Every finding on record at Chateau at Moorings Park, The

Based on record review, and staff interviews, the facility failed to report alleged violations which could constitute abuse or neglect to the State Survey Agency for 1, (Resident #99), of 3 sampled residents. The findings included:Review of the clinical record revealed Resident #99 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including dementia, atrial fibrillation, anxiety, aspiration, muscle weakness, depression, pain, dysphagia, restless leg syndrome, sleep apnea, and hemiplegia. The admission Minimum Data Set (MDS) dated [DATE] documented the resident was dependent for all care and was non-ambulatory. The MDS noted the residents' cognitive skills for daily decision making were intact. On 8/28/25 Resident #99 became unresponsive at the facility and emergency medical services (EMS) was contacted. Review of the nursing progress notes documented on 8/28/25 at 2:27 p.m., Resident #99 was observed unresponsive in his wheelchair sitting in the common area of the unit. His breathing was shallow, and he was returned to bed with the use of a mechanical lift. EMS was notified. Oxygen was applied due to shallow breathing. Resident #99 was sent to the local emergency room (ER) for evaluation. Review of the hospital records revealed EMS had administered Narcan (medication used to reverse an opioid overdose) to Resident #99. Once in the ER a drug screen was completed and documented the resident had tested positive for Fentanyl (a powerful synthetic opioid) that can treat severe pain. Review of the residents medications included: Medications- MiraLAX 17 grams daily, Tylenol 325 milligrams (mg) 2 tablets every 6 hours as needed, aspirin 81 mg daily, amiodarone 200 mg daily, Montelukast 10 mg at HS, Sennosides 8.6 mg one tab at bedtime, Trazodone 50 mg at bedtime, Lidocaine 4% topical patch daily, Plavix 75 mg daily, Pepcid 40 mg at bedtime, Losartan 25 mg daily, metoprolol succinate ER 100 mg twice a day, and Pentoxifylline 400 mg ER three times a day.There were no physician orders for a Fentanyl patch and no orders for opioid medication. On 9/3/25 at 10:30 a.m., in a phone interview with Resident #99's representative said he was contacted by the hospital to report they did a toxicology screen, and his father had tested positive for fentanyl. He said his father never took opioids in his life and had no access to them. He said his father never had access to any opioids and did not know how they got into his system. On 9/3/25 at 10:49 a.m., in an interview, the Assistant Executive Director (AED) said he had a visit by a detective from the local police department telling him the resident had tested positive for Fentanyl, but she had no additional information. He said he contacted the hospital multiple times, but they said they were not able to provide him with any information. We started an internal investigation, but we have not been able to find anything. On 9/3/25 at 11:10 a.m., in a interview the Executive Director provided this writer with a copy of the Investigation, that was a 1/2 sheet of typed paper and said, I think we should discuss this. She said the facility had spoken to the hospital and received no information. The assumption is something could have happened, but it is difficult to make a determination. On 9/3/25 at 11:20 a.m., the AED said, we had one other person in the facility was on a Fentanyl patch that was applied two days prior to the incident. Following this report on Resident #99 we did a full house assessment and no residents had any changes in their status. The Fentanyl patch was on a totally different part of the facility on a different cart, with different staff. Review of the investigation conducted by and provided by the facility documented:1. 8/28 resident was transferred to the hospital following an unresponsive episode around 2:12 p.m.2. On 8/29/25 around 3:30 p.m., a detective arrived at the facility to discuss the incident. Reported that the resident tested positive for fentanyl on 8/28, detective reported that the results came back at 5:11 p.m., on 8/28/25, resident left facility before 2:30 p.m.3. On 8/29 the Director of Nursing (DON) reviewed narcotic disposal and dispense sheets to verify all medications in order. Verified narcotic disposal and procedure is being followed.4. On 8/29 the DON and nursing team completed a full head to toe assessment on all residents.5. 8/29 DON completed in-service with education with nursing team throughout the weekend on drug disposal policy.6. 8/30 DON and Admin met with weekend supervisor and on shift providing additional education.7. 9/2/25 Detective returned to the facility and met with the clinical team on shift 8/28/25 interviewing them.8. 8/29 DON completed in-service with education with nursing team throughout the weekend on drug disposal policy.9. 