Every finding on record at Karcher Post Acute

Based on observation, review of the FDA Food Code, policy review, and staff interviews, it was determined the facility failed to ensure 3 of 3 dumpsters and 1 of 1 garbage can were properly closed to prevent attracting pests and rodents into the facility. This deficient practice had the potential to affect all residents and staff in the facility. Findings include: The U.S. Food and Drug Administration 2022 Food Code, 5-501.115 (Outside Storage): Specifies that outside receptacles (like dumpsters) must be designed with tight-fitting lids, doors or covers that keep pests out and contain odors. The facility's policy titled, [NAME] Post Acute Trash and Dumpster Policy, undated, stated, all trash must be placed inside designated dumpsters. Do not leave trash on the ground. Close lids after use and do not overfill dumpsters. On 5/29/26 at 10:30 AM, three dumpsters and one outside garbage can were observed uncovered. [NAME] #1 stated, the dumpsters should be closed and the garbage can should be covered. On 5/29/26 at 11:03 AM, the Dietary Director stated, the dumpsters and garbage can should be closed.

Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure residents were provided respiratory services consistent with professional standards of practice. This was true for 5 of 16 residents (#16, #33, #37, #38, and #52) whose respiratory devices were not cleaned and stored properly and 2 of 16 residents (#22 and #38) reviewed for physician orders for oxygen therapy. This deficient practice created the potential for residents to develop infection and to receive too little or too much oxygen. Findings include: The facility's policy, titled Oxygen Administration, revised 10/2010, documented the purpose of the procedure is to provide guidelines for safe oxygen administration. Under the section titled, Preparation, 1. documented, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 1. Resident #22 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (COPD is a disease that causes airflow blockage and breathing related problems), respiratory failure, heart failure, and dementia. On 5/26/26 at 10:23 AM, Resident #22 was observed asleep in bed wearing a nasal cannula. Resident #22's oxygen concentrator had a humidification reservoir and was set to deliver 3.5 L of oxygen per minute. On 5/28/26 at 11:28 AM, Resident #22 was observed in their bedroom sitting in a wheelchair, Resident #22 was wearing a nasal cannula attached to a portable oxygen tank hanging on the back of the wheelchair. The portable E size oxygen tank was set to deliver 2 L of oxygen per minute. Resident #22's care plan, revised on 6/27/25, documented they required oxygen therapy, and directed staff to monitor for signs and symptoms of respiratory distress and provide oxygen via nasal cannula per physician orders. Resident #22's physician orders documented the following: -Change/Replace humidifier as needed, dated 6/16/25 -Clean oxygen concentrator/filter once per week, dated 6/16/25 -Monitor oxygen saturation prior to meals and ensure oxygen tank is full, dated 12/26/25 Resident #22's physician orders did not document how much oxygen Resident #22 should have been receiving. On 5/28/26 at 12:33 PM, the DON stated, Resident #22 did not have an oxygen order transcribed upon admission on [DATE]. The DON further stated, Resident #22 should not have been receiving oxygen without a physician order. 2. Resident #38 was readmitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure, pulmonary edema, and COPD. A physician order dated 3/9/26 documented, continuous oxygen at 3 Liters per minute (LPM) via nasal cannula every shift for oxygen use. Resident #38's Treatment Administration Record (TAR) documented Resident #38 was receiving 2 LPM of oxygen. On 5/28/26 at 11:50 AM, Resident #38 was observed sitting on the edge of his bed using 2 LPM of portable oxygen via nasal cannula. On 5/28/26 at 12:07 PM, RN #1 accompanied the surveyor to Resident #38's room and confirmed Resident #38's portable oxygen was set to 2 LPM. When asked about the physician order for Resident #38's oxygen, RN #1 confirmed Resident #38's portable oxygen tank should have been set at 3 LPM. The Facility's Administering Medications through a Small Volume Nebulizer Policy, dated October 2010, directed staff to: Rinse and disinfect the nebulizer equipment according to facility protocol, or: Wash pieces with warm, soapy water; Rinse with hot water; Place all pieces in a bowl and cover with isopropyl (rubbing) alcohol. Soak for five minutes; Allow to air dry on a paper towel. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 1. Resident #33 was readmitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure, congestive heart failure (CHF-a chronic condition where the heart muscle is too weak to pump blood efficiently), and pulmonary edema (a serious condition where excess fluid collects in the lungs' air sacs, making it difficult to breathe). On 5/26/26 at 10:04 AM and 5/27/26 at 2:49 PM, Resident #33's nebulizer face mask was observed sitting on the bedside tabletop without a barrier or a bag. On 5/28/26 at 8:59 AM, Resident #33's nebulizer face mask was observed sitting on top of her nebulizer machine without a barrier or a bag. 2.Resident #37 was admitted to the facility on [DATE], with multiple diagnoses including dementia, asthma, and sleep apnea. On 5/28/26 at 11:44 AM, Resident #37's nebulizer face mask was observed sitting upside down on top of the nebulizer machine. 3. Resident #52 was readmitted to the facility on [DATE], with multiple diagnoses including respiratory failure, COPD, and pulmonary edema. On 5/27/26 at 2:59 PM and 5/28/26 at 9:01 AM, Resident #52's nebulizer face mask was observed sitting on top of the nebulizer machine on top of Resident #52's dresser without a barrier or a bag. 4. Resident #38 was readmitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure, pulmonary edema, and COPD. The following nebulizer observations were made: -On 5/26/26 at 10:15 AM, Resident #38's nebulizer face mask was observed on top of the bedside table without a barrier or a bag. -On 5/28/26 at 11:37 AM, Resident #38's nebulizer face mask was observed hanging over the back end of the bedside table without a bag. 5. Resident #16 was admitted on [DATE], with multiple diagnoses including dependence on supplemental oxygen, chronic pain, and major depressive disorder. On 5/28/26 at 9:25 AM, Resident #16's nebulizer was observed on his nightstand with white particles on the mask and liquid in the nebulizer reservoir. The mask was observed to be touching the nightstand while the tubing was wrapped over the nebulizer machine. On 5/28/26 11:54 AM, the DON stated the nebulizers should be rinsed after each use and should be washed nightly. On 5/28/26 at 12:02 PM, RN #1 stated resident's nebulizers should be rinsed, air dried, and stored in a bag. 6. Resident #8 was admitted to the facility on [DATE] with multiple diagnoses including anxiety, depression, and hypertension. On 5/28/26 at 11:31 AM, Resident #8 was observed sitting in her wheelchair next to her bed. Her nasal cannula was observed resting directly on her blankets. When asked how often she wears her nasal cannula Resident #8 stated she uses her oxygen at night and whenever she sleeps. On 5/28/26 at 11:50 AM, the DON observed the nasal cannula and disposed of it. The DON confirmed the nasal cannula should be placed in a bag when not in use.

