Every finding on record at Blue Lake Post Acute

Based on observation, interview and record review, the facility failed to 1) Provide evidence of an ongoing water management program for the entire facility, 2) Ensure alcohol-based hand sanitizer dispensers were not expired on all wings of the facility, 3) Ensure enteral nutrition tubing was not exposed to potential pathogens in the environment for one (Resident #9) of one resident receiving continuous tube feeding, and 4) Ensure one (Resident #5) of one resident reviewed out of four residents with urinary catheters, received appropriate care for handling the tubing and collection bag to prevent the potential for infection in a sample of 34 active residents. The findings include: 1.In an interview on 4/08/26 at 3:15 PM with the Infection Preventionist and the Unit Manager-in-training for the Infection Preventionist role, they were asked who was responsible for the facility water management program to demonstrate measures to minimize the risk of Legionella and other opportunistic pathogens. They indicated the water management program oversight was the responsibility of the Administrator. On 4/09/26 at 10:45 AM, the Administrator was asked about the facility's water management program. He stated he had only been in his position for a few weeks. He said the water management was a contracted service that was maintained by the previous Maintenance Director. He went on to say they did not have any documentation of the water management program because they believed that documentation was taken by the Maintenance Director when he left last week. During the same interview, the Regional Nurse indicated they were attempting to contact the water management company to retrieve evidence of the program. On 4/10/26 at 10:00 AM, the Administrator and the Regional Nurse were asked if they retrieved any evidence of a water management program. They said they were unable to provide evidence of the water management program. Failure to maintain an effective water management program demonstrates an inability to minimize the risk of Legionella and other opportunistic pathogens in building water systems. 2.On 4/06/26 at 9:12 AM, an observation of the foaming alcohol-based hand sanitizer (ABHS) in rooms [ROOM NUMBERS] revealed an expiration date as follows: EXP 2026/03/25. Observation of the ABHS in the hallway outside of room [ROOM NUMBER] on 4/08/26 at 4:32 PM, revealed an expiration date as follows: EXP 2026/03/25. (Photographic evidence obtained) On 4/08/26 at 3:30 PM, the IP was asked who replaced the dispensers for ABHS. The IP said the housekeeping supervisor was responsible for changing the ABHS dispensers throughout the facility. The IP further stated they had a dispenser in each resident room and others in various spots in the hallways. In an interview with the Housekeeping Supervisor on 4/09/26 at 10:50 AM, he was asked if he was responsible for replacing the ABHS dispensers and he replied yes. He was asked to describe the process for monitoring those that needed replacement due to being empty or expired. He said he checked them during his maintenance rounds every day he was in the facility. He said he did not have a set routine for replacement and when asked if he monitored the expiration dates he replied, no. Further observation of a dispenser in the 100-wing hallway revealed the expiration date was not visible on the bottle. He acknowledged he did not note the expiration dates for the ABHS. After removing the bottle from the dispenser, he explained that some bottles had the expiration date at the base of the bottle where it attached to the dispenser; therefore, the expiration date would not be visible unless the bottle was removed from the dispenser. When asked if he had any tracking for ABHS use to help determine how often the ABHS dispensers needed to be replaced, he replied that he did not keep track of usage or any timeframes for replacement based on expiration dates. The Housekeeping Supervisor performed an inventory count of all dispensers at that time. The facility had a total of 27 ABHS dispensers. ABHS are regulated by the United States Food and Drug Administration. FDA regulations require applicants to provide a stability testing date with expiration date. Expiration dates reflected the time period for which the product retained is strength, quality, and purity. (retrieved from www.fda.gov 04/14/26) 3.Observation of the enteral nutrition tubing for Resident #9 on 4/08/26 at 9:21 AM, revealed the end of the tubing that connected directly to the tube entering the resident's abdomen was hanging over a pole with the pump, tube feeding and water flush tubing. The end of the tubing that connected to the resident's feeding tube was exposed to air and not protected with a cover or cap to prevent contamination. Licensed Practical Nurse (LPN) F was asked if the end of the tubing was intended to be left open for contamination and she said she did not think so, and There should probably be a cap for it somewhere. A review of the resident's medical record revealed orders for indicating that she received her nutrition via enteral (tube) feeding continuously for 20 hours a day. The feeding was turned off from 8:00 AM to 12:00 PM daily. The orders also indicated that Resident #9 received medications via the tube at 9:00 AM. A review of the care plan with a target date of 7/16/26, revealed that Resident #9 required an enteral tube feeding G (gastrostomy) tube related to dysphagia (difficulty swallowing) with late effect cerebral vascular accident (CVA - stroke). One of the goals of the care plan was that the resident be free of side effects or complications related to tube feeding. In an interview with the IP on 4/09/26 at 11:00 AM, she was asked about expectations for infection prevention as it related to tube feeding. She stated the end of the tubing should be protected by a cap when not in use. A review of the Infection Prevention and Control Policy and Procedure (effective 2/01/24 and reviewed 3-31-26), revealed a policy statement showing that the infection prevention and control program was established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Prevention of Infection listed important facets to include institute measures to avoid complications . 4.On 04/06/2026 at 10:35 a.m., Resident #5 was observed lying in bed with his eyes closed. He did not respond to his name being called. His indwelling urinary catheter (Foley) drainage bag was observed on the right side of the bed, resting on the floor. (Photographic evidence obtained) On 04/06/2026 at 12:39 p.m., Resident #5 was observed sitting up in bed, awake and eating lunch. His urinary catheter drainage bag was again observed resting on the floor. (Photographic evidence obtained) On 04/07/2026 at 10:42 a.m., Resident #5 was observed lying in bed with his eyes closed. He did not respond to his name being called. The urinary catheter drainage bag was observed resting on the floor. (Photographic evidence obtained) On 04/08/2026 at 9:47 a.m., Resident #5 was observed lying in bed with his eyes closed. He did not respond to his name being called. The urinary catheter drainage bag was observed resting on the floor. (Photographic evidence obtained) The catheter drainage bag remained in contact with the floor across multiple observations, creating a risk for contamination and infection. These observations were not consistent with the facility's policy requiring catheter tubing and drainage bags to be kept off the floor. During an interview with Certified Nursing Assistant (CNA) G on 04/08/2026 at 10:35 a.m., she stated her training for urinary catheter care included cleaning around the tubing, ensuring there were no kinks in the tubing, and emptying the bag typically twice per shift. When asked about infection control practices, she stated staff members wore a gown and gloves during care. When asked if a urinary catheter drainage bag should be allowed to touch or rest on the floor, she stated no. On 04/09/2026 at 9:40 a.m., during an interview with the Director of Nursing, she stated infection control expectations included staff wearing gloves and a gown during care and performing hand hygiene before and after care. She further stated the catheter drainage bag should be maintained below the level of the bladder and should not rest on the floor. A record review for Resident #5 revealed diagnoses including benign prostatic hyperplasia and flaccid neuropathic bladder. A review of the quarterly Minimum Data Set (MDS) assessment revealed: Section C: Brief Interview for Mental Status (BIMS) score of 6 out of 15 possible points, indicating severe cognitive impairment Section E: No behaviors documented, including no refusals of care A review of current physician orders included: 12/31/2025: Change Foley catheter as needed for leakage, blockage, or dislodgement 12/31/2025: Drain Foley catheter bag every shift and as needed 12/31/2025: Provide Foley catheter care daily and as needed 12/31/2025: Foley catheter to drainage bag for diagnosis of neurogenic bladder A review of the person-centered care plan revealed: Focus (09/14/2018, revised 04/06/2026): Resident has a Foley catheter related to neurogenic bladder Goal (revised 04/06/2026): Resident will remain free from catheter-related trauma and show no signs or symptoms of urinary tract infection Interventions (revised 04/06/2026): Monitor and document for pain or discomfort; monitor, record, and report signs and symptoms of urinary tract infection A review of the facility's policy titled Catheter Care, Urinary (effective 2001), revealed the purpose was to prevent urinary catheter-associated complications, including urinary tract infections. The policy directed that catheter tubing and drainage bags were to be kept off the floor.

Based on observation, interviews, and record review, the facility failed to ensure that nurse staffing information posted for public viewing was current.The findings include:On 4/9/2026 at 9:31 AM, an observation at the reception desk revealed the posted nurse staffing information reflected a date of 4/1/2026, which was not current. There was no evidence that updated staffing information for the day of observation was available for residents, visitors or the public to review.During an interview with the facility's Scheduler on 4/09/2026 at 10:56 AM, she stated she was the only individual responsible for posting daily staffing hours and reported that she attempted to complete staffing sheets in advance for days she was not present, typically on weekends.In a separate interview on 4/10/2026 at 2:02 PM, the Administrator stated he was in the process of training the Scheduler to perform the staffing posting duties.A review of the Scheduler's job description, dated 12/18/2025, revealed that the Scheduler was responsible for creating and maintaining accurate staffing schedules for nursing and other facility departments to ensure adequate coverage.

Based on interviews and record review, the facility failed to designate a full time Director of Nursing (DON) as required, leaving the position vacant from 1/19/26 through 4/5/26. The findings include:During the entrance conference on 4/6/26 at 9:40 a.m., the Administrator was asked to identify the facility's DON. He named the current DON and stated that today, 4/6/26, was her first day back. He confirmed she had resigned in January 2026 and returned to the position on 4/6/26.On 4/7/26 at 8:00 a.m., the DON was interviewed and was asked who had been designated as the facility's DON from the time she resigned in January 2026 until her return on 4/6/26. She stated she did not know who was designated during that period.On 4/7/26 at 11:10 a.m., the Administrator was interviewed again and was asked whether anyone had been designated as the DON from the current DON's resignation in January 2026 through 4/5/26. He stated he was not sure and believed the DON at a sister facility was overseeing things but confirmed he had only been in his role for two weeks.On 4/7/26 at 2:00 p.m., Rehabilitation Director K was interviewed. He stated he had worked at the facility for a little over a year. When asked who the DON was from January 2026 until the current DON returned on 4/6/26, he stated he did not know. When asked who he collaborated with during that time, he stated he reported concerns to the Unit Manager, Licensed Practical Nurse (LPN) D.On 4/7/26 at 2:20 p.m., the Regional Registered Nurse Consultant was interviewed. She stated the DON at a sister facility had been overseeing things. When asked if that individual had been formally designated as the DON for this facility, she stated no.On 4/9/26 at 10:34 a.m., the Consultant Pharmacist was interviewed. She stated she normally sent Medication Regimen Reviews (MRRs) to the DON and the Administrator. When asked who she sent her March 2026 reports to, she stated she sent them to LPN D/Unit Manager because she believed LPN D had been filling in as the interim DON. She stated she had not yet met the newly returned DON.On 4/9/26 at 2:00 p.m., the Advanced Practice Registered Nurse (APRN) was interviewed. She stated from January 2026 until the DON's return on 4/6/26, she coordinated resident care with the team, specifically LPN/Unit Manager D and LPN H.A review of the DON's personnel record revealed a resignation letter dated 1/18/26 stating she was resigning her position as Director of Nursing effective immediately. A second document, dated 3/30/26, was an offer of employment for the DON position with a start date of 4/6/26, signed by the DON on 3/30/26.A review of the facility's job description for the Director of Nursing position (revised 12/18/25), revealed the DON was responsible for the overall leadership, direction, and management of nursing services, including clinical oversight, staff supervision, regulatory compliance, and coordination of resident care.

The facility failed to ensure that drug regimen irregularities identified by the Consultant Pharmacist were reviewed and acted upon by the attending physician, Medical Director, and Director of Nursing (DON). This failure resulted in unaddressed medication irregularities for four (Residents #5, #38, #6 and #2) of seven residents reviewed for their medication regimens. This created the potential for adverse drug outcomes. The findings include: 1.The monthly pharmacy medication reviews for the past six months were requested. On 4/8/26 at 12:45 p.m., the DON provided a binder containing the monthly pharmacy medication reviews for October, November and December of 2025. She stated she needed to request the January, February and March 2026 reviews from the pharmacy because she wasn't here those months and did not know where they were located. She later returned with three separate stacks of paper and stated these were the monthly pharmacy medication reviews for January, February and March of 2026. When asked whether these reviews had been reviewed and acted upon by the attending physician, Medical Director or DON, she replied, No, I don't think they were. I just requested these from the pharmacy representative. During a record review for Resident #5, it was revealed that his medication regimen review was conducted by the Consultant Pharmacist on 1/7/26 and included the following irregularities: Vitamin D 5,000 units was started on 12/31/25, and the pharmacist questioned whether the 50,000 unit daily dose of Vitamin D, active since 12/25/25, should be discontinued. The resident had been receiving Zinc 220 milligrams (mg) (50 mg elemental zinc) twice daily since 11/5/25, and the pharmacist noted prolonged exposure above the tolerable upper intake level may suppress immunity, decrease high-density lipoprotein (HDL) cholesterol, and cause anemia and copper deficiency, recommending evaluation of continued need. A subsequent medication regimen review dated 3/12/26, again identified two active Vitamin D orders (50,000 units daily and 5,000 units daily) and recommended discontinuing the 50,000 unit dose. The pharmacist again noted the excessive zinc dosing and requested evaluation. The pharmacist also requested evaluation of an as needed (PRN) Ativan 0.5 mg order for anxiety, including diagnosis, behaviors, usage patterns, and continued need. Record review did not reveal any evidence that these irregularities had been reviewed or acted upon. During a record review for Resident #38, it was revealed that his medication regimen review was conducted by the Consultant Pharmacist on 2/5/26 and included the following irregularities: the resident was receiving Zoloft (for depression) 75 mg daily, Trazodone (for depression) 100 mg at bedtime, Xanax (for anxiety/panic disorder) 1 mg at bedtime, and Buspar (for anxiety) 10 mg three times daily. The pharmacist requested evaluation of the current doses and consideration of a gradual dose reduction, with instructions to document the clinical rationale in the record or physician progress notes. Record review did not reveal any evidence that these irregularities had been reviewed or acted upon. During a record review for Resident #6, it was revealed that her medication regimen review was conducted by the Consultant Pharmacist on 3/12/26 and included the following irregularity: Alendronate 70 mg weekly was scheduled for administration at 9:00 a.m., and the pharmacist noted that bisphosphonates should be administered in the morning with a full glass of water, at least 30 minutes before the first food, beverage, or medication, and with the resident remaining upright for at least 30 minutes after administration. The pharmacist requested clarification of the order to adjust the dosing time. Record review did not reveal any evidence that this irregularity had been addressed. On 4/10/26 at 10:05 a.m., during an interview with Licensed Practical Nurse (LPN) O, she confirmed she was caring for Resident #6. She reviewed the resident's order for Alendronate 70 mg weekly and stated it was administered on Sundays at 9:00 a.m. She stated the medication could be given between 8:00 a.m. and 10:00 a.m. When asked about special procedures required for administering Alendronate, she stated there were none. She reported that in previous workplaces she recalled giving it on an empty stomach and having the resident remain upright for 30 minutes afterward, but confirmed this was not occurring for Resident #6, who would have already eaten breakfast by the time the medication was administered. She was not aware of any required amount of water or of any pharmacy recommendations regarding the scheduling of this medication. On 4/9/26 at 9:40 a.m., during an interview with the Administrator and the DON, they were asked about the facility's system for receiving and acting on monthly pharmacy medication regimen review recommendations. The DON stated prior to her resignation on 1/18/26, the pharmacy emailed her the monthly review reports with recommendations, which she reviewed with the Advanced Practice Registered Nurse (APRN) and used to update resident orders. She confirmed she returned to the DON position on 4/6/26. When asked who had been reviewing the monthly pharmacy recommendations from 1/18/26 through 4/5/26, the Administrator stated the Unit Manager/LPN D has been receiving them, adding that he believed she was getting the emails or could access the reports through the pharmacy's website. When asked how the January, February, and March 2026 reports were obtained on 4/8/26, the DON stated she contacted the pharmacy representative, who emailed the reports to the Social Services Director for printing. The DON stated the January, February, and March 2026 reports were not in the facility prior to 4/8/26 and had not been reviewed by any staff member or practitioner. She stated she asked the APRN to begin reviewing them on 4/8/26, when she became aware they had not been reviewed. She stated based on her prior experience, Medication Regime Review (MRR) recommendations were typically reviewed within one week of receipt. She confirmed that the January, February, and March 2026 recommendations had not been reviewed by any staff member, APRN, or physician. She stated the facility did not have a policy regarding Medication Regimen Review. On 4/9/26 at 10:34 a.m., an interview was conducted with the Consultant Pharmacist who stated she completed her first monthly pharmacy medication review for the facility on 3/12/26 following the retirement of the previous consultant pharmacist and she performed all monthly reviews in person. She stated she emailed the March 2026 report to LPN D/Unit Manager and the Administrator, believing LPN D was filling in for the DON. She stated she had not yet met the newly returned DON. She stated the retiring pharmacist informed her that the facility typically kept a binder of monthly reports; however, when she arrived in March 2026, staff reported they did not have the January or February 2026 reports. She explained to LPN D how to reprint the reports and reviewed the process with her. She stated LPN D also had to print the March reports during the week of the survey. She stated she was aware that the January and February 2026 reports had not been reviewed and documented this in her pending report. She stated she reviewed this with LPN D and verbally reviewed all procedures with her. She stated all January and February 2026 recommendations were pending action. On 4/9/26 at 2:00 p.m., during an interview with the Advanced Practice Registered Nurse (APRN), she stated she had been providing care in the facility since January 2025. She stated she typically received a stack of MRRs periodically to review, but the last time she received any was from the DON prior to the DON's resignation in January 2026. She stated she did not recall receiving any MRRs after that time until 4/8/26, when she received a large stack of reports for March 2026. She stated she had not reviewed any MRRs from January or February 2026 and was not aware of whether the Medical Director had reviewed them or not. She confirmed she and the Medical Director were the only practitioners in the facility, with her present five days per week and the Medical Director present two days per week. 2.Resident #2's most recent readmission was on 5/21/24 with diagnoses including cerebral atherosclerosis and unspecified dementia with agitation. The most recent Minimum Data Set (MDS) assessment was a Significant Change in Status assessment with an Assessment Reference Date (ARD) of 3/3/2026. The Brief Interview for Mental Status (BIMS) score was 3 out of 15, indicating severe cognitive impairment. A review of the resident's medication regimen revealed the use of psychotropic medications, including Olanzapine 10 mg one tablet at bedtime for unspecified psychosis, and Depakote 500mg, one tablet by mouth three times daily for mood disorder. A pharmacy consultant report dated 3/31/26 recommended a gradual dose reduction (GDR) of Olanzapine. Another pharmacy consultant report, dated 3/31/26, indicated that Depakote 500 mg TID (three times daily), since 6/24/25, had still not been addressed by the facility. There was no documented evidence verifying that the facility implemented a GDR, provided clinical justification for not attempting the GDR, or documented monitoring or supporting continued use at the current dose. On 4/8/26 at 12:45 PM, the DON stated she could not locate evidence that the facility had addressed the pharmacy consultant's recommendations for Resident #2.

Based on interview and record review, the facility failed to ensure six (Residents #7, #8, #38, #45, #52, and #59) of twenty four resident records reviewed, contained evidence of a quarterly assessment completed using the State specified instrument approved by CMS (Centers for Medicare and Medicaid Services) at least every three months. The findings include: A review of Resident #8's medical record revealed that the minimum data set (MDS) quarterly assessment was due on 2/18/26. As of the recertification survey conducted from 4/6/26 – 4/10/26, there was no evidence the assessment had been completed. A review of Resident #38's medical record revealed that the quarterly MDS assessment was due on 2/14/26. As of the recertification survey conducted from 4/6/26 – 4/10/26, there was no evidence the assessment had been completed. A review of Resident #52's medical record revealed that the quarterly MDS assessment was due on 2/21/26. As of the recertification survey conducted from 4/6/26 – 4/10/26, there was no evidence the assessment had been completed. On 4/9/26 at 1:00 p.m., Licensed Practical Nurse (LPN)/MDS Coordinator H was interviewed regarding her process for completing MDS assessments. (The MDS assessment is the Federally required clinical assessment used to determine a resident's functional status, care needs, and the facility's reimbursement rate. The MDS Coordinator is responsible for gathering interdisciplinary information, coding the assessment accurately, and submitting it within required timelines.) LPN H stated she began working as the MDS Coordinator for both this facility and a sister facility approximately two years ago. She stated when she assumed the role, assessments were already behind. She reported that another nurse had been trained to complete MDS assessments at the sister facility but left after nine months, resulting in both buildings' MDS responsibilities returning to her around January 2026. She stated she had been trying to catch up. LPN H was asked to confirm whether the quarterly MDS assessments for Residents #7, #8, #38, #45, #52, and #59 had been completed by their Assessment Reference Dates (ARDs). She confirmed they were late and had not been completed. On 4/10/26 at 12:00 p.m., LPN H was asked to provide the Resident Assessment Instrument (RAI) Manual instructions for timing, completion, and encoding of MDS assessments. She stated she would need to locate them. On 4/10/26 at 12:30 p.m., LPN H stated she had not located the RAI Manual instructions and did not have a facility policy regarding MDS completion or transmission. She stated she was searching online for the RAI Manual instructions and she confirmed these materials were not readily available. A record review revealed that Resident #59's last quarterly MDS assessment was completed on 12/3/25. The facility's electronic medical record (EMR) system showed the next quarterly assessment was due by 3/5/26. As of 4/9/26, the assessment was 21 days overdue. Failure to complete assessments timely impacts the facility's ability to ensure critical indicators of gradual change in a resident's status are monitored. A record review revealed that Resident #7's quarterly MDS assessment with an ARD of 2/16/26 remained incomplete as of 4/9/26, exceeding the required ARD +14-day completion timeframe. A record review revealed that Resident #45's quarterly MDS assessment with an ARD of 3/4/36 remained incomplete as of 4/9/26, exceeding the required ARD + 14-day completion timeframe. On 4/9/26 at 1:00 PM, LPN H/MDS Coordinator stated she was aware of the late completion timeframe of the MDS assessments and she was trying to catch up. According to the Resident Assessment Instrument (RAI)User's Manual, quarterly assessments must be completed no later than 14 days after the Assessment Reference Date (ARD).

Based on observation, interviews, and record review, the facility failed to 1) Ensure refrigerated medications were stored in a locked compartment, and 2) Ensure Schedule II-V controlled medications were secured within a fully protected, double locked system. Schedule II-V controlled medications are substances with accepted medical use that have potential for abuse and may lead to physical or psychological dependence. Although the controlled medications were stored in a separately locked, permanently affixed inner compartment, the refrigerator housing that compartment was left unlocked, resulting in inadequate security. The findings include:On 04/09/2026 at 8:40 a.m., a small refrigerator was observed in the open and unsecured nurses' station area. The refrigerator had a white lock on the front; however, the lock was not engaged, as evidenced by the connector not being secured and the surveyor being able to open the refrigerator without staff assistance or intervention. (Photographic evidence obtained)On 04/09/2026 at 8:47 a.m., during an interview with Licensed Practical Nurse (LPN)/Unit Manager D, she stated the refrigerator contained insulin and inhalers requiring refrigeration. When asked whether any controlled substances were stored inside, she stated, yes, in the locked box. She retrieved a key from the Director of Nursing's office and opened the box, which contained a labeled box of liquid Lorazepam for one resident. (Photographic evidence obtained) When asked about expectations for securing medications, she stated the refrigerator should be locked when medications are stored inside and controlled substances should be double locked. When she was asked to confirm whether the refrigerator was unlocked, she stated yes, it was unlocked and should have been locked.According to the U.S. Drug Enforcement Administration (DEA), Lorazepam is a Schedule IV controlled substance.On 04/09/2026 at 3:15 p.m., during an interview with the Director of Nursing, she confirmed that the small refrigerator in the nurses' station should be locked at all times to prevent unauthorized access to medications stored inside.On 04/10/2026 at 11:30 a.m., during an interview with the facility's Consultant Pharmacist, she confirmed the refrigerator should be locked at all times and controlled substances should be double locked in a permanently affixed compartment.A review of the facility's policy titled Medication Labeling and Storage (effective 2001), revealed that the facility stored all medications and biologicals in a locked compartment under proper temperature, humidity, and light controls, with access limited to authorized personnel. The policy stated compartments containing medications, including refrigerators, were locked when not in use; medications requiring refrigeration were stored in a refrigerator in the medication room or other secured location; and controlled substances listed as Schedule II-V were separately locked in permanently affixed compartments.

Based on observations, interviews, and record review, the facility failed to ensure its medication error rate was not 5% or greater. The facility's medication error rate was calculated at 36%, based on 11 medication errors observed out of 30 opportunities for error.The findings include:On 04/07/2026 at 6:15 a.m., Licensed Practical Nurse (LPN) F was observed during medication administration preparing the following medications for Resident #16: Allopurinol 100 milligrams (mg), Aspirin 81 mg, Citalopram 20 mg, Cranberry Tablet 450 mg, Folic Acid 1 mg, Furosemide 20 mg, Gemtesa 75 mg, Losartan Potassium 50 mg, Metformin 500 mg, Metoprolol Succinate ER 25 mg, and Nitrofurantoin Macrocrystal 50 mg.At 6:18 a.m., LPN F entered Resident #16's room. The lights were off, and the resident was lying in bed with his eyes closed and bedcovers pulled up. LPN F called the resident's name twice; he opened his eyes on the second attempt. She stated it was time for his medications. The resident sat up on the edge of the bed, and LPN F administered the medications. The resident then laid back down, pulled the covers over himself, and closed his eyes.LPN F returned to her medication cart. When asked if she signed medications as given on the electronic medication administration record (eMAR) once administered, she stated she could not sign them because they won't pop up for another half hour, explaining the medications were ordered for 9:00 a.m. When asked why she administered medications scheduled for 9:00 a.m. at 6:18 a.m., she stated, Because that's how I was trained. She stated she normally worked 7:00 a.m. to 7:00 p.m. but came in at 6:00 a.m. that day and started early.A review of Resident #16's current medication orders revealed the following medications were ordered once daily: Allopurinol 100 mg, Aspirin 81 mg, Citalopram 20 mg, Cranberry Tablet 450 mg, Folic Acid 1 mg, Furosemide 20 mg, Gemtesa 75 mg, Losartan Potassium 50 mg, Metformin 500 mg, Metoprolol Succinate ER 25 mg, and Nitrofurantoin Macrocrystal 50 mg.On 4/9/26 at 3:15 p.m., during an interview with the Director of Nursing, she was asked about expectations for administering medications scheduled once daily. She stated daily medications scheduled for 9:00 a.m. could be given up to one hour before or one hour after the scheduled time unless otherwise specified. When asked whether 9:00 a.m. medications would be expected to be administered at 6:18 a.m., she stated they would not and should be administered between 8:00 a.m. and 10:00 a.m.A review of a document titled Medication Times, revealed: Everyday: 9:00 a.m.A review of the facility's policy titled Medication Administration Overview (effective 2/1/24), revealed the purpose was to administer medications according to the principles of medication administration, including the right medication, to the right resident, at the right time, and in the right dose and route. The procedure instructed staff to verify physician orders, read the Medication Administration Record for ordered medication, dose, route, and time, and verify the correct resident, medication, expiration date, dose, dosage form, route, and time prior to administration.

Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #54) of one resident reviewed for rehabilitation/restorative services received necessary care and services, when a physician-ordered left-hand brace was not available and had not been applied as ordered. The findings include: On 04/06/2026 at 11:30 a.m., Resident #54 was observed lying in bed with his eyes open. During an interview, he stated he wanted to start some rehab like physical therapy. He stated, it has been a while, and he felt that if he received therapy, he could improve his overall status. He was observed with left-sided upper and lower extremity deficits. No brace or splint devices were observed in place. He stated he used to have a brace for his left hand, but it had been missing for a long time. When asked how long it had been since he last wore the brace, he stated, I'm not sure, but it's been months - since last year. He was asked if staff had assisted him with applying the brace when it was available. He stated, Yes, I can't put it on myself.On 04/07/2026 at 9:45 a.m., Resident #54 was observed lying in bed with his eyes open. He indicated he would like to speak further at a later time when staff were not present in the room. No brace or splint was observed in place on his left hand.On 04/07/2026 at 10:20 a.m., during a follow-up interview, Resident #54 stated he wanted to reiterate that he felt therapy would help with the weakness on his left side related to a prior stroke. He stated he previously received therapy when he was first admitted to the facility approximately three years ago. No brace or splint was observed in place on his left hand.On 04/08/2026 at 2:00 p.m., during an interview with Certified Occupational Therapy Assistant (COTA)/Rehabilitation Director K, he stated he was familiar with Resident #54. When asked about the resident's diagnoses, he stated the resident had a stroke with left-sided weakness and contractures, with decreased range of motion in the left upper and lower extremities. When asked about the resident's therapy status, he stated the resident was not currently receiving therapy. He stated the resident had been on occupational therapy in January 2026 but was discharged when his payer source changed. He stated the resident previously had a splint during therapy; however, it went missing. He further stated the resident was placed on a restorative nursing program and had a left palmar hand guard, which had been ordered multiple times but also went missing. When asked if any specific nurse or certified nursing assistant (CNA) was responsible for restorative therapy, he stated no. When asked if the hand guard was considered a brace, he stated yes. When asked how long it had been since the resident last wore the brace, he stated it had been sometime last year, but he could not recall exactly when. When asked what the process was when ordered therapy equipment was missing, he stated they had previously notified the Administrator to order a replacement; however, it was not obtained and that Administrator was no longer employed by the facility.Rehabilitation Director K provided a document titled OT (Occupational Therapy) Evaluation and Plan of Treatment (dated 01/09/2026), which he confirmed was the most recent therapy evaluation for Resident #54. The document revealed:Short-term goal: Resident will safely wear palm guard at all times without redness or complaints of discomfort in order to reduce pain caused by joint deformity and to complete daily hygiene and skin checks. (target date: 01/22/2026)Long-term goal: Restorative nursing staff will demonstrate 100% accuracy in donning (applying) and doffing (removing) the left palm guard and completing daily hygiene and skin checks to decrease the risk of pain and injury caused by joint deformity. (target date: 03/09/2026)This document was electronically signed by Occupational Therapist (OT) I on 01/09/2026 and by the resident's physician on 01/19/2026.On 04/09/2026 at 12:35 p.m., during an interview with Resident #54, he stated he did not currently have a left-hand brace or splint. He stated, I used to have one, but I haven't seen it in ages - months. He was not observed wearing a brace or splint on the left hand. With the resident's permission, his bedside drawers and closet were searched; however, no brace or splint was located. When asked if he had ever refused to wear the brace, he stated, No, why would I refuse to wear it if it helps me? During this interview, Licensed Practical Nurse (LPN) F entered the room and was asked if she knew the location of Resident #54's left-hand splint. She replied, I think I've seen it. She searched the resident's drawers but did not locate the item. She asked the resident if he knew where it was, and he stated it had been gone for months and that no one had been applying it. LPN F stated she would follow up with therapy. She returned a few minutes later and stated OT J indicated that the brace may have been lost or discarded with laundry and that the new Administrator was in the process of ordering another.On 04/09/2026 at 12:45 p.m., during an interview with OT I and OT J, they were asked about the status of the resident's left-hand brace. OT J stated therapy did not track these items once a resident was discharged from therapy, and that the brace may have been lost or misplaced. OT I stated the brace had been missing for over a month and therapy had requested that the previous Administrator order a replacement in approximately January 2026. She stated they had also asked the new Administrator to order a replacement. When asked if she could confirm the resident had not had the brace since at least January 2026, she stated that, to her knowledge, that was correct.On 04/09/2026 at 1:36 p.m., during an interview with the Director of Nursing, she was asked if she had knowledge of the left-hand brace ordered for Resident #54. She stated she was not aware of the order and that documentation reflected the brace was applied on some days and marked not applicable on others.On 04/10/2026 at 10:10 a.m., during an interview with LPN O, she stated she had been caring for Resident #54 since December 2025. When asked if the resident used a left-hand brace or splint, she stated no and reported that she had never seen a brace for his left hand.A record review for Resident #54 revealed diagnoses including cerebrovascular accident (CVA - stroke) with left hemiparesis (weakness on one side of the body).A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed:Section C: Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognitionSection E: No behaviors documented, including no refusals of careA review of current physician's orders revealed:06/27/2023: May participate in restorative nursing programs as indicated and tolerated01/09/2026: Occupational therapy (OT) clarification - resident to be seen three times per week for 60 days, including therapeutic activity, self-care management, manual therapy, and orthotic interventions12/24/2025: Passive range of motion (PROM) to the left arm, including elbow, digits, wrist flexion/extension, and internal/external rotation, three sets of 10 repetitions. Assist with application of left-hand splint, remove after two hours, and assess skin before and after useA review of the person-centered care plan revealed:Focus (12/24/2024): Resident is on a passive range of motion (PROM) and splinting program to the left upper extremity (LUE) to reduce risk of contractureGoal (revised 03/20/2026): Resident will maintain or improve current level of functioning through the next reviewInterventions: PROM of left arm as ordered. Assist with application of left-hand splint, remove after two hours. Nursing rehabilitation program (initiated 06/08/2025, revised 06/09/2025): apply palm guard to left hand and wear for six hours dailyA review of the facility policy titled Functional Maintenance (effective 02/01/2024), revealed:Policy Statement: Residents may be discharged from restorative programs when goals are met but may still require nursing interventions to maintain their highest practicable level of function.Procedure: Staff are to be instructed on individualized interventions and provided with specific directions and training.A review of the facility's policy titled Contracture Management (effective 02/01/2024), revealed:Policy Statement: Maintaining joint mobility promotes independence, prevents or reduces contractures, stimulates circulation, and enhances muscle strength.Procedure: Review therapy recommendations for range of motion and splint/brace use, and communicate individualized interventions to caregiving staff.