9/2/25 the Detective returned to the facility and met with the clinical team on shift 8/28/25 interviewing them. On 9/3/25 at 11:75 a.m., in an interview Licensed Practical Nurse (LPN) Staff A said the resident was sitting in the common area and was yelling he wanted to go to bed but the CNA 's (certified nursing assistant) were putting other residents to bed. He had therapy and when they came to take him down to the therapy room, he was unresponsive. The CNA's were hoping the therapists would put him back to bed when they were done but when they came to get him he was unresponsive.Therapy called for myself and the nurse who works with me. We tried to arouse him; he was breathing but shallow. Staff B went with them to put him in bed, and I went to check his code status and call 911. They gave us instructions to lay him flat and elevate his feet, remove the pillow. His oxygen saturations were good but we did start oxygen because his breathing was shallow. It was roughly about 10 minutes between the time he was found and the time he went out of the facility with EMS. He was his normal self, and he was awake when EMS came and they transferred him. They did not say what was wrong with him and I did not see them give him any medications. He was awake once we laid him down. Once they leave the facility, they usually transfer them right away. He never had an issue like this before. He had no opioids he had no narcotics. I gave him medications but no opioids, he did not have any. On 9/3/25 at 12:17 p.m., in an interview Registered Nurse (RN) Staff B said I was here the day the resident was sent to the ER. We were at the nursing station when the therapist came and said someone was unresponsive and we went to the common area. The resident was in the w/c in front of the television. He was not responding, and I did the sternal rub, his eyes rolled back, and he did the puff breathing. I said let's get him to his room and we were checking his status. The aides got vital signs and we got the crash cart. I applied oxygen and we placed him in bed in the Trendelenburg position. He was in and out, of responding. LPN Staff A was calling 911. I left to get the transfer papers once he started to respond. I did not see EMS administer any medications to the resident. Honestly, once they arrived, I moved out of the way so they could do their job and take over. On 9/3/25 at 1:17 p.m., in an interview the DON, said I was there the day EMS came and the resident was unresponsive. His pupils were small, but I would not say they were pinpoint. I'm a cardiac nurse and the resident has a cardiac history, he had a syncope episode. When he got into the room he was responding, yelling and confused but that was his usual. On 9/3/25 at 1:25 p.m., in an interview the AED said the resident did not leave the facility. He had no other visitors and no appointments. I did not interview the staff because when the officer came, she conducted all the interviews while I was there. I have no written interviews, I did not do it, the police have them. On 9/3/25 at 2:00 p.m., during an exit interview, the Executive Director argued that she did not feel the event required reporting because they did not know where the fentanyl came from.

Based on review of the facility's policies and procedures and staff interviews, the facility failed to protect the health, welfare, and rights of each resident by failing to ensure 1 (The Director of Facilities) of 3 staff reviewed was eligible for employment based on background screening and facility roster.The findings included:Review of facility procedure for background screenings which stated, Not Eligible Status: Notify the HR (Human Resources) Representative that the results came back as: Not Eligible. We can't continue with the hiring process.Review of facility policy titled Background Screening which stated, Background checks serve as an important part of the selection process at the company. This type of information is collected as a means of promoting a safe work environment for current and future company employees. Background checks also help the company obtain additional applicant related information that helps determine the applicant's overall employability, ensuring the protection of the residents, employees, property, and information of the organization. The Moorings Park Institute will ensure that all background checks are held in compliance with all federal and state statutes.On 8/20/25 at 9:45 a.m., received copy of the facility assigned user list for the Health Facilities Reporting System (Emergency Management System for AHCA) listing Staff A, Director of Facilities, as active.On 8/20/25 at 10:25 a.m., reviewed background screening for Staff A, Director of Facilities, which showed not eligible effective 7/12/25. The Facility Administrator reviewed the clearinghouse documentation and said he was unaware that Staff A was not eligible per the AHCA Clearinghouse.On 8/20/25 at 10:40 a.m., during an interview the Associate Executive Director of Human Resources said, Several years ago we moved from having everyone employed who cover the entire campus removed off of the skilled nursing roster. It was too confusing to assign people who did not often come to the Chateau to keep them on the roster. The Associate Executive Director of Human Resources and the Campus Executive Director said they were not aware the Director of Facilities status had changed in July 2025. We did not know that his status had changed. They confirmed the facility does not have a process for being aware if someone not on the roster had a change in status.On 8/20/25 at 10:45 a.m., the Facility Administrator said, he would not have been hired if he was not eligible on the background screening. It is a safety concern. On 8/20/25 at 11:20 a.m., the Campus Executive Director confirmed campus wide staff are not on facility rosters in the AHCA Clearinghouse. Confirmed the person not eligible should not have access to the building or near any residents saying, It will be addressed immediately.

