DATE] at 8:59 a.m. in Resident 1's room with LN 1, LN 1 stated, The oxygen tubing and the face mask are changed weekly .Not sure why this is not dated or labeled .The tubes and masks are changed weekly to prevent any respiratory infection . 4. Resident 3 was admitted to the facility in the Spring of 2024 with diagnoses that included sepsis (generalized infection), pneumonitis (lung inflammation), and resistance to multiple antimicrobial drugs. During a review of Resident 3's Physician Orders (PO), dated [DATE], the PO indicated, Oxygen - @ 2 Liters/Min [minute, time measure] Via Nasal Cannula (PRN) .Change O2 .every Fri .Monitor O2 Sats . During a review of Resident 3's PO, dated [DATE], the PO indicated, Admit to .Hospice .Oxygen Change O2 tubing .every Fri. During a review of Resident 3's CP dated [DATE], the CP indicated, [Resident 3] .receiving hospice care .abnormal breathing .and enhanced barrier precautions .MDRO .respiratory system .infection . During a review of Resident 3's PO dated [DATE], the PO indicated, Ipratropium-Albuterol Solution .for SOB [shortness of breath] via nebulizer. During a concurrent observation and interview on [DATE] at 10:11 a.m. in Resident 3's room with the Director of Nursing (DON), the DON verified that the tubing and face mask should be changed weekly, and the antimicrobial bag should be changed monthly .The antimicrobial bag is dated [DATE] .Our residents are susceptible to infections . During an interview on [DATE] at 2:26 p.m. with the DON, the DON stated, The bags, tubes and nebulizers are changed weekly, and this is standard. If they are not being used, they will be placed on the antimicrobial [agent that kills bacterial growth) bag which is the black bag, and we also change the bag for the nebulizer because it gets dirty for a while. About the used tubing, they have to discard them after they are changed and don't leave it in the room, and the tubes and nebulizer should be labeled with the date when they were changed for infection control. During a review of facility's policy and procedure (P&P) titled, Oxygen Administration, revised ,d+[DATE], the P&P indicated, Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter .The Oxygen tubing is changed at least weekly, labeled with the date it was changed, and stored in anti-microbial bag which is changed at least every 30 days. During a review of the facility's P&P titled, Infection Prevention and Control, revised ,d+[DATE], the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent and manage transmission of communicable diseases and infections.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) accurately reflected the resident's current condition for one of 25 sampled residents (Resident 92), when the discharge MDS indicated the resident was discharged to an acute hospital. This failure resulted in Resident 92's MDS inaccurate assessment data submitted to CMS (Centers for Medicare-Medicaid Services). Findings: Resident 92 was admitted to the facility in the middle 2024 with multiple diagnoses which included heart failure and difficulty in walking. During a review of Resident 92's Physician Orders (PO), dated 8/20/24, the PO indicated, Discharge to home with medications . During a review of Resident 92's Nurse's Note (NN), dated 8/21/24 at 10:17 a.m., the NN indicated, Pt [patient] is discharging to home today . During a review of Resident 92's Nurse Practitioner Note (NPN), dated 8/21/24 at 3:04 p.m., the NPN indicated, .resident noted to be discharging to go home today . During a review of Resident 92's MDS, dated [DATE], the MDS titled, Discharge Status, indicated, .Short-Term General Hospital . During a concurrent record review and interview on 10/2/24 at 11:50 a.m. with the MDS Coordinator (MDSC) in the facility conference room, the MDSC verified Resident 92's MDS on 8/21/24 indicated the resident was discharged to short-term general hospital, and stated, .I don't know why .It should've been coded correctly . During an interview on 10/2/24 at 12:20 p.m., with the Director of Nursing (DON) in the facility conference room, when asked about the MDS coding expectation, the DON stated, .make sure it's accurate . During a review of facility's policy and procedure (P&P) titled, Resident Assessments, revised 10/23, the P&P indicated, .Required Assessments are federally mandated, and therefore must be performed for all residents .assessments include: Discharge Assessment (return anticipated and return not anticipated) .The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments. During a review of the undated Resident Assessment Instrument (RAI), the RAI indicated, The RAI process is a means of ensuring that residents receive the highest quality of care and can maintain the highest quality of life .This assessment is completed initially and periodically and is comprehensive, accurate, and standardized.