Based on observation, policy review, FDA Food Code review, resident and staff interviews, it was determined the facility failed to appropriately store, distribute and label foods. This deficient practice had the potential to affect all residents who received food prepared in the facility. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food borne illnesses. Findings include: 1. The FDA Food Code, Section 3-501.19, titled, Time as a Public Health Control, stated, once a Time/Temperature Control for Safety (TCS) food is removed from temperature control (the kitchen steam table or refrigeration), it must be consumed or discarded within 4 hours. Leaving a tray in a residents room for hours violates professional standards for food safety and distribution. Resident #68 was admitted to the facility on [DATE], with multiple diagnoses including heart failure (a chronic condition where the heart muscle doesn't pump blood as effectively as it should) and hypertension. On 5/28/26 at 11:50AM, Resident #68's uncovered breakfast tray was observed still in her room. Resident #68 stated she ate breakfast at 7:30 AM this morning. On 5/28/26 at 11:55 AM, CNA #2 stated, the breakfast trays for Resident #68's hall are usually delivered around 7:30 AM. On 5/28/26 at 3:15 PM, ADON stated, meal trays should be picked up 30 minutes after they are finished. 2. The facility policy titled, Food Receiving and Storage, revised 11/2022, under Dry Food Storage section 3, stated dry foods and goods are handled and stored in a manner that maintain the integrity of the packaging until they are ready for use. In Foods and Snacks Kept on Nursing Units, section 2, stated, all foods belonging to residents are labeled with the resident's name, the item and the use by date. a. On 5/28/26 at 10:30 AM, during kitchen observation, a Quaker Oats container was observed on the shelf with a cracked lid. On 5/28/26 at 1:15 PM, the Dietary Director stated, the box should not be used and it was thrown out. b. On 5/29/26 at 1:10 PM, a Tillamook ice cream container was observed in the assisted dining room freezer which was opened and unlabeled. On 5/29/26 at 1:10 PM, RCM #1 stated the ice cream should be labeled and dated.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 1 of 1 resident (Resident #16) reviewed for respect and dignity. This deficient practice placed residents at risk of embarrassment and diminished self-worth. Findings include: The facility's Dignity policy revised February 2021, documented staff were expected to promote dignity by helping residents to keep urinary bag covered.Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including neuromuscular dysfunction of the bladder and paraplegia (the partial or complete loss of motor and sensory function in the lower half of the body typically caused by spinal cord injury or disease).On 5/26/26 at 12:45 PM and 5/27/26 at 1:16 PM, Resident #16 was observed sitting in his wheelchair outside the Assisted Dining Room with his urinary bag containing urine uncovered.On 5/26/26 at 1:18 PM, the DON who was walking by was informed of Resident #16's urinary bag being uncovered. The DON stated that should be covered.