Based on observations, interviews, and record review, the facility failed to maintain a safe, clean, and comfortable environment when resident room equipment was observed with significant dust accumulation, affecting four residents (#38, #18, #5, and #54) with the potential to affect the facility's remaining 47 residents.The findings include:On 04/07/2026 at 9:40 a.m., Resident #38 was observed lying in bed with an oscillating floor fan positioned past the foot of his bed between his bed and Resident #5's bed. While the fan was turned on and in motion, a thick layer of grey dust was observed on the back grate. During an interview, Resident #38 asked whether the fan was caked in dust and stated, Am I breathing that in? (Photographic evidence obtained) Residents #18, #5, and #54 were also observed in their beds in this room at this time.On 04/08/2026 at 9:50 a.m., Resident #38 was not in the room. The oscillating floor fan at the foot of his bed was again observed turned on and in motion, with a thick layer of grey dust on the back grate. Residents #18, #5, and #54 were present in their beds. Two housekeepers were in the room cleaning. During an interview at this time, Housekeeper E was asked who was responsible for cleaning the backs of fans when dust was present. She stated she did not clean them and that the Housekeeping Director would do that. Housekeeper M was interviewed and stated he did not know who cleaned the backs of the fans.On 04/08/2026 at 10:11 a.m., the Housekeeping Manager was interviewed and stated he was responsible for cleaning oscillating fans and cleaned them every two weeks. When asked if he had observed the fan in Resident #38's room, he stated he had and had just cleaned it. When asked if he observed the thick layer of grey dust on the back grate, he stated yes. When asked whether this supported that the fan had not been cleaned within the past two weeks, he stated he did not know but stated he had cleaned it.The Housekeeping Manager provided a document titled Housekeeping Daily Cleaning Schedule (dated 3/25/26), with checkboxes for daily tasks. A review of the document revealed no reference to a resident-specific room or area and did not specify any fan cleaning or dusting tasks. When asked what on the document indicated that fans were being cleaned on a scheduled basis, he stated the form did not indicate that but it was the daily cleaning schedule. He stated he had no other documentation showing when fans were cleaned.A review of the facility's policy titled Environmental Policy and Procedures Manual (effective 2/24/2026) revealed:The facility will maintain a clean, safe, and functional environment that prevents infection and protects residents' health.Environmental Services is responsible for cleaning, disinfection, and sanitation.Daily cleaning of resident rooms is required, and cleaning logs are to be maintained and available for survey review.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were assessed for safe self-administration of medication as clinically appropriate for medications left at bedside for two (Residents #59 and #55) of two residents reviewed for self-administration of medications out of 34 active sampled residents. The findings include: 1.On 4/06/26 at 1:30 PM, a white, round tablet was observed in a clear medication cup on the bedside table for Resident #59. The resident stated the nurse must have left it for him to take last night. Resident #59 was admitted to the facility on [DATE]. His cognitive status was most recently assessed utilizing the Brief Interview for Mental Status on 12/03/25 to show a score of 15 out of 15, indicating the resident was cognitively intact. A review of the resident's assessments and care plans revealed no indication that the resident had been reviewed for the ability to self-administer medications left at the bedside. On 4/06/26 at 1:59 PM, Licensed Practical Nurse (LPN) P was asked to identify the pill in the cup. She stated it was Simethicone. Simethicone is an over-the-counter medication used to relieve symptoms of excess gas. LPN P stated she had not noticed it earlier that day and the resident received it a few times each day. A review of the active physician's orders revealed an order for Simethicone 80 milligrams three times a day at 9 AM, 2 PM, and 9 PM. A review of the Medication Administration Record (MAR) for 4/05/26 showed the Simethicone was documented as given for all three doses that day. On 04/08/26 at 5:00 PM, the Director of Nursing (DON) was asked about the facility's procedure for residents to self-administer medications. She stated residents would be assessed first and would have a physician's order to self-administer medications. She stated the facility currently had no residents who self-administered their own medication, and medications should not be left at the bedside for residents to self-administer. 2.Resident #55 was admitted to the facility on [DATE] with diagnoses including encephalopathy, and acute and chronic respiratory failure with hypercapnia. A review of the Minimum Data Set (MDS) admission assessment, with an assessment reference date of 1/14/26, revealed that Resident #55 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition. On 4/6/26 at 10:48 AM, Resident #55 was observed lying in bed watching television. A bin containing personal items contained two bottles of 2.48-ounce Fluticasone Propionate 50 micrograms (mcg) allergy nasal spray on the resident's bedside table. Resident #55 stated he used the nasal spray daily for stuffiness. On 4/6/26 at 10:54 AM, the resident's bedside table was observed with License Practical Nurse (LPN) P, the primary care nurse. She acknowledged the two bottles of nasal spray. A review of the resident's active physician's orders with LPN P revealed no orders for the Fluticasone Propionate allergy nasal spray found on the resident's bedside table. LPN P stated there was no order for the resident to self-administer medication, but she would contact the Advanced Registered Nurse Practitioner (ARNP) to inquire and possibly obtain a physician's order for administration of the nasal spray. On 4/8/26 at 5:09 PM, the DON stated the self-administration assessment should be conducted to ensure the resident could safely self-administer medication. Residents should have orders to self-administer medication. A review of the facility's policy and procedure for Self-Administration of Medications by Patients/Residents (dated 2/1/24), revealed: If a resident or family member desires to self-administer medication, an assessment is conducted by the Licensed Nurse to assess the individual's cognitive, physical, and visual ability to carry out this responsibility. On 4/8/26 at 5:00 PM, the DON was asked about the procedure for residents to self-administer medications. She stated residents would be assessed first and would have a physician's order to self-administer medications. She stated the facility currently had no residents who self-administered their medication and medications should not be left at the bedside for residents to self-administer.

Based on observations, interviews, and record review, the facility failed to ensure care was provided in a manner that maintained resident dignity for one (Resident #1) of four residents reviewed for dignity, when the resident's indwelling urinary catheter drainage bag was left uncovered. This failure had the potential to affect four residents in the facility with urinary catheter bags.The findings include:On 04/06/2026 at 11:25 a.m., Resident #1 was observed lying in bed with her eyes closed. A visitor was present at the bedside and identified herself as a lifelong friend, stating she visited Resident #1 daily. Resident #1's indwelling urinary catheter (Foley) drainage bag was observed on the right side of the bed (facing the door) and was uncovered, with clear yellow urine visible in the collection bag. Resident #1 was unable to be interviewed.During an interview at that time, the visitor was asked if she believed Resident #1 would be upset if aware that the urinary catheter bag was exposed. The visitor stated, I don't think she'd like that, with all the staff and visitors that are in and out of the room and able to see it. I think she'd want it covered.On 04/07/2026 at 9:29 a.m., Resident #1 was again observed lying in bed with her eyes closed and did not respond to her name being called. The urinary catheter drainage bag was observed on the right side of the bed (door side), uncovered, with clear yellow urine visible in the collection bag. (Photographic evidence obtained)During an interview with Certified Nursing Assistant (CNA) G on 04/08/2026 at 10:35 a.m., she stated her training for residents with urinary catheters included cleaning around the tubing, ensuring there were no kinks in the tubing, and emptying the bag usually twice per shift. When asked about maintaining resident dignity related to urinary catheter care, she stated the drainage bags should be covered.During an interview on 04/09/2026 at 9:40 a.m., the Director of Nursing (DON) stated the facility's expectation was that urinary catheter drainage bags should be covered to maintain resident privacy and dignity.A record review for Resident #1 revealed diagnoses including neuromuscular dysfunction of the bladder, need for assistance with personal care, and dementia.A review of the person-centered care plan revealed:Focus (11/28/2025): Resident has an indwelling suprapubic catheter.Goal (revised 01/20/2026): Resident will remain free from catheter-related trauma through the review date.Interventions: Position catheter bag and tubing below the level of the bladder and away from the door.A review of the current physician's orders revealed:12/20/2025: Change suprapubic Foley catheter as needed for leakage, blockage, or dislodgement.11/26/2025: Drain suprapubic catheter bag every shift and as needed.11/26/2025: Provide suprapubic catheter care daily and as needed.A review of the facility's policy titled Catheter Care, Urinary (Effective 2001), revealed:The purpose was to prevent urinary catheter-associated complications, including urinary tract infections. The policy included directions to keep the catheter tubing and drainage bag off the floor; however, it did not address covering the catheter drainage bag or placement considerations related to resident dignity.

Based on observation, interviews, and record review, the facility failed to ensure that eight (Residents #1, #2, #3, #4, #5, #6, #7, and #8) of eight residents reviewed for foot care were provided with foot care consistent with professional standards of practice, including assisting residents in making necessary appointments with qualified healthcare providers such as podiatrists. Failure to provide appropriate foot care can result in ingrown toenails, fungal infections, skin infections, and can potentially impact the resident's dignity and sense of self-worth.The findings include:1.On 12/11/25 at 9:45 AM, Resident #1 was observed in her room with Certified Nursing Assistant (CNA) B. When asked if anyone had looked at her feet or if she had seen a Podiatrist, Resident #1, replied, No. CNA B removed the resident's socks. Her toenails were very thick and discolored. The resident then gave permission to photograph her toenails. (Photographic evidence obtained)A review of Resident #1's Physician's orders revealed that no order (current, past, or discontinued) was found for podiatry care/visit/referral.2. On 12/11/25 at 9:48 AM, an interview was conducted with resident #2's daughter in the resident's room. When asked about Podiatry care, she stated her mother had not seen a Podiatrist. When asked to see her mother's toenails, she uncovered her feet. The resident's toenails were long and thick. The daughter gave permission to photograph Resident #2's toenails. (Photographic evidence obtained)A review of Resident #2's Physician's orders revealed that no order (current, past, or discontinued) was found for podiatry care/visit/referral.3. On 12/11/25 at 9:58 AM, Resident #3 was interviewed in his room. The resident was sitting in his wheelchair with his shoes and socks on. When asked about his toenails, he stated they are not cut here. He stated he would like to have them cut because they are very long. A review of Resident #3's Physician's orders revealed that no order (current, past, or discontinued) was found for podiatry care/visit/referral.4. On 12/11/25 at 10:03 AM, Resident #4 was interviewed in his room. The resident was in his bed covered with a blanket. When asked about his care, he stated it was ok. When asked about his toenails, he stated they were very tender and removed the blanket. The resident's toenails were very long and thick. Resident #4 gave permission to photograph his toenails. (Photographic evidence obtained) A review of Resident #4 medical record revealed a Podiatry note: Thick and elongated toenails (Appt time: 2/26/2025 12:30:00 PM) (Arrival time: 9:33 AM) physician removed borders of toenails that were painful on right and left feet. There were no other notes in electronic chart regarding foot/toenail care.5. On 12/11/25 at 12:30 PM, a brief interview was conducted with Resident #5. He stated that he would like to have his nails cut because they bothered him. His toenails were observed to be very long. The resident gave permission to photograph his toenails. (Photographic evidence obtained) A review of Resident #5's Physician's orders revealed that no order (current, past, or discontinued) was found for podiatry care/visit/referral.6. On 12/11/25 at 12:33 PM, a brief interview was conducted with Resident #6. He stated his last podiatry visit was in February, and now he is having transportation difficulties. The resident stated his toenails were hurting his skin and painful and he needed to have them cut. His toenails were observed to be very long. The resident gave permission to photograph his toenails. (Photographic evidence obtained) A review of Resident #6's Physician's orders revealed that no order (current, past, or discontinued) was found for podiatry care/visit/referral.7. On 12/11/25 at 12:38 PM, a brief interview was conducted with Resident #7. He stated he would like to have his nails cut because they bothered him. His toenails were observed to be very long. The resident gave permission to photograph his toenails. (Photographic evidence obtained) A review of Resident #7's Physician's orders revealed that no order (current, past, or discontinued) was found for podiatry care/visit/referral.8. On 12/11/25 at 12:41 PM, a brief interview was conducted with Resident #8. She stated she would like to have her nails cut because they bothered her. Her toenails were observed to be very long. The resident gave permission to photograph her toenails. (Photographic evidence obtained) A review of Resident #8's Physician's orders revealed that no order (current, past, or discontinued) was found for podiatry care/visit/referral.On 12/11/25 at 12:49 PM, an interview was conducted with Unit Manager A. When asked about resident assessments and if they look at their feet, she stated yes, but they are only looking for skin issues. She stated she does look at toenails but does not document anything about them. When asked about the nail care policy and procedure, she stated she was not familiar with it. She stated if she has a resident with long or damaged toenails, she will put that resident on a list to see the Podiatrist. She stated social services sets up the appointments. When asked if she would cut a resident's toenails she stated no. When asked about resident's nails causing them pain, she stated that she would call the nurse practitioner for orders.On 12/11/25 at 12:56 PM, an interview was conducted with the Social Services Director (SSD). When asked about podiatry appointments, she stated the facility has used Aria physicians for this, but they only take cash fee-for-service. She stated that she has recently contracted with another Podiatrist that will see anyone in the building, and she hoped they will be able to start this month. The appointment book for previous and current appointments with the Podiatrist was requested. At 1:10 PM, the SSD returned and stated she could not locate the requested appointment book.On 12/11/25 at 1:14 PM, an interview was conducted with CNA B. She stated, If I observe long nails on a resident, I will report it to the nurse. She explained that the staff do not cut the resident's nails.On 12/11/25 at 1:45 PM, an interview was conducted with the DON. When asked about the condition of the residents' toenails, she stated that the new social services director has contracted with a Podiatrist to come to the facility for nail care. She stated they do not have a start date to her knowledge. When asked about the procedure for nail care, she stated she was not familiar with it.

Based on staff interviews, resident and facility record reviews, and a review of facility policies and procedures, the facility failed to thoroughly investigate sexual abuse for one (Resident #1) of three residents reviewed for abuse. Failure to investigate sexual abuse thoroughly, put the facility's female residents at a likelihood for suffering sexual abuse, which could result in serious psychosocial harm, which would diminish their self-worth and self respect. Immediate Jeopardy (IJ) at a scope and severity of J (isolated) was identified on April 7, 2025 at 3:50 p.m. On April 1, 2025, at 6:55 p.m., Immediate Jeopardy began. On April 8, 2025, at 6:15 p.m., the Administrator was notified of the IJ determination and was provided with Immediate Jeopardy Templates. Immediate Jeopardy was ongoing as of the survey exit on April 8, 2025. The findings include: Cross reference F600, F835, and F867. 1. A review of Resident #1's medical record revealed an admitted [DATE]. Her diagnoses included, but were not limited to, metabolic encephalopathy (brain dysfunction leading to altered consciousness, cognitive decline and other neurological symptoms), attention and concentration deficit following cerebral infarction (stroke); extended-spectrum beta-lactamase resistance (ESBL - bacterial infection resistant to antibiotics); dementia in other diseases classified elsewhere, unspecified severity with agitation; general anxiety disorder; schizoaffective disorder; and a need for assistance with personal care. A review of the resident's 3/2/25 physician's orders revealed: - Donepezil Oral tablet 10 milligrams (mg) - give 1 tablet by mouth at bedtime for dementia. - Quetiapine (antipsychotic) Fumarate Oral tablet 50 mg - give 1 tablet by mouth one time a day for anxiety. - Quetiapine Fumarate Oral tablet 50 mg - give 3 tablets by mouth at bedtime for anxiety. - Alprazolam (benzodiazepine - slows the nervous system) oral tablet 0.5 mg - give 1 tablet by mouth every morning and at bedtime for anxiety. - Sertraline HCL (hydrochloride) (selective serotonin reuptake inhibitor - can be used to treat depression, obsessive compulsive disorder, posttraumatic stress disorder, social anxiety disorder and/or panic disorder) oral tablet 100 mg - give 1 tablet by mouth one time a day for depression. - 1:1 monitoring every shift - discontinued on 3/7/25. Additional physician's orders included: - 3/7/2025 - 30-minute monitoring for behaviors, (This order, 30-minute monitoring, was discontinued on 3/19/25). No documentation for increased/frequent monitoring was found from 3/19/2025 through 4/1/2025. - 3/24/2025 - Ciprofloxacin HCL (antibiotic) oral tablet 500 mg - give 500 mg by mouth two times a day for urinary tract infection (UTI) for 14 days. - 4/1/2025 - One-on-one monitoring for behaviors - every shift. A review of the Psychotropic Evaluation nursing note dated 3/2/2025, revealed that Resident #1 had behaviors (e.g. combativeness, verbal disruptions) that were harmful to self or others or limited participation in activities. Increased in acuteness. She could be aggressive with staff. Resident has anxiety or nervousness that impairs his/her quality of life or limits participation in activities. A review of a Behavior Note dated 3/3/2025 revealed: Resident has pulled out her peripherally inserted central catheter (PICC) line from her right upper arm. Some bleeding was observed, pressure applied and Tegaderm (transparent, waterproof, sterile medical dressing) placed after it stopped. Resident remains aggressive, attempting to bite several staff members and kick. New order for Haldol (antipsychotic) intramuscularly (IM) given per Advanced Practice Registered Nurse (APRN) - Ineffective, continues to walk around yelling and screaming. Redirected as staff walks along with her. A review of the Provider Encounter dated 3/14/25 revealed that the resident wandered and attempted to hit and bite staff. She continued to refuse clothing changes as needed. Psychiatry was consulted to see resident and schedule next week. The Haldol order remained in place for behavioral management. (Psychiatry notes were requested but not provided during the survey.) An Encounter note dated 3/20/25 recommended that the resident continue with 30-minute behavior checks for safety monitoring. (The order was not implemented. Copies obtained) An Encounter note dated 4/2/25 revealed that Resident #1 was seen for a behavioral follow up. She was found in a male resident's bed last night with what appears to be inappropriate touching and sexual behavior. Resident was returned to one-on-one (1:1) care. A Nursing Progress note dated 4/2/25 read, Resident is up pacing around in her room, up and down in her bed, difficult to redirect, very aggressive with staff, swinging at them, screaming out loud, cursing, knocked over everything on her bedside table, attempted to get in a bed with a resident in the bed, displayed aggressive behavior when trying to redirect. New order given to administer Haldol 0.5 mg IM (intramuscularly - in the muscle) due to aggressive behavior. She remains on 1:1 care. A review of the Admission 5-day minimum data set (MDS) assessment with a reference date of 3/6/25, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 01 out of 15 possible points, indicating severe cognitive impairment. The resident was noted to be delusional, and physically and verbally aggressive with wandering behavior. She received antipsychotic, antianxiety, antidepressant, and antibiotic medications during the assessment period. A review of the Care Plan (initiated 4/1/25, revised 4/1/25) revealed that the resident had Impaired Cognitive Function/Dementia or Impaired Thought Processes related to dementia, schizoaffective disorder, difficulty making decisions and psychotropic drug use. The resident will be able to communicate basic needs on a daily basis. The care plan noted that the resident had a behavior problem of making inappropriate sexual advances to other residents, aggression and other inappropriate behaviors with a history of UTIs, pacing, wandering, disrobing, inappropriate response to verbal communication, violence, aggression towards staff/others. Pulled out PICC line. Pulled out Foley (urinary) catheter. Resident will have fewer episodes of undesired behaviors. The resident will have no evidence of behavior problems. 1:1 care (downgraded, failed attempt) frequent checks 1:1 caregiver reinitiated 4/1. Move to a room away from patient she appears to favor. 2. A review of Resident #2's medical record revealed an admitted [DATE] and a discharge date of [DATE]. His diagnoses included dysphagia (difficulty swallowing) following cerebral infarction (stroke), type 2 diabetes mellitus (DM), difficulty walking, lack of coordination, and hypertension (HTN). No psychiatric diagnoses/mental health disorders were noted. A review of Resident #2's 3/18/25 physician's orders revealed: - Occupational therapy (OT) - Resident to be seen 5 times a week for 60 days with a focus on therapeutic exercises, therapeutic activity, self-care management, neuromuscular re-education training, group treatment when appropriate, and wheelchair management. - Skilled physical therapy (PT) services following hospitalization for 5 times a week for 4 weeks for therapeutic exercises, therapeutic activities, neuromuscular re-education, gait training, group therapy and manual. - Clopidogrel bisulfate (inhibits blood clotting) 75 mg via percutaneous endoscopic gastrostomy (PEG) tube (feeding tube passed into a resident's stomach through the abdominal wall) one time a day (QD) for deep vein thrombosis (DVT). - Amlodipine 10 mg via PEG QD for HTN. - Ezetimibe (cholesterol medication) 10 mg via PEG at bedtime for hyperlipidemia. - Lantus (insulin) 100 unit/ml (units per milliliter) inject 16 units subcutaneously (beneath the skin) at bedtime for DM. There was no physician's order for one-on-one (1:1) supervision. (Copies obtained) A review of Resident #2's Admission 5-day MDS, with a reference date of 3/24/25, revealed that the resident had a BIMS score of 12 out of 15 possible points, indicating moderate cognitive impairment. No behaviors were noted. He reported feeling depressed with little to no interest in doing things. He ambulated with a cane and required partial to moderate assistance with transfers. He did not receive psychotropic medications during the assessment period. A review of Resident #2's Care Plan, initiated on 4/3/25, revealed that the resident had a focus area for Behavior related to hypersexuality and was noncompliant with dietary restrictions. Interventions included the following: 1. Administer medications as ordered. Monitor side effects and effectiveness. 2. Caregivers to provide opportunity for positive interaction, attention. Stop and talk to him/her as passing by. 3. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. 4. Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. 5. Praise any indication of the resident's progress/improvement in behavior. All interventions were initiated on 4/3/25, two days after the event. There was no intervention for increased supervision for Resident #2 from the care plan initiation date through his transfer to the sister facility on 4/6/25. (Copy obtained) The Care Plan revealed a focus area for Impaired Cognitive Function/Dementia or Impaired Thought Processes related to impaired decision making, initiated on 4/1/25. Interventions included, but were not limited to, the following: 1. Administer medications as ordered. Monitor/document for side effects and effectiveness. 2. Ask yes/no questions in order to determine the resident's needs. 3. Communicate with the resident/family/caregivers regarding resident's capabilities and needs. 4. Cue, reorient and supervise as needed. 5. Monitor/document and report PRN (as needed) any changes in cognitive function, specifically changes in decision making ability, memory, recall, and general awareness, difficulty expressing self, and difficulty understanding others. There was no intervention for increased supervision for Resident #2 after the 4/1/25 incident through the resident's transfer to the sister facility on 4/6/25. (Copy obtained). A Nursing Progress note dated 4/2/25, revealed that Resident #2's family member was notified that the resident could be transferred to the sister facility on Friday (4/4/25). The family member stated he would think everything over because he was not in agreement. The administrator would follow up with him. A Physician's Note dated 4/2/25, revealed that the resident was seen for behavioral follow-up status post incident with resident. Female resident was found in the resident's bed with likely inappropriate touching or sexual behavior noted. The female resident is quite confused. He (Resident #2) was placed on one-on-one care for observation. He was told about the inappropriateness of his behavior. He appeared to be slightly confused but is aware of inappropriate behavior. A Physician's Note dated 4/4/25, revealed that Resident #2 was evaluated for discharge. He will be discharged to another skilled nursing facility, as he had a sexual encounter with another resident at this facility. On 4/7/25 at 1:25 p.m., the Administrator and the Administrator in Training (AIT) were interviewed regarding the timeline of events as related to the 4/1/25 incident between Residents #1 and #2. The Administrator stated on 4/1/25 at approximately 6:00 p.m., Residents #1 and #2 were in the dining room area. Resident #1 was observed tapping Resident #2's shoulder. The assigned nurse, Licensed Practical Nurse (LPN) C, who was at the nurses' station, separated the residents. Approximately five minutes later, Resident #1 was observed attempting to sit on Resident #2's walker. Again, the residents were separated and put at different ends of the dining area. Resident #2 was educated and voiced understanding. At approximately 6:30 p.m., LPN C went to conduct blood glucose monitoring for another resident and walked away from the dining area. When she returned, she noticed that both Resident #1 and Resident #2 were not in the dining area. LPN C walked to Resident #2's room and found both residents (#1 and #2). Resident #1 was observed in Resident #2 's bed lying supine, fully clothed, with her pants unbuttoned and her zipper down. Resident #2 stood to the right of her. He was fully clothed with his hand inside of Resident #1's pants. He quickly pulled his hand out of her pants when the nurse walked in. The Administrator stated during the investigation, however, the assigned nurse, LPN C, could not determine if Resident #2's hand was actually inside Resident #1's pants. The Administrator further stated Resident #2 may have had the intention of placing his hand in Resident #1's pants, but he had not actually done it. He just pulled his hand away when the nurse walked into the room. Resident #1 was taken back to her room. When the Administrator was asked if there were any other witnesses to the event, he replied that Registered Nurse (RN) A/Weekend Supervisor, was the only witness present at the time and she also wrote a statement. During an interview on 4/07/25 at 3:30 p.m., Registered Nurse (RN) A stated she had been employed by the facility for about a year as a floor nurse. In November 2024 she was promoted to evening supervisor. As of Friday (4/4/25), she was asked to be the interim Director of Nursing (DON) since the previous DON had resigned. When asked if she was familiar with Residents #1 and #2, she stated Resident #1 was confused, verbally and physically aggressive towards staff, and refused care and medications. She stated the resident had not had any sexually inappropriate behaviors before this incident with Resident #2. Resident #2 was alert and oriented times three (person, place and time). He had no behaviors except noncompliance with diet orders. She stated on 4/1/24 she was working on the floor on the 200 hall. At 5:30 p.m., Residents #1 and #2 were observed in the dining area watching television. She was at the nurses' station with Licensed Practical Nurse (LPN) C, and they were completing their daily documentation. She stated at approximately 6:00 p.m., Resident #1 was seated on Resident #2's walker. LPN C separated the two residents. The residents were again observed holding hands, and she approached both residents and explained to Resident #2 that he could not hold hands with resident #1 because she was not alert and oriented. The residents were separated again. She then left the area to attend to another resident and left LPN C at the nurses' station. She stated she was not present in Resident #2's room when the two residents were found there. A telephone interview was conducted on 4/7/25 at 3:50 p.m. with LPN B who stated she had worked in the facility for about a year and on 4/1/25, she was coming in to work her 7:00 p.m. to 7:00 a.m. shift when the assigned nurse (LPN C) mentioned that Residents #1 and #2 were having behaviors. At that time, they noticed that neither Resident #1 nor Resident #2 were in the dining area. LPN B and LPN C then went to Resident #2's room together at approximately 6:55 p.m. looking for the residents. As they walked into Resident #2's room, they saw that his right hand was inside of Resident #1's pants. LPN B stated she and LPN C separated the residents and LPN C notified the Administrator (referring to the AIT). LPN B explained that she completed a witness statement and pushed it under the Administrator's door. When asked if the written statement was in addition to/followed by a telephone interview, she replied, No one called me. I typed up my observations. She provided a copy of her statement. A follow-up interview was conducted on 4/7/25 at 4:31 p.m. with the Administrator who was asked for any surveillance videos. He stated the surveillance video cameras were not working. When asked again if there was another witness to the incident, he said, There were no other witnesses. He was asked about the witness noted in the federal incident report. The Administrator stated she was another nurse who was assisting with a respiratory program. He further stated this other nurse was asked by LPN C (assigned nurse) if she had seen the residents. LPN C and this other nurse then both walked into Resident #2's room. The Administrator stated this other nurse/witness entered Resident #2's room after the assigned nurse (LPN C) and did not witness what happened. When asked if he had a witness statement from this second nurse, the Administrator stated he might not have put it in the investigative file that had been provided to the surveyor. He stated he would provide it. At 4:53 p.m., the Administrator provided a statement indicating that a phone interview was conducted on 4/1/25 with LPN I, whose name was on the statement. The statement indicated that LPN I did not witness the incident. When asked why LPN I was not on the schedule for 4/1/25, the Administrator stated the staffing person may have forgotten to add LPN I since she was not working a medication cart. He further stated he would provide an updated schedule. The reprinted schedule provided for review did not match the name of LPN B (who witnessed the incident with LPN C) or LPN I; it indicated LPN J. A review of the employee roster printed on 4/7/25 revealed that there was no employee by the name of LPN I, who was noted in the witness statement, on the facility's roster. Another interview was conducted with the Administrator on 4/7/25 at 5:08 p.m. He was asked about the differing names on the federal incident report, the witness statement he provided, and the schedule for 4/1/25. He stated LPN B went by LPN J's name. When asked why the schedule had a different name (LPN J), he walked out of the room stating he would clarify with the staffing department. A follow-up interview was conducted with LPN B on 4/8/25 at 5:18 p.m. She confirmed her full name as well as her [NAME]. She stated the name on the statement the Administrator had provided for review was her sister's name. She added that her sister, who also worked in the facility, would not have been able to make a statement regarding the incident involving Residents #1 and #2, because she was not working on the day of the incident, 4/1/25. LPN B stated she and LPN C entered Resident #2's room at the same time on 4/1/25 and again confirmed they both witnessed Resident #2 with his hand under the zipper and inside the pants of Resident #1. LPN B again confirmed that her sister was not in the facility at the time of the incident, and that she did not have an [NAME]. Another follow up interview was conducted on 4/7/25 at 5:50 p.m. with the Administrator who stated he contacted LPN B, and she confirmed that she entered the room at the same time with LPN C and witnessed Resident #2 removing his hand from Resident #1's pants. He stated he had contacted LPN C and was unable to reach her. He added that with the new information he would close the investigation and substantiate the abuse allegation. On 4/8/25 at 11:45 a.m., a visit was made to the sister facility where Resident #2 had been discharged after the incident. Resident #2 was observed in the bed adjacent to the window with his eyes closed. He was clean and appropriately dressed. There was a rollator walker and a cane at his bedside. He opened his eyes, and an interview was conducted at this time. Resident #2 stated he was a little sleepy. When asked if he was unwell, he replied, no. When he was asked when and why he was discharged to this sister facility, he said, They transferred me here a few days ago. I did not have a choice. When asked if he could recall the 4/1/25 incident in the other facility where a female resident was found in his bed, he replied, A female resident? Yes, she was in my bed. He declined to provide further details about the incident. He said, I don't want to answer any more questions. On 4/8/25 at 12:07 p.m., a joint interview was conducted with LPN L/MDS Nurse and Registered Nurse N/Director of Nursing (DON) at the sister facility. They both stated they were involved with the admission process. They both stated that a care plan was established from the resident's diagnoses, physician's orders, and any additional information from the medical record. When they were asked about Resident #2's functional status, LPN L stated Resident #2 had a BIMS score of 14 out of 15 possible points, indicating intact cognition was ambulatory with the use of a walker. They both stated Resident #2 was transferred from the sister facility because of a sexual encounter with another resident and the need for long-term care placement. When asked if they had established any behavior care plan for this resident, they stated the behavior care plan established was only related to non-compliance with the resident's diet. They added that they did not initiate a sexual behavior care plan because they were informed that the other female resident initiated the sexual act. During an interview on 4/8/25 at 2:19 p.m., the Administrator and the AIT where asked if there were any identified opportunities for improvement. The Administrator stated there was a missed opportunity for Resident #1 regarding her behaviors. He further stated there were opportunities on 4/1/25 when Resident #1 had behaviors and staff could have provided more supervision, but they walked away. When asked if they had identified opportunities for improving their abuse investigation and reporting, the Administrator replied, What exactly? He was reminded that he had mentioned on 4/7/25 that the allegation could not be verified, and then at the end of the day he stated that the allegation was substantiated. He said that per LPN C they could not verify the allegation. He confirmed that he did not obtain a statement from Resident #2. A telephone interview was conducted on 4/8/25 at 5:37 p.m. with LPN C. She stated she had worked at the facility for about a year. She confirmed that she was assigned to Residents #1 and #2 on 4/1/25. She explained that she was sitting at the nurses' station at approximately 6:00 p.m. and observed Resident #1 rubbing Resident #2's shoulder and trying to pull him close to her while grabbing his hand. Resident #2 allowed her to do so after being told three times that Resident #1 was not as alert and oriented as him and he should not allow the behavior. This behavior went on over the course of 15-20 minutes. Resident #1 was also observed trying to sit on Resident #2's walker. Resident #2 was informed that he should not allow her to do that. Resident #1 was redirected and went back to the chair she was sitting in before - away from Resident #2. Both residents continued to watch television with the other residents. At approximately 6:30 p.m., LPN C went to complete blood glucose monitoring on a resident near the dining room. When she came out of that resident's room, the night shift nurse had arrived (LPN B). LPN A noticed that the two residents (#1 and #2) were not in the dining room any longer. Together with the night nurse (LPN B) at approximately 6:55 p.m., LPN C quickly went to Resident #2's room and observed Resident #1 lying in his bed on her back fully clothed with her pants unbuttoned and her zipper down while Resident #2 stood to the right of her fully clothed with his right hand inside of Resident #1's pants. When he saw the nurses, he quickly pulled his hand out of her pants. Resident#1 was quickly assisted out of the room while Resident #2 remained in his room. LPN C confirmed that she and LPN B entered the room at the same time. She stated she notified the evening supervisor, the DON, and the Administrator. She stated both residents were placed on 1:1 supervision. She confirmed that she was not contacted by any administrative team member at facility about the 4/1/25 incident until 4/8/25. On 4/8/25, the Administrator contacted her and she explained to the Administrator what occurred exactly as she had in her previously written statement. A review of the facility's Abuse, Neglect, and Misappropriation policy (effective 2/1/24, reviewed 1/1/25), revealed: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual Abuse: Is defined as non-consensual sexual contact of any type with a resident. E. Investigation Guidelines 1. The facility Administrator will investigate all allegations, reports, grievances, and incidents that potentially could constitute allegations of abuse, injuries of unknown source, exploitation, or suspicions of crime as defined in this document. the facility Administrator retains the ultimate responsibility to oversee and complete the investigation, and to draw conclusions regarding the nature of the incident. 2. The investigation should include interviews of the involved persons, including alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 3. To the extent possible and applicable, provide complete and thorough documentation of the investigation. 4. The investigation should be documented, and any specific forms required by the State, or as otherwise instructed by legal counsel use (if applicable). The documentation will be kept in the facility Administrator or Director of Nursing's office in a secure administrative file marked confidential, or as otherwise instructed by legal counsel (if applicable). If any written statements or notes relating to the investigation are prepared, they should not be placed in any Stakeholder's personnel files. 5. All investigation documents and materials are to be held in strict confidence and cannot be shared with any unauthorized person. 6. The facility Administrator will make reasonable efforts to determine the root cause of the alleged violation and will implement corrective action consistent with the investigative findings and take steps to eliminate any ongoing danger to the resident or residents. 7. Any affected resident's physician and family/responsible party will be informed of the result of the investigation. 8. Every substantiated allegation of abuse will be reviewed by the facility's Quality Assurance and Performance Improvement Committee to detect potential patterns or trends, and for consideration of further interventions or training opportunities. The Medical Director should be notified and involved. 9. If the investigation substantiates an allegation of abuse or suspicion of crime by a Stakeholder, the facility Administrator will inform the applicable state licensure authority or Aide Abuse Registry pursuant to such agency's reporting procedures and as required by state or federal law. 10. The Governing Body will be informed of the receipt of allegations of abuse, neglect, exploitation, or misappropriation and the results of the investigation via the QAPI (Quality Assurance and Performance Improvement) process.