Based on observations, interviews and facility document reviews, the facility failed to ensure a safe, functional environment for 2 Random Residents (36 & 37) when the wardrobe closets in each of the residents' rooms were unsecured and tilted forward when the doors were opened. This failure had the potential to cause serious injury and even death to the residents, staff and visitors. Based on the above failure, an Immediate Jeopardy (IJ) was called on 10/21/15 at 12:02 p.m. On 10/21/15 at 12:02 p.m., the administrator was informed of the IJ situation causing potential serious harm to residents when the wardrobe closets were unsecured and tipped forward with minimal effort in two rooms within the facility. The Administrator presented an interim Plan of Correction (POC) to the survey team on 10/21/15 at 3:59 p.m. which was accepted. On 10/21/15 at 5:22 p.m., the survey team was notified by the administrator the wardrobe closets had been secured to the walls of each of the rooms involved. The administrator was informed each room would be observed by the Team and the secured closets would be verified. On 10/21/15 at 6:05 p.m. the Administrator was informed the IJ was removed. He was informed the immediacy of the IJ was removed with the secured closets completed and the interim POC accepted. Findings: Random Resident 36's face/admit sheet indicated she was admitted to the facility with weakness and a history of falling. Random Resident 36 had cognitive impairment with intermittent confusion, required assistance with activities of daily living, was able to use a wheelchair for mobility and was not her own responsible party for decision making. A concurrent interview and observation was made with Certified Nursing Assistant (CNA) 1 on 10/21/15 at 11:46 a.m. She stated there were more closets in other rooms and led the surveyor to Random Resident 36's room. CNA 1 opened the closet door on the right side and the whole closet leaned forward as if it would fall forward on her. She said, This is the worst one I've seen. CNA 1 stated the closets should all be secured to the wall. Yes, they aren't safe. Random Resident 37's face/admit sheet indicated she was admitted to the facility with [DIAGNOSES REDACTED]. Random Resident 37 required one person assist with activities of daily living. Random Resident 37 was her own responsible party for decision making. During the Initial Tour on 10/20/15 at 8 a.m., during a concurrent observation and interview, Random Resident 37 was lying in bed eating her breakfast. Random Resident 37 stated there was a concern about the wobbly closet in the room. The wardrobe closet was observed against the wall with the doors opening toward the foot of the resident's bed. The closet doors opened on the left and the right sides by pulling the doors. As the right side door was pulled open, the closet tipped forward. The closet was easily pushed back into place with one hand. Random Resident 37 said, See, they are not strong. I'm afraid it will fall. An interview was conducted on 10/21/15 at 11:46 a.m. with CNA 1 outside of Random Resident 37's room. When questioned about the furniture in the residents' rooms, CNA 1 stated some of them (wardrobe closets) were loose and could be dangerous. She further stated she had been concerned about the unsecured closets for more than a week. CNA 1 said, They aren't safe. CNA 1 was questioned about any injuries with the unsecured closets, she stated there had been an incident with a closet falling on a resident. On 10/21/15 at 1:16 p.m. an interview and concurrent record review were conducted with the Director of Nursing (DON). A review of an investigative report dated 9/12/15 and titled Resident/Incident Report indicated the following information: Description of Situation: Nurse reported that resident had unwitnessed fall in room. Resident was standing up to reach for briefs in her closet and lost her balance. Resident stated she grabbed the closet door and the closet fell on top of her. Summary of Investigation: . Closet was not secured to wall . closet fell on w/c (wheelchair), resident was on the floor. Recommendations/New Interventions: . Maintenance to be notified of securing closet. The clinical document titled Event Report, dated 9/14/15 indicated the resident suffered a headache and left foot and finger (right hand) abrasions when the closet fell . Review of a facility policy titled Safety and Supervision of Residents revised December 2007 indicated, Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.2. Safety risks and environmental hazards are identified on an ongoing basis . facility-wide commitment to safety at all levels of the organization . 