Based on review of the State Operations Manual (SOM), record review, and staff interview it was determined the facility failed to ensure residents exercised their right to formulate an Advanced Directive. This was true for 1 of 3 residents (Resident #33) whose records were reviewed. This failed practice created the potential for an adverse outcome if the resident's wishes were not followed. Findings include:The State Operation Manual (SOM), Appendix PP, defined an Advance Directive is a written instruction such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Physician Orders for Life-sustaining Treatment (or POLST) paradigm form is a form designed to improve patient care by creating a portable medical order form that records patient's treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST paradigm form is not an advanced directive.Resident #33 was readmitted to the facility on [DATE], with multiple diagnoses including congestive heart failure, pulmonary edema, and chronic respiratory failure.Resident #33's care plan, initiated on 5/4/26 and revised on 5/18/26, documented Resident #33 had an Advanced Directive on file and was up to date.An IDT Conference Note dated 5/12/26 documented, Resident #33's Advanced Directives were reviewed, accurate, and up to date.Resident #33's Advanced Directive was unable to be located in Resident #33's record.On 5/28/26 at 2:08 PM, when asked where Resident #33's Advanced Directive was located, the ADON stated she only saw Resident #33's POST form. When asked if a POST form is an Advanced Directive, the ADON stated, no, a POST form is different from an Advanced Directive. The ADON further stated she didn't believe Resident #33 ever gave the facility an Advanced Directive and confirmed there was not a copy of Resident #33's Advanced Directive on file.