Based on observations, a review of resident and facility records, interviews with staff, and a review of job descriptions and facility policies and procedures, the facility failed to protect the resident's right to be free from sexual abuse from a resident. This resulted in sexual contact for one resident who was unable to consent to sexual activity (Resident #1) of three residents reviewed for abuse. The facility failed to develop and implement interventions necessary to protect Resident #1 from sexual contact by Resident #2, who had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points, indicating moderate cognitive impairment, and who was independently ambulatory with the use of a cane. This created a likelihood that Resident #1 could be abused again, or any other vulnerable resident could be sexually assaulted and suffer serious psychosocial and/or physical harm from Resident #2. Resident #1 was unable to consent to sexual activity due to severely impaired cognition. She had a likelihood to suffer serious psychosocial harm not yet realized, because of her inability to consent to sexual activity. Other residents also could suffer the same outcome if Resident #2 were to sexually abuse them. This diminished their self-worth and self-respect. Immediate Jeopardy (IJ) at a scope and severity of J (isolated) was identified on April 7, 2025 at 3:50 p.m. On April 1, 2025, at 6:55 p.m., Immediate Jeopardy began. On April 8, 2025, at 6:15 p.m., the Administrator was notified of the IJ determination and was provided with Immediate Jeopardy Templates. Immediate Jeopardy was ongoing as of the survey exit on April 8, 2025. The findings include: Cross reference F610, F835, and F867. 1. A review of Resident #1's medical record revealed an admitted [DATE]. Her diagnoses included, but were not limited to, metabolic encephalopathy (brain dysfunction leading to altered consciousness, cognitive decline and other neurological symptoms), attention and concentration deficit following cerebral infarction (stroke); extended-spectrum beta-lactamase resistance (ESBL - bacterial infection resistant to antibiotics); dementia in other diseases classified elsewhere, unspecified severity with agitation; general anxiety disorder; schizoaffective disorder; and need for assistance with personal care. A review of the resident's 3/2/25 physician's orders revealed: - Donepezil Oral tablet 10 milligrams (mg) - give 1 tablet by mouth at bedtime for dementia. - Quetiapine (antipsychotic) Fumarate Oral tablet 50 mg - give 1 tablet by mouth one time a day for anxiety. - Quetiapine Fumarate Oral tablet 50 mg - give 3 tablets by mouth at bedtime for anxiety. - Alprazolam (benzodiazepine - slows the nervous system) oral tablet 0.5 mg - give 1 tablet by mouth every morning and at bedtime for anxiety. - Sertraline HCL (hydrochloride) (selective serotonin reuptake inhibitor - can be used to treat depression, obsessive compulsive disorder, posttraumatic stress disorder, social anxiety disorder and/or panic disorder) oral tablet 100 mg - give 1 tablet by mouth one time a day for depression. - 1:1 monitoring every shift - discontinued on 3/7/25. Additional physician's orders included: - 3/7/2025 - 30-minute monitoring for behaviors, (This order, 30-minute monitoring, was discontinued on 3/19/25). No documentation for increased/frequent monitoring was found from 3/19/2025 through 4/1/2025. - 3/24/2025 - Ciprofloxacin HCL (antibiotic) oral tablet 500 mg - give 500 mg by mouth two times a day for urinary tract infection (UTI) for 14 days. - 4/1/2025 - One-on-one monitoring for behaviors - every shift. A review of the Psychotropic Evaluation nursing note dated 3/2/2025, revealed that Resident #1 had behaviors (e.g. combativeness, verbal disruptions) that were harmful to self or others or limited participation in activities. Increased in acuteness. She could be aggressive with staff. Resident has anxiety or nervousness that impairs his/her quality of life or limits participation in activities. A review of a Behavior Note dated 3/3/2025 revealed: Resident has pulled out her peripherally inserted central catheter (PICC) line from her right upper arm. Some bleeding was observed, pressure applied and Tegaderm (transparent, waterproof, sterile medical dressing) placed after it stopped. Resident remains aggressive, attempting to bite several staff members and kick. New order for Haldol (antipsychotic) intramuscularly (IM) given per Advanced Practice Registered Nurse (APRN) - Ineffective, continues to walk around yelling and screaming. Redirected as staff walks along with her. A review of the Provider Encounter dated 3/14/25 revealed that the resident wandered and attempted to hit and bite staff. She continued to refuse clothing changes as needed. Psychiatry was consulted to see resident and schedule next week. The Haldol order remained in place for behavioral management. (Psychiatry notes were requested but not provided during the survey.) An Encounter note dated 3/20/25 recommended that the resident continue with 30-minute behavior checks for safety monitoring. (The order was not implemented. Copies obtained) An Encounter note dated 4/2/25 revealed that Resident #1 was seen for a behavioral follow up. She was found in a male resident's bed last night with what appears to be inappropriate touching and sexual behavior. Resident was returned to one-on-one (1:1) care. A Nursing Progress note dated 4/2/25 read, Resident is up pacing around in her room, up and down in her bed, difficult to redirect, very aggressive with staff, swinging at them, screaming out loud, cursing, knocked over everything on her bedside table, attempted to get in a bed with a resident in the bed, displayed aggressive behavior when trying to redirect. New order given to administer Haldol 0.5 mg IM (intramuscularly - in the muscle) due to aggressive behavior. She remains on 1:1 care. A review of the Admission 5-day minimum data set (MDS) assessment with a reference date of 3/6/25, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 01 out of 15 possible points, indicating severe cognitive impairment. The resident was noted to be delusional, and physically and verbally aggressive with wandering behavior. She received antipsychotic, antianxiety, antidepressant, and antibiotic medications during the assessment period. A review of the Care Plan (initiated 4/1/25, revised 4/1/25) revealed that the resident had Impaired Cognitive Function/Dementia or Impaired Thought Processes related to dementia, schizoaffective disorder, difficulty making decisions and psychotropic drug use. The resident will be able to communicate basic needs on a daily basis. The care plan noted that the resident had a behavior problem of making inappropriate sexual advances to other residents, aggression and other inappropriate behaviors with a history of UTIs, pacing, wandering, disrobing, inappropriate response to verbal communication, violence, aggression towards staff/others. Pulled out PICC line. Pulled out Foley (urinary) catheter. Resident will have fewer episodes of undesired behaviors. The resident will have no evidence of behavior problems. 1:1 care (downgraded, failed attempt) frequent checks 1:1 caregiver reinitiated 4/1. Move to a room away from patient she appears to favor. Resident #1 was admitted on [DATE]. The following comprehensive care plans were initiated: 3/3/2025 - Nutrition/Hydration Risk 3/4/2025 - Depression 3/8/2025 - Urinary Tract Infection The incident with Resident #2 occurred on 4/1/25. The following comprehensive care plans were initiated on 4/1/25: 4/1/2025 - Dementia 4/1/2025 - Skin Integrity 4/1/2025 - Activities 4/1/2025 - Incontinence 4/1/2025 - Fall Risk 4/1/2025 - Infection 4/1/2025 - Psychotropic Use 4/1/2025 - Anxiety 4/1/2025 - Elopement Risk 4/1/2025 - Dehydration 4/1/2025 - Behaviors 4/1/2025 - Advance Directives 4/1/2025 - Anticoagulant Therapy 4/1/2025 - Cardiovascular 4/1/2025 - Gastrointestinal 4/1/2025 - ADL Self-Care Performance Deficit 2. A review of Resident #2's medical record revealed an admitted [DATE] and a discharge date of [DATE]. His diagnoses included dysphagia (difficulty swallowing) following cerebral infarction (stroke), type 2 diabetes mellitus (DM), difficulty walking, lack of coordination, and hypertension (HTN). No psychiatric diagnoses/mental health disorders were noted. A review of Resident #2's 3/18/25 physician's orders revealed: - Occupational therapy (OT) - Resident to be seen 5 times a week for 60 days with a focus on therapeutic exercises, therapeutic activity, self-care management, neuromuscular re-education training, group treatment when appropriate, and wheelchair management. - Skilled physical therapy (PT) services following hospitalization for 5 times a week for 4 weeks for therapeutic exercises, therapeutic activities, neuromuscular re-education, gait training, group therapy and manual. - Clopidogrel bisulfate (inhibits blood clotting) 75 mg via percutaneous endoscopic gastrostomy (PEG) tube (feeding tube passed into a resident's stomach through the abdominal wall) one time a day (QD) for deep vein thrombosis (DVT). - Amlodipine 10 mg via PEG QD for HTN. - Ezetimibe (cholesterol medication) 10 mg via PEG at bedtime for hyperlipidemia. - Lantus (insulin) 100 unit/ml (units per milliliter) inject 16 units subcutaneously (beneath the skin) at bedtime for DM. There was no physician's order for one-on-one (1:1) supervision. (Copies obtained) A review of Resident #2's Admission 5-day MDS, with a reference date of 3/24/25, revealed that the resident had a BIMS score of 12 out of 15 possible points, indicating moderate cognitive impairment. No behaviors were noted. He reported feeling depressed with little to no interest in doing things. He ambulated with a cane and required partial to moderate assistance with transfers. He did not receive psychotropic medications during the assessment period. A review of Resident #2's Care Plan, initiated on 4/3/25, revealed that the resident had a focus area for Behavior related to hypersexuality and was noncompliant with dietary restrictions. Interventions included the following: 1. Administer medications as ordered. Monitor side effects and effectiveness. 2. Caregivers to provide opportunity for positive interaction, attention. Stop and talk to him/her as passing by. 3. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. 4. Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. 5. Praise any indication of the resident's progress/improvement in behavior. All interventions were initiated on 4/3/25, two days after the event. There was no intervention for increased supervision for Resident #2 from the care plan initiation date through his transfer to the sister facility on 4/6/25. (Copy obtained) The Care Plan revealed a focus area for Impaired Cognitive Function/Dementia or Impaired Thought Processes related to impaired decision making, initiated on 4/1/25. Interventions included, but were not limited to, the following: 1. Administer medications as ordered. Monitor/document for side effects and effectiveness. 2. Ask yes/no questions in order to determine the resident's needs. 3. Communicate with the resident/family/caregivers regarding resident's capabilities and needs. 4. Cue, reorient and supervise as needed. 5. Monitor/document and report PRN (as needed) any changes in cognitive function, specifically changes in decision making ability, memory, recall, and general awareness, difficulty expressing self, and difficulty understanding others. There was no intervention for increased supervision for Resident #2 after the 4/1/25 incident through the resident's transfer to the sister facility on 4/6/25. (Copy obtained) Resident #2 was admitted on [DATE]. The following comprehensive care plan was initiated on 3/24/2025 - Nutrition/Hydration Risk. The incident with Resident #1 occurred on 4/1/25. The following comprehensive care plans were initiated on 4/1/25 and later: 4/1/2025 - History if CVA (cardiovascular accident)/Stroke 4/1/2025 - Advance Directives 4/1/2025 - Diabetes 4/1/2025 - Cardiovascular 4/1/2025 - Cognitive Deficit 4/1/2025 - Pain 4/1/2025 - Activities 4/1/2025 - Anticoagulant Use 4/1/2050 - Hypertension 4/1/2025 - Elopement Risk 4/1/2025 - Fall Risk 4/1/2025 - G Tube (feeding tube) 4/1/2025 - Noncompliance with Dietary Restrictions and Activities of Daily Living. 4/3/2025 - Behavior (hypersexuality) - Two days after the incident with Resident #1. On 4/6/25, Resident #2 was transferred to the sister facility. On 4/7/25 and later, he was care planned for the following: 4/7/2025 - Nutritional/Hydration Risk 4/7/2025 - Tube Feeding 4/8/2025 - Risk for Falls related to gait/balance problem. 4/8/2025 - Behaviors/Sexual Advances related to hypersexuality. Interventions did not include close supervision or supervision at all. Many interventions called for specific information that was left blank. There was no care plan for Impaired Cognition. A Physician's Note dated 4/2/25, revealed that the resident was seen for behavioral follow-up status post incident with resident. Female resident was found in the resident's bed with likely inappropriate touching or sexual behavior noted. The female resident is quite confused. He (Resident #2) was placed on one-on-one care for observation. He was told about the inappropriateness of his behavior. He appeared to be slightly confused but is aware of inappropriate behavior. On 4/7/25 at 1:25 p.m., the Administrator confirmed that Resident #2's one-on-one (1:1) supervision was discontinued because Resident #1 was the resident who initiated the sexual behavior. During an interview on 4/07/25 at 3:30 p.m., Registered Nurse (RN) A stated she had been employed by the facility for about a year as a floor nurse. In November 2024 she was promoted to evening supervisor. As of Friday (4/4/25), she was asked to be the interim Director of Nursing (DON) since the previous DON had resigned. When asked if she was familiar with Residents #1 and #2, she stated Resident #1 was confused, verbally and physically aggressive towards staff, and refused care and medications. She stated the resident had not had any sexually inappropriate behaviors before this incident with Resident #2. Resident #2 was alert and oriented times three (person, place and time). He had no behaviors except noncompliance with diet orders. She stated on 4/1/24 she was working on the floor on the 200 hall. At 5:30 p.m., Residents #1 and #2 were observed in the dining area watching television. She was at the nurses' station with Licensed Practical Nurse (LPN) C, and they were completing their daily documentation. She stated at approximately 6:00 p.m., Resident #1 was seated on Resident #2's walker. LPN C separated the two residents. The residents were again observed holding hands, and she approached both residents and explained to Resident #2 that he could not hold hands with resident #1 because she was not alert and oriented. The residents were separated again. She then left the area to attend to another resident and left LPN C at the nurses' station. She stated she was not present in Resident #2's room when the two residents were found there. A telephone interview was conducted on 4/7/25 at 3:50 p.m., with LPN B. She stated she had worked in the facility for about a year and on 4/1/25, she was coming in to work her 7:00 p.m. to 7:00 a.m. shift when the assigned nurse mentioned that Residents #1 and #2 were having behaviors. At that time, they noticed that neither Resident #1 nor Resident #2 were in the dining area. LPN B and LPN C then went to Resident #2's room together at approximately 6:55 p.m. looking for the residents. As they walked into Resident #2's room, they saw that his right hand was inside of Resident #1's pants. LPN B stated she and LPN C separated the residents and LPN C notified the Administrator (referring to the Administrator in Training (AIT). On 4/8/25 at 11:45 a.m., a visit was made to the sister facility where Resident #2 had been discharged after the incident. Resident #2 was observed in the bed adjacent to the window with his eyes closed. He was clean and appropriately dressed. There was a rollator walker and a cane at his bedside. He opened his eyes, and an interview was conducted at this time. Resident #2 stated he was a little sleepy. When asked if he was unwell, he replied, no. When he was asked when and why he was discharged to this sister facility, he said, They transferred me here a few days ago. I did not have a choice. When asked if he could recall the 4/1/25 incident in the other facility where a female resident was found in his bed, he replied, A female resident? Yes, she was in my bed. He declined to provide further details about the incident. He said, I don't want to answer any more questions. On 4/8/25 at 12:07 p.m., a joint interview was conducted with LPN L/MDS Nurse and Registered Nurse N/Director of Nursing (DON) at the sister facility. They both stated they were involved with the admission process. They both stated that a care plan was established from the resident's diagnoses, physician's orders, and any additional information from the medical record. When they were asked about Resident #2's functional status, LPN L stated Resident #2 had a BIMS score of 14 out of 15 possible points, indicating intact cognition was ambulatory with the use of a walker. They both stated Resident #2 was transferred from the sister facility because of a sexual encounter with another resident and the need for long-term care placement. When asked if they had established any behavior care plan for this resident, they stated the behavior care plan established was only related to non-compliance with the resident's diet. They added that they did not initiate a sexual behavior care plan because they were informed that the other female resident initiated the sexual act. An interview was conducted on 4/8/25 at 1:43 p.m. with Resident #1's spouse. He stated he was contacted by the facility when the incident occurred. This was the first time anything like this had happened. He was asked how he felt his wife would have responded to the actions of Resident #2 if she was not cognitively impaired. He stated that in her previous life his wife was very modest. She would have been very upset over Resident #2's actions. A telephone interview was conducted on 4/8/25 at 5:37 p.m. with LPN C. She stated she had worked at the facility for about a year. She confirmed that she was assigned to Residents #1 and #2 on 4/1/25. She explained that she was sitting at the nurses' station at approximately 6:00 p.m. and observed Resident #1 rubbing Resident #2's shoulder and trying to pull him close to her while grabbing his hand. Resident #2 allowed her to do so after being told three times that Resident #1 was not as alert and oriented as him and he should not allow the behavior. This behavior went on over the course of 15 to 20 minutes. Resident #1 was also observed trying to sit on Resident #2's walker. Resident #2 was informed that he should not allow her to do that. Resident #1 was redirected and went back to the chair she was sitting in before - away from Resident #2. Both residents continued to watch television with the other residents. At approximately 6:30 p.m., LPN C went to complete blood glucose monitoring on a resident near the dining room. When she came out of that resident's room, the night shift nurse had arrived (LPN B). LPN A noticed that the two residents (#1 and #2) were not in the dining room any longer. Together with the night nurse (LPN B) at approximately 6:55 p.m., LPN C quickly went to Resident #2's room and observed Resident #1 lying in his bed on her back fully clothed with her pants unbuttoned and her zipper down while Resident #2 stood to the right of her fully clothed with his right hand inside of Resident #1's pants. When he saw the nurses, he quickly pulled his hand out of her pants. Resident#1 was quickly assisted out of the room while Resident #2 remained in his room. LPN C confirmed that she and LPN B entered the room at the same time. She stated she notified the evening supervisor, the DON, and the Administrator. She stated both residents were placed on 1:1 supervision. She confirmed that she was not contacted by any administrative team member at facility about the 4/1/25 incident until 4/8/25. On 4/8/25, the Administrator contacted her and she explained to the Administrator what occurred exactly as she had in her previously written statement. A review of the job descriptions for Charge Nurse LPN/RN (both effective January 2025), revealed that the primary purpose of the Charge Nurse was to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing or Unit Manager to ensure that the highest degree of quality care is maintained at all times. ESSENTIAL DUTIES AND RESPONSIBILITIES - Direct/supervise the day-to-day functions of the licensed nurses and nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility. - Ensure that all assigned nursing personnel comply with the written policies and procedures established by the facility. - Make written and oral reports/recommendations concerning the activities of your shift as required. - Cooperate with other resident services when coordinating nursing services to ensure that the resident's total regimen of care is maintained. - Participate in the development maintenance, and implementation of the facility's quality assurance program for the nursing service department. - Periodically review the resident's written discharge plan. Participate in the updating of the resident's written discharge plan as required. - Assist in planning the nursing services portion of the resident's discharge plan as necessary. - Complete accident/incident reports as necessary. - Transcribe physician's orders to resident charts, Kardex, medication cards, treatment/care plans, as required. - Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. - Fill out and complete accident/incident reports. Submit to Director as required. - Chart all reports of accidents/incidents involving residents. Follow established procedures. - Fill out and complete transfer forms in accordance with established procedures. - Provide leadership to nursing personnel assigned to your unit/shift. - Receive telephone orders from physicians and record on the Physicians' Order Form. - Transcribe physicians' orders to resident charts, Kardex, medication cards, treatment/care plans as required. - Chart all reports of accidents/incidents involving residents. Follow established procedures. - Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures. - Notify the resident's attending physician and responsible party when the resident is involved in an accident or incident. - Ensure that residents who are unable to call for help are checked frequently. - Monitor nursing care to ensure that all residents are treated fairly, and with kindness, dignity and respect. - Report and investigate all allegations of resident abuse and/or misappropriation of resident property. - Supervises RNs/LPNs/CNAs. A review of the Administrator's job description (effective January 2025), revealed that the primary purpose of the Administrator was to oversee, manage and direct the day-to-day functions and overall operations of the facility in accordance with current federal, state and local government regulations that govern long-term care facilities and the Operators requirements. The Administrator's focus is on maintaining the highest degree of quality care for the resident/patient while achieving the facility's business objectives. As the Administrator, you are delegated the Governing Body and administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. CUSTOMER SERVICE - Demonstrates positive customer service when performing the role of the Administrator, with residents, family members, internal and external staff. - Displays flexibility, team spirit, compassion, respect honesty, politeness and accountability when dealing with residents, family members and facility staff. - Demonstrates an awareness of and sensitivity for resident's rights in all interfaces with residents and family members. - Develops an environment that allows for creative thinking, problem solving and empowerment in the development of a facility management team. - Communicates effectively via open, straightforward communication, including the use of listening skills. - Seeks validation of knowledge base, quality, decision-making and skill level by actively questioning when necessary. - Utilizes survey information to address areas of importance as defined by our customers. ESSENTIAL DUTIES AND RESPONSIBILITIES - Leads facility management staff in developing and working from a business plan that focuses on all aspects of facility operations, including setting priorities and job assignments. - Serves on various committees of the facility (i.e., Infection Control, Quality Assurance & Assessment, etc.) Committee Functions: - Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. - Evaluate and implement recommendations from the facility's committees as necessary. - Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services. Ensure that an adequate number of appropriately trained professional and auxiliary personnel are on duty at all times to meet the needs of the residents. MISCELLANEOUS - Ensure that all residents receive care in a manner and in an environment that maintains or enhances their quality of life without abridging the safety and rights of other residents. A review of the facility's Abuse, Neglect, and Misappropriation policy (effective 2/1/24, reviewed on 1/1/25), revealed: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual Abuse: Is defined as non-consensual sexual contact of any type with a resident. Training: a. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. b. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property. c. Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical or psychosocial indicators. d. Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal. e. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms include, but are not limited to, the following: - Aggressive and/or catastrophic reactions of residents. - Wandering or elopement-type behaviors. - Resistance to care. - Outbursts or yelling out. - Difficulty in adjusting to new routines or stakeholders. Prevention: 1. Establishing a safe environment that supports, to the extent possible, a resident's safety. 2. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur. 4. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Investigative Guidelines: 1. The facility Administrator will investigate all allegations, reports, grievances, and incidents that potentially could constitute allegations of abuse, injuries of unknown source, exploitation, or suspicions of crime as defined in this document. the facility Administrator retains the ultimate responsibility to oversee and complete the investigation, and to draw conclusions regarding the nature of the incident. 2. The investigation should include interviews of the involved persons, including alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 3. To the extent possible and applicable, provide complete and thorough documentation of the investigation. 6. The facility Administrator will make reasonable efforts to determine the root cause of the alleged violation and will implement corrective action consistent with the investigative findings and take steps to eliminate any ongoing danger to the resident or residents. 7. Any affected resident's physician and family/responsible party will be informed of the result of the investigation. 8. Every substantiated allegation of abuse will be reviewed by the facility's Quality Assurance and Performance Improvement Committee to detect potential patterns or trends, and for consideration of further interventions or training opportunities. The Medical Director should be notified and involved. Protection: 2. If a stakeholder observes any form of abuse, the stakeholder will intervene immediately, remove and/or separate residents involved, and move them to an environment where the residents' safety can be assured. 6. The Administrator will identify, intervene and correct situations in which reported abuse, neglect, exploitation, or misappropriation of resident property may occur.

Based on staff interviews, resident and facility record reviews, and a review of job descriptions, the facility's administration failed to ensure that staff provided appropriate supervision to protect vulnerable residents from sexual abuse for one (Resident #1) of three residents reviewed for abuse. The facility administration failed to ensure that staff developed and implemented interventions necessary to protect Resident #1, who was unable to consent, from sexual contact by Resident #2. Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points, indicating moderate cognitive impairment, and was independently ambulatory with the use of a cane. This created a likelihood that Resident #1 or any other vulnerable resident could be sexually assaulted and suffer serious psychosocial and/or physical harm from Resident #2. Immediate Jeopardy (IJ) at a scope and severity of J (isolated) was identified on April 7, 2025 at 3:50 p.m. On April 1, 2025, at 6:55 p.m., Immediate Jeopardy began. On April 8, 2025, at 6:15 p.m., the Administrator was notified of the IJ determination and was provided with Immediate Jeopardy Templates. Immediate Jeopardy was ongoing as of the survey exit on April 8, 2025. The findings include: Cross reference F600, F610, and F867. 1. A review of Resident #1's medical record revealed an admitted [DATE]. Her diagnoses included, but were not limited to, metabolic encephalopathy (brain dysfunction leading to altered consciousness, cognitive decline and other neurological symptoms), attention and concentration deficit following cerebral infarction (stroke); extended-spectrum beta-lactamase resistance (ESBL - bacterial infection resistant to antibiotics); dementia in other diseases classified elsewhere, unspecified severity with agitation; general anxiety disorder; schizoaffective disorder; and a need for assistance with personal care. A review of the resident's 3/2/25 physician's orders revealed: - Donepezil Oral tablet 10 milligrams (mg) - give 1 tablet by mouth at bedtime for dementia. - Quetiapine (antipsychotic) Fumarate Oral tablet 50 mg - give 1 tablet by mouth one time a day for anxiety. - Quetiapine Fumarate Oral tablet 50 mg - give 3 tablets by mouth at bedtime for anxiety. - Alprazolam (benzodiazepine - slows the nervous system) oral tablet 0.5 mg - give 1 tablet by mouth every morning and at bedtime for anxiety. - Sertraline HCL (hydrochloride) (selective serotonin reuptake inhibitor - can be used to treat depression, obsessive compulsive disorder, posttraumatic stress disorder, social anxiety disorder and/or panic disorder) oral tablet 100 mg - give 1 tablet by mouth one time a day for depression. - 1:1 monitoring every shift - discontinued on 3/7/25. Additional physician's orders included: - 3/7/2025 - 30-minute monitoring for behaviors, (This order, 30-minute monitoring, was discontinued on 3/19/25). No documentation for increased/frequent monitoring was found from 3/19/2025 through 4/1/2025. - 3/24/2025 - Ciprofloxacin HCL (antibiotic) oral tablet 500 mg - give 500 mg by mouth two times a day for urinary tract infection (UTI) for 14 days. - 4/1/2025 - One-on-one monitoring for behaviors - every shift. A review of the Psychotropic Evaluation nursing note dated 3/2/2025, revealed that Resident #1 had behaviors (e.g. combativeness, verbal disruptions) that were harmful to self or others or limited participation in activities. Increased in acuteness. She could be aggressive with staff. Resident has anxiety or nervousness that impairs his/her quality of life or limits participation in activities. A review of a Behavior Note dated 3/3/2025 revealed: Resident has pulled out her peripherally inserted central catheter (PICC) line from her right upper arm. Some bleeding was observed, pressure applied and Tegaderm (transparent, waterproof, sterile medical dressing) placed after it stopped. Resident remains aggressive, attempting to bite several staff members and kick. New order for Haldol (antipsychotic) intramuscularly (IM) given per Advanced Practice Registered Nurse (APRN) - Ineffective, continues to walk around yelling and screaming. Redirected as staff walks along with her. A review of the Provider Encounter dated 3/14/25 revealed that the resident wandered and attempted to hit and bite staff. She continued to refuse clothing changes as needed. Psychiatry was consulted to see resident and schedule next week. The Haldol order remained in place for behavioral management. (Psychiatry notes were requested but not provided during the survey.) An Encounter note dated 3/20/25 recommended that the resident continue with 30-minute behavior checks for safety monitoring. (The order was not implemented. Copies obtained) An Encounter note dated 4/2/25 revealed that Resident #1 was seen for a behavioral follow up. She was found in a male resident's bed last night with what appears to be inappropriate touching and sexual behavior. Resident was returned to one-on-one (1:1) care. A Nursing Progress note dated 4/2/25 read, Resident is up pacing around in her room, up and down in her bed, difficult to redirect, very aggressive with staff, swinging at them, screaming out loud, cursing, knocked over everything on her bedside table, attempted to get in a bed with a resident in the bed, displayed aggressive behavior when trying to redirect. New order given to administer Haldol 0.5 mg IM (intramuscularly - in the muscle) due to aggressive behavior. She remains on 1:1 care. A review of the Admission 5-day minimum data set (MDS) assessment with a reference date of 3/6/25, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 01 out of 15 possible points, indicating severe cognitive impairment. The resident was noted to be delusional, and physically and verbally aggressive with wandering behavior. She received antipsychotic, antianxiety, antidepressant, and antibiotic medications during the assessment period. A review of the Care Plan (initiated 4/1/25, revised 4/1/25) revealed that the resident had Impaired Cognitive Function/Dementia or Impaired Thought Processes related to dementia, schizoaffective disorder, difficulty making decisions and psychotropic drug use. The resident will be able to communicate basic needs on a daily basis. The care plan noted that the resident had a behavior problem of making inappropriate sexual advances to other residents, aggression and other inappropriate behaviors with a history of UTIs, pacing, wandering, disrobing, inappropriate response to verbal communication, violence, aggression towards staff/others. Pulled out PICC line. Pulled out Foley (urinary) catheter. Resident will have fewer episodes of undesired behaviors. The resident will have no evidence of behavior problems. 1:1 care (downgraded, failed attempt) frequent checks 1:1 caregiver reinitiated 4/1. Move to a room away from patient she appears to favor. 2. A review of Resident #2's medical record revealed an admitted [DATE] and a discharge date of [DATE]. His diagnoses included dysphagia (difficulty swallowing) following cerebral infarction (stroke), type 2 diabetes mellitus (DM), difficulty walking, lack of coordination, and hypertension (HTN). No psychiatric diagnoses/mental health disorders were noted. A review of Resident #2's 3/18/25 physician's orders revealed: - Occupational therapy (OT) - Resident to be seen 5 times a week for 60 days with a focus on therapeutic exercises, therapeutic activity, self-care management, neuromuscular re-education training, group treatment when appropriate, and wheelchair management. - Skilled physical therapy (PT) services following hospitalization for 5 times a week for 4 weeks for therapeutic exercises, therapeutic activities, neuromuscular re-education, gait training, group therapy and manual. - Clopidogrel bisulfate (inhibits blood clotting) 75 mg via percutaneous endoscopic gastrostomy (PEG) tube (feeding tube passed into a resident's stomach through the abdominal wall) one time a day (QD) for deep vein thrombosis (DVT). - Amlodipine 10 mg via PEG QD for HTN. - Ezetimibe (cholesterol medication) 10 mg via PEG at bedtime for hyperlipidemia. - Lantus (insulin) 100 unit/ml (units per milliliter) inject 16 units subcutaneously (beneath the skin) at bedtime for DM. There was no physician's order for one-on-one (1:1) supervision. (Copies obtained) A review of Resident #2's Admission 5-day MDS, with a reference date of 3/24/25, revealed that the resident had a BIMS score of 12 out of 15 possible points, indicating moderate cognitive impairment. No behaviors were noted. He reported feeling depressed with little to no interest in doing things. He ambulated with a cane and required partial to moderate assistance with transfers. He did not receive psychotropic medications during the assessment period. A review of Resident #2's Care Plan, initiated on 4/3/25, revealed that the resident had a focus area for Behavior related to hypersexuality and was noncompliant with dietary restrictions. Interventions included the following: 1. Administer medications as ordered. Monitor side effects and effectiveness. 2. Caregivers to provide opportunity for positive interaction, attention. Stop and talk to him/her as passing by. 3. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. 4. Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. 5. Praise any indication of the resident's progress/improvement in behavior. All interventions were initiated on 4/3/25, two days after the event. There was no intervention for increased supervision for Resident #2 from the care plan initiation date through his transfer to the sister facility on 4/6/25. (Copy obtained) The Care Plan revealed a focus area for Impaired Cognitive Function/Dementia or Impaired Thought Processes related to impaired decision making, initiated on 4/1/25. Interventions included, but were not limited to, the following: 1. Administer medications as ordered. Monitor/document for side effects and effectiveness. 2. Ask yes/no questions in order to determine the resident's needs. 3. Communicate with the resident/family/caregivers regarding resident's capabilities and needs. 4. Cue, reorient and supervise as needed. 5. Monitor/document and report PRN (as needed) any changes in cognitive function, specifically changes in decision making ability, memory, recall, and general awareness, difficulty expressing self, and difficulty understanding others. There was no intervention for increased supervision for Resident #2 after the 4/1/25 incident through the resident's transfer to the sister facility on 4/6/25. (Copy obtained) A Physician's Note dated 4/2/25, revealed that the resident was seen for behavioral follow-up status post incident with resident. Female resident was found in the resident's bed with likely inappropriate touching or sexual behavior noted. The female resident is quite confused. He (Resident #2) was placed on one-on-one care for observation. He was told about the inappropriateness of his behavior. He appeared to be slightly confused but is aware of inappropriate behavior. A Physician's Note dated 4/4/25, revealed that Resident #2 was evaluated for discharge. He will be discharged to another skilled nursing facility, as he had a sexual encounter with another resident at this facility. On 4/7/25 at 1:25 p.m., the Administrator and the Administrator in Training (AIT) were interviewed regarding the timeline of events as related to the 4/1/25 incident between Residents #1 and #2. The Administrator stated on 4/1/25 at approximately 6:00 p.m., Residents #1 and #2 were in the dining room area. Resident #1 was observed tapping Resident #2's shoulder. The assigned nurse, Licensed Practical Nurse (LPN) C, who was at the nurses' station, separated the residents. Approximately five minutes later, Resident #1 was observed attempting to sit on Resident #2's walker. Again, the residents were separated and put at different ends of the dining area. Resident #2 was educated and voiced understanding. At approximately 6:30 p.m., LPN C went to conduct blood glucose monitoring for another resident and walked away from the dining area. When she returned, she noticed that both Resident #1 and Resident #2 were not in the dining area. LPN C walked to Resident #2's room and found both residents (#1 and #2). Resident #1 was observed in Resident #2 's bed lying supine, fully clothed, with her pants unbuttoned and her zipper down. Resident #2 stood to the right of her. He was fully clothed with his hand inside of Resident #1's pants. He quickly pulled his hand out of her pants when the nurse walked in. The Administrator confirmed that Resident #2's one-on-one (1:1) supervision was discontinued because Resident #1 was the resident who initiated the sexual behavior. During an interview on 4/07/25 at 3:30 p.m., Registered Nurse (RN) A stated she had been employed by the facility for about a year as a floor nurse. In November 2024 she was promoted to evening supervisor. As of Friday (4/4/25), she was asked to be the interim Director of Nursing (DON) since the previous DON had resigned. When asked if she was familiar with Residents #1 and #2, she stated Resident #1 was confused, verbally and physically aggressive towards staff, and refused care and medications. She stated the resident had not had any sexually inappropriate behaviors before this incident with Resident #2. Resident #2 was alert and oriented times three (person, place and time). He had no behaviors except noncompliance with diet orders. She stated on 4/1/24 she was working on the floor on the 200 hall. At 5:30 p.m., Residents #1 and #2 were observed in the dining area watching television. She was at the nurses' station with Licensed Practical Nurse (LPN) C, and they were completing their daily documentation. She stated at approximately 6:00 p.m., Resident #1 was seated on Resident #2's walker. LPN C separated the two residents. The residents were again observed holding hands, and she approached both residents and explained to Resident #2 that he could not hold hands with resident #1 because she was not alert and oriented. The residents were separated again. She then left the area to attend to another resident and left LPN C at the nurses' station. She stated she was not present in Resident #2's room when the two residents were found there. A telephone interview was conducted on 4/7/25 at 3:50 p.m. with LPN B who stated she had worked in the facility for about a year and on 4/1/25, she was coming in to work her 7:00 p.m. to 7:00 a.m. shift when the assigned nurse (LPN C) mentioned that Residents #1 and #2 were having behaviors. At that time, they noticed that neither Resident #1 nor Resident #2 were in the dining area. LPN B and LPN C then went to Resident #2's room together at approximately 6:55 p.m. looking for the residents. As they walked into Resident #2's room, they saw that his right hand was inside of Resident #1's pants. LPN B stated she and LPN C separated the residents and LPN C notified the Administrator (referring to the AIT). LPN B explained that she completed a witness statement and pushed it under the Administrator's door. When asked if the written statement was in addition to/followed by a telephone interview, she replied, No one called me. I typed up my observations. She provided a copy of her statement. A follow-up interview was conducted on 4/7/25 at 4:31 p.m. with the Administrator who was asked for any surveillance videos. He stated the surveillance video cameras were not working. When asked again if there was another witness to the incident, he said, There were no other witnesses. He was asked about the witness noted in the federal incident report. The Administrator stated she was another nurse who was assisting with a respiratory program. He further stated this other nurse was asked by LPN C (assigned nurse) if she had seen the residents. LPN C and this other nurse then both walked into Resident #2's room. The Administrator stated this other nurse/witness entered Resident #2's room after the assigned nurse (LPN C) and did not witness what happened. When asked if he had a witness statement from this second nurse, the Administrator stated he might not have put it in the investigative file that had been provided to the surveyor. He stated he would provide it. At 4:53 p.m., the Administrator provided a statement indicating that a phone interview was conducted on 4/1/25 with LPN I, whose name was on the statement. The statement indicated that LPN I did not witness the incident. When asked why LPN I was not on the schedule for 4/1/25, the Administrator stated the staffing person may have forgotten to add LPN I since she was not working a medication cart. He further stated he would provide an updated schedule. The reprinted schedule provided for review did not match the name of LPN B (who witnessed the incident with LPN C) or LPN I; it indicated LPN J. A review of the employee roster printed on 4/7/25 revealed that there was no employee by the name of LPN I, who was noted in the witness statement, on the facility's roster. Another interview was conducted with the Administrator on 4/7/25 at 5:08 p.m. He was asked about the differing names on the federal incident report, the witness statement he provided, and the schedule for 4/1/25. He stated LPN B went by LPN J's name. When asked why the schedule had a different name (LPN J), he walked out of the room stating he would clarify with the staffing department. Another follow up interview was conducted on 4/7/25 at 5:50 p.m. with the Administrator who stated he contacted LPN B, and she confirmed that she entered the room at the same time with LPN C and witnessed Resident #2 removing his hand from Resident #1's pants. He stated he had contacted LPN C and was unable to reach her. He added that with the new information he would close the investigation and substantiate the abuse allegation. On 4/8/25 at 11:45 a.m., a visit was made to the sister facility where Resident #2 had been discharged after the incident. Resident #2 was observed in the bed adjacent to the window with his eyes closed. He was clean and appropriately dressed. There was a rollator walker and a cane at his bedside. He opened his eyes, and an interview was conducted at this time. Resident #2 stated he was a little sleepy. When asked if he was unwell, he replied, no. When he was asked when and why he was discharged to this sister facility, he said, They transferred me here a few days ago. I did not have a choice. On 4/8/25 at 12:07 p.m., a joint interview was conducted with LPN L/MDS Nurse and Registered Nurse N/Director of Nursing (DON) at the sister facility. They both stated they were involved with the admission process. They both stated that a care plan was established from the resident's diagnoses, physician's orders, and any additional information from the medical record. When they were asked about Resident #2's functional status, LPN L stated Resident #2 had a BIMS score of 14 out of 15 possible points, indicating intact cognition was ambulatory with the use of a walker. They both stated Resident #2 was transferred from the sister facility because of a sexual encounter with another resident and the need for long-term care placement. When asked if they had established any behavior care plan for this resident, they stated the behavior care plan established was only related to non-compliance with the resident's diet. They added that they did not initiate a sexual behavior care plan because they were informed that the other female resident initiated the sexual act. During an interview on 4/8/25 at 2:19 p.m., the Administrator and the AIT were asked if there were any identified opportunities for improvement. The Administrator stated there was a missed opportunity for Resident #1 regarding her behaviors. He further stated there were opportunities on 4/1/25 when Resident #1 had behaviors and staff could have provided more supervision, but they walked away. When asked if they had identified opportunities for improving their abuse investigation and reporting, the Administrator replied, What exactly? He was reminded that he had mentioned on 4/7/25 that the allegation could not be verified, and then at the end of the day he stated that the allegation was substantiated. He said that per LPN C they could not verify the allegation. He confirmed that he did not obtain a statement from Resident #2. A telephone interview was conducted on 4/8/25 at 5:37 p.m. with LPN C. She stated she had worked at the facility for about a year. She confirmed that she was assigned to Residents #1 and #2 on 4/1/25. She explained that she was sitting at the nurses' station at approximately 6:00 p.m. and observed Resident #1 rubbing Resident #2's shoulder and trying to pull him close to her while grabbing his hand. Resident #2 allowed her to do so after being told three times that Resident #1 was not as alert and oriented as him and he should not allow the behavior. This behavior went on over the course of 15-20 minutes. Resident #1 was also observed trying to sit on Resident #2's walker. Resident #2 was informed that he should not allow her to do that. Resident #1 was redirected and went back to the chair she was sitting in before - away from Resident #2. Both residents continued to watch television with the other residents. At approximately 6:30 p.m., LPN C went to complete blood glucose monitoring on a resident near the dining room. When she came out of that resident's room, the night shift nurse had arrived (LPN B). LPN A noticed that the two residents (#1 and #2) were not in the dining room any longer. Together with the night nurse (LPN B) at approximately 6:55 p.m., LPN C quickly went to Resident #2's room and observed Resident #1 lying in his bed on her back fully clothed with her pants unbuttoned and her zipper down while Resident #2 stood to the right of her fully clothed with his right hand inside of Resident #1's pants. When he saw the nurses, he quickly pulled his hand out of her pants. Resident#1 was quickly assisted out of the room while Resident #2 remained in his room. LPN C confirmed that she and LPN B entered the room at the same time. She stated she notified the evening supervisor, the DON, and the Administrator. She stated both residents were placed on 1:1 supervision. A review of the Administrator's job description (effective January 2025), revealed that the primary purpose of the Administrator was to oversee, manage and direct the day-to-day functions and overall operations of the facility in accordance with current federal, state and local government regulations that govern long-term care facilities and the Operators requirements. The Administrator's focus is on maintaining the highest degree of quality care for the resident/patient while achieving the facility's business objectives. As the Administrator, you are delegated the Governing Body and administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. CUSTOMER SERVICE - Demonstrates positive customer service when performing the role of the Administrator, with residents, family members, internal and external staff. - Displays flexibility, team spirit, compassion, respect honesty, politeness and accountability when dealing with residents, family members and facility staff. - Demonstrates an awareness of and sensitivity for resident's rights in all interfaces with residents and family members. - Develops an environment that allows for creative thinking, problem solving and empowerment in the development of a facility management team. - Communicates effectively via open, straightforward communication, including the use of listening skills. - Seeks validation of knowledge base, quality, decision-making and skill level by actively questioning when necessary. - Utilizes survey information to address areas of importance as defined by our customers. ESSENTIAL DUTIES AND RESPONSIBILITIES: - Leads facility management staff in developing and working from a business plan that focuses on all aspects of facility operations, including setting priorities and job assignments. - Serves on various committees of the facility (i.e., Infection Control, Quality Assurance & Assessment, etc.) Committee Functions: - Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. - Evaluate and implement recommendations from the facility's committees as necessary. - Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services. Ensure that an adequate number of appropriately trained professional and auxiliary personnel are on duty at all times to meet the needs of the residents.