3. When accident hazards are identified, the QA & A/Safety (Quality Assurance and Safety) Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible . 4. Employees shall be trained and inserviced on potential accident hazards and how to identify and report accident hazards, and try to prevent avoidable accidents . Review of a facility policy titled Maintenance Service and revised December 2009 indicated, 1. The Maintenance Department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times . 2.b. Maintaining the building in good repair and free from hazards . 8. The Maintenance Director is responsible for maintaining the following records/reports. a. Inspection of the building . An interview was conducted with the DON on 10/21/15 at 1:21 p.m. She stated she doesn't know why all closets weren't assessed and secured after the accident on 9/12/15. An interview was conducted with the Maintenance Supervisor (MS) on 10/22/15 at 8:30 a.m. MS stated there was a maintenance log located at each nursing station. He stated staff were expected to document maintenance concerns or issues in the logs; although, he acknowledged at times staff communicated their concerns verbally. There was no documentation/communication system in place to ensure maintenance was taking care of problems in the facility or assessing a potential for a widespread problems in the building. There was no evidence a facility-wide process was in place for preventing accident/hazards from occurring. A maintenance policy was requested from the DON on 10/21/15 at 3:45 p.m. The DON stated there was no policy related to maintenance. Review of a facility policy titled QA (Quality Assurance) Committee-Role of Environmental Services (Maintenance, Housekeeping, and Laundry Services), revised April 2012 indicated the following; Duties and responsibilities to the Quality Assessment and Assurance Program include, but are not limited to: 1. Assisting the Environmental Services staff in the development and the use of departmental policies, procedures . 5. Making written and oral reports/recommendations to the Administrator as necessary/required, concerning the operation of the Environmental Services Department . 8. Reviewing and developing a plan of correction for environmental services deficiencies noted during survey inspections and providing a written copy of such to the Administrator . 12. Monitoring facility practice to ensure compliance with acceptable standards of practice.

Based on observation, resident and staff interviews, clinical record review, and facility document reviews, the facility failed to ensure residents were free from sexual and mental abuse for 2 of 17 sampled resident (1, and 2) when: 1. Resident 1 was sexually abused by CNA 1 in the shower on five occasions; 2. Resident 2 was mentally abused and sexually harassed in her room by CNA 1; and These failures had the potential to cause long term emotional distress, mental anguish, and diminished quality of life. Findings: 1. Resident 1's Admission Minimum Data Set (MDS, an assessment tool) indicated Resident 1 was moderately impaired cognatively. She was not steady, only able to stabilize with staff assistance. Resident 1 required extensive assistance with bed mobility, transgering, dressing and personal hygiene. She was frequently incontinent of bowel and bladder. The resident did not have a poor appetite, ate with limited assistance, and did not have hallucinations or delusions. Resident 1 usually understands and was understood during conversations. She was deemed as her own responsible party upon admission. A review of Resident 1's clinical record indicated CNA 1 had provided direct care on the following dates: 4/5/14 at 16:39 (4:39 p.m.) shower was given. 4/9/14 at 16:53 (4:53 p.m.) shower was given. 4/9/14 at 21:07 (9:07 p.m.) shower was given (second shower was given during the same evening). 4/30/14 at 17:31 (5:31 p.m.) shower was given. 