Based on policy review, record review, review of the facility grievances, and resident and staff interview, it was determined the facility failed to ensure grievances were investigated and prompt corrective action was taken to resolve them. This was true for 1 of 1 resident (Resident #6) reviewed for grievances. This failure created the potential for psychological harm if residents' grievances were not acted upon. Findings include:The facility's Grievance policy and procedure revised March 2019 documented concerns/grievances may be presented verbally or in writing. The policy also documented grievance should be completed with appropriate actions and follow-up. The Social Service Director/Designee should:-assist concerned resident(s), resident representative, other family members(s), or advocated that have issues or concerns to complete a Grievance/Concern Form. If the person with concern does not want to complete a Grievance Form, any format should be accepted.-log all concerns/grievances received onto the facility grievance log.-should keep a running log of concerns voiced and their resolution as well as copy of the completed grievance forms.-monitor trending of the issues noted, and report as needed to the facility's QA Committee as well as the designated Grievance Officer.Resident #6 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including aftercare following surgery on the skin and subcutaneous tissue, Parkinson's Disease with dyskinesia (a movement disorders that causes involuntary, erratic and uncontrollable muscle movements).On 5/26/26 at 10:27 AM, Resident #6 stated he was unable to sleep due to his roommate's TV being so loud. Resident #6 also stated his roommate was turning the heater on and it was too hot in their room and was making it difficult to breathe. Resident #6 stated he reported his concerns to the Social Worker three times, the last one was this morning. He said the Social Worker spoke to his roommate, but nothing had changed.Review of the facility's Grievances' file did not include Resident #6's concerns regarding his roommate.On 5/26/26 at 2:19 PM, the LSW stated Resident #6 expressed his concerns regarding his roommate and spoke to his roommate. The LSW stated Resident #6's roommate denied turning the heater on. The LSW stated Resident #6's roommate was offered to use headphones, but he refused. The headphones then were offered to both residents, Resident #6 stated he would wear the headphones if his roommate was going to wear them too. The LSW stated Resident #6 spoke to her again this morning regarding his concerns with his roommate, that it was not resolved. The LSW stated she failed to complete a grievance form for Resident #6. LSW stated, Yes, it should have been completed. When asked if she had follow-up on Resident #6's concern, the LSW stated, No, I did not make a follow-up, and I should have.

Based on observation, staff interview, policy and record review, it was determined the facility failed to ensure a seatbelt was assessed as potential restraints and a consent from the residents and/or their representatives was obtained. This was true for 1 of 1 resident (Resident #6) reviewed for potential restraint. This deficient practice had the potential for harm if the seatbelt were improperly used. Findings include: The facility's Use of Restraints policy revised April 2017, documented prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptoms and to determine if there are less restrictive interventions that may improve the symptoms. The policy also stated restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative.Resident #6 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including aftercare following surgery on the skin and subcutaneous tissue, Parkinson's Disease with dyskinesia.On 5/26/26 at 10:27 AM and 5/27/26 at 10:30 AM, Resident #6 was observed sitting in his power chair with a seatbelt on.Resident #6's record did not include documentation he was assessed prior to him using the seatbelt as a potential restraint.On 5/28/26 at 2:49 PM, the ADON stated the resident should be assessed and obtained consent from the resident and/or their representative before initiating the use of seat belt. The ADON stated she was unable to find documentation Resident #6 was assessed prior to initiating the use of the seatbelt.

Based on record review and staff interview, it was determined the facility failed to ensure residents were appropriately monitored for side effects of anti anxiety medication. This was true for 1 of 5 residents (Resident #9) reviewed for unnecessary medications. This failure created the potential for inappropriate pharmacological interventions and adverse outcomes, including oversedation. Findings include:Resident #9 was admitted on [DATE] with multiple diagnoses including dementia with behavioral disturbances, history of falls, and anxiety.A review of Resident #9's care plan showed no documentation of monitoring for anti anxiety medication side effects, despite the resident's diagnosis of anxiety and use of anti anxiety medication.A physician order dated 3/16/26 documented: Anti anxiety medication: monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior.A review of Resident #9's TAR for anti anxiety side effect monitoring from 3/16/26 through 5/26/26 documented only a check mark for each monitoring entry.The TAR did not indicate whether any side effects were present or absent, nor did it provide descriptive information required to evaluate the resident's response to treatment.On 5/29/26 at 10:30 AM, the DON stated the record reflected that Resident #9 was monitored for side effects and that if side effects were present, the nurse would enter a progress note.When asked how the facility evaluates the resident's ongoing need for anti anxiety medication based on the monitoring entries, the DON stated she would change the order to require documentation of Y for yes and N for no to indicate whether side effects were present.