Based on staff interviews, resident and facility record reviews, and a review of facility policies and procedures, the facility's Quality Assessment and Quality Assurance Committee (QAA) failed to develop and implement appropriate plans of action to correct identified quality deficiencies, particularly those that caused adverse outcomes. This resulted in a lack of improvement of their systems and processes. This failure contributed to the sexual abuse of one (Resident #1) out of three residents reviewed for abuse. It also placed all other vulnerable female residents at a likelihood for serious adverse outcomes related to potential sexual abuse from Resident #2. Immediate Jeopardy (IJ) at a scope and severity of J (isolated) was identified on April 7, 2025 at 3:50 p.m. On April 1, 2025, at 6:55 p.m., Immediate Jeopardy began. On April 8, 2025, at 6:15 p.m., the Administrator was notified of the IJ determination and was provided with Immediate Jeopardy Templates. Immediate Jeopardy was ongoing as of the survey exit on April 8, 2025. The findings include: Cross reference F600, F610, and F835. A review of Resident #1's medical record revealed an admitted [DATE]. Her diagnoses included, but were not limited to, metabolic encephalopathy (brain dysfunction leading to altered consciousness, cognitive decline and other neurological symptoms), attention and concentration deficit following cerebral infarction (stroke); extended-spectrum beta-lactamase resistance (ESBL - bacterial infection resistant to antibiotics); dementia in other diseases classified elsewhere, unspecified severity with agitation; general anxiety disorder; schizoaffective disorder; and a need for assistance with personal care. A review of the resident's 3/2/25 physician's orders revealed: - Donepezil Oral tablet 10 milligrams (mg) - give 1 tablet by mouth at bedtime for dementia. - Quetiapine (antipsychotic) Fumarate Oral tablet 50 mg - give 1 tablet by mouth one time a day for anxiety. - Quetiapine Fumarate Oral tablet 50 mg - give 3 tablets by mouth at bedtime for anxiety. - Alprazolam (benzodiazepine - slows the nervous system) oral tablet 0.5 mg - give 1 tablet by mouth every morning and at bedtime for anxiety. - Sertraline HCL (hydrochloride) (selective serotonin reuptake inhibitor - can be used to treat depression, obsessive compulsive disorder, posttraumatic stress disorder, social anxiety disorder and/or panic disorder) oral tablet 100 mg - give 1 tablet by mouth one time a day for depression. - 1:1 monitoring every shift - discontinued on 3/7/25. Additional physician's orders included: - 3/7/2025 - 30-minute monitoring for behaviors, (This order, 30-minute monitoring, was discontinued on 3/19/25). No documentation for increased/frequent monitoring was found from 3/19/2025 through 4/1/2025. - 3/24/2025 - Ciprofloxacin HCL (antibiotic) oral tablet 500 mg - give 500 mg by mouth two times a day for urinary tract infection (UTI) for 14 days. - 4/1/2025 - One-on-one monitoring for behaviors - every shift. A review of the Psychotropic Evaluation nursing note dated 3/2/2025, revealed that Resident #1 had behaviors (e.g. combativeness, verbal disruptions) that were harmful to self or others or limited participation in activities. Increased in acuteness. She could be aggressive with staff. Resident has anxiety or nervousness that impairs his/her quality of life or limits participation in activities. A review of a Behavior Note dated 3/3/2025 revealed: Resident has pulled out her peripherally inserted central catheter (PICC) line from her right upper arm. Some bleeding was observed, pressure applied and Tegaderm (transparent, waterproof, sterile medical dressing) placed after it stopped. Resident remains aggressive, attempting to bite several staff members and kick. New order for Haldol (antipsychotic) intramuscularly (IM) given per Advanced Practice Registered Nurse (APRN) - Ineffective, continues to walk around yelling and screaming. Redirected as staff walks along with her. A review of the Provider Encounter dated 3/14/25 revealed that the resident wandered and attempted to hit and bite staff. She continued to refuse clothing changes as needed. Psychiatry was consulted to see resident and schedule next week. The Haldol order remained in place for behavioral management. (Psychiatry notes were requested but not provided during the survey.) An Encounter note dated 3/20/25 recommended that the resident continue with 30-minute behavior checks for safety monitoring. (The order was not implemented. Copies obtained) An Encounter note dated 4/2/25 revealed that Resident #1 was seen for a behavioral follow up. She was found in a male resident's bed last night with what appears to be inappropriate touching and sexual behavior. Resident was returned to one-on-one (1:1) care. A Nursing Progress note dated 4/2/25 read, Resident is up pacing around in her room, up and down in her bed, difficult to redirect, very aggressive with staff, swinging at them, screaming out loud, cursing, knocked over everything on her bedside table, attempted to get in a bed with a resident in the bed, displayed aggressive behavior when trying to redirect. New order given to administer Haldol 0.5 mg IM (intramuscularly - in the muscle) due to aggressive behavior. She remains on 1:1 care. A review of the Admission 5-day minimum data set (MDS) assessment with a reference date of 3/6/25, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 01 out of 15 possible points, indicating severe cognitive impairment. The resident was noted to be delusional, and physically and verbally aggressive with wandering behavior. She received antipsychotic, antianxiety, antidepressant, and antibiotic medications during the assessment period. A review of the Care Plan (initiated 4/1/25, revised 4/1/25) revealed that the resident had Impaired Cognitive Function/Dementia or Impaired Thought Processes related to dementia, schizoaffective disorder, difficulty making decisions and psychotropic drug use. The resident will be able to communicate basic needs on a daily basis. The care plan noted that the resident had a behavior problem of making inappropriate sexual advances to other residents, aggression and other inappropriate behaviors with a history of UTIs, pacing, wandering, disrobing, inappropriate response to verbal communication, violence, aggression towards staff/others. Pulled out PICC line. Pulled out Foley (urinary) catheter. Resident will have fewer episodes of undesired behaviors. The resident will have no evidence of behavior problems. 1:1 care (downgraded, failed attempt) frequent checks 1:1 caregiver reinitiated 4/1. Move to a room away from patient she appears to favor. 2. A review of Resident #2's medical record revealed an admitted [DATE] and a discharge date of [DATE]. His diagnoses included dysphagia (difficulty swallowing) following cerebral infarction (stroke), type 2 diabetes mellitus (DM), difficulty walking, lack of coordination, and hypertension (HTN). No psychiatric diagnoses/mental health disorders were noted. A review of Resident #2's 3/18/25 physician's orders revealed: - Occupational therapy (OT) - Resident to be seen 5 times a week for 60 days with a focus on therapeutic exercises, therapeutic activity, self-care management, neuromuscular re-education training, group treatment when appropriate, and wheelchair management. - Skilled physical therapy (PT) services following hospitalization for 5 times a week for 4 weeks for therapeutic exercises, therapeutic activities, neuromuscular re-education, gait training, group therapy and manual. - Clopidogrel bisulfate (inhibits blood clotting) 75 mg via percutaneous endoscopic gastrostomy (PEG) tube (feeding tube passed into a resident's stomach through the abdominal wall) one time a day (QD) for deep vein thrombosis (DVT). - Amlodipine 10 mg via PEG QD for HTN. - Ezetimibe (cholesterol medication) 10 mg via PEG at bedtime for hyperlipidemia. - Lantus (insulin) 100 unit/ml (units per milliliter) inject 16 units subcutaneously (beneath the skin) at bedtime for DM. There was no physician's order for one-on-one (1:1) supervision. (Copies obtained) A review of Resident #2's Admission 5-day MDS, with a reference date of 3/24/25, revealed that the resident had a BIMS score of 12 out of 15 possible points, indicating moderate cognitive impairment. No behaviors were noted. He reported feeling depressed with little to no interest in doing things. He ambulated with a cane and required partial to moderate assistance with transfers. He did not receive psychotropic medications during the assessment period. A review of Resident #2's Care Plan, initiated on 4/3/25, revealed that the resident had a focus area for Behavior related to hypersexuality and was noncompliant with dietary restrictions. Interventions included the following: 1. Administer medications as ordered. Monitor side effects and effectiveness. 2. Caregivers to provide opportunity for positive interaction, attention. Stop and talk to him/her as passing by. 3. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. 4. Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. 5. Praise any indication of the resident's progress/improvement in behavior. All interventions were initiated on 4/3/25, two days after the event. There was no intervention for increased supervision for Resident #2 from the care plan initiation date through his transfer to the sister facility on 4/6/25. (Copy obtained) The Care Plan revealed a focus area for Impaired Cognitive Function/Dementia or Impaired Thought Processes related to impaired decision making, initiated on 4/1/25. Interventions included, but were not limited to, the following: 1. Administer medications as ordered. Monitor/document for side effects and effectiveness. 2. Ask yes/no questions in order to determine the resident's needs. 3. Communicate with the resident/family/caregivers regarding resident's capabilities and needs. 4. Cue, reorient and supervise as needed. 5. Monitor/document and report PRN (as needed) any changes in cognitive function, specifically changes in decision making ability, memory, recall, and general awareness, difficulty expressing self, and difficulty understanding others. There was no intervention for increased supervision for Resident #2 after the 4/1/25 incident through the resident's transfer to the sister facility on 4/6/25. (Copy obtained) A Physician's Note dated 4/2/25, revealed that the resident was seen for behavioral follow-up status post incident with resident. Female resident was found in the resident's bed with likely inappropriate touching or sexual behavior noted. The female resident is quite confused. He (Resident #2) was placed on one-on-one care for observation. He was told about the inappropriateness of his behavior. He appeared to be slightly confused but is aware of inappropriate behavior. During an interview on 4/07/25 at 3:30 p.m., Registered Nurse (RN) A stated she had been employed by the facility for about a year as a floor nurse. In November 2024 she was promoted to evening supervisor. As of Friday (4/4/25), she was asked to be the interim Director of Nursing (DON) since the previous DON had resigned. When asked if she was familiar with Residents #1 and #2, she stated Resident #1 was confused, verbally and physically aggressive towards staff, and refused care and medications. She stated the resident had not had any sexually inappropriate behaviors before this incident with Resident #2. Resident #2 was alert and oriented x3 (person, place and time). He had no behaviors except noncompliance with diet orders. She stated on 4/1/24 she was working on the floor on the 200 hall. At 5:30 p.m., Residents #1 and #2 were observed in the dining area watching television. She was at the nurses' station with Licensed Practical Nurse (LPN) C, and they were completing their daily documentation. She stated at approximately 6:00 p.m., Resident #1 was seated on Resident #2's walker. LPN C separated the two residents. The residents were again observed holding hands, and she approached both residents and explained to Resident #2 that he could not hold hands with resident #1 because she was not alert and oriented. The residents were separated again. She then left the area to attend to another resident and left LPN C at the nurses' station. She stated she was not present in Resident #2's room when the two residents were found there. On 4/7/25 at 1:25 p.m., the Administrator confirmed that Resident #2's one-on-one (1:1) supervision was discontinued because Resident #1 was the resident who initiated the sexual behavior. During an interview on 4/07/25 at 3:30 p.m., Registered Nurse (RN) A stated she had been employed by the facility for about a year as a floor nurse. In November 2024 she was promoted to evening supervisor. As of Friday (4/4/25), she was asked to be the interim Director of Nursing (DON) since the previous DON had resigned. When asked if she was familiar with Residents #1 and #2, she stated Resident #1 was confused, verbally and physically aggressive towards staff, and refused care and medications. She stated the resident had not had any sexually inappropriate behaviors before this incident with Resident #2. Resident #2 was alert and oriented x3 (person, place and time). He had no behaviors except noncompliance with diet orders. She stated on 4/1/24 she was working on the floor on the 200 hall. At 5:30 p.m., Residents #1 and #2 were observed in the dining area watching television. She was at the nurses' station with Licensed Practical Nurse (LPN) C, and they were completing their daily documentation. She stated at approximately 6:00 p.m., Resident #1 was seated on Resident #2's walker. LPN C separated the two residents. The residents were again observed holding hands, and she approached both residents and explained to Resident #2 that he could not hold hands with resident #1 because she was not alert and oriented. The residents were separated again. She then left the area to attend to another resident and left LPN C at the nurses' station. She stated she was not present in Resident #2's room when the two residents were found there. A telephone interview was conducted on 4/7/25 at 3:50 p.m., with LPN B. She stated she had worked in the facility for about a year and on 4/1/25, she was coming in to work her 7:00 p.m. to 7:00 a.m. shift when the assigned nurse mentioned that Residents #1 and #2 were having behaviors. At that time, they noticed that neither Resident #1 nor Resident #2 were in the dining area. LPN B and LPN C then went to Resident #2's room together at approximately 6:55 p.m. looking for the residents. As they walked into Resident #2's room, they saw that his right hand was inside of Resident #1's pants. LPN B stated she and LPN C separated the residents and LPN C notified the Administrator (referring to the Administrator in Training (AIT). On 4/8/25 at 11:45 a.m., a visit was made to the sister facility where Resident #2 had been discharged after the incident. Resident #2 was observed in the bed adjacent to the window with his eyes closed. He was clean and appropriately dressed. There was a rollator walker and a cane at his bedside. He opened his eyes, and an interview was conducted at this time. Resident #2 stated he was a little sleepy. When asked if he was unwell, he replied, no. When he was asked when and why he was discharged to this sister facility, he said, They transferred me here a few days ago. I did not have a choice. When asked if he could recall the 4/1/25 incident in the other facility where a female resident was found in his bed, he replied, A female resident? Yes, she was in my bed. He declined to provide further details about the incident. He said, I don't want to answer any more questions. On 4/8/25 at 12:07 p.m., a joint interview was conducted with LPN L/MDS Nurse and Registered Nurse N/Director of Nursing (DON) at the sister facility. They both stated they were involved with the admission process. They both stated that a care plan was established from the resident's diagnoses, physician's orders, and any additional information from the medical record. When they were asked about Resident #2's functional status, LPN L stated Resident #2 had a BIMS score of 14 out of 15 possible points, indicating intact cognition was ambulatory with the use of a walker. They both stated Resident #2 was transferred from the sister facility because of a sexual encounter with another resident and the need for long-term care placement. When asked if they had established any behavior care plan for this resident, they stated the behavior care plan established was only related to non-compliance with the resident's diet. They added that they did not initiate a sexual behavior care plan because they were informed that the other female resident initiated the sexual act. In an interview on 4/8/25 at 12:30 p.m., the facility's Medical Director stated he conducted rounds at the facility every Tuesday and Thursday, and during each visit, he asked the Administrator if there was anything to report. He stated he had just left the sister facility and was informed that surveyors were in the facility for a complaint investigation, but he was not provided details. He said that he contacted the facility Administrator to ask him whether he needed to make him aware of anything. When the Administrator then notified the Medical Director of the 4/1/25 incident between Residents #1 and #2, the Medical Director asked, What is this about? I am not aware. The Medical Director stated a brief overview of the incident was provided by the Administrator. He stated he told the Administrator, I'm not aware. I just came back from that facility and was not notified. As the Medical Director and QAPI committee member, I should be made aware. The Medical Director stated he would not comment on the incident because he had to review the documentation first. He stated he was not informed that Resident #2 had been transferred to the sister facility, but he would visit the resident after this interview. An interview was conducted on 4/8/25 at 1:43 p.m. with Resident #1's spouse. He stated he was contacted by the facility when the incident occurred. This was the first time anything like this had happened. He was asked how he felt his wife would have responded to the actions of Resident #2 if she was not cognitively impaired. He stated that in her previous life his wife was very modest. She would have been very upset over Resident #2's actions. During an interview on 4/8/25 at 2:19 p.m., the Administrator and the Administrator in Training stated they had identified areas of improvement related to failure to provide enough supervision to Resident #1 after several observations of new behaviors. It was confirmed with the Administrator that an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting had not been held. When the Administrator was asked why an ad hoc QAPI meeting was not conducted, he replied that there was no reason to do so. When he was asked if the Medical Director was notified of the incident after it occurred, he said that he tried to contact him, but was unable to reach him, so he notified the Medical Director's Advanced Practice Registered Nurse (APRN). He confirmed that he did not follow up with the Medical Director. A telephone interview was conducted on 4/8/25 at 5:37 p.m. with LPN C. She stated she had worked at the facility for about a year. She confirmed that she was assigned to Residents #1 and #2 on 4/1/25. She explained that she was sitting at the nurses' station at approximately 6:00 p.m. and observed Resident #1 rubbing Resident #2's shoulder and trying to pull him close to her while grabbing his hand. Resident #2 allowed her to do so after being told three times that Resident #1 was not as alert and oriented as him and he should not allow the behavior. This behavior went on over the course of 15-20 minutes. Resident #1 was also observed trying to sit on Resident #2's walker. Resident #2 was informed that he should not allow her to do that. Resident #1 was redirected and went back to the chair she was sitting in before - away from Resident #2. Both residents continued to watch television with the other residents. At approximately 6:30 p.m., LPN C went to complete blood glucose monitoring on a resident near the dining room. When she came out of that resident's room, the night shift nurse had arrived (LPN B). LPN A noticed that the two residents (#1 and #2) were not in the dining room any longer. Together with the night nurse (LPN B) at approximately 6:55 p.m., LPN C quickly went to Resident #2's room and observed Resident #1 lying in his bed on her back fully clothed with her pants unbuttoned and her zipper down while Resident #2 stood to the right of her fully clothed with his right hand inside of Resident #1's pants. When he saw the nurses, he quickly pulled his hand out of her pants. Resident#1 was quickly assisted out of the room while Resident #2 remained in his room. LPN C confirmed that she and LPN B entered the room at the same time. She stated she notified the evening supervisor, the DON, and the Administrator. She stated both residents were placed on 1:1 supervision. She confirmed that she was not contacted by any administrative team member at facility about the 4/1/25 incident until 4/8/25. On 4/8/25, the Administrator contacted her, and she explained to the Administrator what occurred exactly as she had in her previously written statement. A review of the facility's policy titled Quality Assurance and Performance Improvement Policy for Skilled Nursing Center (effective 2/1/24, reviewed 1/1/25), revealed: Policy Statement: The purpose of Quality Assurance and Performance Improvement (QAPI) is to continually take a proactive approach to assure and improve the way we provide care and engage with our patients, employees, and other stakeholders so that we may fully realize our vision, mission, and commitment to caring pledge. Procedure: All employees and contracted staff are responsible for the quality of care and services within their respective departments and are expected to participate in the QAPI Program. Each center must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care, quality of life, and resident choice. It is the expectation of the SNF (skilled nursing facility) QAPI Program that the center will follow the established QAPI process to guide and direct the operations of the location. The executive leadership sets the expectation and provides the resources for implementation. Quality Assurance Performance Improvement (QAPI) information flows up and down the organization in an organized format. The center culture supports the premise that knowledge is shared, and information flows freely. Improvements in processes or outcomes as a result of the QAPI Program are communicated throughout the center and to stakeholders (residents, families and vendors). When improvement opportunities are identified through quality assessment activities, the center takes action to improve performance, including education, modification of systems and processes, or formal Performance Improvement Projects. IV. PERFORMANCE IMPROVEMENT PROJECTS (PIPs): As part of its QAPI Program, the SNF develops, implements, and evaluates performance improvement projects. - The facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the center must reflect the scope and complexity of the facility's services and available resources. - The center must set priorities for its performance improvement projects based on the results of quality monitoring that consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

Based on interviews and record review, the facility failed to ensure that all alleged violations related to abuse were reported immediately, but not later than two hours after the allegation was made, to officials (including the State Survey Agency). The facility also failed to report the results of the investigations to the State Survey Agency within five working days of the incidents. This involved three (Residents #1, #2, and #3) of three residents reviewed for abuse, from a total survey sample of eight residents. Reporting requirements under this regulation are based on real (clock) time, not business hours. The findings include: 1. A review of Resident #3's medical record revealed an admitted [DATE]. His diagnoses included acute respiratory failure with hypoxia (condition where the respiratory system is unable to deliver enough oxygen to the blood, resulting in low blood oxygen levels); congestive heart failure (condition where the heart's pumping action is not strong enough to supply the body's needs, leading to fluid buildup in the lungs and other tissues); Type 2 diabetes mellitus (chronic condition where the body either doesn't produce enough insulin, or the body's cells become resistant to insulin, leading to high blood sugar levels); morbid obesity (severe form of obesity (accumulation of excess body fat) characterized by a Body Mass Index (BMI) of 40 or higher, or a BMI of 35 or higher with obesity-related health complications); diverticulitis of the large intestine (condition where pouches in the large intestine (colon) become inflamed or infected); non-ST segment elevation myocardial infarction (NSTEMI) (type of heart attack where there is a partial blockage of a coronary artery, leading to reduced blood flow to the heart muscle); atrial fibrillation (irregular heartbeat); and chronic kidney disease - stage 3 (moderate loss of kidney function). A review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #3 scored 11 out of 15 possible points on the Brief Interview for Mental Status (BIMS) assessment, indicating moderate cognitive impairment. An interview was conducted with the Administrator on 4/7/25 at 1:26 p.m. He stated he received an allegation from the son of Resident #3 stating that a certified nursing assistant (CNA) came in to answer the call light and was rude and too rough helping him get on the bed pan. The Administrator stated the resident's son said the incident occurred during the 11:00 p.m. to 7:00 a.m. shift on Friday (4/4/25). An interview was conducted on 4/8/25 at 9:41 a.m. with the Social Services Director (SSD). She advised that she was new and had been employed in the facility for about a week. When asked, she stated she was familiar with the incident involving Resident #3. She stated she had just begun employment in the facility, and she immediately completed a grievance form related to the incident once she was informed of it. When asked if there had been more than one incident involving Resident #3, the SSD stated the incident in question was the only incident she was aware of since she started working in the facility. She confirmed the incident involving Resident #3 was originally reported to her by the family as an allegation of abuse due to the staff member being rough with the resident. An interview was conducted with Resident #3 on 4/8/25 at 10:47 a.m. The resident was advised of the purpose for the interview. When asked if he recalled the date of the incident, he stated it was at the end of last month (March) or the beginning of this month (April). When asked to describe the details of the grievance submitted by his son, the resident explained that he pressed his call light because he needed assistance with toileting. When the staff member came into his room, she was angry and aggressive. While attempting to turn him onto his left side, she forcefully pushed his right leg near the knee area. The resident confirmed that he did not report the incident to the staff; instead, he informed his son about it. An interview was conducted with the son and daughter of Resident #3 on 4/8/25 at 3:07 p.m. The resident's son stated the incident did not occur on 4/4/25 as the Administrator had previously informed the survey team. The resident's daughter stated Resident #3 was admitted to the facility on [DATE] and the incident occurred on 3/28/25 or 3/29/25. She stated Resident #3 had initially advised her of the incident by phone and she told him that she would report it to the facility. She did so on 3/31/25. She stated the resident reported that he felt bad and humiliated. She stated in less than 24 hours they were informed by the facility that the staff member involved had been terminated. The SSD asked if she could close the grievance since the staff member had been terminated. She advised her no because her brother, Resident #3's son, was also involved and they believed things were looking suspicious. She stated this occurred on 4/1/2025. When the family realized the facility wasn't taking the incident seriously, they went on the State Survey Agency website to learn how the incident should be handled. They confronted the facility Administrator with what they had discovered, and that was when the facility filed the official report. A follow-up interview was conducted with the SSD on 4/8/25 at 5:30 p.m. She was shown the facility's Grievance Checklist (photographic evidence obtained) and asked if she had completed a grievance form. She stated she had not and that was the first time she had seen the form. She was asked about the incident involving Resident #3. She stated her understanding of the incident was that it was related to how the certified nursing assistant (CNA) changed the resident after a bowel movement. She stated the daughter of Resident #3 was very upset when she came to her, so she wrote the grievance on 3/31/25. Another interview was conducted on 4/8/25 at 6:21 p.m. with the Administrator. He was asked about the actual date of the incident with Resident #3. He stated there was only one incident. He stated it was initially reported as a customer service issue because the staff was rude. He stated the report was initially filed on 3/31/25. He again stated that the facility didn't file an abuse report because it was a customer service issue. A record review revealed that on 3/31/25, a grievance was filed by the daughter of Resident #3. The facility's Social Services Director completed the grievance form. Per the grievance form, [Resident #3] uses a bed pan. He had to have a bowel movement. Assigned aide came in and was visibly angry. Reported that when she had to clean him, she was not gentle enough with his leg. Results of action taken: Staff educated. Per the facility's grievance form, the grievance was resolved. Resident notified of results and education. The method used to notify the resident and/or representative of the resolution was listed as: Telephone and one-to-one conversation. Both the date of the resolution and the date of notification were 4/2/25. 2. A review of Resident #1's medical record revealed an admitted [DATE]. Her diagnoses included, but were not limited to, metabolic encephalopathy (brain dysfunction leading to altered consciousness, cognitive decline and other neurological symptoms), attention and concentration deficit following cerebral infarction (stroke); extended-spectrum beta-lactamase resistance (ESBL - bacterial infection resistant to antibiotics); dementia in other diseases classified elsewhere, unspecified severity with agitation; general anxiety disorder; schizoaffective disorder; and a need for assistance with personal care. An Encounter note dated 4/2/25 revealed that Resident #1 was seen for a behavioral follow up. She was found in a male resident's bed last night (4/1/25) with what appears to be inappropriate touching and sexual behavior. A review of Resident #2's medical record revealed an admitted [DATE] and a discharge date of [DATE]. His diagnoses included dysphagia (difficulty swallowing) following cerebral infarction (stroke), type 2 diabetes mellitus (DM), difficulty walking, lack of coordination, and hypertension (HTN). No psychiatric diagnoses/mental health disorders were noted. A Physician's Note dated 4/2/25, revealed that the resident was seen for behavioral follow-up status post incident with resident. Female resident was found in the resident's bed with likely inappropriate touching or sexual behavior noted. The female resident is quite confused. He (Resident #2) was placed on one-on-one care for observation. He was told about the inappropriateness of his behavior. He appeared to be slightly confused but is aware of inappropriate behavior. A telephone interview was conducted on 4/7/25 at 3:50 p.m., with LPN B. She stated she had worked in the facility for about a year and on 4/1/25, she was coming in to work her 7:00 p.m. to 7:00 a.m. shift when the assigned nurse mentioned that Residents #1 and #2 were having behaviors. At that time, they noticed that neither Resident #1 nor Resident #2 were in the dining area. LPN B and LPN C then went to Resident #2's room together at approximately 6:55 p.m. looking for the residents. As they walked into Resident #2's room, they saw that his right hand was inside of Resident #1's pants. LPN B stated she and LPN C separated the residents and LPN C notified the Administrator (referring to the Administrator in Training (AIT). During a joint interview on 4/8/25 at 2:19 p.m., the Administrator and the Administrator in Training confirmed that the 5-day federal report for the 4/1/25 incident was submitted on 4/7/25. The Administrator stated he had five business days to submit the report, therefore it was submitted timely. When asked if that was the facility's policy, he replied, We have always done it like that. A review of the facility's Abuse, Neglect, and Misappropriation policy (effective 2/1/24, reviewed 1/1/25), revealed: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual Abuse: Is defined as non-consensual sexual contact of any type with a resident. G. Reporting/Response: 1. Every Stakeholder shall immediately report any allegation of abuse, injury of unknown origin, or suspicion of a crime, as those terms are defined above, to the facility Administrator or designee as assigned by the facility Administrator in his/her absence. Failure to report an allegation of abuse, injury of unknown origin or suspicion of crime may result in disciplinary action, including termination of employment, and/or further legal or criminal action against any person who is required to, but fails to make such a report. Reporting Guidelines: Any abuse allegation must be reported to within two hours from the time the allegation was received. Any reasonable suspicion of a crime with serious bodily injury must be reported to the State and Police. Any allegation of neglect, exploitation, mistreatment or misappropriation of resident property must be reported to the State Regulatory Agency within 24 hours. In the case of neglect, exploitation, mistreatment, or misappropriation resulting in serious bodily injury, it must be reported to the State Regulatory Agency and Police within two hours.