Based on observations and staff interviews, the facility failed to store, prepare, distribute, and serve food according to professional standards for food service safety and sanitary conditions and to prevent foodborne illnesses for 2 of the 2 observations of the main kitchen. The findings included: A review of the National Serve Safe dated September 2012, titled Cleaning and Sanitizing Practices That Will Prevent Cross Contamination, showed the following: To prevent cross-contamination from surfaces, the correct cleaning solution and sanitizing procedures must be followed. Cross-contamination can occur when wiping clots are not stored in a sanitizer solution between uses, and the sanitizing solutions are not at the required levels to sanitize objects. https://www.servsafe.com/ServSafe/media/ServSafe/Documents/NFSEM_wk3_Actvy-Clean-Sanitize. In the initial visit to the main kitchen conducted on 1/27/25 at 9:30 a.m., the following were noted: 1.The Senior General Manager of Dining Services was observed in the food production area with no facial hair restraint. 2. The Director of dining was observed in the food production area with no facial hair restraint. 3. The Sous Chef was observed in the food production area with no facial hair restraint. 4. The facility's Clinical Dietitian was noted in the food production area, wearing a hair net. A large portion of the left side of her hair was out of the hair net, touching her shoulder. 5. A large container of granulated sugar was noted, and the scoop inside the bin touched the sugar particles. 6. A dirty used rag that was noted in a metal container and not in the designated red sanitation bucket. Six of seven red solution buckets were measured for the concentration of sanitizing solutions ranging from 0 (parts per million) to 400 parts per million. A normal range of solutions is noted between 100 parts per million to 400 parts per million. The first red bucket showed a range of 0 which indicated that it did not have effective sanitizer in the bucket and was not within guidelines. The second red bucket showed a range of 0, which indicated that it did not have effective sanitizer in it and was not within guidelines. The third red bucket showed a range between 0 and 100, which indicated that it did not have the effective sanitizer in the bucket and was not within guidelines. The fourth red bucket showed a range of 100, which indicated that it did not have the effective sanitizer in the bucket and was not within guidelines. The fifth red bucket showed a range of 0, which indicated that it did not have the effective sanitizer in the bucket and was not within guidelines. The sixth red bucket showed a range of 0, which indicated that it did not have the effective sanitizer in the bucket and was not within guidelines. 8. A blue plastic personal bottle was noted in the food production area near a cutting board and a knife. 9. A metal container in the walk-in Refrigerator with pieces of raw fish dated 1/21/25 and a used-by date of 1/28/25. 10. A large metal container in the walk-in Refrigerator, with pieces of raw fish dated 1/21/25 and used by date of 2/2/25. 11. Staff A, Dietary Staff, was observed attempting to calibrate a facility's thermometer. When asked about acceptable ranges for the calibrated thermometer, she said she did not know. Another staff member stepped in and took over the calibration of the thermometer. In an observation conducted on 1/27/25 at 12:47 p.m., a large pink plastic personal cup with a straw was found on the food production counter in the pantry/satellite kitchen room near the Banyan dining room. In an observation conducted on 1/28/25 at 9:36 a.m., two undated Styrofoam round containers of ice cream were found in the kitchen area of the Banyan Wing C unit. In a follow-up visit to the main kitchen conducted on 1/29/25 at 11:22 a.m., during the lunch tray line, the following was noted: 12. The Senior General Manager of Dining Services was observed in the food production area with no facial hair restraint. 13. The Director of dining was observed in the food production area with no facial hair restraint. 14. Staff A was noted to wear a cloth hat that did not cover the back of her hair, and her ponytail was exposed in the back. 15. Staff A was observed using a facility thermometer to take the temperature of a Chicken Salad Pecan on the tray line (taken from the walk-in Refrigerator) that was to be served for the lunch meal. She proceeded to take the temperature of the chicken salad without first calibrating the thermometer. The first reading showed 44.3 degrees Fahrenheit and not the necessary 40 degrees and below Fahrenheit. The Executive Chef moved the Chicken Salad Pecan to a smaller 4-inch metal container and placed it directly on an ice bath in the tray line. He proceeded to take the temperature of the chicken salad without first calibrating the thermometer. The second reading showed that the Chicken Salad was 46.3 degrees Fahrenheit and not the necessary 40 degrees and below Fahrenheit. In this observation, the Executive Chef said that he would pull another batch of Chicken Salad from the walk-in Refrigerator. 16. Continued observation of the lunch tray line showed Staff A using a facility thermometer to take the temperature of the Pureed Chicken Salad Pecan on the tray line (taken from the walk-in Refrigerator) that was to be served for the lunch meal. The reading showed 45.8 degrees Fahrenheit and not the necessary 40 degrees and below Fahrenheit.