Based on record review and staff interviews, it was determined the facility failed to ensure the required discharge process was followed when residents were transferred to a higher level of care. This was true for 2 of 2 residents (#6 and #16 ) reviewed for hospital discharge process. This failure created the potential for incomplete information of transfers, delay in care, and lack of required notifications. Findings include: 1.Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including dependence on supplemental oxygen, chronic pain, and major depressive disorder. a. A nursing progress note dated 4/18/26 at 10:42 PM documented, Resident #16 was found unresponsive to verbal and physical stimulation. The LN documented Resident #6's oxygen saturation at 70% (normal 95–100%) and noted respiratory distress with snoring and gasping respirations. The LN called 911, and Resident #6 was transported to a higher level of care. A review of Resident #16's record showed no documentation that the State Long Term Care Ombudsman was notified of Resident #16's transfer to the hospital. On 5/28/26 at 2:45 PM, the ADON stated the facility does not notify the State Ombudsman of hospital discharges. b. A review of Resident #16's medical record showed no documentation of what discharge information, such as medical records, medication lists, or clinical summaries, was provided to the receiving healthcare institution. On 5/29/26 at 9:26 AM, RCM #2 stated Resident #16's record did not include documentation of what information was sent with the resident at the time of transfer. 2. Resident #6 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including aftercare following surgery on the skin and subcutaneous tissue, Parkinson's Disease with dyskinesia. A physician assistant progress notes dated 2/17/26, documented Resident #6 was discharged to the hospital for flap surgery. There was no documentation the Ombudsman was notified of Resident #6's discharge to the hospital. On 5/28/26 at 2:24 PM, the ADON stated Resident #6 went to the hospital for his scheduled flap surgery and they did not notify the Ombudsman of his discharge. The ADON stated the Ombudsman was being notified when the residents were discharged to the community or to their home.

Based on the State Operations Manual (SOM), record review, and staff interview, it was determined the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) was completed when new mental health diagnoses were identified for 1 or 4 residents (Resident #4), whose records were reviewed for PASRR screenings. This failure created the potential for harm if the resident required but did not receive specialized services for mental health while residing in the facility. Findings include:Appendix PP of the State Operations Manual, revised 7/23/25, documented any resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition must be referred by the facility to the appropriate state-designated mental health or intellectual disability authority for review. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including aphasia (inability to communicate verbally), hemiplegia and hemiparesis (paralysis and weakness on one side of the body), and stimulant abuse.Resident #4's medical record documented on 2/25/25, he received two new mental health diagnoses, bipolar II disorder and anxiety disorder.On 5/28/26 at 2:40 PM, the ADON stated Resident #4 should have had a new PASRR Level I conducted when he was diagnosed with bipolar II disorder and anxiety.

Based on record review and staff interview, it was determined the facility failed to ensure PASRR screening for serious mental illness, intellectual disability, or related conditions were completed accurately. This was true for 2 of 4 residents (#22 and #44) whose PASRR records were reviewed. This failure placed Resident #22 at risk for harm if their needs went unmet when a diagnosis of serious mental illness was omitted from their PASRR level 1, and placed Resident #44 at risk for harm when a new PASRR level 1 was not completed. Findings include: 1. Resident #22 was admitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, depression, and chronic respiratory failure. Resident #22's record documented a PASRR level 1 dated 5/14/26. The PASRR level 1 documented Resident #22 did not have any major mental illnesses, such as bipolar disorder. On 5/28/26 at 2:22 PM, the ADON stated Resident #22's PASRR level 1 from 5/14/26 was not accurate and should have been corrected upon her admission. 2. Resident #44 was readmitted to the facility on [DATE], with multiple diagnoses including bipolar disorder and depression. Resident #44's record was reviewed for PASRR level 1 screening for serious mental illness or intellectual disability. There was no documentation in Resident #44's record indicating a PASRR level 1 had been completed when Resident #44 readmitted to the facility on [DATE]. On 5/28/26 at 2:40 PM, the ADON and the LSW confirmed Resident #44's PASRR should have been completed when Resident #44 readmitted to the facility.