Based on a review of closed resident records, facility policies and procedures, and interviews with the resident and staff, the facility failed to provide and document sufficient preparation and orientation to one (Resident #2) of three residents reviewed, to ensure a safe and orderly discharge from the facility. The findings include: A review of Resident #2's medical record revealed an admission date of 3/18/25 and a discharge date of 4/6/25. The resident's diagnoses included dysphagia (difficulty swallowing) following cerebral infarction (stroke), type 2 diabetes mellitus (DM), difficulty walking, lack of coordination, and hypertension (HTN). No psychiatric diagnoses/mental health disorders were noted. A review of Resident #2's 3/18/25 physician's orders revealed: - Occupational therapy (OT) - Resident to be seen 5 times a week for 60 days with a focus on therapeutic exercises, therapeutic activity, self-care management, neuromuscular re-education training, group treatment when appropriate, and wheelchair management. - Skilled physical therapy (PT) services following hospitalization for 5 times a week for 4 weeks for therapeutic exercises, therapeutic activities, neuromuscular re-education, gait training, group therapy and manual. - Clopidogrel bisulfate (inhibits blood clotting) 75 mg via percutaneous endoscopic gastrostomy (PEG) tube (feeding tube passed into a resident's stomach through the abdominal wall) one time a day (QD) for deep vein thrombosis (DVT). - Amlodipine 10 mg via PEG QD for HTN. - Ezetimibe (cholesterol medication) 10 mg via PEG at bedtime for hyperlipidemia. - Lantus (insulin) 100 unit/ml (units per milliliter) inject 16 units subcutaneously (beneath the skin) at bedtime for DM. There was no physician's order for one-on-one (1:1) supervision. There was no discharge order. (Copies obtained) A review of Resident #2's admission 5-day MDS, with a reference date of 3/24/25, revealed that the resident had a BIMS score of 12 out of 15 possible points, indicating moderate cognitive impairment. No behaviors were noted. He reported feeling depressed with little to no interest in doing things. He ambulated with a cane and required partial to moderate assistance with transfers. He did not receive psychotropic medications during the assessment period. The resident's Care Plan, initiated on 4/1/25 and updated on 4/8/25 revealed no discharge care plan. A Nursing Progress note dated 4/2/25 revealed that Resident #2's son was notified that the resident could be transferred to the sister facility on Friday. The resident's son stated he would like to think everything over because he was not in agreement. The Administrator would follow up with him. A Physician's Note dated 4/4/25 revealed that the resident was evaluated for discharge. He will be discharged to another skilled nursing facility, as he had a sexual encounter with another resident in this facility. A review of the Discharge Summary Recapitulation of Stay form dated 4/4/25 at 1:31 p.m. revealed that Resident #2's discharge goal was rehab and the reason for the discharge was transfer. Under B. Discharge, the form asked whether discharge goals were achieved. Answer: Goals are ongoing. Question: Why were the admission goals not achieved? Answer: He is transferring to another SNF (skilled nursing facility). Name of SNF: [sister facility]. Under C. Psychosocial needs, the form asked whether the resident/family were comfortable with the transfer. Answer: Yes. Under Ba. Functional Abilities, the resident was documented as independent with bed mobility, transfers, and wheelchair mobility. He required partial/moderate assistance to walk 50 or more feet. The form was signed by Licensed Practical Nurse (LPN) C on 4/6/25. In an interview on 4/8/25 at 9:53 a.m., the SSD stated she was new to the facility and started her employment last week. She stated she was involved in Resident #2's discharge. The discharge was due to an incident with another resident. She added that the resident was also changing the discharge plan to long-term care, and the sister facility was a long-term care facility. The discharge notification was made to the family via email, but the family had not signed the form yet. The Ombudsman was notified monthly. She provided a copy of the transfer/discharge form, and a copy of the email sent to Resident #2's son. She confirmed that the form was not signed by the physician. She stated she was waiting for the son to sign the form first. When she was asked if a resident should be discharged before the physician signed the discharge paperwork, she did not answer. Further review of the record revealed that Resident #2 received an Agency for Health Care Administration (AHCA - Florida state survey agency) Nursing Home Transfer and Discharge Notice on 4/4/25 for an effective discharge date of 5/5/25. The location of discharge was the facility's sister facility. The reason for the discharge was noted as: To meet the needs of the patient. None of the reasons for transfer on the form were checked. There was no indication of why the resident's needs could not be met at this facility. If the reason for the transfer included that either the resident's needs could not be met at the discharging facility, or the safety of other individuals in the facility was endangered, a physician's signature was required on the form. There was no physician's signature on the form. The form was not signed by the resident/representative. The lines asking for the dates the notice was given to the resident/legal guardian/representative, the local long-term care Ombudsman, and the date the clinical record was noted were all left blank. The Administrator in Training signed the form as the facility designee on 4/4/25. (Copy obtained) A review of the CMS (Centers for Medicare and Medicaid Services) Notice of Medicare Non-Coverage revealed that services would end on 4/5/25. On page two, a handwritten note indicated that the resident's son was spoken with on 4/3/25 at 4:55 p.m. and was made aware that the resident's last day of coverage would be 4/5/25. The form was signed by the Social Services Director (SSD) but was not dated. The signature line for the resident/representative and the date line were left blank. A review of an email from the SSD to the resident's son, dated 4/4/25 at 11:36 a.m., revealed that the SSD was requested that the resident's son sign attached paperwork. The son was then notified that Resident #2 would be discharged to the sister facility on Sunday (4/6/25). On 4/8/25 at 11:45 a.m., a visit was made to the sister facility where Resident #2 had been discharged after the incident. Resident #2 was observed in the bed adjacent to the window with his eyes closed. There was a rollator walker and a cane at his bedside. He opened his eyes, and an interview was conducted at this time. Resident #2 stated he was a little sleepy. When asked if he was unwell, he replied, no. When he was asked when and why he was discharged to this sister facility, he said, They transferred me here a few days ago. I did not have a choice. In an interview on 4/8/25 at 11:58 a.m., LPN K (assigned to Resident #2 on 4/8 at the sister facility) confirmed that she was Resident #2's assigned nurse. She stated the resident was alert and oriented times three (The resident is awake, aware of their name, their location, and the date/time.) She stated Resident #2 ambulated with a walker and had been in bed today because he had some blood work done. When asked the reason for his admission, LPN K said she was not sure and would have to review the admission notes. On 4/8/25 at 12:07 p.m., a joint interview was conducted with LPN L/MDS Nurse and Registered Nurse N/Director of Nursing (DON) at the sister facility. They both stated they were involved with the admission process. They both stated that a care plan was established from the resident's diagnoses, physician's orders, and any additional information from the medical record. When they were asked about Resident #2's functional status, LPN L stated Resident #2 had a BIMS score of 14 out of 15 possible points, indicating intact cognition. He was ambulatory with the use of a walker. They both stated Resident #2 was admitted from the sister facility because of a sexual encounter with another resident and the need for long-term care placement. When asked if they had established any behavior care plan for this resident, and they replied that the behavior care plan established was only related to non-compliance with the resident's diet. They added that they did not initiate a sexual behavior care plan because they were informed that the female resident involved in the incident initiated the sexual act. In an interview on 4/8/25 at 12:30 p.m. with the discharging facility's Medical Director, who was also Resident #2's physician, he stated he was not aware that Resident #2 had been transferred to the sister facility. A review of the facility's policy and procedure titled Discharge Planning (effective 2/1/24, revised 2/20/25), revealed: Discharge planning will begin with each resident and resident's representative upon admission. The process is coordinated by Social Services or designee. The resident, resident representative, and Interdisciplinary Team (IDT) are involved in the planning process. The post-discharge plan of care is developed with the participation of the resident and/or the resident's representative with the resident's consent. The discharge plan will be monitored and revised as necessary throughout the resident's stay. Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to, did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. Procedure: 1. Discharge and care plan goals will be established with the IDT, resident and resident representative at the time of admission based on the resident's discharge goals and treatment preferences in conjunction with needs as identified by the IDT. 2. Discharge care plans will be updated after the Post admission Care Conference, reviewed quarterly, prior to the anticipated discharge date , and as needed. 3. Community resources should be determined based on input from the resident, resident representative to include consideration of care giver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs, and the IDT via the Post admission Care Conference and ongoing care plan meetings. For residents who are transferring/discharging to another SNF (skilled nursing facility), HHA, IRF, or LTCH, assistance must be provided in selecting a post-acute care provider. Resources to be used in this selection process are standardized patient assessment data, quality measures, and data on resource use to the extent the data is available. 6. The Discharge Recapitulation form, which includes the final summary of resident's status, will be completed by each discipline on the IDT prior to or on the scheduled date of discharge. The Social Services Director provides oversight for the completion of this process and reviews all aspects of care with the resident and resident representative. 7. The Discharge Form is utilized to send the documents necessary for transfers to: The Nursing Home, Home, Home Health, Assisted Living, and Hospice. Assemble required documents that will be given to the resident, resident representative and community service provider. 8. A completed Discharge Recapitulation of Stay Form will be given at the time of discharge. 9. Discharge Summary along with all other pertinent information is communicated/conveyed to the continuing care provider or receiving facility at the time of discharge. 10. For residents for whom discharge to the community has been determined to not be feasible, the medical record must contain information about who made that decision and the rationale for that decision. .

Based on observations and interviews with staff, the facility failed to store refrigerated food in a manner to prevent contamination by airborne matter, by failing to ensure the evaporator fan was clean and free of build-up and debris. This had the potential to effect all 42 residents in the facility who ate by mouth, by potentially contaminating exposed food with the built-up matter on the fan. The findings include: During an intial tour of the kitchen on 7/14/24 at 11:34 AM, the walk-in refrigerator was inspected. The evaporator fan on the back wall of the unit was observed with a build up of thick, dark matter resembling dust on the grates of the fan cover. The debris was moving in response to the fan blowing the cold air around. During an inspection of the walk-in refrigerator on 7/18/24 at 3:24 PM, the fan was observed in the same condition and had still not been cleaned. There was visible build up of dust-like debris on all surfaces of the fan. There was a tray of sandwiches on the top rack, which had been covered in plastic wrap and parchment paper. The force of the fan had blown the plastic wrap off the entire edge of the tray, exposing the bread and meat to possible contamination by the debris on the fan. (Photographic evidence obtained) An interview was conducted with the certified dietary manager (CDM) at the time of the finding, who stated the Maintenance Department was responsible for cleaning this fan. The CDM looked at the fan and confirmed its soiled condition and the risk to the uncovered food in the refrigerator.

Based on a facility record review and a staff interview, the facility failed to maintain documentation to demonstrate evidence of its ongoing Quality Assurance Performance Improvement (QAPI) program. This failure could potentially affect all facility residents. The findings include: On 7/18/24 at 3:15 PM, during the Quality Assurance Performance Improvement (QAPI) review with the Administrator and the Director of Nursing, they could provide no current documentation to verify the development, implementation and maintenance of an effective, comprehensive, data-driven QAPI program focused on indicators of the outcomes of care and quality of life. When they were asked to share documentation of their QAPI program, they provided a form that read QAPI Plan Review (dated 1/13/2022), which was a sign-in sheet with a number of staff signatures on it, and policy and procedure manuals including a Comprehensive Federal Emergency Program (FEP), and a Comprehensive State and Local Emergency Management Plan/Disaster Manual. (Copies obtained) The Administrator stated the facility held a QAPI meeting monthly, but no evidence of that was produced. He stated the facility had two current performance improvement plans in place currently (antibiotic surveillance/infection preventionist and tuberculosis vaccinations, but no documented evidence was produced to corroborate that. The Administrator was asked about the annual review of facility policies and procedures. He stated that was completed and reviewed with the QAPI committee, but no documented evidence was produced to verify that this occurred. He was asked for the facility's QAPI policy, but it was not provided at the time of the survey.

Based on clinical record review, staff interviews, resident interview, observation, significant other and family interviews and policy and procedure review, the facility failed to implement their discharge planning process by ensuring post-discharge needs for durable medical equipment, nursing services for wound care, oxygen and nebulizer treatments and other appropriate supports were in place in the community for one resident (#1) out of three sampled residents. The facility failed to contact the resident's family member who owned the family home, prior to the discharge, to ensure the resident could be discharged to the family home. Resident #1 was discharged by the facility to a location that was not determined to be a place he could reside prior to an approaching hurricane, was then transported to a shelter by law enforcement and ultimately to a hospital emergency room due to experiencing acute [MEDICAL CONDITION]. The facility failed to arrange necessary services for treatment upon discharge, which resulted in acute [MEDICAL CONDITION] and subsequent hospitalization for Resident #1. The findings include: A review of the electronic clinical record revealed Resident #1 was a long-term care resident, who was admitted on [DATE]. His most recent readmission was on [DATE], and he was discharged on [DATE]. His [DIAGNOSES REDACTED]. He was also noted with [MEDICAL CONDITIONS], low back pain and [MEDICAL CONDITION]. Resident #1 was listed as his own responsible party, but also had his sister listed as his Power of Attorney and Health Care Surrogate, who was to be provided with his personal health information until [DATE], when the resident changed his mind. A review of the current physician's orders for Resident #1, revealed an order dated [DATE] (Tuesday) that read, Resident to be discharged home per MD (physician), per resident request, okay to send resident with meds (medications), including narcotics enough for Friday. Resident to come back to facility on Friday to pick up scripts (prescriptions) from MD. Start date [DATE]. End date: [DATE]. Physician's orders were noted for the following medications and treatments: [MEDICATION NAME] liquid 4 mg/0.1 ml (milligrams per milliliter), inject 1 ml intramuscularly as needed for suspected or known acute opioid overdose. Start [DATE]. [MEDICATION NAME] HCL ([MEDICATION NAME]) tablet 100 mg, give 1 tablet by mouth at bedtime related to major [MEDICAL CONDITION]. Start [DATE]. The resident was also receiving [MEDICATION NAME] (antidepressant) and [MEDICATION NAME] (mood stabilizer) with behavior monitoring in place. Ordered [DATE]. Clean wound on lower left leg with normal saline. Pat dry, apply [MEDICATION NAME] Calcium Alginate Silver and dry dressing once daily until healed. Every night shift for wound care. Start [DATE] (revised [DATE]). End date [DATE]. Oxygen at 2 liters per minute via nasal cannula as needed for [MEDICAL CONDITION] as needed for shortness of breath. Start [DATE]. [MEDICATION NAME] tablet 10 mg, give 1 tablet by mouth one time a day for [MEDICAL CONDITION]. Start [DATE]. ProAir HFA (hydrofluoroalkane - propellant) Aerosol solution 108 mcg/act (micrograms per actuation), 2 puff inhale orally two times a day related to [MEDICAL CONDITION]. Start [DATE]. [MEDICATION NAME] Aerosol ,[DATE].5 mcg/act, 1 inhalation inhale orally two times a day for [MEDICAL CONDITION]. Rinse mouth with water and spit back into cup after each use to prevent thrush. Start [DATE]. The resident also had orders for nebulizer and oxygen tubing to be changed weekly with filter cleaned. Start [DATE]. A review of the nursing progress note dated [DATE] at 8:19 p.m. read, Written by (facility nurse), Licensed Practical Nurse (LPN). Resident returned to the facility from leave of absence (LOA) in stable but obviously inebriated condition accompanied by a gentleman who also presented to be intoxicated. Both gentlemen were slurring their words and presented with red flushed faces. When resident was asked to sign back into the facility, he was reluctant to do so. The director of nursing (DON) asked him if he had any cigarettes and he stated, I have many cartons. The DON asked him to relinquish the cigarettes to be locked up because he could not keep them in his room. (Resident #1) became agitated and demanded to be discharged immediately. Staff called MD and obtained orders to discharge resident from the facility at resident's request. The resident and staff and his guest went to his room to pack up his belongings after approximately 10 minutes of packing staff observed resident's guest yelling and swearing at (Resident #1). Staff escorted his guest out of the facility and explained to him that he would have to wait for (Resident #1) outside. Resident was given his medications and narcotics pain medication to last him until Friday morning ([DATE]). Medication and discharge instructions reviewed with resident. He was also told to return to the facility on Friday to obtain prescriptions from MD and his motorized wheel chair. Resident verbalized his understanding of his medication and discharge instructions. Resident left facility in stable condition self-propelling in his wheelchair. A nursing progress note dated [DATE] at 1:36 p.m., revealed that the resident's left posterior lower leg was discovered with an open wound measuring 3.0 cm (centimeters) long by 0.50 cm wide by 0.20 cm deep. A second wound was identified on the resident's left shin, measuring 4.5 cm long by 1.50 cm wide by 0.20 cm deep. Orders were obtained and wound care with dressing change was initiated daily and as needed. A subsequent nursing note dated the same day at 10:35 p.m., revealed the resident was being started on oral antibiotics twice a day for 10 days for infected wounds. A review of the social services progress note dated [DATE] at 12:53 p.m. revealed, Written by (social services director). QUARTERLY: (Resident #1) is a long- term care (LTC) resident here at (facility) and has a Brief Interview of Mental Status (BIMS) score of ,[DATE]. (Resident #1) is alert to self and others and able to make needs known. (Resident #1) states he has no concerns at this time. SSD will continue to f/u (follow up) with (Resident #1). A review of the Care Plan/Interdisciplinary team (IDT) note dated [DATE] at 12:13 p.m. revealed the care plan meeting was held and Resident #1 was present. Social services is working along with his sister to have him placed closer to her. According to the nursing progress notes reviewed from [DATE] through [DATE], Resident #1 was receiving [MEDICATION NAME]-[MEDICATION NAME] ,[DATE] mg every 4 hours as needed for severe pain. He received this medication on ,[DATE], ,[DATE], ,[DATE] and [DATE]. According to the nursing progress note dated [DATE] at 2:13 p.m., the resident was ordered [MEDICATION NAME] Nebulization Solution, 2.5 mg/3 ml (milligrams per milliliter) 0.083%, 1 vial inhale orally via nebulizer four times a day for shortness of breath. According to a nursing progress note dated [DATE] at 6:32 a.m., Resident #1 was involved in an altercation with a second resident, which included loudly arguing over money in the facility's dining room. Staff had to intervene to diffuse the situation. A review of the Care Plan/IDT note dated [DATE] at 9:34 a.m. revealed, (Resident #1) attended in person. His sisters Hospice attended by telephone. Care plans were reviewed. Main issue being discharge plans for (Resident #1). Both sister and Hospice were in agreement that going to the family home was not in the best interest for (Resident #1) at this time. (Resident #1) became very emotional, but verbalized acceptance at staying long-term care for the time being. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #1 had verbal behaviors toward others which occurred one to three days during the 7-day assessment period. He was assessed as being independent in bed mobility, transfers, locomotion on and off the unit, toilet use and personal hygiene. He required supervision with eating, bathing and dressing. He was not steady on his feet, and did no walking during the assessment period. He used a wheelchair for mobility. He was at risk for pressure ulcers. He experienced frequent pain, used tobacco and received oxygen therapy. A review of the Care Plan dated [DATE], revealed the following Focus Areas: Activities of Daily Living (ADL) care - The resident cannot complete ADL care independently and requires individualized interventions to maintain because of weakness. The resident has potential to demonstrate behaviors of aggression and irritability related to a [DIAGNOSES REDACTED]. Keeps moldy food in room. Buys sodas at local convenience store and sells them to other residents. Uses foul language toward staff. Demanding of his medications with foul language. Does not follow smoking policies. Diabetes mellitus. Blood glucose monitoring before meals and one hour after meals. Risk of falls. [MEDICAL CONDITION] diagnosis. Uses oxygen as needed. Potential for pain related to [DIAGNOSES REDACTED]. Use of [MEDICAL CONDITION] medication. [MEDICAL CONDITION] disorder. Resident is a smoker. Wound risk. Current wound. Skin tear to left lower leg and left shin areas related to fragile skin. Antibiotic use for infection of left lower leg. Hearing deficit. Use of hearing amplifiers for both ears. Use of diuretic medication. [MEDICAL CONDITION] diagnosis. Discharge planning: (Resident #1)/family have decided he will remain a long-term care (LTC) resident of facility. (Note dated [DATE]) Goal read: (Resident #1) will adjust appropriately to LTC status through next review date. (Goal dated [DATE]) During an interview with the Social Services Director (SSD) on [DATE] at 1:20 p.m., she stated she had been the SSD since (MONTH) 2019. Resident #1 was discharged home per his request. The physician signed a discharge order. The resident wanted to go home. He would sign himself out, go on a leave of absence (LOA) and not come back until late at night. He had met his goals as far as needing to be in a skilled facility. She had spoken to Resident #1 and his sister about finding an assisted living facility (ALF), because he had behaviors, but none of them would take him. He would often talk about moving closer to where his mother and sister lived. He went to the family home (his mother's home) the day he was discharged . His sister stated he had mental issues and could not stay there. I guess you would say it was a planned discharge. The doctor signed the discharge. He had wanted to go home. The discussions with the sister were to move him closer to her. Resident #1's girlfriend was living at the house (his mother's home). The day he was discharged was the same day as the hurricane (Dorian). It was the day he requested discharge. He was always screaming at people. The DON called the doctor for an order to discharge. He had been informed that if he went against medical advice (AMA), he would not get his medications. He was instructed to come back to the facility to pick up his medications. The evening he was discharged , he and his friend were slurring their words and appeared intoxicated. He had rolled himself in his wheelchair to the family home that day. He had a friend bring him back to the facility that evening. He was at his mother's house during most of the day. He and his friend got into an argument and the staff had to escort his friend out of the building. The SSD then stated, There was no plan to discharge. He wanted out and he wanted out then. I had been calling around to find him an ALF, but they won't take them if they have behaviors. His sister was named power of attorney (POA), but he was his own decision maker. His sister wanted to make decisions for him, so he went and had a letter discontinuing his election for POA notarized on [DATE]. He talked about wanting to go home but the sisters would tell him he couldn't. He would take himself over there (mother's house) every day. She confirmed that there had not been a home health provider set up because it was a sudden discharge. She had not set up a provider for oxygen therapy. She stated he needed a hospital bed and oversized commode because he was a large man. He was supposed to come back and get his prescriptions. She was going to call Medicaid for him and see about getting him a hospital bed and a commode, but she never saw him again after [DATE]. She heard the sister called the police on him to have him taken to a crisis stabilization unit, but no one had called the facility to see if he could return. The SSD stated she e-mailed the sister the day of the hurricane or the day before and asked why they were allowing Resident #1 to leave the building with a hurricane coming, but earlier in this conversation she stated that There was no plan to discharge. He wanted out and he wanted out then. As far as the SSD knew, Resident #1's sister did not know he was discharging himself unless he called her himself. She stated she did not notify his family. During an interview with the hospital care management department manager on [DATE] at 3:46 p.m., she stated she was working on [DATE] when Resident #1 was admitted from the shelter. The Sheriff's Office transported him to the emergency room (ER). At the time he was admitted he was having shortness of breath and was diagnosed with [REDACTED]. His oxygen saturation level in the emergency room that evening was 80% on room air. At the time of the interview, Resident #1 was still in the hospital. They were having trouble finding placement for him. The department manager stated Resident#1 was discharged to his sister's home with no oxygen, no wound care and no safe discharge plan. She remembered it was raining that day as the hurricane was approaching. Resident #1 told her that his mother's home was his house. She did not know whether he ever owned it. He claimed he owned it and could go there when he wanted to go. He told the hospital care manager he was dropped off there on [DATE] before the hurricane was supposed to arrive. She looked up the ownership of the house and said it looked like it belonged to the resident's sister. She called the administrator of the nursing home to discuss whether she would readmit him, and she was told by the administrator that the house Resident #1 was discharged to was his home and he wanted to go there. He was his own decision maker and could leave and go home if he wanted to. The administrator told her that Resident #1 did not need oxygen and only wore it as needed. She stated that the facility let Resident #1 go to an unconfirmed discharge location. The administrator told the hospital department manager that the resident was verbally abusive, and they would not take him back. The hospital manager stated the hospital case managers had been talking to Resident #1's sister. The sister was telling them that she was not capable of taking care of him. She wanted him placed in long-term care. She rented the house out. The deed was not in his name and never had been. Resident #1's sister told the hospital case managers that the facility staff were aware of this information, because she had explained it to them on many occasions. A review of the hospital records, dated [DATE], revealed Resident #1 was admitted with the [DIAGNOSES REDACTED]. and [MEDICAL CONDITION] bilaterally to lower extremities. He was admitted for these [DIAGNOSES REDACTED]. During an interview with Resident #1 on [DATE], he stated that the house he was discharged to on [DATE] was his family home. His mother owned the house. He was allowed to go to the house during the day. His girlfriend lived there. She rented a room from his mother. He stated he signed himself out of the facility and wheeled himself over there almost every day. On the day he was discharged , he had been at his mother's house most of the day. He confirmed that he did consume alcohol when he was away from the facility. He was drinking that day. In the evening, a friend of his pushed him back over to the facility. When he got there the Director of Nursing (DON) asked him if he had any cigarettes. He told her he did, but he did not want to give them to her. He wanted to go smoke. They had an argument about the cigarettes, and he told the DON he wanted to be discharged . He stated, They got my paperwork ready and packed up all my stuff in my room. The lady in charge threw it in the back of her truck and drove it over to my mom's house and dumped it in the front yard. He indicated that his belongings were in large plastic garbage bags. He stated that he was given most of his medications. He stated it was the facility staff's idea to have him go back to his mother's home. He stated his sister did not want him living there. A staff member assisted him by pushing him in his wheelchair to his mother's home. They left him in the front yard and drove away. Three police cars showed up, and they eventually took him to a shelter set up for the hurricane at the county fairgrounds. He thought he stayed there for about 24 hours, and then he was taken to the hospital because he was short of breath. He did not have any oxygen supplies, and no one provided wound care to him while he was at the shelter. He did not have a nebulizer treatment while at the shelter. He did not have a bed to sleep in that night, so he slept in his wheelchair. He stated he needed a wide hospital bed because his was a large man. When asked whether he needed oxygen therapy every day, he replied, Yeah, I gotta have it. I'd die without it. The resident had a bandage covering his left lower leg. He stated the nurses at the facility had been cleaning it and changing the dressing every day until he was discharged . During an interview with the Administrator on [DATE] at 5:29 p.m., she stated the previous administrator had issued him a 30-day discharge notice. Close to the day of discharge on the 30-day notice given to him, he decided he did not want to go anywhere. He then went out into the woods and his legs got cut up. His legs got infected, so they withdrew the discharge notice. She issued him a new discharge notice on [DATE], but that was the day he came back intoxicated, demanding to be discharged . He decided he did not want to live here anymore. He demanded a discharge notice. The doctor was not available. This was a couple weeks prior to [DATE]. He had many behaviors. He yelled and screamed when he got angry. He would steal from other residents. He became angry when she put a new key lock on the back door to the smoking porch, because he was not able to go out there any time he wanted to. The evening of [DATE], she told him when he was demanding to leave, that she would call the physician covering for his regular physician. That physician told her that he would come in on Friday [DATE] and give Resident #1 prescriptions. She stated, I got an order for [REDACTED]. She confirmed that Resident #1's property was transported by herself in her vehicle. A staff member pushed him in his wheelchair across the street. They left his belongings in the front yard. There was an older gentleman screaming from inside the house He's not allowed to live here. He came to this facility as a skilled, short-term resident. She confirmed he was a hospice recipient when he was first admitted . She stated, His name is on the deed for the family home, and he used to live there with his girlfriend. The sister put her name on the deed so he would qualify for Medicaid. He was able to make his own decisions and he demanded to be discharged . We can't keep him here if he wants to leave. During a telephone interview with Resident #1's sister and her mother on [DATE] at 12:47 p.m., his sister confirmed that the house was owned by her mother and she and her mother were on the deed. Her brother was not on the deed. He had never been on the deed. They rented the house to Resident #1's girlfriend and another man. Resident #1 was living there and paying rent at one time, but became very ill and almost died because he was not taking his medications or taking care of himself. On [DATE], the facility did not contact her or her mother to let them know he had been discharged and confirm that he could go back to the family home to live. She confirmed the police called them to inform them that he was at the home and had been discharged . She confirmed that she was no longer his power of attorney (POA) - he rescinded it. Resident #1's mother confirmed everything that was said by her daughter, and stated that she could not take care of him and no one could take care of him because he was nasty and would yell at the caregivers and swing at them. He used to hit her too. She stated, He has a mental issue and he does not make good decisions. I can't have him living there anymore. Resident #1's sister stated that the facility staff knew he was not allowed to go back to the family home to live. He was allowed to go see his girlfriend, but he was not allowed to move back in. She confirmed that he needed oxygen therapy and a hospital bed. She was aware that he had wounds on his left leg. A review of the facility policy and procedure entitled Transfer or Discharge Notice revealed: A resident will be given a thirty-day advance notice of an impending discharge from our facility. At the time of the notification, the facility will provide each resident and responsible party with the following information: [NAME] The plan of the transfer and adequate relocation of the resident. C. Assurances that the resident will be transferred to the most appropriate facility or setting to meet his needs in terms of quality, service and location. A review of the facility policy and procedure entitled Discharge Summary and Plan revealed: 1. When the facility anticipates a resident's discharge to a private residence, a discharge summary and post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. 4. Every resident will be evaluated for his discharge needs and will have an individualized post-discharge plan. 5. The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include: a. Where the individual plans to reside, b. Arrangements that have been made for follow-up care and services; c. a description of the resident's stated goals; d. The degree of caregiver/support person availability, capacity and capability to perform required care; e. How the IDT will support the resident in the transition to post-discharge care.

Based on interviews and record reviews, the facility failed to allow readmission for two residents who were transferred to the hospital from a sample of five residents reviewed for admission, transfer and discharge rights. (Residents #24 and #25). The findings include: 1. Record review for Resident #24 found he was admitted to the facility on [DATE] and had several hospitalization s and readmissions. His most recent readmission was on 12/15/2018 with a transfer to the hospital on [DATE]. Further record review revealed Resident #24 was receiving Medicaid for his stay at the facility. Resident #24 was sent out to the emergency roiagnom on [DATE] and had not returned to the facility. Review of a 2/20/2019 interact transfer form found Resident #24 was alert and oriented. He was being transferred to the hospital for abnormal labs. He had a wound on his sacrum and was on antibiotics for a wound infection and on isolation precautions while at the facility. An interview was conducted with the hospital representative on 5/21/19 at 9:30 AM. She stated that Resident #24 was discharged from the hospital to another nursing home on 4/16/19. They were tracking his progress and anticipated his return to the facility. The facility had not provided the hospital with any notices. On 4/6/19 when the resident was ready to leave the hospital, they were informed that he could not return to the facility which had been his home. An interview was conducted on 5/21/2019 at 2:58 PM with the Director of Nursing (DON) from the facility's sister facility. The DON stated they decided not to take the resident back due to the state survey because they needed to clean the facility up. She added that due to the condition of the resident with a new debrided wound and a wound vac they did not think it was safe, and that they could not meet his needs. She stated they stopped taking all new admissions and did not feel that they needed to take him back based on his needs and having his bed hold run out. During an interview on 5/22/2019 at 9:00 AM, with Resident #24's physician, he stated he often has residents on intravenous antibiotics and with wounds and [DEVICE]. He stated he was not involved in making any recommendations to not accept Resident #24 back to the facility. He also confirmed that he was the Medical Director at the facility. 2. Record review for Resident #25 found he was admitted to the facility on [DATE] and went out to the hospital on [DATE]. During an interview with the Interim Director of Nursing on 5/22/2019 at 8:48 AM, she stated Resident #25 did not return to the facility. She was asked why and she stated, He is not allowed back because his bed hold was up. During an interview with the Administrator on 5/22/2019 at 8:52 AM, he stated he did not speak to Resident #25 or his family about coming back to the facility. He was asked if he made the decision to not accept the resident back. His answer was, I went with what the team told me. During an interview with Resident #25's physician on 5/22/2019 at 9:00 AM, he stated the first time he saw Resident #25 was in (MONTH) of 2019. He stated he was not involved in any decision not to readmit Resident #25 to the facility. He did not know why he was sent out or why the facility might not have been able to meet his needs. 3. During a telephone interview with Resident #25 on 5/22/2019 at 11:15 AM, he stated he was on his last day of antibiotics. He had planned to return to the facility, but was told he could not because his bed hold was up. He stated he left the faciity on [DATE] and did not return on his last day of the bed hold because his antibiotics were too expensive to get at the facility. He stated the facility was saving his bed space until Saturday and he had to stay in the hospital due to the cost of the medication. Now the facility will not take him back. He was aware the facility was not full. He stated he did not get a 30 day notice. They have all of his possessions and his $130.00. He stated he does not feel good about it. He was a low risk patient. He minded his own business. He added he was told by the Admissions Coordinator there was a moratorium so he could not go back to the facility since he missed his bed hold. He stated he needs to get back into the swing of things and needs to go somewhere with a rehab center. He added, lying in bed and not knowing where he can go is upsetting, how it dirty handed they are at the facility by not letting him back. He felt he was being swept under the rug. 4. During an interview on 5/22/2019 at 11:50 AM with the Administrator from the sister facility, she stated the facility did not have to take Resident #24 back on 4/8/2019 because he was past his 30 day notice. She was asked about Resident #25 and she stated their insurance would not allow them to take the resident back due to his weight. 5. During a telephone interview with the Admissions Director on 5/23/2019 at 10:25 AM, he was asked why Resident #24 was not readmitted to the facility. He stated Resident #24 went out to the hospital and was back and forth between the intensive care unit and the progressive care unit. They were going to send him to their other location and then decided not to and since his 8 day bed hold had ended, they did not need to accept him back. During the same interview the Admissions Director was asked why Resident #25 was not readmitted to the facility. He stated he was working to get him back during the 8 day bed hold period and when it ended he could not take him back because he was over the weight limit of 350 lbs. He stated other than his weight being an issue he could not come back due to the cost of his medication. 6. Record review of the facility census provided by the Administrator revealed on 4/8/2019 when Resident #24 was ready to return to the facility, the patient census was 43 out of 60 beds. On 5/17/2019 the patient census was 42 out of 60 beds. On 5/22/2019 when Resident #25 was interviewed and wanting to come back to the facility, the census was 40. 7. Record review of the bed hold policy revealed under 5. If a Medicaid resident exceeds he state bed hold period, he or she will be permitted to return to the facility to his or her previous room (if available) or immediately upon the first availability of a bed in a semi-private room provided that the resident: A Requires the services of the facility; and is eligible for Medicare skilled nursing services or Medicaid nursing services.