Based on interviews and record review the facility failed to reassess the effectiveness of the interventions and revise the care plan to meet the needs of the resident for 2 (Residents #7 and #36) of 4 resident sampled for falls and accidents. The findings included: Review of the facility's policy titled, Fall Interventions with an effective date of 08/2003 included in part the following: 7. The care plan interventions are reviewed and revised accordingly to help minimize the risk of a recurring fall or fall with injury. 8. The Falling Star program includes: any residents that have fallen twice in a month or two consecutive months in a row; any resident may be added to the program at the discretion of the interdisciplinary team. They will be identified by: a. Placing a star on the resident's name plate outside their room b. Placing a star on their walker, wheelchair or any other assistive device c. Any resident remaining free from falls for 90 days may be removed from the program. 9. Falls will be discussed at the interdisciplinary team daily in the Morning Meeting and weekly at the Standards of Care Committee. Record review for Resident #7 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Unspecified Dementia, Type 2 Diabetes, and Muscle Weakness. Review of the Quarterly Minimum Data Set (MDS) for Resident #7 with a target date of 1/6/25 documented in Section C a Brief Interview of Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Review of Resident #7's care plan effective from 8/31/18 to present with an active (current) problem of Resident needs assist with ADLs (activities of daily living) r/t (related to) diagnosis of Dementia and decreased mobility. Potential for falls r/t hx (history) of falls and medication side effects of Psychotropic drug use, vision impairment 01/01/21/25 fall in room - no injuries. At risk for impaired communication r/t hearing loss, resident's daughter not fixing hearing aides at this time - per nursing. The goal was for the resident to have no serious injury r/t falls with goal date of 05/03/25. The interventions included the following: Fall risk, Fall precautions, Falling Star, Frequent safety checks, independent with mobility risk of fall/injury, keep areas free of obstructions to reduce the risk of falls or serious injury, verbal reminders to call/ask for assist if dizzy to avoid falls and or serious injury, monitor for side effects of psychotropic drug use (all interventions listed as active (current) with no date when added to care plan. Review of the facility fall log from 7/01/24 to 1/25/25 documented Resident #7 had the following falls: On 9/7/24 fall no injury. On 9/8/24 fall no injury. On 11/6/24 fall no injury. On 12/24/24 fall no injury. On 1/21/25 fall no injury. During an interview conducted on 1/29/25 at 3:30 p.m., with the Director of Nursing (DON) who was asked about falls for Resident #7, the DON stated the resident had a fall risk assessment on 7/6/24 which indicated the resident was a high risk for falls. The DON stated on 9/7/24 Resident #7 had an unwitnessed fall, slid from her recliner with no injury reported. Physician and family notified no diagnostic ordered. On 9/8/24 Resident #7 had a fall from her bed not witnessed with no injuries physician and family notified no orders received. On 11/6/24 Resident #7 had an unwitnessed fall when she slid out of couch in her room with no injuries, physician and family notified no orders received. On 12/24/24 Resident #7 had an unwitnessed fall in her bathroom with no injuries, family and physician notified, no orders received. On 1/21/25 Resident #7 had an unwitnessed fall, found next to bed with no injuries, family and physician notified no orders received. The DON was asked about the care plan for Resident #7 and what interventions were implemented each time the resident had a fall, she acknowledged she could not see any dates associated with the interventions and would have Minimum Data Set (MDS) Coordinator pull the care plans. During an interview conducted on 1/30/25 at 1:00 p.m., with Staff C MDS Coordinator who stated she has worked at the facility for about two years. When asked about Resident #7's fall care plan, she stated every time the resident has a fall they add the fall information and date to the care plan problem. When resident has a fall, they do a risk management assessment and if they determine an intervention should be added they will add the intervention. She stated that when a resident has a fall the MDS Coordinator, the Assistant Director of Nursing (ADON) or the DON can put in an intervention into the care plan. They also have standards of care (meeting) on Fridays to review falls for the previous week and they review the interventions and can put in additional interventions as appropriate. She acknowledged the fall interventions were not updated each time Resident #7 had a fall. Record review for Resident #36 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Alzheimer's Disease with Late Onset and Anxiety Disorder. Review of the Significant Change in Status MDS for Resident #36 with a target date of 12/30/24 documented in Section C a BIMS was not performed due to the resident is rarely/never understood. Review of Resident #36's care plan effective 11/8/24 to present with an active (current) problem of the resident requires assist with ADLs due to impaired mobility following s/p (status post) hospitalization for syncope (a temporary loss of consciousness, commonly known as fainting or passing out). Potential for pain d/t (due to) decreased mobility. Potential for falls d/t weakness and medication side effects. Potential for skin breakdown d/t medication side effects and decreased mobility. The goal was for the resident to be free from injury with a goal date of 02/08/25. The interventions included Fall risk, Frequent checks, and Falling star. All interventions were active (current) with no date when they were added to the care plan. Review of the facility fall log from 7/1/24 to 1/25/25 documented Resident #36 had the following falls: On 11/23/24 fall with injury. On 12/14/24 fall. On 12/22/24 fall. On 12/23/24 fall. On 1/26/25 fall with injury. During an interview conducted on 1/29/25 at 3:40 p.m., with the DON who was asked about the falls for Resident #36, the DON stated the resident had a fall risk assessment completed on 11/7/24 which indicated she was a very high risk for falls. On 11/23/24 she fell on floor next to bed, unwitnessed, resident