5/7/14 at 20:20 (8:20 p.m.) shower was given. Resident 1 was interviewed on 5/21/14 8:30 a.m. She stated, "(CNA 1's name) helped me into the shower and as I was washing myself, he pulled his pants down and told me to look as his penis. He had an erection and he said, 'Look what I have.' I told him no and asked him what he was doing. He kissed me and said he loves patients like me and I would have to keep this a secret or he would lose his job and not be able to feed his kids and send them to school. He reminded me several times this was our secret and not to report to anyone." Resident 1 further stated she had been "assaulted" by CNA 1 on five separate occasions. She stated CNA 1 "assaulted" her by exposing himself and forcefully kissing her against her will. She said, "I gave up fighting back because I was scared of him." She further stated she requested another CNA to take care of her and when the new CNA was assisting her, she reported the abuse. Resident 1 said, "I was afraid of what would happen to me if I told anyone. (CNA 1) kept telling me not to report to anyone or he wouldn't be able to send his kids to school. He made me feel afraid of what would happen if I told anyone about what he was doing to me. He really scared me." Resident 1 further stated, "He (CNA 1) assaulted me each time he assisted with my showers." An interview was conducted on 5/21/14 at 10:26 a.m. with CNA 1. He was observed to be wringing his hands and walking back and forth in the room. He took a seat at the table and was observed to continue wringing his hands and provided no eye contact. He was flipping his right foot around and knocked his sandal off of his right foot. CNA 1 then said, "I know why you called me in here for this interview." Without prompting or mentioning any specific residents, CNA 1 again said, "I know why you called me in for an interview. (Resident 1 and Resident 2) complained about me, right?" Upon further interview about what had happened with Resident 1, CNA 1 stated, "Well, I helped (Resident 1's name) to the shower and you know I have diabetes and can't hold my urine. I pulled my pants down in the shower and urinated in the shower." When asked again about what happened in the shower with Resident 1, the CNA stated, "I pulled my pants down and showed (Resident 1) my penis. I kissed her and told her not to tell anyone because I would lose my job and my kids couldn't go to school." When asked about how many times this had happened, CNA 1 stated, "I showered her about five times and kissed her every time. I showed her my penis one time." When asked if he had an erection, CNA 1 said, "Yes, I had an erection. I told her to look and (Resident 1) said 'no' and I pulled my pants up. I told her she couldn't tell anyone because I will not be able to feed my family." The Director of Staff Development (DSD) was interviewed on 5/21/14 at 10:47 a.m. She stated CNA 1 often volunteered to do the "showers only" on the assignment sheets on his shift if staff needed help with their assignments. An interview was conducted with Licensed Nurse (LN) 1 on 5/21/14 at 3:38 p.m. LN 1 was in charge of the evening shift when CNA 1 was on duty. LN 1 was responsible for the oversight of provision of care performed by CNA 1. The LN was questioned about CNA 1 providing two showers on one shift on 4/9/14. She stated, "I didn't know that happened." Review of a facility policy titled Preventing Resident Abuse revised December 2006 included: "Policy Interpretation and Implementation: 1. The facility's goal is to achieve and maintain an abuse-free environment. i. Monitoring staff on all shifts to identify inappropriate behaviors toward residents... k. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavior issues; n. Identify areas within the facility that may make abuse and/or neglect more likely to occur (e.g., secluded areas) and monitoring these areas regularly..." Another interview with LN 1 was conducted on 5/21/14 at 3:56 p.m. When questioned about supervising the CNAs showering residents on the evening shift, LN said, "I look at the care being provided by the CNAs but I didn't check the shower rooms or the shower schedules." Review of the clinical record for Resident 1 indicated changes in her behavior: 4/14/14 progress note included, "...P(atien)t declining in self-feeding... Pt observed with... gagging at times (appears to be behavioral)... On 4/11/14 Resident was attempting to harm herself by attempting to induce emesis and not eating..." 4/15/14 progress note included, "...Pt continues to exhibit several behaviors during lunch meal requiring 1:1 assist/redirection for initiation, task completion... consuming about 20% of meals..." 4/16/14 progress note under Nursing Services: "Nursing is monitoring behaviors as resident is noted to have some anxiety, crying episodes and recently attempting to make herself vomit." 