Based on observation, record review and staff interviews, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets necessary to care for residents' needs, by failing to implement safe medication practices related to the administration of intravenous (IV) medications for three (Residents # 3, 14, 38) of four residents sampled for intravenous (IV) therapy, to ensure IV therapy provided was administered only by LPNs with State-approved IV certification. On 2/25/2019 at 11:17 AM, Immediate Jeopardy (IJ) started. On 2/27/19 at 10:09 AM, the Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy determination. On 3/1/19 at 3:30 PM, the facility provided an acceptable credible Allegation of Compliance (A[NAME]) related to LPNs administering IV therapy without required certification. On 3/1/2019 at 8:50 PM, the Immediate Jeopardy was removed after validation of the implementation of the A[NAME]. The findings include: 1. A record review for Resident #14 revealed a [AGE] year-old male admitted on [DATE] with the following Diagnoses: [REDACTED]. He was alert and oriented and required extensive assistance with activities of daily living, except for meals he was independent. On 1/26/19, he was found to have cloudy urine and mental status changes. An order was given to obtain a urinalysis and culture and sensitivity. The culture report, dated 1/29/19, showed ESBL (Extended spectrum beta lactamase) bacteria in the urine. The culture report indicated that only medications administered IV (intravenously) were sensitive to treat the infection. The physician ordered placement of a midline IV catheter. The catheter was inserted on 1/31/19 by an infusion company that specialized in placing midlines and PICC lines (peripherally inserted central catheter). On 1/31/19, the order for [MEDICATION NAME] sulfate 250 mg (milligrams) IV two times a day for ESBL in the urine for 10 days was started. There was also an order [REDACTED]. A review of the Medication Administration Record [REDACTED]. The Florida Nurse Practice act requires LPNs to have 30 hours of certification training in IV therapy to be qualified to administer IVs. On the following dates and times, the LPNs administering the IV antibiotic [MEDICATION NAME] were not certified for IV therapy: On 2/6/19 at 6:00 am (Employee D) and 10:00 pm (Employee K), on 2/7/19 at 6:00 am (Employee K), on 2/10/19 at 10:00 pm, on 2/11/19 at 6:00 am (Employee K), on 2/13/19 at 10:00 pm, and on 2/14/19 at 6:00 am. On 2/3, 2/4, 2/5, and 2/11/19 at 10:00 pm, on 2/12 at 6:00 am, and on 2/13 at 6:00 am and 2:00 pm, the IV antibiotics were administered by agency LPNs. It was unknown whether or not they were certified. An interview was conducted with the Director of Nursing (DON) on 2/25/19 at 4:30 pm. She was asked if all LPNs employed by the facility were IV certified. She stated she wasn't sure and would have to review the personnel files. She was asked for a list of all LPNs working in the facility and to designate which had IV certification. The list produced contained the names of nine LPNs. Of the nine, there were only two with IV certifications in the files. The DON stated that two other LPNs told her they were IV certified, however, she could not verify that information. The DON was asked if the facility performed competencies for IVs with the nurses that were IV certified as well as the LPNs sent from agencies. She stated they did not perform clinical competencies for IV's. She further stated they did not do competencies for the agency nurses related to the IVs, as that was done by the agencies. She was asked if she requested competencies from the agencies for nurses administering IV's, and she replied no. She was asked if Employee D and Employee K were IV certified, and she replied that Employee K was not certified and Employee D came to them from another state with certification in that state, but did not have Florida IV training or a clinical competency by the facility. She was asked if she was aware of which of the LPN's were IV trained prior to the request for those names, and she only knew of one. 2. A record review for Resident #38 revealed a [AGE] year-old male admitted [DATE] with [DIAGNOSES REDACTED]. He was alert and oriented, but required extensive assistance with activities of daily living. He was independent with eating. A urine culture report dated 1/10/19 showed ESBL in the urine. On 1/13/19 an order was given for [MEDICATION NAME] sulfate 250 mg every 12 hours IV for 10 days. The physician ordered placement of a midline and contact isolation. On 1/15/19, a new order was received for a urine culture by straight catheter (one time only) to recheck the urine. The culture still showed ESBL in urine. The antibiotic was extended to 2/2/19. A urine culture was ordered on [DATE], and the results on 2/18/19 showed ESBL in the urine. The report indicated that another IV antibiotic would be more effective. A new order was received for [MEDICATION NAME] HCL (antibiotic) solution reconstituted, 1 gram IV two times a day for ESBL for four days. An order was given to place a midline. The new antibiotic was started on 2/20/19 at 9:00 am. Due to difficulty with the midline on 2/21/19, a new order for a peripheral IV was given. The resident's last dose of [MEDICATION NAME] was on 2/25/19. A urine culture was ordered for 2/27/19 and results were pending. A review of the Medication Administration Records (MARs) for (MONTH) 2019 revealed that LPNs were documenting administration of the intravenous (IV) antibiotics, and the 10 cc normal saline flushes before and after the medication. The Florida Nurse Practice act requires LPNs to have 30 hours of certification training in IV therapy to be qualified to administer IV's. On the following dates and times the LPNs administering the IV antibiotic [MEDICATION NAME] were not certified for IV therapy. On 2/20/19 at 9:00 am (Employee D) and 9:00 pm (Employee K), on 2/22/19 at 9:00 pm (Employee K), on 2/23/19 and 2/24/19 at 9:00 am (Employee D) and 9:00 pm (Employee K). On 2/27/19 and 2/28/19 at 9:00 am (Employee D), and on 2/22/19 at 9:00 am and 2/26/19 at 9:00 pm, the IV antibiotics were administered by agency LPNs. It was unknown whether or not they were IV certified. 3. A record review for Resident #3 revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. She was alert and oriented and required limited assistance with activities of daily living. She was ordered IV antibiotics for ongoing cellultis and a left leg wound with osteo[DIAGNOSES REDACTED]. She had a PICC line catheter (central line) in her right upper arm for administration of IV antibiotics. She was ordered Meropenem solution, reconstituted, 1 gram every eight hours for six weeks. A review of the Medication Administration Records (MARs) for (MONTH) 2019 revealed that the LPNs were documenting administration of Intravenous (IV) antibiotics and the 10 cc normal saline flushes before and after the medication. The Florida Nurse Practice act requires LPNs to have 30 hours of certification training in IV therapy to be qualified to administer IV's. On the following dates and times the LPNs administering the IV antibiotic Meropenem were not certified for IV therapy. On 1/11/19 at 6:00 am and 10:00 pm (Employee K), on 1/12/19 at 2:00 pm (Employee D) and 10:00 pm (Employee K), on 1/13/19 at 6:00 am and 10:00 pm (Employee K) and at 2:00 pm (Employee D), on 1/14/19 at 6:00 am (Employee K), and on 1/20/19 at 2:00 pm (Employee D). On the following days the IV antibiotic was administered by agency LPNs: 1/10/19 at 10:00 pm, on 1/11/19 at 6:00 am, 2:00 pm, and 10:00 pm. On 1/12/19 at 6:00 am, on 1/14/19 at 2:00 pm and 10:00 pm, on 1/15/19 and 1/16/19 at 6:00 am, 2:00 pm and 10:00 pm, on 1/17/19 and 1/18/19 at 6:00 am and 10:00 pm, on 1/19/19 at 6:00 am and 10:00 pm, on 1/20/19 at 6:00 am, on 1/21/19 at 6:00 am and 10:00 pm, and on 1/23/19 at 6:00 am, 2:00 pm and 10:00 pm. It was unknown whether or not they were IV certified. On 2/25/19, during the survey, an agency LPN (Employee A) was assigned to Resident #3. A review of the MAR for 2/25/19 revealed she documented having administered the IV antibiotic Meropenem at 2:00 pm. An interview was conducted on 2/25/19 at 4:35 pm with the Registered Nurse (RN) Unit Manager/Infection Control Nurse. She was asked whether LPNs could flush a PICC line, and she stated only if the LPN had been IV certified (with PICC line training). She was asked if the agency LPN assigned to Res #3 was IV certified, and she stated that she would need to check. She was asked for the policy and procedure for management of IV PICC lines, and she reported that she wasn't sure if the facility had one, but she would find a list of nurses that had IV certification and were working in the facility. On 2/26/19, an interview was conducted at 10:00 am with the Staff Development nurse. She was asked if she knew which of the LPNs were IV certified, and she said she would need to check the files. On 2/27/19 at 11:10 am, an interview was conducted with the DON. She was asked if the agency LPN who worked on 2/25/19 during the morning shift was IV certified. She said she should be coming from an agency. She was asked when requesting nurses from an agency did she request that the LPNs be IV certified when there were residents in the facility receiving IV medications, and she replied no. She was asked if the facility performed clinical competencies for the facility nurses and the agency nurses, and she replied no. She stated it was the agency's responsibility to perform clinical competencies prior to sending nurses to the facility. An interview was conducted with the owner of the nursing agency on 2/27/19 at 1:46 pm. He was asked if all of the LPN's employed by the agency were IV certified. He reported that none of their LPNs were required to be IV certified. He was asked if the LPN (Employee A) sent on 2/25/19 during the day shift had IV certification, and he stated he had nothing on file to confirm she was certified. Per the owner, if a facility needed a nurse to manage an IV, then he would have sent an registered nurse (RN) to the facility. The practice of practical nursing as defined by Section 464.003(3)(b), Florida Statutes, includes the administration of treatments and medication, under direction, and holds the licensed practical nurse responsible and accountable for making decisions . based upon the individual ' s educational preparation and experience in nursing. As medical science advances and the demands for health care in Florida grow, the scope of nursing practice, in general, and of the practice of practical nursing, in particular, is expanding. It has become necessary that the licensed practical nurse, when qualified by training and education and when approved by the institution at which the licensed practical nurse is employed, engage in the limited administration of intravenous therapy both to serve the public and to allow the professional nurse to better perform those acts requiring professional nursing specialized knowledge, judgment and skill. (2) The purpose of this rule is to protect the public by ensuring the availability of intravenous therapy and its competent administration in the care of the ill, injured or the infirm. In keeping with the purpose, this rule authorizes the qualified licensed practical nurse to administer those aspects of intravenous therapy within the scope of practice of the licensed practical nurse, enumerates those aspects of intravenous therapy outside the scope of practice of the licensed practical nurse, and sets out the educational and/or competency verification necessary to administer, under direction, limited forms of intravenous therapy. Specific Authority 464.006 FS. 64B9-12.004 Authority for the LPN to Administer Limited Forms of Intravenous Therapy. With the exception of those aspects of intravenous therapy deemed outside the scope of practice of the licensed practical nurse by Rule 64B9-12.003, F.A.C., above, and subject to the approval of the institution at which the licensed practical nurse is employed, any licensed practical nurse who meets the competency knowledge requirements of Rule 64B9-12.005, F.A.C., below, is authorized to administer intravenous therapy under the direction of a registered professional nurse. 64B9-12.005 Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy. The board endorses the Intravenous Therapy Course Guidelines issued by the Education Department of the National Federation of Licensed Practical Nurses, November, 1983. Central Lines. The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.002(2), F.A.C. Appropriate education and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. Providers: The LPN/IV education must be sponsored by a provider of continuing education courses approved by the Board pursuant to Rule 64B9-5.005, F.A.C. To be qualified to teach any such course, the instructor must be a currently licensed registered nurse in good standing in this state, have teaching experience, and have professional nursing experience, including IV therapy. The provider will be responsible for issuing a certificate verifying completion of the requisite number of hours and course content. On 2/27/19 at 10:09 AM, the Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy determination. Information was shared regarding Licensed Practical Nurse A's failure to cleanse the glucometer between multiple residents' use, and LPNs administering IV fluids and medications without the state-required certification. The facility's A[NAME] related to LPNs not qualified to administer IV medications was received on 3/1/19 at 3:30 PM. The survey team verified implementation of the A[NAME] through observations of RN staff providing IV medications on 3/1/19, interviews with nursing staff to determine their knowledge of who can administer IV medications, interviews with the DON and Administrator regarding how they would communicate nursing needs to the agencies providing nurses to the facility, as well as their plans for orienting agency staff to their policies and procedures and facility expectations, a review of re-education provided to staff as well as IV competencies completed through 3/1/19, and review of the revised policies and procedures. These activities occurred throughout the day on 3/1/2019 until the IJ was removed at 8:50 PM on 3/1/19.

Based on observations, interviews, record reviews, a review of the Evencare G2 Blood Glucose Monitoring System QA/QC (quality assurance/quality control) reference guidelines, and a review of the Centers for Disease Control and Prevention guidelines, the facility failed to provide treatment and care in accordance with professional standards of practice, by failing to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to provide safe blood glucose monitoring to residents to protect them from the spread of bloodborne pathogens. During observations of Blood Glucose Monitoring (BGM) via finger stick, one of one Licensed Practical Nurses (Employee A), failed to clean and disinfect the glucometer (a device used to measure blood glucose levels) between each resident's use for three (Resident #28, #3, and #10) of three residents observed, out of a total of thirteen (13) residents who required scheduled blood glucose monitoring, and three (3) that required as needed blood glucose monitoring, including two residents (Resident #28 and #10) who had [DIAGNOSES REDACTED]. This failure placed the residents at risk for transmission of potentially infectious blood-borne pathogens such as [MEDICAL CONDITION] (HBV), [MEDICAL CONDITION] (HCV), and human immunodeficiency virus ,[MEDICAL CONDITION]. The facility also failed to observe infection control precautions during administration of intravenous (IV) medication for one (Resident #38) of four residents sampled for intravenous (IV) therapy, placing the resident at further risk for infection, and the facility failed to properly set up isolation rooms, dispose of isolation waste, and handle isolation linens for three (Rooms 205, 206 and 208) of three isolation rooms observed over the course of the survey. On 2/25/2019 at 11:17 AM, Immediate Jeopardy (IJ) started. On 2/27/19 at 10:09 AM, the Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy determination. On 2/28/19 at 3:42 PM, the facility provided an acceptable credible Allegation of Compliance (A[NAME]) related to the failure to clean glucometers. On 3/1/2019 at 8:50 PM, the Immediate Jeopardy was removed after validation of the implementation of the A[NAME]. The findings include: 1. On 2/25/19 at 11:17 AM, Employee A, Licensed Practical Nurse (LPN), was observed obtaining a blood glucose reading for Resident #28 . She removed all of her supplies (glucometer, lancet, alcohol wipe, and test strip), and laid them on the top of the cart without a barrier. She then picked up all of the supplies, took them into the resident's room and placed them on the table, again without a barrier. The nurse donned clean gloves without washing her hands first. She obtained the resident's blood glucose reading and then rolled the test strip and alcohol wipe up in her gloves and threw them in the trash can in the resident's room. The nurse placed the lancet in the sharps container on the medication cart. She then placed the Evercare G2 blood glucose meter (glucometer) in the top drawer of her medication cart without cleaning and/or disinfecting it. On 2/25/19 at 11:35 AM, Employee A, LPN, removed the same glucometer from the medication cart that was used for Resident #28. She removed a lancet, test strip, and alcohol wipe from the cart, and again placed them all on top of the cart without a barrier. She picked up all of the items and took them into the room, then placed them on the bedside table without a barrier. She obtained the blood glucose reading for Resident #3. She then returned to the cart and placed the glucometer back into the top drawer of the cart. She failed to clean and/or disinfect it. On 2/25/19 at 11:41 AM, Employee A, LPN, was observed obtaining a blood glucose reading for Resident #10 with the same glucometer that she used for Resident #28 and Resident #3. She removed the glucometer, lancet, alcohol wipe, and a blood test strip, and placed them on top of her cart without a barrier. She picked up all of the items, took them into the resident's room, and placed them on her nightstand without a barrier. She then obtained the blood glucose reading for Resident #10. She wrapped the blood test strip and the alcohol wipe in her gloves and threw them into the resident's trash can. She placed the lancet in the sharps container on her medication cart. She failed to clean the glucometer, and placed it in the top drawer of the medication cart. On 2/25/19 at 12:54 PM, an interview was conducted with Employee A, LPN, regarding the protocol for cleaning the glucometer between residents, and she stated, I forgot, and I am not going to lie, I am not used to anyone standing over me. She was asked if she had received any training in the facility related to cleaning the glucometers and she stated, No, I didn't. She was asked if supplies were provided on the cart to clean the glucometers with, and she stated, Yes, they have bleach wipes down here, and I can also use alcohol wipes. She was asked about her practice of not placing a barrier down when taking the supplies into the resident's room, and she stated, Yeah, I forgot that too. When asked about her practice of not washing her hands between any of the residents, she stated, I usually do, or use sanitizer, but I didn't, I forgot. She was then asked to remove the bleach wipes from the cart, and she removed the blue and white container of Micro-Kill Bleach wipes. She was asked to describe the proper technique, per the facility's policy, for cleaning the glucometers with the wipes, and she stated, I don't know how they use them here. I'm Agency, and they called me in late. I did not even get here until 10:00 am. I don't know what they usually do. An interview was conducted with the Unit Manager, Registered Nurse (RN), on 2/25/2019 at 4:10 pm. She was asked if there was a policy regarding the use and cleaning of the glucometers. She stated the facility used the glucose monitoring nurse competency and disinfection check list. The checklist contained all of the steps for performing the procedure, and there was no written policy for cleaning the glucometers. She was asked for the manufacturer's guidelines for the glucometers used in the facility, and she stated that they did not have one available. On 2/25/19 at 4:30 PM, an interview was conducted with the Director of Nursing (DON) regarding the check list used for the nurses for glucometer cleaning. She stated she would obtain and provide for review the completed competency check lists for the nursing staff. She was then asked if she had the manufacturer's booklet that went with the glucometers, and she confirmed that they did not have one. On 2/25/19 at 5:41 PM, the DON returned with the glucometer checklists. Upon review of the check lists provided and the current employee list, it was discovered that the majority of check lists provided were for nurses no longer employed at the facility. A review of the check lists provided and the nurses currently employed at the facility revealed that only five (5) of the fifteen (15) nurses employed by the facility (not agency nurses) had completed the competency checklist. On 2/27/19 at 12:31 PM, the Medical Director, Administrator, and DON entered the conference room to discuss the concerns with the glucometers and the resident with [MEDICAL CONDITION]. The concerns that were observed during the survey were explained to the Medical Director. He confirmed that it was a nursing standard to clean the glucometers with bleach wipes. He further stated he thought it was an unfortunate occurrence, and the risk of transmission varied with the pathogen. He stated with [MEDICAL CONDITION] (Hep C), the transmission would be relatively small. It would require contact with direct blood that contained the Hep C. He stated they had a plan in place to eliminate that risk. He stated that the resident in question did have the history brought on by IV (Intravenous) drug use. They had ordered a panel for all residents involved and would repeat them in six weeks. He stated, It is one of those things that should not happen, but unfortunately it did. We are just trying to figure out her infection level. She has had some increased enzymes. That will also help determine what the other residents have been exposed to. He confirmed there was no zero chance with anything, however, with Hep C there was a very low risk of it being transmitted. According to the instruction manual for the Evencare G2 glucometer at https://www.medline.com/media/mkt/pdf/EvenCare-Lit928-EvenCare-G2-Clinical-Data.pdf, the following information should be adhered to during cleaning of the glucometers: Page 12 of 30 Cleaning and Disinfecting your Evercare G2 Meter Materials: Evercare G2 meter, gloves, and a validated disinfecting wipe. Cleaning and disinfecting the meter and lancing device is very important in the prevention of infectious disease. Cleaning is the removal of dust and dirt from the meter and lancing device surface so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface. The EvenCare G2 Meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products are validated for disinfecting the EvenCare G2 Meter: »» Dispatch® Hospital Cleaner Disinfectant Towels with Bleach (EPA Registration Number: -8) »» Medline Micro-Kill+ (Trademark) Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number: -10- ) »» Clorox Healthcare® Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: -12) »» Medline Micro-Kill (Trademark) Bleach Germicidal Bleach Wipes (EPA Registration Number: -1) Procedure: 1. Wash hands with soap and water and dry thoroughly. 2. Inspect for blood, debris, dust, or lint anywhere on the meter. 3. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. NOTE: »» Do not get water inside the meter or immerse the meter in water or any other liquids. »» Do not use glass or household cleaners on the meter. »» Avoid using ammonia to clean the meter. »» Avoid wetting the test strip port of the meter. 4. To disinfect the meter, clean the meter with one of the validated disinfecting wipes. Wipe all external areas of the meter including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe ' s directions for use. 5. Wipe meter dry or allow to air dry. 6. Wash hands with soap and water and dry thoroughly. A review of the Centers for Disease Control and Prevention (CDC) guidelines for Infection Prevention during Blood Glucose Monitoring and Insulin Administration (6/8/2017) at https://www.medline.com/media/mkt/pdf/EvenCare-Lit928-EvenCare-G2-Clinical-Data.pdf, revealed the following, The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. On 2/27/19 at 10:09 AM, the Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy determination. Information was shared regarding Licensed Practical Nurse A's failure to cleanse the glucometer between multiple residents' use. The facility's Allegation of Compliance (A[NAME]) was received on 2/28/19 at 3:22 PM. The survey team verified implementation of the A[NAME] through multiple observations of staff providing blood glucose monitoring including additional observations after 2/28/19 at 3:22 PM, interviews with nursing staff to determine their knowledge of the disinfection process, interviews with the DON and Administrator, a review of re-education provided to staff, and review of the revised policies and procedures. These activities occurred throughout the day on 3/1/2019 until the IJ was removed at 8:50 PM on 3/1/19. 2. On 2/25/19 at 12:34 pm an observation was made of Registered Nurse (RN) (Employee I) administering intravenous (IV) antibiotics to Resident #38. He was receiving IV antibiotics due to ESBL (extended spectrum beta-lactamase) in the urine and was on contact isolation. There was PPE (personal protective equipment)( disposable gowns , gloves, masks and red bags) located in a hanging rack on the outside of the resident's door. There was no signage on the door informing anyone entering to see the nurse prior to going in. Employee I and the surveyor donned gowns and gloves prior to entering the room. The nurse administered the IV antibiotic, and when completed, she began to remove her gown and gloves. She was asked where she would dispose of the items, and she replied in the trash can next to the resident's bed. An observation of the trash can found it was full of PPE. When asked why there was no covered trash receptcle at the door for soiled isolation equipment, she stated the facility did not have any. She was asked how the staff handled the isolation linens, as there was no covered linen hamper in the room. She stated the staff was supposed to double bag the linens, take them outside and place them in bins for the linen company to pick up. The facility did not have an in-house laundry. After the IV was completed, the Certified Nursing Assistant (CNA) (Employee M) knocked on the door and announced that she had the resident's lunch tray. The CNA asked the nurse if she could give him the tray since she was already in the room. The nurse took the tray and brought it to the resident. An observation of Resident #38's overbed table located between the beds revealed it was totally covered with all of his personal items and could not be used for his meal tray. The resident stated she could put it on his lap since he was sitting in bed. During an interview with Resident #38 at 12:45 pm, he was asked if he wanted another beside table to eat his lunch. He said he doubted they had any extra, as he had asked before. Again, while the nurse was still in the room, the CNA returned with the roommate's meal tray and asked the nurse to bring it in to the resident since she already had a gown and gloves on. The nurse said she couldn't take the tray over to the roommate as she had not changed her gown and gloves. She instructed the CNA to bring the tray into the roommate quickly without PPE and dont touch anything. The CNA was observed taking the tray across the room to the roommate without any PPE. An interview was conducted with the CNA on 2/25/19 at 12:55 pm. When asked about the facility's protocol for entering resident rooms who were on isolation precautions, she said she would put on a gown and gloves before going into room and mask if instructed by the nurse. When asked why she had not put on the PPE, she said the nurse told her to just bring in the tray and don't touch anything. On 2/25/19 at 1:10 pm, the Activities Director (AD) was asked who the Housekeeping Supervisor (HS) was, and she replied that she had been in the position for about three weeks. When asked if she was filling in, she said no, the previous administrator had made that decision. She was asked what the protocol was for handling isolation trash and linens. She said the trash including the PPE were disposed of in trash cans in the resident rooms, and the linens were placed in double bags and were taken outside to the linen containers. She was asked to accompany the surveyor to the isolation rooms. There were three rooms with residents on isolation precautions, Rooms 205, 206 and 208. Upon observation of all three rooms, there were no trash cans designated for disoposal of isolation equipment or trash. The staff were using the trash cans next to the residents' beds. When asked how the isolation trash was to be handled, she stated there should be a trash can with a red bag as you exit the room. She confirmed there were no trash cans at the door and no red bags in any of the trash cans next to the residents' beds. She was asked where staff disposed of soiled isolation trash, and she replied that any items in red bags were placed in a biohazard box. When asked who was responsible for empting the isolation trash from the rooms, she said the CNAs. She was also asked how isolation linen was handled, and she replied that the items should be double bagged, taken out of the room and placed outside in the linen bins for the outside laundry vendor to pick up. When asked if there was a separate bin for isolation linen, she said no. She was asked how often the housekeepers cleaned the isolation rooms, and stated she thought it was two times a week. An interview was conducted with CNA (Employee M) on 2/25/19 at 2:15 pm. She was asked where the staff disposed of isolation trash and linens. She stated that the trash was put in the trash can in the resident's room, and the laundry was bagged up and taken outside to the laundry bins. When asked if there was a separate bin for isolation laundry or trash she said no. An interview was conducted with the unit mananger/infection control nurse on 2/25/19 at 4:00 pm. When asked who was responsible for setting up resident rooms when isolation precautions were required, she stated that nursing placed the hanging rack with PPE on the door as well as the sign on the door to see the nurse before entering. She was asked how and where staff disposed of isolation PPE when leaving the room. She said a trash can was placed by the door so the items could be disposed of prior to leaving. She was asked how they handled isolation linen, and she said they were to double bag linens and take them outside to the laundry bin. She was asked how the laundry company was made aware of which linens were taken from isolation rooms, and she said she didn't know. When asked why there were no separate covered trash cans for isolation rooms, she said there should be a separate trash can by the door so isolation items could be disposed of prior to leaving the room. Observations made on 2/25/19 at 4:15 pm with the unit manager of the three isolation rooms, found no trash cans by the doors. There were only trash cans by the beds for resident use, which were also being used for disposal items, including gowns and gloves. She was asked if the facility had covered trash containers to put the soiled disposal items in to prevent the spread of infection, and she stated no but would have housekeeping order some. When asked if the facility placed linen hampers in the isolation rooms, she said no, the staff were instructed to double bag linen and take it outside. She was asked what the facility policy was regarding handling of linens and trash, and she replied that the facility was in the process of reviewing the infection control policies and procedures. An interview was conducted on 2/28/19 at 10:55 am with the housekeeping supervisor/activities director. She was asked how long she had been serving as the housekeeping supervisor, and she replied she had started about three weeks ago. She was asked what training she received and who provided the training. She stated that the previous supervisor trained her for two days before she left. She was asked if she was provided infection control education related to housekeeping services, and she said the previous supervisor only oriented her to the job duties. She was asked if she had a policy and procedure manual for housekeeping services, and she stated she did. She retrieved the manual from her office, and reported that she had been reading it a little at a time. When asked if she had been provided infection control training by the infection control nurse, she said she attended an in-service for infection control that all staff were required to attend, but nothing specific to her job. Interview was conducted with the housekeeper (Employee C) on 2/28/19 at 11:00 am. When asked what training had she received about infection control and how she cleaned isolation rooms, she said the previous supervisor did the training. She further stated the facility had a new supervisor, who was also the activity director. When asked how she knew what PPE to use when going into isolation rooms, she said she asked the nurse. When asked how often she cleaned the isolation rooms, she replied every day. She left those rooms for last since she had to change the mop water before and after she cleaned them. When asked how she disposed of the PPE when she was finished cleaning, she said she threw it in the trash barrel in the room, or she bagged it up and took it out to the trash. She was asked where the blood spill kits located, and she stated at the nursing station. She further stated nursing was responsible for cleaning the blood spills. Then they notified housekeeping and housekeeping mopped the floor with disinfectant. On 2/28/19 at 4:45 pm, an interview was conducted with LPN (Employee N). She was asked where the blood spill kits were kept. She stated the housekeepers had them. When asked who was responsible for cleaning blood spills, she replied housekeeping. An interview and a review of the infection control program was conducted with the infection control nurse on 3/1/19 at 3:32 pm. She stated she started at the facility in (MONTH) (YEAR). She was in the process of reviewing what policies and procedures they had and what they needed. She stated the facility had new owners last year, and the previous owners took many of the manuals. She was asked how often she conducted surveillance of the facility and monitored staff to ensure compliance with handwashing and isolation precautions. She stated she monitored the staff daily and checked isolation rooms randomly. When asked how she tracked infections, she said she completed a form for each resident to ensure the symptoms met the criteria for infection. She kept a log of the infections and mapped the location of types of infection. She was asked what measures were put into place related to three residents with ESBL in the urine and a wound in close proximity (Rooms 205, 206 and 208). She stated she and the staff education coordinator did in-service training regarding handwashing and infection control. When asked the date (s) the training was provided, she stated it was done in (MONTH) 2019. The staff education nurse came in at 4:00 am to cover all shifts.

Based on observations, record reviews, and staff interviews, the facility failed to store all drugs in a locked compartment and permit only authorized personnel to have access for 7 out of 11 storage areas. The unsecured medications were potentially accessible to 10 ambulatory or wheelchair mobile residents, out of 49 residents on the current census, as well as other staff members, families, and visitors. The facility also failed to ensure that the accurate reconciliation of controlled drugs was maintained for 2 of the 2 medication carts. The facility's failure to properly store and lock medications and accurately reconcile controlled drugs, which could possibly result in loss or diversion of medications, placed all independent residents, staff, families, and visitors at risk for serious harm, injury, impairment, or death, if ingested. These conditions resulted in Immediate Jeopardy (IJ). The immediate jeopardy was identified on 3/20/15 and was ongoing at the time of exit on 5/8/15. The facility was informed of the IJ on 5/8/15. Cross reference to F425 and F353. The findings include: 1. An observation was conducted on 5/4/2015 at 9:15 AM revealed the 200 hallway treatment cart was unlocked. The cart contained various types of medicated creams and ointment (Santyl, used in wound care to remove dead tissue, and Clindamycin, antibiotic ointment). An interview was conducted on 5/4/2015 at 9:20 AM with Employee Z, and she confirmed the cart was left unlocked when she went into a resident's room to administer medications. An observation was conducted on 5/4/2015 at 2:15 PM of the nurse's station. The station is near the front door of the facility and is open to the main dining and common area of the facility. On the back wall of the station were cabinets with locks on the doors. These cabinets housed newly filled medications that could not fit on the medication carts, and medications that needed to be returned to the pharmacy. In the bottom cabinets, an Emergency Drug supply kit (EDK) was observed. These cabinets were not locked and were able to be opened. In the cabinets, multiple various pills and injectable and liquid medications were stored. Medications were observed in pre-filled individual foil packets stored in little white boxes, which held a month's supply of medications for residents. Some of the medications that were accessible in this cabinet were Warfarin (blood thinner), Keppra (anti-seizure medication), Clonidine (used for High blood pressure), Cymbalta (used for depression), Neurontin (anticonvulsant and pain reliever), Plavix (blood thinner), Fluphenazine (antipsychotic), Lisinopril (for high blood pressure), and Nudexta (treats neurological disorders). There were 3 boxes of prefilled injectable syringes of Lovenox (blood thinner) and 2 vials of injectable Clindamycin (ointment). Side effects if these medications were ingested would possibly include unusual bleeding, coughing up blood, bladder pain, joint pain, psychotic reactions, vomiting, suicidal behavior, sudden weakness, severe headaches, trouble breathing and confusion. Multiple observations were conducted on 5/4/15 at 8:05AM; 5/5/15 at 9:40AM; and 5/15/15 at 3:25 PM. The nurse's station was observed unmanned and multiple staff members, residents, and guests were walking around the station with access to the cabinets. A staff interview was conducted with the DON on 5/4/2015 at 2:15 PM and she confirmed the cabinets were unlocked and should be locked at all times. An observation was conducted on 5/4/2015 at 2:50 PM of the nurse's station and the 6 cabinets remained unlocked. An observation was conducted on 5/4/2015 at 2:59 PM of Employee G, the maintenance director, working with the locks on the cabinets in the nurse's station. An interview was conducted at that time and Employee G confirmed that the cabinets' locks did not work properly and he was trying to lock the cabinets for the nurses. He stated, The nurses complain their keys don't work. A staff interview was conducted on 5/4/2015 at 3:05 PM with Employees L and Z. Both nurses confirmed they had not been in the 6 cabinets all day and the 11-7 shift must have left the cabinets unlocked. A staff interview was conducted with Employee N (CNA) on 5/4/15 at 5:45 PM. The employee confirmed that for the 3pm-11pm shift, the nurses' station was unattended due to the staff being assigned to work on the 100 and 200 hallways. She stated, If we have 5, they will put somebody at the desk, but we usually work with 4. A staff interview was conducted on 5/5/15 at 8:20 AM with Employee II (Nurse Consultant). She confirmed the locks on the cabinets did not work most of the time and then demonstrated how the locks would turn without having a key in them. An observation was conducted on 5/5/15 at 8:27 AM. A female resident was seen ambulating in her wheelchair behind the nurse's station in close proximity to the cabinets which would allow access to the the medications in the cabinets. A review was conducted on 5/5/2015 of the Policy & Procedure for Disposal of Medications and it revealed on page 1 of 4; #2 That Medications are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal and state laws and regulations. The facility had no other policy regarding medications storage as per the Administrator. 2. An observation was conducted of the 200 hallway medication cart on 5/4/15 at 10:30 AM. A medication card was pulled out for Resident #23. The medication was Oxycodone/Acetaminophen (pain reliever) 5/325, with 9 pills seen in the card. The medication card was turned over and tape was observed to the back of the card, holding the 9th pill in the card. An observation was conducted of the 200 hallway medication cart on 5/4/15 at 10:30 AM. A medication card was pulled for Resident #24 for Ativan (used for anxiety) 0.5 mg and tape was also observed to the back of the card where the 26 and 27 pill slots were. After closer observation, it was noticed that there was still a pill stuck to the tape in the 27th pill slot. The medication was signed on the Controlled Drug Sheet as given on 4/21/15 (time and nurse signature unable to read). The Controlled Drug Shift Audit sheet reflected that the count was being documented as accurate up to 5/4/2015. A review of the Controlled Drug Record for Resident #27 was conducted and it revealed that for 8 times, the medications had been signed off then lined out for a new entry. A review of Controlled Drug Record was conducted for Resident #25. It revealed on the back of the sheet a date of 5/4/15, stating, 1 taped in packaged, signed by Employee Z & Employee Q. A review was conducted of the facility's Control Drug Record for both the 100 and 200 hallway medication carts. Residents #2, #4, #9, #10, #21, #23, #24, #25, and #26's Controlled Drug Record revealed multiple discrepancies where the nurses dated, entered time, and initialed for accountability of drug count. These discrepancies do not record the reason for the error as to if it was wasted, dropped, or signed in error. This was noted on some residents up to 8 times on one sheet (30 pills) where there were multiple documentation discrepancies. A review was conducted of the Consultant Pharmacist Med Station Review Sheets, dated 1/30/15, 2/26/2015, 3/31/15, and 4/31/15. All of the sheets had marked under the Criteria for Controlled Medications stored/locked per regulation policy as not met. The pharmacist also listed on the 3/31/15 documentation that Ativan 0.5 mg for Resident #25 had tape adhered to the back of her card holding a pill in place, which had been signed out as given. An interview was conducted on 5/7/15 at 6:30 PM with Employee V, the Consultant Pharmacist. She confirmed she had seen a medication card with tape on it and that she did not remove the card of the time of her review, but did inform the administrator of her findings at the time of her exit on 3/31/15. Employee V confirmed that on her visits to the facility on [DATE], 2/26/2015, 3/31/2015 and 4/31/15, the facility Always failed to have the medication storage cabinets behind the nurses' station locked at the time of her entry into the facility. Employee V verified she observed tape on the back of a controlled drug card, but did not remove the card (that had tape to the back of it) at the time of the audit. Employee V verified she notified the Administrator and DON and they were made aware of the tape, as well as the storage cabinets not being locked at her exit conference.