Based on policy review, record review, and staff interviews, it was determined the facility failed to ensure residents were provided with a comprehensive, person centered care plan as required. This was true for 2 of 17 residents (Residents #5 and #6) reviewed for care plans. Comprehensive, person centered care plans are essential for identifying resident needs, directing staff actions, and ensuring coordinated care. This deficient practice created the potential for unidentified or unmet care needs. Findings include:The facility's policy titled Care Plans, Comprehensive Person Centered, revised 3/22, documented: The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 1. Resident #5 was admitted on [DATE], with diagnoses including unspecified psychosis, depression, and insomnia. A Comprehensive MDS assessment dated [DATE] documented, under Section I (Active Diagnoses) that Resident #5 had depression and a psychotic disorder. A physician progress note dated 4/30/26 at 8:00 AM, documented an active diagnosis of generalized anxiety disorder. A review of physician orders documented Duloxetine 20 mg at bedtime for anxiety. A review of Resident #5's care plan showed no documentation of anxiety, related needs, or interventions. On 5/29/26 at 11:20 AM, the DON confirmed Resident #5's care plan did not reflect the anxiety diagnosis or associated interventions, stating it should have been included. 2. Resident #6 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including aftercare following surgery on the skin and subcutaneous tissue, Parkinson's Disease with dyskinesia. a. On 5/26/26 at 10:20 AM, Resident #6 stated he had a colostomy (a surgical procedure that creates an opening, called ostoma, in the abdominal wall) done a few months ago. Resident #6's care plan did not document he had a colostomy. On 5/27/26 at 1:43 PM, the DON stated Resident colostomy was not in the care plan. The DON stated, Yes, it should be in the care plan. b. On 5/26/26 at 10:27 AM and 5/27/26 at 10:30 AM, Resident #6 was observed sitting in his power chair with a seatbelt on. Resident #6's care plan did not document he was using a seatbelt. On 5/28/26 at 2:49 PM, the ADON stated Resident #6's seatbelt was not documented in his care plan. The ADON stated, Yes, it should be in the care plan. c. Resident #6's TAR documented he was being monitored for the following behaviors: verbal aggression, vulgar/sexual remarks, tearfulness, and isolation, started on 3/14/26. Resident #6's care plan documented he was being monitored for the following behaviors: voiced sadness due to recent loss of ex-wife, frustration with current medical circumstance, rejection of care/medicines, and yelling/lashing out. On 5/27/26 at 2:02 PM, the LSW reviewed Resident #6's care plan. The LSW stated Resident #6's target behavior was not in the care plan. The LSW stated, Yes, the target behavior should be the one documented in the care plan. On 5/27/26 at 2:28 PM, the DON stated Resident #6's behaviors that was being monitored were not in the care plan and it should be in the care plan.

Based on observation, record review, the National Council of State Boards of Nursing (NCSBN) website, and staff interview, it was determined the facility failed to ensure physician orders were clarified to verify the correct route of medication administration. This was true for 1 of 2 residents (Resident #2) whose physician orders were reviewed. This deficient practice created the potential for harm if residents were to receive oral medications when they were ordered to receive nothing by mouth. Findings include:According to the NCSBN website, accessed 6/4/26, nurses are professionally obligated to clarify and verify any order that is incomplete, inaccurate, unclear, or contraindicated before implementing it. The facility's policy, titled Administering Medications, stated, medications are administered in a safe and timely manner, and as prescribed. Section 10 stated, the individual administering medications checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including Cerebral Palsy (a neurological disorder that affects muscle control, balance, and posture) and dysphagia (difficulty swallowing).Resident # 2 had a PEG-tube (a percutaneous endoscopic gastrostomy tube surgically placed directly into the stomach through the abdominal wall for medication, nutrition, and hydration).On 5/27/26 at 12:10 PM, RN #1 was observed administering a probiotic via PEG-tube.Resident #2's physician's order included the following:- NPO to texture, diet and consistency dated 8/29/25.-Probiotic Oral Capsule, Give 1 capsule by mouth in the morning for gut health, dated 12/17/25.- Milk of Magnesia Oral Suspension 400 mg/5ml, give 30 ml by mouth as needed for bowel care as needed for no BM in 3 day, dated 12/17/25On 5/29/26 at 2:37 PM, the DON stated Resident #2 was NPO and should have nothing by mouth.