complained of right should right knee pain. The physician and family were notified, x-rays were ordered and were negative. Resident was treated for pain. On 12/14/24 the resident had an unwitnessed fall found on floor next to bed no apparent injuries. Family and physician were notified, no orders received. On 12/22/24 the resident had an unwitnessed fall. She was found kneeling next to bed. The resident stated she lost her balance, no injuries. Family, physician and hospice services were notified. No orders received. On 12/23/24 resident had fallen from bed unwitnessed with bruising to both knees and skin tears. Family, physician and hospice were notified. Orders received for treatment to skin tears to bilateral lower extremities. On 1/26/25 resident had an unwitnessed fall. She was observed on floor in her room. She sustained skin tears to the right knee and right shin. Family, physician and hospice were notified. Hospice came to evaluate resident and gave treatment orders for skin tears. The DON was asked about the care plan for Resident #36 and what interventions were implemented each time the resident had a fall. She acknowledged she could not see any dates associated with the interventions and would have the Minimum Data Set (MDS) Coordinator pull the care plans. During an interview conducted on 1/30/25 at 1:20 p.m., with Staff D MDS Coordinator, she was asked about the care plan for Resident #36, specifically the interventions added or updated in relation to the residents falls. Staff D MDS Coordinator stated the interventions were not updated in the care plan each time the resident had a fall and was not able to see the dates when the current interventions for falls were added to the care plan.

Based on observation, record review, resident and staff interviews, the facility failed to ensure all medications are secured at all times for 1 (Resident #35) of 17 sampled residents. The findings included: Review of the facility's policy titled, Medications -Central Storage of with an effective date of [DATE] included in part the following: All medication for which the facility is responsible for administering or providing assistance are labeled with the resident's name and the manufacturers label with directions for use kept with the medications. The resident may self-administer medications unless the health assessment or physician's orders specifically requires medications to be administered. Self-administered medications that the resident utilizes may be stored by the resident in his/her own room. Record review for Resident #35 revealed the resident was admitted to the facility on [DATE] with the diagnoses in part as follows: Influenza Due to Identified Novel Influenza A with Pneumonia, Acute Bronchitis due to Hemophilus Influenzae, Influenza due to other identified Influenza Virus with other Respiratory Manifestations, Atrial Fibrillation, Gastro-esophageal Reflux Disease with Esophagitis, Pain, Edema, Disorder of Lipoprotein Metabolism, Insomnia, Chronic Systolic (Congestive) Heart Failure, Retention of Urine, Essential (Primary) Hypertension, Heart Failure, Nausea, and Hyperkalemia (a higher than normal level of potassium). Review of the Minimum Data Set for Resident #35 dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #35 revealed no order for self-administration of medications. Record review for Resident #35 revealed no assessment for self-administration of medications. Review of the Care Plan for Resident #35 revealed no care plan for self-administration of medications. On [DATE] at 10:52 a.m., an observation was conducted of Resident #35 sitting in chair in his room. Several over the counter medications were observed on the table next to the resident. During an interview conducted on [DATE] at 10:55 a.m., Resident #35 said some of the medications were his and some were for his wife. On [DATE] at 9:20 a.m., an observation was made of Resident #35 in his room with his wife and Staff B Registered Nurse (RN). On the table between the husband and wife were four over the counter medications (Vitamin D3 50,000 units, Saw Palmetto 450mg, Omega 3 Fish oil 1,200 mg, Motrin 200mg). On the table between the bed and an empty chair were 11 additional over the counter medications (Magnesium, Cold Crush, Hair Switch, Magnesium Glycinate, Golden Revive, ARNRA, Pro Dental, InflammaSelect, Saccharomyces boulardii, BacilloSpore Select and L-glutamine). On [DATE] at 9:20 a.m., in an interview Resident #35's wife said her husband took the four medications on the table and the other ones on the other table were hers. RN Staff B was present during the interview. During an interview conducted on [DATE] at 9:22 a.m., RN Staff B stated she has worked at the facility for two and a half years. She acknowledged Resident #35 had 15 unsecured medications at the bedside . RN Staff B said if residents are alert and oriented, some can have medications at the bedside and some cannot. When asked if the medications at the bedside should be locked/secured, she said if it is a narcotic, it needs to be locked up. When asked if it is not a narcotic does it need to be locked/secured, she stated it just needs to be in a drawer. She clarified the drawer does not need to be locked. When asked about Resident #35 having the medications at the bedside, she said the resident should have an order for the medications at the bedside. RN Staff B acknowledged there was no order for the resident to have medications at the bedside and also acknowledged the resident did not have any assessment to self-administer medications. RN Staff B acknowledged the resident did not have a physician's order for the medications that were at the bedside. During an interview conducted on [DATE] at 9:40 a.m., the Director of Nursing stated residents should not have medications at the bedside unless specifically assessed and able to administer their medications. If they are able to self administer their medications, the medications would be on the medication administration record (MAR). When asked, she said she was not sure if the medications stored at the bedside needed to be secured. During an interview conducted on [DATE] at 9:45 a.m., the Assistant Director of Nursing (ADON) stated all medications at the bedside should be in a locked box, not just put in a drawer. During in telephone interview conducted on [DATE] at 11:45 a.m., the Consultant Pharmacist for the facility stated medications should be secured at all times, unless in use.