Based on observations, record reviews, and staff interviews, the facility's consultant pharmacist failed to develop mechanisms for resolving issues related to pharmaceutical services. The Consultant Pharmacist's recommendations for January, February, March, and April of 2015 identified problems related to medication storage and controlled drug packaging during random audits, which could lead to medication errors. Also, the pharmacist failed to inform the Medical Director, who was the attending physician for the 49 residents, when the facility did not correct the Identified problems. The pharmacist did not meet with the Director of Nursing (DON) in March or April to report findings during her visit. The facility's failure to act upon the Consultant Pharmacist's reports and recommendations to properly store and lock medications and to not tamper with medication packaging placed all residents who received medication administration at risk for serious harm, injury, impairment, or death. These conditions resulted in Immediate Jeopardy (IJ). The immediate jeopardy was identified on 3/20/15 and was ongoing at the time of exit of the facility 5/8/15. The facility was informed of the IJ on 5/8/15. Cross reference to F431 and F353. The findings include: 1. An observation was conducted on 5/4/2015 at 9:15 AM of the 200 hallway treatment cart and it was found unlocked. The cart contained various types of medicated creams and ointment (Santyl, used in wound care to remove dead tissue, and Clindamycin, antibiotic ointment). An interview was conducted on 5/4/2015 at 9:20 AM with Employee Z and she confirmed the cart was left unlocked when she went into a resident's room to administer medication. An observation was conducted on 5/4/2015 at 2:15 PM of the nurse's station. The station is near the front door of the facility and is open to the main dining and common area of the facility. On the back wall of the station were cabinets with locks on the doors. These cabinets housed newly filled medications that could not fit on the medication carts, and medications that needed to be returned to the pharmacy. In the bottom cabinets, an Emergency Drug supply kit (EDK) was seen. These cabinets were unlocked and were able to be opened. In the cabinets, multiple various pills, and injectable and liquid medications too numerous to count were observed. Medications were observed in pre-filled individual foil packets stored in little white boxes, which held a month's supply of medications for residents. Some of the medications that were accessible in this cabinet were Warfarin (blood thinner), Keppra (anti-seizure medication), Clonidine (used for High blood pressure), Cymbalta (used for depression), Neurontin (anticonvulsant and pain reliever), Plavix (blood thinner), Fluphenazine(antipsychotic), Lisinopril (for high blood pressure), and Nudexta (treats neurological disorders). There were 3 boxes of prefilled injectable syringes of Lovenox (blood thinner) and 2 vials of injectable Clindamycin (ointment). Side effects if these medications were ingested would possibly include unusual bleeding, coughing up blood, bladder pain, joint pain, psychotic reactions, vomiting, suicidal behavior, sudden weakness, severe headaches, trouble breathing and confusion. Multiple observations were conducted on 5/4/15 at 8:05AM; 5/5/15 at 9:40AM; and 5/15/15 at 3:25PM. The nurse's station was observed unmanned and multiple staff members, residents, and guests were walking around the station with access to the cabinets. A staff interview was conducted with the DON on 5/4/2015 at 2:15 PM and she confirmed the cabinets were unlocked and should be locked at all times. An observation was conducted on 5/4/2015 at 2:50 PM of the nurse's station and the 6 cabinets remained unlocked. An observation was conducted on 5/4/2015 at 2:59 PM of Employee G (maintenance director) working with the locks on the cabinets in the nurse's station. An interview was conducted at that time and Employee G confirmed that cabinets' locks did not work properly and he was trying to lock the cabinets for the nurses. He stated, The nurses complain their keys don't work. A staff interview was conducted on 5/4/2015 at 3:05 PM with Employees L and Z. Both nurses confirmed they had not been in the 6 cabinets all day and the 11-7 shift must have left the cabinets unlocked. A staff interview was conducted with Employee N (CNA) on 5/4/15 at 5:45 PM. The employee confirmed that for the 3pm-11pm shift, the nurses station was unattended due to the staff being assigned to work on the 100-200 hallways. She stated, If we have 5, they will put somebody at the desk, but we usually work with 4. A staff interview was conducted on 5/5/15 at 8:20 AM with Employee II (Nurse Consultant). She confirmed the locks on the cabinets did not work most of the time and then demonstrated how the locks would turn without having a key in them. An observation was conducted on 5/5/15 at 8:27 AM of a female resident seen ambulating in her wheelchair behind the nurse's station, in close proximity to the cabinets which would allow access to the the unlocked medications in the cabinets. A review was conducted on 5/5/2015 of the Policy & Procedure for Disposal of Medications and it revealed on page 1 of 4: #2 That Medications are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal and state laws and regulations. The facility had no other policy regarding medication storage as per the Administrator. 2. An observation was conducted of the 200 hallway medication cart on 5/4/15 at 10:30 AM. A medication card was pulled for Resident #23. The medication was oxycodone/acetaminophen (pain reliever) 5/325 with 9 pills seen in the card. The medication card was turned over and tape was observed on the back of the card holding the 9th pill in the card. An observation was conducted of the 200 hallway medication cart on 5/4/15 at 10:30AM. A medication card was pulled for Resident #24 for Ativan (used for anxiety) 0.5mg and tape was also observed on the back of the card where the 26 and 27 pill slots were. After closer observation, it was noticed that there was still a pill stuck to the tape in the 27th pill slot. The medication was signed on the Controlled Drug Sheet as given on 4/21/15 (time and nurse signature unable to read) . The Controlled Drug Shift Audit sheet reflected that the count was being documented as accurate up to 5/4/2015. A review of the Controlled Drug Record for Resident #27 was conducted and it revealed that for 8 times, the medication had been signed off then lined out for a new entry. A review of Controlled Drug Record was conducted for Resident #25. It revealed on the back of the sheet a date of 5/4/15, stating, 1 taped in packaged signed by Employee Z and Employee Q. A review was conducted of the facility's Control Drug Record for both the 100 and 200 hallway medication carts. Residents #2, #4, #9, #10, #21, #23, #24, #25, and #26's Controlled Drug Record revealed multiple discrepancies where the nurses dated, entered time, and initialed for accountability of drug count. These discrepancies did not record the reason for the error as to if it was wasted, dropped, or signed in error. This was noted on some residents up to 8 times on one sheet (30 pills) where there were multiple documentation discrepancies. A review was conducted of the Consultant Pharmacist's Med Station Review Sheets, dated 1/30/15, 2/26/2015, 3/31/15, and 4/31/15. All of the sheets had marked under the Criteria for Controlled Medications stored/locked per regulation policy as not met. The Pharmacist also listed on 3/31/15 documentation that Ativan 0.5mg for Resident #25 had tape adhered to the back of her card holding a pill in place, which had been signed out as given. A telephone interview was conducted on 5/7/15 at 6:30 PM with Employee V, the Consultant Pharmacist. She confirmed she had seen a medication card with tape on it and that she did not remove the card at the time of her review, but did inform the administrator of her findings at the time of her exit on 3/31/15. She also confirmed that on her visits to the facility on [DATE], 2/26/2015, 3/31/2015 and 4/31/15, the facility Always failed to have medication storage cabinets behind the nurses station locked at the time of her entry into the facility. Employee V verified she observed tape on the back of a controlled drug card, but did not remove the card (that had tape to the back of it) at the time of the audit. Employee V verified she notified the Administrator and DON, and they were made aware of the tape, as well as the storage cabinets not being locked at her exit conference.

Based on record review, observations, and resident and staff interviews, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to administration of routine and controlled drugs, storage of medications, and nurse's training and competency. Additionally, the facility failed to ensure that required staff members (Director of Nursing, and Physician) attended the QAA meetings. The facility's failure to provide an effective QA committee placed all 49 residents who receive medication administration at risk for serious harm, injury, impairment, or death. These conditions resulted in Immediate Jeopardy (IJ). The immediate jeopardy was identified on 3/20/15 and was ongoing at the time of exit on 5/8/15. The facility was informed of the IJ on 5/8/15. Cross reference to F353, F425, F431, and F490. The findings included: 1. A record review of the facility Event Log (Grievance), dated March 2015, revealed the facility had 13 residents from the 100 hallway with an event listed as Medication Variance on 3/20/15 (Residents # 3, #4, #5, #9, #10, #12, #13, #14, #17, #18, #19, #20, and #21). The times of the event were between 5:00 PM to 9:00 PM. No specific details of the medication variances were documented on the event log. An interview was conducted with Resident #16 on 5/4/15 at 12:15 PM. The resident resided on the 100 hallway and stated that he had complained to the nurses several times before that he didn't receive some of his evening medications in the past. He said the facility never got back to him about his concerns or let him know what was being done about it. An interview was conducted with the son of Resident #4 (who resided on the 100 hallway) on 5/4/15 at 12:30 pm. The son stated that he told the Director of Nursing (DON) sometime in March that he was concerned Employee H, Licensed Practical Nurse (LPN), was not administering his mother's Klonopin as ordered, as the nurse was frequently assigned to his mother's care. Regarding the March recollection, he said he went to Employee H around 5:15 PM and asked her what time she gave his mother her Klonopin, and her reply was at 5:45 PM. He said the time was 5:15 pm, and Employee H did not open the medication book to verify this. The son was curious and questioned the nurse how she could administer the medication at 5:45 PM when it was only 5:15 PM. He said Employee H then changed her answer and said she just gave his mom the medication. The son of Resident #4 waited another 30 minutes, to see if his mom would calm down. The son stated, Usually within 30 minutes of my mother receiving her Klonopin, my mom will not be jerky and calms down. He said he re-approached Employee H after an hour because his mom was still jerky and seemed no different. He said Employee H's reply was she gave Resident #4 her medication and it didn't work yet. The son then waited another 30 minutes and his mother had still not calmed down. He said he went to Employee H again and she said she would give her an As needed (PRN) Klonopin. The son said his mom started to calm down within 30 minutes of receiving the medication and he then left the facility. He said a few days later, he reported this to the DON and explained to her what happened and explained he felt like his mother was not receiving her Klonopin as ordered since Employee H had appeared altered at work before. He said he knew about an incident that happened with Employee H a few months ago where she had been impaired at work. He said administration knew about Employee H's previous behavior and did nothing about it, and continued to let her work with the same residents. The son also confirmed the Administrator or DON did not follow up with him about his concerns. A review of the March Medication Administration Record (MAR) revealed Resident #4 received a PRN Klonopin on 3/14/15 at 7:45 PM. A review of the event log, dated March 2015, revealed there were no concerns listed from the family of Resident #4. An employee record review was conducted for Employee H and it revealed the nurse had no disciplinary action in her file, but a drug screen was conducted on 1/13/2015. Additionally, there was no documentation observed for competency, retraining, or supervision of medication administration. An interview was conducted with Employee W, LPN, on 5/6/15 at 7:24 PM. She confirmed Residents #7 and #14 had told her previously (unknown date) that Employee H had not administered their medications as prescribed (dates unknown). Employee W confirmed she never told anyone and never investigated it. 2. An interview was conducted with the Administrator on 5/4/2015 at 12:59 PM. She confirmed there was an incident at the facility involving a nurse, Employee H, on 3/20/15. She said the nurse (Employee H) was found staggering, stumbling, and slurring her words after she returned from break around 8:00 PM. The nurse stated she had low blood sugar issues, but testing of her sugar was conducted and was found to be within normal limits (116 & 118). The other nurses scheduled that night (Employee EE & Employee Z) observed the nurse to have constricted pupils and non-reactive. She said the facility was not certain if Employee H administered her scheduled medications, as well as her narcotic medications for the evening medication pass on 3/20/15. A review of a Police Report Case # 1891, dated 3/20/15 at 11:01 PM, revealed Employee H was arrested on 3/20/2015 for Theft of Controlled Substances, Possession of Schedule II, III, IV,V narcotics. A written statement from Employee H revealed, There are extra pills during count that I did not know what to do with so I stuck them in a bottle in my bag. The Administrator said all the residents were interviewed to see if they received their medications after the nurse was taken out of the facility. The Administrator confirmed there was no documentation that anyone assessed the residents to ensure no adverse outcomes related to missed medications. The Administrator further confirmed there was no documentation that the physician, medical director, or DON followed up with the residents after the incident. She stated that as of today, we will be taking this information to QAA and put in place a system to ensure narcotic sheets are signed out correctly. She said we will also complete an in-service for the nurses on how to sign out narcotics on the narcotic sign out sheet, as well as educate them when a pill comes out of the card, not to tape it back in. She confirmed nothing had been completed before today, and she had not put anything new in place since the incident on 3/20/15. Additionally, the Administrator confirmed Employee H was terminated on 3/23/15 for lack of documentation on the MAR and Not for stealing drugs. A review of a narcotic medication audit, dated 3/20/2015, revealed the facility conducted a controlled drug count for the 100 hallway medication cart at approximately 11:00 PM. The facility did so due to the possibility that Employee H diverted controlled drugs (she was arrested on 3/20/15 with over 40 medications, including controlled drugs), and her altered mental status upon return after her break. There were approximately 17 medications that could not be accounted for. A record review conducted of the March MAR's for the 100 hallway's medication cart revealed that on the evening of 3/20/15, Employee H did not sign for her medications. The following residents' medications were not signed and the nursing staff did not question or investigate to see if residents received their scheduled medication: Resident #5's 5 pm Blood Glucose Monitoring (BGM) was not completed. Resident #5 was scheduled to receive [MEDICATION NAME] (Injectable Insulin) 33 units, along with [MEDICATION NAME] (blood pressure), [MEDICATION NAME] (anti-[MEDICAL CONDITION]), and [MEDICATION NAME] (anti-convulsant) 375 milligrams (mg) which were not signed as administered on 3/20/15. Resident #5's BGM was 97 mg/dl on 3/20/15 in the am, and on 3/21/15, it was 136 mg/dl. Resident #7 was scheduled to receive Humalog (injectable insulin) with a sliding scale at 5PM, [MEDICATION NAME] at 5PM, and [MEDICATION NAME] (Injectable insulin) 33 units at 9pm, and was not signed on the MAR as administered. Resident #7's BGM was 280 mg/dl on 3/21/15 in the morning. Resident #11 was scheduled to receive [MEDICATION NAME] (injectable Insulin) 42 units at 10 pm and the MAR was not signed as administered. BGM for Resident #11 on 3/21/15 AM was 144 mg/dl. Resident #12 was scheduled to receive [MEDICATION NAME] (injectable Insulin) 40 units, as well as a blood pressure medication and anti-convulsant on 3/20/15, but was not signed as administered on the MAR. The BGM for Resident #12 on 3/21/15 AM was 117 mg/dl. Resident #13 was scheduled to receive [MEDICATION NAME] N (injectable insulin) sliding scale, a BGM, an anti-convulsant and [MEDICATION NAME]. No evening BGM was documented nor was the MAR signed for administering the Insulin or the medications for this resident. A BGM on 3/21/15 revealed it was 109 mg/dl. Also, [MEDICATION NAME] and the anti-convulsant were not signed out. Resident #14 was scheduled to receive Levimir (injectable insulin) 100 units and [MEDICATION NAME] (synthetic sugar) but were not signed as administered. A BGM on 3/21/15 revealed a reading of 380 m/dl. Further review of the MAR for Resident #14 revealed BGM results greater between 450-500 mg/dl on 20 occasions in March and no documentation that the Medical Director was notified as ordered to call MD for BGM >450 mg/dl. Resident #15 was scheduled to receive [MEDICATION NAME] (injectable Insulin), as well as [MEDICATION NAME] (injectable Insulin) sliding scale and a BGM. No BGM was documented as done, as well as 3/21/15 morning BGM. The medications were not in the narcotic medication card and were not signed out as given on the evening of 3/20/15. Comments were seen written on the right side of the audit sheet for Resident #3 that stated, did not get meds and crushed with other meds. Additionally, comments were seen for Resident #10 for did not get meds and crushed with other meds. The facility administrator on 5/6/15 at 1:55 pm admitted never questioning all of the residents or families of residents who were not interviewable on the 100 hallway if they received their medications. She said they only questioned the residents who received controlled drugs. An interview was conducted with Resident #3 on 5/4/15 at 2:00 PM. The resident stated she had told her CNAs 6-7 times in the past that she was not receiving [MEDICATION NAME](sleeping pill) and [MEDICATION NAME] (for anxiety) as ordered in the evenings. The resident verified she had never heard from the DON or Administrator in regards to these complaints. The stated she cannot sleep when she does not receive her Ambien. 3. An observation conducted on 5/4/2015 at 9:15 AM of the 200 hallway's treatment cart revealed it was unlocked. The cart contained various types of medicated creams and ointments. An interview was conducted on 5/4/2015 at 9:20 AM with Employee Z, nurse, and she confirmed the cart was left unlocked when she went into a resident's room to administer medications. An observation was conducted on 5/4/2015 at 2:15 PM of the nurse's station. The station is near the front door of the facility and is open to the main dining and common area of the facility. On the back wall of the station were cabinets with locks on the doors. These cabinets housed newly filled medications that could not fit on the medication carts, and medications that needed to be returned to the pharmacy. In the bottom cabinets, an Emergency Drug supply kit (EDK) was observed. These cabinets were not locked and were able to be opened. In the cabinets, multiple various pills, and injectable and liquid medications were observed. Medications were observed in pre-filled individual foil packets stored in little white boxes, which held a month's supply of medications for residents. Some of the medications that were accessible in this cabinet were [MEDICATION NAME] (blood thinner), [MEDICATION NAME] [MEDICATION]), [MEDICATION NAME] (used for High blood pressure), [MEDICATION NAME] (used for depression), [MEDICATION NAME] (anticonvulsant and pain reliever), [MEDICATION NAME] (blood thinner), [MEDICATION NAME] (antipsychotic), [MEDICATION NAME] (for high blood pressure), and Nudexta (treats neurological disorders). There were three boxes of pre-filled injectable syringes of [MEDICATION NAME] (blood thinner) and two vials of injectable [MEDICATION NAME] (ointment). Side effects if these medications were ingested would possibly includ: unusual bleeding, coughing up blood, bladder pain, joint pain, psychotic reactions, vomiting, suicidal behavior, sudden weakness, severe headaches, trouble breathing and confusion. Multiple observations were conducted on 5/4/15 8:05AM; 5/5/15 at 9:40AM; and 5/15/15 at 3:25PM. The nurse's station was observed unmanned and multiple staff members, residents, and guests were walking around the station with access to the cabinets. An interview with the DON on 5/4/2015 at 2:15 PM confirmed the cabinets were unlocked and should be locked at all times. An observation was conducted on 5/4/2015 at 2:50 PM of the nurse's station, where the six cabinets remained unlocked. An observation was conducted on 5/4/2015 at 2:59 PM of Employee G (Maintenance Director) working with the locks on the cabinets in the nurse's station. An interview was conducted at that time and Employee G confirmed that cabinets' locks did not work properly and he was trying to lock the cabinets for the nurses. He stated, The nurses complain their keys don't work. An interview was conducted on 5/4/2015 at 3:05 PM with Employees L & Z. Both nurses confirmed they had not been in the 6 cabinets all day and the 11-7 shift must have left the cabinets unlocked. A staff interview was conducted with Employee N (CNA) on 5/4/15 at 5:45 PM. The employee confirmed that on the 3pm-11pm shift, the nurse's station was unattended due to the staff being assigned to work on the 100-200 hallways. She stated, If we have 5, they will put somebody at the desk, but we usually work with 4. An interview was conducted on 5/5/15 at 8:20 AM with Employee II (Nurse Consultant). She confirmed the locks on the cabinets did not work most of the time and then demonstrated how the locks would turn without having a key in them. An observation was conducted on 5/5/15 at 8:27 AM of a female resident seen ambulating in her wheelchair behind the nurse's station in close proximity to the cabinets, which would allow access to the medications in the cabinets. A review was conducted on 5/5/2015 of the Policy & Procedure for Disposal of Medications and it revealed on page 1 of 4, #2 That Medications are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal and state laws and regulations. The facility had no other policy regarding medications storage as per the Administrator. 4. A record review was conducted on 5/5/2015 of the following nurse employees: Employee T - Date of Hire (DOH) 4/17/15; Employee J - DOH 4/17/15; Employee U - DOH 4/8/15; Employee Y - DOH 4/8/15; Employee Z - DOH 2/18/15; Employee AA - DOH 1/21/15; Employee BB - DOH 3/10/15; Employee CC - DOH 3/10/15; Employee DD - DOH 1/12/15; Employee EE - DOH 3/12/15; Employee FF - DOH 3/30/15; and Employee GG - DOH 4/22/15. The review revealed no training had been conducted for any new hires after February 1, 2015. The employees were not trained in Medical Error Prevention & Recognition, Accident Prevention and Safety Awareness,[MEDICAL CONDITION].Infection Control, Incident Reporting, Abuse/Neglect/Exploitation, Medication Competency for nurses, and Risk Management, or any of the facility's policy and procedures. A staff interview was conducted with Employee E, Business Office Manager, on 5/4/2015 at 4:55 PM. She confirmed the employees had not been trained in any area and there were no training certificates in the files. She also verified there was not a staff member assigned to do the training, so it was not being done An interview was conducted with Employee T (RN) on 5/4/15 at 3:52 PM. He said that he received 4 days of training and It was okay but I wished I would have been trained by one of the smart nurses, like Employee W or Employee Q. A staff interview was conducted with Employee M, Social Worker/Marketing, on 5/5/2015 at 9:30 AM. She confirmed there was no training conducted for newly hired staff since February [MEDICAL CONDITION].Infection Control, Incident Reporting, Abuse, Neglect and Exploitation, Medication Competency for nurses, or Risk Management, or any of the facility's policy and procedures. She stated, I haven't done training on any of them. I don't even have a file for them. An interview was conducted with the Administrator on 5/4/15 at 12:59 PM. She confirmed the nurses are not trained in competency and there had been no new hire trainings since February. 5. Record review of the attendance sign in sheet for the Quality Assessment and Assurance (QAA) Committee meeting revealed missing signatures of the DON in January and February 2015. Record review of the attendance sign in sheet for the QAA meeting, dated February 2015, revealed the Medical Director's signature was missing. Further review revealed that no other physician signed in for the February 2015 QAA meeting. Record review of the attendance sign in sheet for the QAA meeting that was conducted in March 2015 revealed the signature of the DON was missing, and she was listed to instruct the committee on various medication issues. An interview was conducted with the Administrator on 5/5/2015 at 3:00 PM. She confirmed the Director of Nursing's signatures were missing and was not in attendance for the meetings. She stated, The DON had to be on a conference call and I forgot to get her to sign it. She also confirmed the Medical Director did not sign the February 2015 QAA log because he was not in attendance. The Administrator added that she delivered and talked about the issues with medications and nursing care regarding the events from 3/20/15. She said she could not produce any handouts or information she used at this meeting. On 5/6/15, the facility's Regional Vice President presented the Performance Improvement Plan (PIP), initiated on 3/20/2015. It recorded the DON as accountable for the administration of controlled drugs and to ensure the responsible party was notified. It also recorded the DON as responsible for an audit of the narcotic sheets, resident interviews for administration of medications, and monitoring of the residents for any side effects. Follow up status recorded responsible parties were notified and the Narcotic and MAR sheets were verified for accuracy. Monitoring was recorded to be completed three times weekly and brought to QAA for 3 months. The committee comments and recommendations recorded the following: a. Audit of administration of Narcotics/MAR sheets b. Resident interview for administration of medication c. Monitor residents for side effects d. Educate nursing on abuse, neglect, exploitation e. Educate on customer service for resident f. Educate on handling of controlled drugs g. Educate on inventory of controlled drugs h. Educate on discrepancies of controlled medication Further review of the QAA action plan revealed that it failed to address any concerns with nurse competency, evaluation of nursing staff performance, re-training for nurses, random drug screening of employees, investigation of any medication related complaints, investigation to determine the root cause of this event and to ensure the facility maintains the current practice standards, and accurate monitoring systems so that residents are not put at risk for harm related to medication errors or omissions. An interview was conducted with the Administrator on 5/6/15 at 2:20 PM. She confirmed there had not been a QAA meeting since 3/30/15. In addition, the Administrator stated she had no paperwork or correspondence showing the completion of any audits or monitoring that was to be conducted and brought to QAA meeting for April. Record review of the Airamid Risk Management Program Event Management Policy and Procedure, not dated, stated, All events are to be tracked, trended and reported through the facility monthly Risk Management and Quality Improvement Meeting. Also, the policy stated, All events are tracked, trended and reported through the facility monthly Risk Management and Quality Improvement Meeting .

Based on observations, record reviews, and staff interviews, the Medical Director failed to coordinate medical care in the facility by not properly notifying the facility in writing, and with the approval from the facility, of his leave of absence. He failed to ensure a qualifying physician was covering for him while he was out of the country as per his signed Medical Director Agreement. The Medical Director also failed to monitor and assess residents after a Medication Variance on 3/20/15. Additionally, the Medical Director continued to write Class II controlled drug prescriptions while he was out of the country. The facility's failure to coordinate medical care during his absence placed all 49 residents at risk for serious harm, injury, impairment, or death. These conditions resulted in Immediate Jeopardy (IJ). The immediate jeopardy was identified on 3/20/15 and was ongoing at the time of exit on 5/8/15. The facility was informed of the IJ on 5/8/15. The findings include: An interview was conducted with the Administrator on 5/5/15 at 10:50 am regarding the absence of the Medical Director and she verified the Medical Director was out of the country at a conference. The Administrator was not able to identify the physician who was covering for the Medical Director, and confirmed she had not obtained anything in writing giving her approval. She stated she had been in contact with the Medical Director via text messaging. The Administrator stated the Medical Director was out of the country and she was not made aware and did not know the date of his return. Record review on 5/5/15 of a memo from the Medical Director, not dated, revealed the Medical Director Will be out of town from May 1-May 11, 2015 and physician's assistant (Employee X) will be covering for him. This memo was not signed by the facility showing the Administrator's approval or acknowledgement that it was received. A review of the Medical Director's signed contract, dated 9/5/2011, stated he was to Assist in arranging for continuous physician coverage for medical emergencies. Also, If the Medical Director is not available, the Medical Director will appoint another physician, subject to the Facility's approval, to be available in his absence. An interview was conducted with the Social Worker/Marketing Director on 5/5/2015 at 5:10 PM. She stated the original physician they thought was covering for the Medical Director was also unavailable. Employee M said she called another physician, Employee JJ, and asked him if he would cover while the Medical Director was out of the country. She confirmed the physician she called was not one of the physicians who practices at this facility. A phone interview was conducted with a Physician's Assistant (PA) on 5/6/2015 at 12:30 PM. The PA confirmed he was covering for the Medical Director while he was out of the country. The PA was just made aware on 5/6/15 that Employee JJ would now be the covering physician and he would correspond with him. A review was conducted of the Florida Board of Medicine's guidelines for supervision for a Physician Assistant and it revealed the following: Supervision means responsible supervision and control. Except in cases of emergency, supervision requires the easy availability or physical presence of the licensed physician for consultation and direction of the actions of the physician assistant. For the purposes of this definition, the term easy availability includes the ability to communicate by way of telecommunication. The boards shall establish rules as to what constitutes responsible supervision of the physician assistant. A phone interview was conducted with the newly covering physician on 5/8/15 at 3:41 PM. The doctor confirmed he was covering for the Medical Director, but only for Class II controlled substances that may need to be refilled. He confirmed that he was not seeing or giving orders for the residents; he was just to give refills on residents who had pre-existing Class II narcotic medications and may need refills while the Medical Director was out of the country. 2. A record review was conducted on 5/4/2015 of the Event Log for the facility for the month of March 2015. It revealed the facility had 11 residents (Residents #1, #3, #4, #5, #6, #10, #13, #14, #17, #18, #19, and #20) who had an event listed as med variance on 3/20/15, with times of the event between 5 PM-9 PM. An interview was conducted with the Administrator on 5/4/15 at 12:59 pm. The Administrator confirmed the Medical Director was the physician for Residents #1, #3, #4, #5, #6, #10, #13, #14, #17, #18, #19 and #20, and was contacted on 3/20/15 (unknown time) of the medication variances that were made due to possible omissions in the residents' narcotic medications. There were 22 residents potentially affected on the 100 hallway on 3/20/15. A record review was conducted for Resident #3 and it revealed no documentation had been entered by the Medical Director on 3/20/15 or after in reference that he had seen the resident and was following up on the medication variance listed for Resident #3 on 3/20/15. A review of the Quality Assessment and Assurance (QAA) Committee meeting minutes revealed the Medical Director was in attendance at the 3/30/15 meeting and no further investigation by the Medical Director for the incident involving all 22 residents on the 100 hallways on the night of 3/20/15 was documented. A phone interview was conducted on 5/7/15 at 7:30 PM with Employee V, Consultant Pharmacist. Employee V confirmed she had not spoken to the Medical Director of the possible medication errors that occurred on 3/20/15, or any of the issues that have been occurring with the facility's failed medication practices. She also confirmed a physician cannot write a prescription for Class II narcotics unless they are in the state of Florida. 3. A phone interview was conducted with Employee LL, Pharmacist, on 5/8/2015 at 3:15 PM. The pharmacy was not made aware that the Medical Director was out of the country from May 1st-11th, 2015. Employee LL confirmed the pharmacy had received 7 prescriptions from the Medical Director since May 1st, 2015. She verified she had received prescriptions for [MEDICATION NAME] Class IV, [MEDICATION NAME] IV, [MEDICATION NAME] III, three [MEDICATION NAME] II, and a [MEDICATION NAME]. On May 4, 2015, the pharmacy received an original prescription from the Medical Director from his physician prescription pad for Resident #23, and two more prescriptions written for [MEDICATION NAME] and [MEDICATION NAME], also from his prescription pad. She stated, We received an e-mail for a Class II from the facility, but have not yet received a hard copy script.