4/21/14 progress note contained the following information: "When pt was first admitted she was self-feeding on mechanical soft (diet), then she started complaining on not able to eat. For the past 2 weeks she has become increasingly agitated and had been refusing to eat... Alert. Tearful at times... Often speaking like a young child..." Significant weight loss was noted on the 4/21/14 progress note, 13.6 pounds in nearly a month. Review of a progress note dated 5/7/14 at 11:48 a.m. with Resident 1's clinical record included the following: "Reason for visit: lab review... Pt (patient) with noted psych issues. Has difficulty swallowing which has been determined to be psych related. Poor po (oral) intake..." A review of a progress note dated 5/27/14 at 14:04 (2:04 p.m.) included a follow up visit from a Nurse Practitioner with Resident 1. The following information was contained in the document: "Date of visit: 5/22/14, Reason for visit: Request to evaluate patient's status [REDACTED]. ...She (Resident 1) stated the worst encounter took place on her second day in the facility. She states that while in the shower room, the male CNA asked if she would like to see his p (penis). CNA began to unzip his pants and brought out a very hairy square shaped p (penis) and asked me to look at it. Subsequently, patient stated that several times CNA forced himself to kiss her on her mouth. The patient stated that twice she gave up struggling and let him kiss her, but she pulled away quickly. Patient stated CNA told her, we have to get along and he asked her never to discuss this secret with anybody as he would no longer be working at this facility and his children will not complete college. Patient started to get upset and hyperventilate...The patient stated that in the last few days she told the CNA that she was going to tell about his encounter with her and the CNA told her he had a similar incident like this one three or four years ago and it had never been resolved..." On 5/21/14 at 8:40 a.m., the Director of Nursing (DON) was interviewed. She stated CNA 1 "works on the evening shift and sometimes the night shift. He has been working in the facility for [AGE] years." When questioned about any disciplinary action for the CNA, she said, "I don't recall." Review of the most recent disciplinary action was dated 11/5/13 indicated CNA 1 had violated a resident's rights and dignity. There were no details indicating the specifics of the violation. The document noted CNA 1 had a written warning for a facility policy violation and poor customer service. The document did not include the name of the resident involved, details of the violation(s) or a follow-up on the disciplinary action taken. The document was signed on 11/7/13 by the DON and the DSD. Another interview was conducted on 5/27/14 at 7 a.m. with the DSD. When questioned about the disciplinary action taken against CNA 1 dated 11/5/13 and signed on 11/7/13, the DSD stated CNA 1 told a resident she needed to go in her briefs and she could not get up to use the toilet until Physical Therapy cleared her to get out of bed. The DSD stated, "(CNA 1) was written up for poor customer service and violating the facility's policy. He also lied to the resident about not being able to get up to use the toilet." The DSD further stated the details of the incident were not documented on the disciplinary action form, and there was no follow-up to evaluate CNA 1's performance regarding resident care. A physician visit for Resident 1 was documented on 6/2/14 at 20:59 (8:59 p.m.) which included, "...Pt (patient) with poor po (oral) intake, eating less than 50 percent meals including if husband brings in food... appears confused and lethargic with childlike voice..." Review of a facility policy titled Recognizing Signs and Symptoms of Abuse/Neglect revised April 2011 included the following: "Policy Interpretation and Implementation: 1. Abuse is defined as willful infliction of ... intimidation...with resulting...mental anguish. c. Possible signs/symptoms of psychological abuse/neglect: (3) Depression, (4) New or increasing confusion or disorientation, (5) Withdrawal, (8) Anger..." Review of a facility's policy titled Reporting Abuse to Facility Management, revised April 2011 included the following: "2.a. Abuse is defined as the willful infliction of ...intimidation... with resulting... mental anguish...c. Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault..." In a continued interview with the DSD on 5/27/14 at 7 a.m., she stated after a written disciplinary action was signed by CNA 1, he would be monitored. When questioned about the monitoring documentation, the DSD said, "Staff were basically observed as they worked and no monitoring was documented." She confirmed there was no follow-up on the provision of care by CNA 1 to ensure he was not violating the residents' rights. When questioned again on how monitoring would ensure the residents were free from abuse, she said, "I watched the work being performed and didn't write anything down. When questioned about a tool to measure the quality of care being provided, the DSD said, "There is no such tool, no documented evaluation." 