Based on record review, facility policy review, and staff interview, the facility failed to report an allegation of abuse to the appropriate state agencies for 1 (Resident #1) of 3 residents reviewed for abuse reporting. Caregivers in institutional settings can experience stress at levels that lead to elder abuse. Nursing home staff may be prone to elder abuse if they lack training, have too many responsibilities, are unsuited to caregiving, or work under poor conditions. Failure to report has a potential to allow abuse to be tolerated. The findings included: A review of the facility's Abuse Prevention Policy (effective 8/2/1999) revealed, All alleged violations and all substantiated incidents will be reported to the administrator of the facility, the state agency, adult protective services and to all other agencies as required A review of the facility's concern log revealed an allegation of abuse was made by Resident #1's Health Care Surrogate on 5/1/19. The allegation was of a sexual assault to her family member by another resident. The facility investigation, dated 5/3/19, had no indication the appropriate state agencies were notified of the allegation. On 5/16/19 at 10:54 a.m., the Director of Nursing acknowledged the allegation of sexual assault had not been reported to the state or other agencies.

Based on medical record review, and administrative interviews the facility failed to monitor 1 (Resident #109) of 5 sampled residents for unnecessary medication and high risk drugs. Failure to monitor resident's response to medication put the resident at risk for serious adverse effects. The findings included: On 11/7/17 review of the medication flow sheets for Resident #109 revealed the Resident was receiving [MEDICATION NAME] 80 (milligrams) mg twice a day and 20 mg once a day for a total of 100 mg daily. Per the National Institute of Health: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=eadfe464-720b-4dcd-a0d8-45dba706bd33 [MEDICATION NAME], is a potent diuretic which, if given in excessive amounts, can lead to a profound diuresis with water and electrolyte depletion. Therefore, careful medical supervision is required and dose schedules must be adjusted to individual patient's needs. When doses exceeding 80 mg/day and given for prolonged periods, careful clinical observation and laboratory monitoring are particularly advisable. The medical record revealed Resident #109 started on [MEDICATION NAME] 40 mg twice a day on 7/6/17 and [MEDICATION NAME] 20 mg was started on 7/26/17. The medication flow sheets revealed the resident received 100 mg [MEDICATION NAME] daily without monitoring. The medical records revealed a laboratory test on 7/24/17, the resident was receiving [MEDICATION NAME] 40 mg twice a day. An additional 20 mg [MEDICATION NAME] was ordered on [DATE]. The medical record did not provide evidence of clinical monitoring after the [MEDICATION NAME] 20 mg was added to the medication profile, bring the total dose to 100 mg/daily. The medical record failed to provide evidence of a care plan for a resident taking diuretics and the monitoring for signs and symptoms of [MEDICATION NAME] adverse reaction and over dosage. During an interview on 11/7/17, at 2:00 p.m., the Director of Nursing (DON) confirmed the last laboratory test was conducted on 7/24/17, before the resident started on the additional 20 mg/daily. During an interview on 11/7/17, at 2:30 p.m. the Pharmacist Consultant said, . a Lab should have been drawn a few days after [MEDICATION NAME] 20 mg was ordered. Yes, I should have made a recommendation for labs. You are right there was no recommendation for a lab in August, September, or October for labs. Sorry I missed that.