Based on observations, record reviews, and resident and staff interviews, the Director of Nursing (DON) failed in her managerial oversight of the nursing staff and medication storage by allowing a nurse to continue working who had indications she was not capable of performinf her nursing duties in a safe and competent manner. The facility failed to ensure the nursing staff was administering medications, documenting, accurately reconciling controlled drugs (narcotics), and securing/locking medications in the nurses' station. The facility failed to assign a nurse to the residents on the 100 hallway on the evening of 3/20/15 after Employee H, Licensed Practical Nurse, (LPN) was arrested for diverting medications. The facility failed to properly train all newly hired LPNs and Registered Nurses (RN) in Medical Error Prevention and Recognition; Accident Prevention and Safety Awareness;[MEDICAL CONDITION].abuse, neglect, exploitation; what and whom to report change of condition; resident rights; and medication competency since February, due to staff development or Human Resource personnel not being available to do training. The facility failed to act on complaints from residents and staff about an impaired nurse (Employee H) and allowed this impaired nurse to have control of a medication cart and administer medications without supervision. The facility failed to investigate previous Controlled Drug reconciliation sheets and MARs for residents on the 100 hallway to see if Nurse H diverted medications or failed to administer medications after an event in January 2015. The facility failed to have the Director of Nursing (DON) perform her duties regarding impaired nurse (Employee H) by assigning her to resident care, and the failure to investigate and follow up on any medication administration complaints from residents, families, and staff, which put all 49 facility residents on the current census at risk for serious harm, injury, impairment, or death. These conditions resulted in Immediate Jeopardy (IJ). The immediate jeopardy was identified on 3/20/15 and was ongoing at the time of exit on 5/8/15. The facility was informed of the IJ on 5/8/15. Cross reference to F425 and F431. The findings include: 1. During an interview with the Administrator on 5/4/2015 at 12:59 PM, she confirmed there was an incident at the facility involving a nurse, Employee H, on 3/20/15. The nurse was found after her break staggering, stumbling, and slurring her words after she returned from break around 8 PM. The Administrator questioned Employee H and was not certain if the nurse gave evening medication pass to her assigned residents on 3/20/15. The Administrator was asked to provide information on the investigation she had completed regarding Employee H, and what she had put in place to make sure this never happened again. The Administrator could not provide any documentation of an investigation or new practices put in place to ensure the residents' safety. The Administrator had not spoken to any residents or families concerning medication administration on 3/20/15. The Administrator confirmed she had not called the Board of Nursing for Employee H or reported an Adverse Incident with the State. She stated, We were waiting to see if they pressed charges, and we did not fire her for stealing; we fired her for not documenting. We could not prove she took the medications from here so I did not do anything about it. An interview was conducted with Resident #16 on 5/4/15 at 12:15 PM and revealed he had complained before that he didn't receive some of his evening meds in the past, but nobody from the facility ever let him know or looked into his complaints. An interview was conducted with Resident #3 on 5/4/15 at 2:00 PM, and revealed she had told the staff 6 or 7 times in the past between January through March 2015 that she wasn't receiving [MEDICATION NAME](sleeping pill) and [MEDICATION NAME] (for anxiety) as ordered in the evenings. The resident verified she had never heard from the Employee HH (previous DON) or the Administrator in regard to these complaints. This was not seen on the facility's Event Log. Record review of the Controlled Substance Policy and Procedure, dated October 2007, revealed, The DON documents irreconcilable discrepancies in a report to the administrator. The Administrator was unable to produce such documentation that this was done. An interview was conducted with the Administrator on 5/6/15 at 10:20 AM. She confirmed she has not reported Employee H to the Board of Nursing because to she was waiting to see if the police pressed charges and she couldn't prove Employee H took the medications. An interview was conducted with Employee N (CNA) on 5/6/2015 at 3:05 PM. She confirmed that she had made complaints to Employee Q (Acting DON) regarding Employee H's behavior and was concerned the residents were not getting medications as scheduled at night. She also confirmed that Employees Q, HH, or the Administrator never came and asked her questions or ever looked into her complaints. An interview was conducted on 5/6/15 at 4:20PM with Employee Q. She confirmed that CNAs reported to her and complained about Employee H's behavior (unsteady and stumbling), and were concerned she was not giving medications to residents correctly. She confirmed she told Employee HH about these concerns. Employee Q was informed that the facility Can't make accusations like that. Employee Q confirmed Employee HH never did an investigation or questioned her any further after that day, and Employee Q never went to the Administrator with the CNA's concerns. (She could not give specific date). An interview was conducted with Employee W, nurse, on 5/7/15 at 7:25 PM. She confirmed she came in for her shift on 3/20/15 at 11:00 PM, and was not informed that the residents she was assigned on the 100 hallway may have not received their scheduled medications for that evening. She also verified she did not take any BGM's or vitals on her 22 residents. She stated, We had no guidance, the DON wasn't here and I didn't see her until 3/21/15 around 2:30 PM. We went by what the Administrator told us to do. We were told to count the narcotics so that's what we did. I wasn't informed the residents may not have received their evening Insulins or medications. Employee W verified she had made a written statement of events from the night of 3/20/15. 2. A review was conducted of 14 facility Event Reports, dated 3/21/15, which revealed that 13 residents (Residents #3, #4, #5, #6, #9, #10, #12, #13, #14, #17, #19, #20, and #21) had event reports for medication variances. The report was signed by the former DON and the Administrator, and dated 3/21/15, one day after the event. There was a line where details were to be provided about medication variance, but was left blank. Under Documentation Checklist, it was marked that the doctor was notified and resident or responsible party notified, but no dates, names, or substantiating documentation were entered on the report. All other information on the event documenting staff, CNA, and nurse involved was also left blank. The Administrator did not provide this information to the surveyor. On 5/6/15 at 1:55 PM she stated, We did it, we just didn't document. Record review was conducted of a narcotic medication audit that was done on 3/20/15. It revealed a controlled drug count was conducted for the 100 hallway medication cart at approximately 11:00 PM. The facility did so due to the possibility of Employee H, LPN, possibly diverting controlled drugs. Employee H, LPN, complained that she had low blood sugar, but the staff tested her sugar and it was within normal limits. The Administrator was called about Employee H's behavior and she directed the staff to perform a count of the narcotics due to Employee H's behavior and possibility of diverting narcotics and had previous altered mental status. The narcotic medication audut revealed there were approximately 17 medications that could not be accounted for (the controlled drugs were popped out of the medication cards, but were not signed off on the MAR indicated [REDACTED]. Some of the narcotic medications not accounted for on the evening of 3/20/15 were [MEDICATION NAME] (pain reliever), [MEDICATION NAME] (anti-anxiety),[MEDICATION NAME](for sleep), and [MEDICATION NAME] (pain reliever), and Klonopin (for psychiatric disorders). On the right side of the audit sheets were comments written for Resident #3, did not get meds, and crushed with other meds, and Resident #10 did not get meds. On 5/6/15 at 10:20 AM, the facility's Administrator admitted to never questioning all the residents on the 100 hallway if they received their medications. The facility only questioned the residents who received controlled drugs and this was not conducted until the next day, on 3/21/2015. The facility did not review the residents' MARs for 3/20/15, or any other previous dates when Employee H was assigned to their care to determine the possible medication errors or omissions. A record review was conducted of the March MAR's for the 100 hallway's medication cart and it revealed that on the evening of 3/20/15, Employee H did not sign for her medications. The following residents' medications were not signed and the nursing staff did not question or investigate if residents received these scheduled medications: [REDACTED] Resident #5's 5:00 pm Blood Glucose Monitoring (BGM) was not done. Resident #5 was scheduled to receive [MEDICATION NAME] (Injectable Insulin) 33units, along with [MEDICATION NAME] (blood pressure), [MEDICATION NAME] (anti-[MEDICAL CONDITION]), and [MEDICATION NAME] (anticonvulsant) 375mg which were not administered on 3/20/15. Resident #5's BGM was 97 on 3/20/15 in the am, and on 3/21/15, it was 13 mg/dl. Resident #7 was scheduled to received Humalog (injectable insulin) sliding scale at 5PM, Glypizide at 5PM, and [MEDICATION NAME] (Injectable insulin) 33units at 9pm which were not signed on the MAR indicated [REDACTED]. Resident #11 was scheduled to receive [MEDICATION NAME] (injectable Insulin) 42 units at 10pm and the MAR indicated [REDACTED]. Resident #12 was scheduled to receive [MEDICATION NAME] (injectable Insulin) 40 units, as well as a blood pressure medication and an anticonvulsant on 3/20/15, but they were not signed as administered on the MAR. The BGM for Resident #12 on 3/21/15 AM was 117 mg/dl. Resident #13 was scheduled to received [MEDICATION NAME] N (injectable insulin) sliding scale, a BGM, an anti-convulsant and [MEDICATION NAME] (blood pressure). No evening BGM was documented nor signature seen for administering the Insulin or the medications for this resident. A BGM on 3/21/15 revealed BGM was 109 mg/dl. Also, [MEDICATION NAME] (blood pressure medication) and anti-convulsant were not signed out. Resident #14 was scheduled to receive Levimir (injectable insulin) 100 units and [MEDICATION NAME] (synthetic sugar), but they were not signed as administered. A BGM on 3/21/15 revealed a reading of 380. Further review of the MAR for Resident #14 revealed BGM results greater between 450-500 mg/dl on 20 occasions in March and there was no documentation that the Medical Director was notified as ordered for a BGM greater than 450 mg/dl. Resident #15 was scheduled to receive [MEDICATION NAME] (injectable Insulin), as well as [MEDICATION NAME] (injectable Insulin) sliding scale and a BGM. No BGM was documented on 3/21/15 in the morning. 3. An observation was conducted on 5/4/2015 at 9:15 AM of the 200 hallway treatment cart which remained unlocked while Employee Z, an LPN, left the cart and went to administer medications. The cart housed various types of medicated creams and ointments, including Santyl (used in wound care to remove dead tissue), [MEDICATION NAME] (antibiotic) ointment, and Lacting (for skin issues). An interview was conducted on 5/4/2015 at 9:20 AM with Employee Z and she confirmed the cart was left unlocked while she went into a resident's room to administer medication. An observation was conducted on 5/4/2015 at 2:15 PM of the nurse's station. The station is near the front door of the facility and is open to the main dining and common area of the facility. On the back wall of the station were cabinets with locks on the doors. These cabinets housed newly filled medications that could not fit on the medication carts and medications that needed to be returned to the pharmacy. In the bottom cabinet was an Emergency Drug supply kit (EDK). These cabinets were not locked and were able to be opened. The cabinets stored multiple, various pills, and injectable and liquid medications. Medications were observed in pre-filled individual foil packets stored in little white boxes, which held a month's supply of medications for residents. Some of the medications that were accessible in this cabinet were [MEDICATION NAME] (blood thinner), [MEDICATION NAME] [MEDICATION]), [MEDICATION NAME] (used for High blood pressure), [MEDICATION NAME] (used for depression), [MEDICATION NAME] (anticonvulsant and pain reliever), [MEDICATION NAME] (blood thinner), [MEDICATION NAME] (antipsychotic), [MEDICATION NAME] (for high blood pressure), and Nudexta (treats neurological disorders). There were three boxes of pre-filled injectable syringes of [MEDICATION NAME] (blood thinner) and two vials of injectable [MEDICATION NAME] (ointment). Side effects if these medications were ingested would possibly include unusual bleeding, coughing up blood, bladder pain, joint pain, psychotic reactions, vomiting, suicidal behavior, sudden weakness, severe headaches, trouble breathing, and confusion. Multiple observations were conducted on 5/4/15 at 8:05AM, 5/5/15 at 9:40AM, and 5/5/15 at 3:25PM of the nurse's station being unmanned. Multiple staff members, residents, and guests were observed walking around the station with access to the cabinets. A staff interview was conducted with the DON on 5/4/2015 at 2:15 PM and she confirmed the cabinets were unlocked and should be locked at all times. An observation was conducted on 5/4/2015 at 2:50 PM of the nurse's station and the 6 cabinets remained unlocked. A staff interview was conducted on 5/4/2015 at 3:05 PM with Employees L & Z. Both nurses confirmed they had not been in the 6 cabinets all day and the 11-7 shift must have left the cabinets unlocked. A staff interview was conducted on 5/5/15 at 8:20 AM with Employee II (Nurse Consultant). She confirmed the locks on the cabinets did not work most of the time and then demonstrated how the locks would turn without having a key in them. Record review on 5/5/2015 of the Policy & Procedure for Disposal of Medications, dated 10/200 revealed, Medications are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal and state laws and regulations. 4. An observation was conducted of the 200 hallway medication cart on 5/4/15 at 1030 AM. A medication card was pulled out for Resident #23. The medication was [MEDICATION NAME]/[MEDICATION NAME] (pain reliever) 5/325 with 9 pills seen in the card. The medication card was turned over and tape was observed on the back of the card holding the 9th pill in the card. An observation was conducted of the 200 hallway medication cart on 5/4/15 at 10:30 AM. A medication card was pulled for Resident #24 for [MEDICATION NAME] (used for anxiety) 0.5 mg, and tape was observed on the back of the card where the 26 & 27 pill slots were. After closer observation, it was noticed that there was still a pill stuck to the tape in the 27th pill slot. The medication was signed on the Controlled Drug Sheet as given on 4/21/15 (time and nurse signature unable to read). The Controlled Drug Shift Audit sheet reflected that the count was being documented as accurate up to 5/4/2015. A review of the Controlled Drug Record for Resident #27 was conducted and it revealed that 8 times the medication had been signed off, then lined out for a new entry. Documentation was seen on the back, dated 5/4/15, 1 taped in packaged, signed by Employee Z, LPN, and Employee Q, Acting DON. A review was conducted of the facility's Control Drug Record for both the 100 and 200 hallway medication carts. Residents #2, #4, #9, #10, #21, #23, #24, #25, and #26's Controlled Drug Record revealed multiple discrepancies where the nurses date, enter time, and initial for accountability of drug count. These discrepancies did not record the reason for the error as to if it was wasted, dropped, or signed in error. This was noted on some residents up to 8 times on one sheet (30 pills) where there were multiple documentation discrepancies. A review was conducted on 5/5/2015 of the Consultant Pharmacist's Med Station Review Sheets, dated 1/30/15, 2/26/2015, 3/31/15, and 4/31/15. All the sheets had marked under the Criteria for Controlled Medications stored/locked per regulation policy as not met. The pharmacist also listed on the 3/31/15 documentation that [MEDICATION NAME] 0.5 mg for Resident #25 had tape adhered to the back of the medication card holding a pill in place. A phone interview was conducted on 5/7/2015 at 6:30 PM with Employee V, the Consultant Pharmacist. She confirmed that on her visits to the facility on [DATE], 2/26/2015, 3/31/2015, and 4/31/15 the facility always failed to lock the medication storage cabinets behind the nurse's station at the time of her entry into the facility. Employee V verified she observed tape on the back of a controlled drug card, but did not remove the card (that had tape to the back of it) at the time of the audit. Employee V verified she notified the Administrator and DON and they were made aware of the tape, as well as the storage cabinets being unlocked at her exit conference; however, no action was taken regarding these findings. 5. A record review was conducted on 5/5/2015 of the following nurse employees: Employee T - Date of Hire (DOH) 4/17/15; Employee J - DOH was 4/17/15; Employee U - DOH 4/8/15; Employee Y - DOH was 4/8/15; Employee Z - DOH was 2/18/15; Employee AA - DOH was 1/21/15; Employee BB - DOH was 3/10/15; Employee CC - DOH was 3/10/15; Employee DD - DOH was 1/12/15; Employee EE - DOH was 3/12/15; Employee FF - DOH was 3/30/15; and Employee GG - DOH was 4/22/15. The review revealed no training had been conducted for any new hires after February 1, 2015. The employees were not trained [MEDICAL CONDITION].Infection Control, Incident Reporting, Abuse/Neglect/Exploitation, Medication Competency for nurses, and Risk Management, or any of the facility's policy and procedures. A staff interview was conducted with Employee E, the Business Office Manager, on 5/4/2015 at 4:55PM. She confirmed the employees had not been trained in any area and there were no training certificates in the files. She also verified there was not a staff member assigned to do the training so it was not being done An interview was conducted with Employee T, an RN, on 5/4/15 at 3:52PM. He said that he received 4 days of training and it was okay, but I wished I would have been trained by one of the smart nurses, like Employee W or Employee Q. A staff interview was conducted with Employee M on 5/5/2015 at 9:30AM. Employee M is an LPN who also functions at the facility's Social Worker and marketing person. She confirmed there was no training conducted for newly hired staff since February on any Medical Error Recognition or Prevention,[MEDICAL CONDITION].Infection Control, Incident Reporting, Abuse/Neglect/Exploitation, Medication Competency for nurses, Risk Management, or any of the facility's policy and procedures. She stated, I haven't done training on any of them; I don't even have a file for them. An interview was conducted with the Administrator on 5/4/15 at 12:59PM. She confirmed the nurses were not trained in competency and there had been no new hire trainings since February 2015.

Based on observations, record reviews, and staff interviews, the Administrator failed to administer the facility in a manner that enabled it to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being of the residents. This was evidenced by the Administrator's failure to identify issues with security of medication storage to prevent the potential loss and tampering of residents' medications and act upon the pharmacy's recommendations related to these issues; failure to properly investigate and document resident grievances; failure to follow company policy and procedures for event reporting; failure to report an adverse incident; failure to report theft of controlled substances to the pharmacist; failure to ensure the training of all newly hired staff; failure to report Licensed Practical Nurse (LPN) to Board of Nursing after acknowledgment of an arrest for theft of controlled substances; failure to ensure required Qualiry Assessment (QA) committee members to attend the QA meetings; failure to identify, implement and the follow a plan of action for areas of concern at QA meetings; and failure to coordinate resident care during the Medical Director's absence with another qualified physician, which resulted in placing all 49 of 49 residents on the current census at risk for harm or serious injury. The facility's failure to provide an Administrator to administer the facility in a manner that enabled it to effectively and efficiently attain or maintain the highest practicable physical, mental and psychosocial well-being placed all 49 residents at risk for serious harm, injury, impairment, or death. These conditions resulted in Immediate Jeopary (IJ). The immediate jeopardy was indentified on 3/20/15 and was ongoing at the time of exit on 5/8/15. The facility was informed of the IJ on 5/8/15. Cross reference to F353, F425, F431, F501 and F520. The findings include: 1. An observation was conducted on 5/4/2015 at 9:15 AM of the 200 hallway treatment cart. The cart was observed unlocked and unattended by Employee Z, LPN, who left to administer medications. The cart contained various types of medicated creams and ointments (Santyl, used in wound care to remove dead skin; [MEDICATION NAME], antibiotic; and Lactin ointment). An interview was conducted on 5/4/2015 at 9:20 AM with Employee Z, LPN, and she confirmed the cart was left unlocked and unattended when she went to pass medications. An observation was conducted on 5/4/2015 at 2:15 PM of the nurse's station. Six cabinets were observed containing newly filled medications that would not fit on the medication carts, and medications that needed to be returned to the pharmacy. In the bottom cabinets, an Emergency Drug supply kit (EDK) was seen. These cabinets were not locked and were able to be opened. In the cabinets, multiple various pills, and injectable and liquid medications were observed being stored. Medications were observed in pre-filled individual foil packets stored in little white boxes, which held a month's supply of medications for residents. Some of the medications that were accessible in this cabinet were [MEDICATION NAME] (blood thinner), [MEDICATION NAME] [MEDICATION]), [MEDICATION NAME] (used for High blood pressure), [MEDICATION NAME] (used for depression), [MEDICATION NAME] (anticonvulsant and pain reliever), [MEDICATION NAME] (blood thinner), [MEDICATION NAME] (antipsychotic), [MEDICATION NAME] (for high blood pressure), and Nudexta (treats neurological disorders). There were 3 boxes of pre-filled injectable syringes of [MEDICATION NAME] (blood thinner) and 2 vials of injectable [MEDICATION NAME] (ointment). Side effects if these medications were ingested would possibly include unusual bleeding, coughing up blood, bladder pain, joint pain, psychotic reactions, vomiting, suicidal behavior, sudden weakness, severe headaches, trouble breathing and confusion. All six cabinets were left unlocked and were accessible to all ambulatory residents, staff, visitors, and third party agencies that had access to the nurse's station. A staff interview was conducted with the Employee Q (Acting Director of Nursing) on 5/4/2015 at 2:15 PM. Employee Q confirmed that the cabinets were unlocked and should be locked at all times. She informed the surveyor she did not have a key to lock the cabinets and would get a nurse to lock them. An observation was conducted on 5/4/2015 at 2:50 PM of the nurse's station and the six cabinets remained unlocked. An interview was conducted with the Administrator on 5/4/15 at 2:55 PM. The surveyor made her aware that the six cabinets in the nurses' station that housed residents' medications were unlocked and had been unlocked since 2:15 PM, and her DON was notified, but still had not lock them. An observation was conducted on 5/4/2015 at 2:59 p.m. of Employee G (Maintenance Director) working with the locks on the cabinets at the nurse's station. An interview was conducted at that time and Employee G confirmed that the cabinets' locks did not work properly and he was trying to lock the cabinets for the nurses. He stated, The nurses complain their keys don't work. An interview was conducted on 5/4/2015 at 3:05 PM with Employees L and Z (LPNs). Both nurses confirmed they had not been in the six cabinets all day and the 11-7 shift must have left the cabinets unlocked. An interview was conducted on 5/5/15 at 8:20 AM with Employee II (Nurse Consultant). She confirmed the locks on the cabinets did not work most of the time and then demonstrated how the locks would turn without having a key in them, thus allowing entry into the cabinets. A review was conducted of the Policy & Procedure for Disposal of Medications and it revealed on page 1 of 4, #2 That Medications are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal and state laws and regulations. A review was conducted of the Consultant Pharmacist Med Station Review Sheets, dated 1/30/15, 2/26/2015, 3/31/15, and 4/31/15. All of the sheets had marked under the Criteria for Controlled Medications stored/locked per regulation policy as not met. A phone interview was conducted on 5/7/2015 at 6:30 PM with Employee V (Consultant Pharmacist). She confirmed that on her visits to the facility on [DATE], 2/26/2015, 3/31/2015, and 4/31/15, the facility always failed to have medication storage cabinets behind the nurses' station locked at the time of her entry into the facility. The consultant pharmacist verified she made the Administrator & DON aware of her findings of cabinets not being unlocked at her time of exit from the facility. The facility continued to not lock the cabinets and the EDK monthly, despite the pharmacist's findings and instructing them to lock the medications at the time of her visits. 2. An observation was conducted of the 200 hallway medication cart on 5/4/15 at 9:22 AM. A medication card was pulled out for Resident #23 labeled [MEDICATION NAME]/[MEDICATION NAME] (pain reliever) 5/325mg, and nine pills were observed in the card. When the medication card was turned over, tape was observed on the back of the card holding the 9th pill in place in the card. An observation was conducted of the 200 hallway medication cart on 5/4/15 at 9:22 AM. A medication card was pulled for Resident #24 for [MEDICATION NAME] (used for anxiety) 0.5mg. Tape was also observed on the back of the card where the 26 & 27 pill slots were. After closer observation, it was noticed that there was still a pill stuck to the tape in the 27th slot. The Controlled Drug Record showed the count for the [MEDICATION NAME] should be 25. There were 26 pills remaining in the medication card. The 27th pill was signed as given on 4/21/15, and the count had been signed off as accurate since that date. A review of the Controlled Drug Record for Resident #27 revealed mulitple documentation errors. When the back of the record was turned over, it revealed that pill #1 was wasted due to tape on the back of the card. A review was conducted of the Pharmacist Med Station review sheet, dated 3/30/15. The pharmacist had checked that there was a card found on the 200 Hallway cart for Resident #25 with tape on the back of the [MEDICATION NAME] 0.5mg medication. An interview was conducted on 5/7/15 at 6:30 PM with Employee V (Consultant Pharmacist). She confirmed during her visit in March that she found a medication card for Resident #25 with tape seen on the back of the card. Employee V verified she did not remove the card at the time of her review, but did inform the administrator of her findings before her exit of the facility. However, no action was taken regarding the findings. A review was conducted on 5/4/2015 of the 100 & 200 hallways medication carts and three medication cards for Residents #23, #24 and #27 were found with tape on the back of medication cards, even after the pharmacist findings and recommendations to the Administrator on 3/30/15. 3. An interview was conducted with the Administrator on 5/5/15 at 2:40 PM. The Administrator informed the surveyor that the Medical Director was out of the country and she was not made aware that he was leaving and did not know the date of his expected return. The Administrator was unable to verify who would be covering for the Medical Director, who was also the attending physician for the facility's 49 residents. The Administrator was unable to provide documentation of the Medical Director's leave of absence. Review of an undated memo from the Medical Director revealed Medical Director Will be out of town from May 1-May 11, 2015 and physician's assistant, Employee X, will be covering for me. This memo was not signed by the facility showing the Administrator approval or acknowledgment. An interview was conducted with the Administrator on 5/5/15 at 4:15PM. She verified the Medical Director was out of the country at a conference. The Administrator was not able to identify the name of the physician who was covering for the Medical Director, and confirmed she had not obtained anything in writing prior to his leaving the country. A review of the Medical Director's signed contract, dated 9/5/2011, revealed on page 2 #9: Assist in arranging for continuous physician coverage for medical emergencies; and Page 2 #16: If the Medical Director is not available, the Medical Director will appoint another physician, subject to the Facility's approval, to be available in his absence. An interview was conducted with Employee M (Social Services) on 5/5/2015 at 5:10PM. She stated that the original doctor they thought was covering for the Medical Director was also unavailable and she had Employee X on the phone. She stated, (Employee X) would cover the building for the Medical Director while he was out of the country. A phone interview was conducted with Employee X (Physician Assistant) on 5/6/2015 at 12:30 PM. Employee X confirmed he was covering for the Medical Director while the director was out of the country. Employee X (Physician Assistant) was just made aware on 5/6/15 (unknown of time) that he would now be the covering physician and he would correspond with the Medical Director as needed. A phone interview was conducted with Employee JJ, physician, on 5/8/15 at 3:41 PM. Employee JJ confirmed he was covering for the Medical Director, but only for Class II controlled substances that may need to be refilled. He confirmed that he was not seeing residents or giving orders for the residents; he was just to give refills on residents who had pre-existing Class II narcotic medications and may need refills while the Medical Director was out of the country. The employee was not aware if the facility knew he was covering for the Medical Director. 4. An interview was conducted with Resident #16 on 5/4/15 at 12:15 PM. The resident confirmed he has complained before to the staff that he did not receive some of his evening meds in the past. He stated nobody from the facility has ever talked to him about this or looked into his complaints. A family interview was conducted with the son of Resident #4 on 5/4/15 at 12:30 pm. The family member confirmed they had mentioned in the past to Employe HH (previous DON) that they were concerned that Employee H, LPN, was not giving his mother's Klonopin as ordered. He had observed his mother after he was told she received her medication to still be anxious (jerky) on a night when Employee H was working. The son also verified there was never any investigation or follow up done with him or the resident about his concerns. This was not listed on the facility event log. He mentioned, (Employee H) had been altered at work before and the facility suspended her, but they brought her back and continued to let her work and now she gets arrested. An interview was conducted with the Administrator on 5/4/2015 at 12:59 p.m. She confirmed there was an incident at the facility involving a nurse, Employee H, on 3/20/15. The nurse was found after her break staggering, stumbling, and slurring her words after she returned from break around 8 PM. The Administrator questioned Employee H and was not certain if the nurse gave the evening medication pass to her assigned residents on 3/20/15. The Administrator confirmed after talking with the residents that a resident did complain about not receiving their medications, but no further investigation was done. A review of the Medication Administration Record (MAR) sheets was conducted on 5/5/15 for the 100 hallway residents' evening medication pass for 3/20/15. There were 22 residents assigned to Employee H for the 100 hallway on 3/20/15. It revealed Employee H did not sign for her controlled drugs or sign the MAR for the residents' scheduled medications during her scheduled evening shift on 3/20/15, thus affecting all 22 residents. This included the possibility that the residents' routine medications, such as [MEDICATION NAME] (blood thinner), [MEDICATION NAME] injectable insulin, blood pressure medications, blood glucose monitoring, antibiotics, anticonvulsant, anti-psychotic, pain relievers, and sleeping pills were not given, as well as any prescribed 'as needed' medications that a resident may have requested for pain, anxiety or [MEDICAL CONDITION]. A review was conducted of a narcotic medication audit that was done on 3/20/15. It revealed a controlled drug count was done for the 100 hallway medication cart at approximately 11:00 PM. The facility did so due to the possibility of Employee H diverting controlled drugs. Employee H complained that she had low blood sugar, but the staff tested her sugar and it was within normal limits. The Administrator was called about Employee H's behavior and she directed the staff to perform a count of the narcotics due to Employee H's behavior and possibility of diverting narcotics and had previous altered mental status. There were approximately 17 medications that could not be accounted for (the controlled drugs were popped out of the medication cards, but were not signed off on the MAR or the Controlled Drug Record as given). Some of the narcotic medications not accounted for on the evening of 3/20/15 were [MEDICATION NAME] (Pain reliever), [MEDICATION NAME] (anti-anxiety),[MEDICATION NAME](for sleep), [MEDICATION NAME] (pain reliever), and Klonopin (for psychiatric disorders). On the right side of the audit sheet, comments were seen written for Resident #3, did not get meds and crushed with other meds. Resident #10's sheet revealed, did not get meds. The audit revealed the facility's Administrator admitted to never questioning all of the residents on the 100 hallway if they received their medications. The facility only questioned the residents who received controlled drugs, and this was not done until the next day on 3/21/2015. The facility did not review the residents' MARs for 3/20/15, or any other previous dates when Employee H was assigned to their care to determine the possible medication errors or omissions. An interview was conducted with Resident #3 on 5/4/15 at 2:00 PM. The resident confirmed that she had told the staff 6 or 7 times in the past between January to March that she wasn't receiving [MEDICATION NAME](sleeping pill) and [MEDICATION NAME] (for anxiety) as ordered in the evenings. The resident verified she had never heard from Employee HH (previous DON) or the Administrator in regards to these complaints. This was not seen on the facility's Event Log. An interview was conducted with the Administrator on 5/4/15 at 12:59 PM. The Administrator was asked to provide information on the investigation she had done regarding Employee H, and what she had put in place to make sure this never happened again. The Administrator could not provide any documentation of an investigation or new practices put in place to ensure the residents' safety. At the time of exit, the Administrator had not spoken to any residents or families concerning medication administration on 3/20/15. A review was conducted of the Controlled Substance Policy and Procedures, and Page 2 #9 reads, The DON documents irreconcilable discrepancies in a report to the administrator. The Administrator was unable to produce such documentation that this was done. A review of 14 Event Reports, dated 3/21/15, was conducted and it revealed that Residents #1, #3, #4, #5, #6. #9, #10, #12, #13, #14, #17, #19, #20, and #21 all had event reports for medication variances. The report was signed by Employee HH (previous DON) and the Administrator and dated 3/21/15 (one day after event). There was a line where details were to be provided about medication variance, but was left blank. Under Documentation Checklist, it was marked that the MD notified and Residents/Responsible Parties, but no dates, names, or substantiating documentation was entered on the report. All other information on the event documenting staff, CNA, or nurse involved was also left blank. The Administrator did not provide this information before exit. On 5/6/15 at 1:55 PM she stated, We did it, we just didn't document. An interview was conducted with the Administrator on 5/6/15 at 10:20AM. The Administrator was asked if she ever went back to the residents after 3/20/15 to let them know that there was an active investigation in regards to discrepancies of medications. The Administrator replied, No, we went around that night and asked the residents and nobody could remember if they did or didn't get their medications. We couldn't prove she took the medications from here so we didn't do anything. An interview was conducted with Employee W, LPN, on 5/6/15 at 7:25 PM. She confirmed that the previous DON was not in the facility on the night of 3/20/15 and that she didn't see her until around 2:30 PM on 3/21/15. 5. A review of a Police Report, Case # 1891, dated 3/20/15 at 11:01 PM, revealed Employee H was arrested and charged on 3/20/2015 for Theft of Controlled Substances, Narcotic offense for possible Scheduled II, IV and V, and possession of new legend drug without a prescription. A written statement was also reviewed from Employee H in which she wrote, There are extra pills during count that I did not know what to do with so I stuck them in a bottle in my bag. An interview was conducted with the Administrator on 5/4/2015 at 12:59 PM and she confirmed she had not called the Board of Nursing for Employee H or reported an Adverse Incident with the State. She stated, We were waiting to see if they pressed charges, and we didn't fire her for stealing; we fired her for not documenting. We couldn't prove she took the medications from here so I didn't do anything about it. An interview was conducted with Employee N (CNA) on 5/6/2015 at 3:05 PM. She confirmed that she had made complaints to Employee Q (Acting DON) regarding Employee H's behavior and was concerned the residents were not getting medications as scheduled at night. She also confirmed Employee Q, Employee HH, nor the Administrator ever came and asked her questions or ever looked into her complaints. An interview was conducted on 5/6/15 at 4:20 PM with Employee Q, Acting DON. She confirmed that CNAs reported to her and complained about Employee H's behavior (unsteady and stumbling), and were concerned she wasn't giving medications to residents correctly. She confirmed she told Employee HH about these concerns, but Employee Q was instructed that the facility Can't make accusations like that. Employee Q confirmed Employee HH never did an investigation or questioned her any further after that day. (She could not give specific date.) An interview was conducted with the Administrator on 5/6/15 at 10:20 AM. She reconfirmed she had not reported Employee H to the Board of Nursing because she was waiting to see if the police pressed charges and she couldn't prove Employee H she took the medications. 6. A review was conducted of the sign-in sheet for the Quality Assessment and Assurance (QA) committee meeting for the facility that was conducted in January 2015. It revealed that the signature of the Director of Nursing (DON) was missing. An interview was conducted with the Administrator on 5/5/2015 at 3:00 PM. She confirmed the Director of Nursing's signature was missing. She stated, The DON had to be on a conference call and I forgot to get her to sign it. A review was conducted of the sign-in sheet for the Quality Assessment and Assurance (QA) meeting for the facility that was conducted in February 2015. It revealed the signatures of the Director of Nursing (DON) and the Medical Director were missing. An interview was conducted with the Administrator on 5/5/2015 at 3:00 PM. She confirmed the Medical Director and the DON's signatures were missing and they were not in attendance for the February meeting. A review was conducted of the sign-in sheet for Quality Assessment and Assurance (QA) meeting for the facility that was conducted in March 2015. It revealed the signature of the Director of Nursing (DON) was missing and she was listed to instruct the committee on various medication issues. An interview was conducted with the Administrator on 5/5/2015 at 3:00 PM. She confirmed the Director of Nursing's signature was missing and she was not in attendance for the March meeting, and that she (the Administrator) delivered and talked about the issues with medications and nursing instead of the DON. She also confirmed she was not a nurse and could not produce any handouts or information she used at this meeting. A review of the QA meeting topics to be covered revealed the following as items to be conducted by the DON, dated 3/20/15: ISSUES: Administration of controlled medications and responsible party notified. Action Items: Audit of administration of narcotic sheets, resident interview for administration of medications, and monitored resident side effects. Follow up status: Narc/MAR sheets verified for accuracy, Audits to be completed 3 x's weekly on site, Weekly - bring audits in QI for 3 months. The QA action plan failed to address any concerns with nursing competency, revised policy and procedures for controlled drugs accountability, evaluate staff performance, re-training for nurses, random drug screening for employees, investigation of any medication complaints, investigate to determine the root cause of this event, and to ensure the facility maintains current practice standards and accurate monitoring systems so residents are not put at risk for harm. An interview was conducted with the Administrator on 5/6/15 at 2:20 PM . She confirmed there has not been a QA meeting since 3/30/15. In addition, the Administrator had no paperwork or correspondence showing the completion of the audits/monitoring that was to be done and brought to the QA meeting for April for the follow up as listed for March. In addition, the facility failed to evaluate the current interventions/audits due to the inaccuracy in controlled drug reconciliation and multiple documentation errors found by the surveyor on 5/4/2015 for both medication carts. An interview was conducted on 5/5/15 at 3:38 PM with Employees Q & M. Both confirmed the facility had not conducted any tracking or trending of medication pass or medication errors. Employee M stated, There have been no changes. Honestly, it was a one time occurrence. 7. A record review was conducted on 5/5/2015 of the following nurse employees: Employee T - Date of Hire (DOH) 4/17/15; Employee J - DOH 4/17/15; Employee U - DOH 4/8/15; Employee Y - DOH 4/8/15; Employee Z - DOH 2/18/15; Employee AA - DOH 1/21/15; Employee BB - DOH 3/10/15; Employee CC - DOH 3/10/15; Employee DD - DOH 1/12/15; Employee EE - DOH 3/12/15; Employee FF - DOH 3/30/15; and Employee GG - DOH 4/22/15. This review revealed no training had been conducted for any new hires after February 1, 2015. The employees were not trained in Medical Error Prevention and Recognition, Accident prevention and safety awareness,[MEDICAL CONDITION].Infection Control, Incident Reporting, Abuse/Neglect/Exploitation, Medication competency for nurses, and Risk Management, or any of the facility's policy and procedures. An interview was conducted with Employee E, Business Office Manager, on 5/4/2015 at 4:55PM. She confirmed the employees had not been trained in any area and there were no training certificates in the files. She also verified there was not a staff member assigned to do the training, so it was not being done An interview was conducted with Employee T, RN, on 5/4/15 at 3:52 PM. He said that he received 4 days of training and stated, It was okay but I wished I would have been trained by one of the smart nurses like Employee W or Employee Q. A staff interview was conducted with Employee M, Social Worker/Marketing, on 5/5/2015 at 9:30 AM. She confirmed there was no training conducted for newly hired staff since February on [MEDICAL CONDITION].Infection Control, Incident Reporting, Abuse/Neglect/Exploitation, Medication Competency for nurses, or Risk Management, or any of the facility's policy and procedures. She stated, I haven't done training on any of them; I don't even have a file for them. An interview was conducted with the Administrator on 5/4/15 at 12:59 PM. She confirmed the nurses were not trained in competency and there had been no new hire trainings since February. 8. Record review of the Administrator's position description, signed and dated 1/19/15, included the following Essential Duties and Responsibilities: -Ensures that the most current resident care policies, personnel policies and other operational policies and procedures necessary to remain in compliancewith requiredlaws, regulations and guidelines are available and followed. -Ensures that adequate number of personnel are employed to meet the needs of the residents and State requirements. -Responsible for the financial, administrative and personnel management of the facility.