2. Resident 2's admission Minimum Data Set (MDS, an assessment tool) indicated she had no short term or long term memory problems, she could make herself understood and could understand instructions. She required assistance with activities of daily living, did not have a poor appetite, or had trouble falling or staying asleep. Resident 2 was her own responsible party for decision making. According the the Progress Notes within the clinical record: On 4/13/14 at 2:33 p.m., a Physical Therapist wrote, "Pt (patient) anxious, pulling her hair." On 4/14/14 at "12:23" a Certified Occupational Assistant wrote, "Pt tearful and seemed anxious and c/o (complained of) being overwhelmed by life circumstances..." On 4/15/14 at 11:09, a member of the licensed nursing staff documented the receipt of a new order for [MEDICATION NAME] (an antianxiety medication) 0.25 milligrams (mg) per the resident's and family's request. The physician's orders [REDACTED]. An interview with Resident 2 was conducted on 5/21/14 at 8:10 a.m. When questioned about what had happened with CNA 1, Resident 2 said, "The CNA came into my room a couple of weeks ago and he was at the foot of the bed. It looked like he was crouched down behind the foot of the bed. He looked like he was hiding behind the foot of the bed. He started to tickle my feet and then he kissed my toes. He was giggling like a child. Then, he came closer to my face and kissed my neck and planted one on my lips. I told him to stop it and he said I had to keep this between us or his kids wouldn't be able to go to school. He put his finger to his lips and said shhh." When questioned about the number of times CNA 1 had exhibited this behavior, Resident 2 said, "One time. He tried to come into my room one evening and I told him to get out. I didn't know his name because he didn't wear his name badge. I requested another CNA to care for me and he still tried to come into my room after I had made the request. I felt scared of him. He repeated I should not report any of this to anyone or he wouldn't be able to feed his children or send them to college. I didn't want to get anyone in trouble." Resident 2 further stated one evening shortly after this incident, CNA 1 attempted to come into her room again and she stated she was so angry, she threw a cup at him and told him to leave. She stated she had become anxious after the CNA had assaulted her. She stated she was having difficulty sleeping and the anxiety was really bothering her. Resident 2 concluded the interview stating she didn't want to discuss the issue anymore as it was upsetting to her. During a review of an untitled document dated 10/28 (unable to read the year) a declaration written and signed by CNA 1, which included, "...understand that I must wear my name badge during the duration of my shift. I also understand that failure to wear my badge may result in discipline..." Review of a progress note dated 5/23/14 and timed 18:09 (6:09 p.m.) for Resident 2 included a follow-up note by Social Service Assistant (SSA) regarding a request to transfer out of the facility: "...Upon resident return from appointment at the GACH (General Acute Care Hospital), she was very anxious. Writer met with Resident and informed her about plans of transferring to different skilled nursing facility..." Review of a facility policy titled Reporting Abuse to Facility Management and revised April 2011 indicated the following: "2.a. Abuse is defined as the willful infliction of ... intimidation, or punishment with resulting... mental anguish...c. Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault..." On 5/21/14 at 10:26 a.m., CNA 1 was questioned about what had happened with Resident 2, he said, "I was hiding at the foot of the bed of (Resident 2) and started to tickle her feet, her toes. When she woke up, I started to kiss her toes and I was laughing and moved closer to her face. I kissed her neck and kissed her on the mouth. She was mad at me and pushed me away. One time I tried to return to her room and she threw a cup at me and told me to get out." CNA 1 was questioned about how many times this had happened to Resident 2 and he said, "One time. She got mad at me." When questioned about other residents in the facility, CNA 1 said, "I don't want to say anymore."