Based on record review, administrative staff and pharmacy consultant interview, the pharmacist failed to monitor and make recommendations related to the use of an excessive amount of a diuretic medication for 1 (Resident #109) of 5 sampled residents reviewed for unnecessary medication. The failure to adequately monitor an excessive amount of a diuretic may contribute to adverse consequences such as increased fluid loss, electrolyte imbalance, and dehydration. The findings included: 1. Review of Resident #109's medical record revealed physician's orders [REDACTED]. On 7/26/17, the physician ordered an additional 20 mg of Furosemide to be given to equal 100 mg/day. Record review found the last laboratory monitoring of the medication was 7/24/17. This test was before the additional 20 mg of Furosemide was added. The medical record failed to show a care plan had been developed for the use of the diuretic to include how the facility was monitoring for potential adverse consequences of the excessive amount of the medication. 3. During an interview on 11/7/17 at 2:00 p.m., the Director of Nursing (DON) confirmed Resident #109's last laboratory test used to evaluate the efficacy of the Furosemide was on 7/24/17, which was before the additional 20 mg of Furosemide was added. Per the National Institute of Health (https://www.ncbi.nlm.nih.gov/pubmedhealth): Furosemide is a potent diuretic which, if given in excessive amounts, can lead to a profound diuresis with water and electrolyte depletion It works by acting on the kidneys to increase the flow of urine .Therefore, careful medical supervision is required and dose schedules must be adjusted to individual patient's needs. When doses exceeding 80 mg./day and given for prolonged periods, careful clinical observation and laboratory monitoring are particularly advisable. On 11/7/17, at 2:30 p.m., the pharmacy consultant stated, .a lab should have been drawn a few days after Furosemide 20 mg was ordered. Yes, I should have made a recommendation for labs .there were no recommendation for labs in August, September, or October . Sorry, I missed that.

Based on observation, record review and staff interview the facility failed to ensure that intervention to prevent an injury from a fall were in place at all times for 1 (Resident #243) of 1 resident reviewed who had sustained a fall. The findings include: Resident #243 was admitted to the facility on [DATE]. Record review shows that the resident has [DIAGNOSES REDACTED]. The resident's record shows there is Physician Orders, dated 11/11/13, for Blue mats on floor to bedside and an order dated 11/12/13 low bed - fall precaution. Review of the nursing progress notes shows that nursing staff documented on 11/11/13 at 7:00 a.m., "Assisted thru the night to turn and reposition. Observed by staff on several occasions with legs off side of bed. Mats at bedside on floor, Bed in low position. U/A C & S obtained. On 11/11/13 at 10:45 p.m., nursing documented "Res. observed by Certified Nursing Assistant (CNA) sitting on blue mat next to side of bed on floor. No injury noted. Range of motion (ROM) within normal limits (WNL) for resident. No signs or symptoms (S/S) pain/discomfort. Writer placed call to Dr.(name) and message left. Daughter (name) notified." Observation of the resident on 11/13/13 at showed that the resident was in bed. At that time the bed was in the lowest position, approximately a foot and a half from the floor. Bilateral cushion mats were on the floor next to the bed. During an observation on 11/14/13 at 1:32 p.m., the resident was resting in bed. At that time the bed was not in the lowest position, The bilateral floor mats were not on the floor,they were stored near the resident's chair. The resident was awake, alert and moving in the bed, pulling on the blanket. On 11/14/13, at approximately 1:35 p.m., Staff C, the CNA assigned to the resident was asked how she would know what interventions to use for this resident to prevent further falls. She said that they tell give her report . She also said that they have a written care plan for the resident and it is in the computer. She demonstrated in the computer, in the fall precaution section, that you would check yes or no in response to the following questions in the computer: Did you check resident every 15 min.? Is the call light in reach?, Did you encourage use of the call light?, Is the bed in low position,? Are fall mats on floor? She said they only check yes for the ones that the resident has. We then went to the ADL Book for the CNA care plan and the care plan for this resident did not include the fall precautions of mats on the floor or for the bed to be in the lowest position. On 11/14/2013 at 1:42 p.m., after surveyor intervention, the CNA was observed putting the resident's bed in the low position and placing blue mats on the residents floor. On 11/14/2013 at 1:52 p.m., Staff D identified herself as the resident's nurse. She was asked who updates the CNA care plans and she said she does for her residents. She was given the CNA Plan and she documented the interventions of placing mats on the floor at bedside and putting the bed in low position on the form at that time. The facility faied to ensure that this resident,who had already fallen out of bed once, had interventions in place at all times to prevent injury if another fall should occur.

Based on clinical record review and staff interview, the facility failed to clarify orders to ensure the drug regimen for 2 (Residents #243, #398) of 5 were free from unnecessary medications. This is evidenced by the facility's failure to ensure that that medications were administered per manufacturer's recommendations (Resident #243) and to clarify an insulin order (Resident #389). The findings include: Resident #398 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders included the use of Humalog Insulin 5 units subcutaneously at 9:00 a.m., and 8 units subcutaneously with dinner at 4:30 p.m. Review of the clinical record revealed a physician's telephone order, dated 11/12/13, that read, "Order clarification: Sliding scale (Humalog) per protocol." The order was signed and dated on 11/13/13 by the physician. The physician's order did not identify the amount of insulin to be administered for the resident's blood sugar results. Upon reviewing the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Humalog 100 units/ml vial insulin [MEDICATION NAME] Check blood sugars before each meals and at bedtime The Sliding Scale for the amount of insulin to be given for elevated blood sugars were documented as: 0-70 = 0.0 unit Call MD, 71-120 = 0.0 unit 121-150 = 2.0 units, 151-200 = 4.0 units, 201-250 = 6.0 units, 251-300 = 8.0 units, 301-400 =10.0 units, 401-402 = 12.0 units, call MD. Upon request the Unit Manager provided the surveyor with a document titled: "Physician orders-Sliding Scale Insulin Protocol" which she stated is the official protocol used by the facility. The protocol contained 2 different parameters (standard low and standard plus) of insulin does to be administered based on the results of the resident's blood sugar. It did not specify the frequency for the monitoring of the blood glucose. The protocol was not signed by a Practitioner. Further review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s order. Interview on 11/14/13 at 4:15 p.m., with the Director of Nursing (DON) confirmed the findings. She stated the insulin protocol has been established for years and had never been signed by any physician or the Medical Director. She stated although the form says protocol, it's just a guideline for the nurses to use. She confirmed the order should have been clarified and she will speak to the physician about it. Resident #243 was admitted to the facility on [DATE]. Record review shows the resident has [DIAGNOSES REDACTED]. On 11/15/13, during medication review, it was noted that the resident's physician order sheet for November, 2013 shows that the resident is prescribed Alendronate ([MEDICATION NAME]) 70 mg. tablet by mouth (p.o.) once weekly on Tuesday at 9:00 a.m., review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Alendronate is a [MEDICATION NAME] medication which is prescribed to persons with [MEDICAL CONDITION] to prevent bone reabsorption, and strengthen the bones reducing the risk of bone fractures. Review of the facility's Nursing 2013 Drug Handbook shows that instruction for P.O. administration for Alendronate are: Give drug with 6 to 8 ounces of water at least 30 minutes before patient's first food or drink of the day to facilitate delivery to the stomach; Give at least 2 ounces of water after oral solution; Don't allow patient to lie down for 30 minutes after taking drug and until after first food of the day. Listed Interactions include: Any food: May decrease absorption of the drug. Advise patient to take with full glass of water at least 30 minutes before food, beverages, or ingestion of other drugs." The resident had been at the facility for five weeks. During this time the medication was administered, on Tuesdays, at 9:00 a.m. On 11/15/2013 at 10:12 a.m., interview with the Director of Nurses (DON) revealed that the resident receives breakfast at 8:30 a.m. When asked if the pharmacist had reviewed the resident's medications, the DON said that the pharmacist was scheduled to come to the facility week. The order was reviewed with the DON and she contacted the pharmacy and physician. The order was changed so that the resident would receive the medication at 6:30 a.m., prior to breakfast.

Based on record review, observation and interview, the facility failed to ensure an acceptable handwashing technique was utilized during the performance of a pressure ulcer treatment for 1 (Resident #4) of a sample of 26 residents. The findings include: On 9/29/11 at 2:00 p.m., a pressure ulcer treatment was observed being performed of the right heel of Resident #4. During the procedure, the licensed nurse washed her hands on three different occasions. The surveyor timed each handwashing as being done for 10 seconds. Upon questioning at the completion of the procedure, the licensed nurse stated that hand washing should be done for "60 seconds, but I think it's 30 seconds here." When the surveyor stated that the licensed nurse was observed only washing her hands for 10 seconds, she stated "I sang 'Happy Birthday.'" The Assistant Director of Nursing provided the facility policy regarding "handwashing," at the surveyor's request, on 9/29/11 at 4:00 p.m. Review of the facility policy, no date, (Chapter 7 - Medical Asepsis) states "g. Perform hand hygiene using plenty of lather and friction for at least 10-15 seconds." Centers for Disease Control and Prevention (CDC) cites the following procedure for handwashing: "Continue rubbing your hands for at least 20 seconds. Need a timer? Hum the 'Happy Birthday' song from beginning to end twice." During an interview on 9/30/11 at 10:45 a.m., the Director of Nursing and Assistant Director of Nursing, after being provided with a copy of the CDC handwashing procedure (http://.cdc.gov/handwashing/), acknowledged that the facility procedure was not in compliance with acceptable standards of care.