Based on observation, policy review, and staff interview it was determined the facility failed to ensure professional standards of practice were followed for 1 of 2 residents (Resident #2) reviewed for enteral feeding. This failure created the potential for adverse outcomes when Resident #2's physician orders were not followed for enteral flush and medication administration. Findings include: The facility's policy titled Enteral Feeding Tubes, reviewed 4/2022 stated, it is the policy of this center that residents receiving enteral tube feedings receive appropriate treatment and services to prevent complications. It further stated under Water Flush/Administration, the licensed nurse administers water flushes per physician order using lukewarm or room temperature water. If physicians orders are not specified, the recommendations are as follows:A. 15-30 cc pre/post medication administration.B. 5-10 mL prior to individual medication administration. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including Cerebral Palsy and dysphagia. On5/27/27 at 9:45 AM, Resident #2 was observed with a PEG-tube. Resident #2's physician order included the following: -Enteral Feed Order: every shift Enteral Water flushes; a. 15-30cc pre/post medication administration when multiple medications are administered together.b. 5-10cc prior to individual medication administration.c. 15-30cc pre/post tube feeding administration/discontinuation. -Enteral Feed Order four times a day for nutrition needs Vital AF 1.2- 250 ml bolus feeds QID to provide 1000 ml, 1200 kcal, 75 g protein, 75 ml flush pre/post bolus. On 5/27/26, Resident #2's feeding bag was observed to be empty between 9:45 AM to 11:50 AM. On 5/27/26 at 11:55 AM, RN #1 was observed to prepare Resident #2's medications and placed them crushed into 13 individual medication cups. On 5/27/26 at 12:10 PM, RN #1 entered Resident #2's room to administer his medications. Resident #2's empty feeding bag was observed still connected to his PEG tube, with enteral feeding still in the tubing. RN #2 was observed to put 240 ml of water into the feeding bag as a bolus. RN #1 then mixed each of Resident #2's medications with water and administer them one at a time via his PEG tube using a large syringe. RN #1 flushed Resident #2's PEG tube with more than 30 ml of water between each medication administration. RN #1 was observed returning to the sink three times to obtain approximately 250 ml of water each time during Resident #2's medication administration. On 5/27/26 at 12:40 PM, when asked RN #1 how much water he used, he stated, I have no idea. When asked what time he started Resident #2's enteral feeding, he stated, about 9:00 AM and it should have finished about 9:30 AM. On 5/27/26 at 4:04 PM, when asked when a feeding tube should be flushed after completion, RN #1 stated Resident #2's PEG tube should be flushed with water after the enteral feeding was finished, but he did not flush it until before he administered medication. On 5/27/26 at 4:19 PM, the DON stated when an enteral feeding was done, it should be checked for residual and then flushed within minutes of completion. On 5/29/26 at 2:37 PM, the DON stated RN #1 did not follow the physician's orders regarding flushing Resident #2's PEG tube.

Based on record review and staff interview, it was determined the facility failed to ensure Certified Nursing Assistants (CNAs) received the required 12 hours of annual in-service training and performance reviews. This was true for 1 of 3 CNAs reviewed for skills and qualifications. This failure created the potential to affect resident safety by limiting staff competency in providing care. Findings include:On 5/29/26 at 12:57 PM, a request was made for CNA education records and performance reviews.On 5/29/26 at 1:50 PM, the Administrator stated that 1 of 3 CNAs did not have documentation of the required 12 hours of annual training or a performance review.

Based on record review and staff interview, it was determined the facility failed to ensure resident records accurately reflected active medical diagnoses. This was true for 1 of 17 residents (Resident #5) reviewed for accuracy of records. This failure created the potential for miscommunication and unmet or unidentified care needs. Findings include:Resident #5 was admitted on [DATE], with multiple diagnoses, including unspecified psychosis, depression, and insomnia.A physician progress note dated 4/30/26 at 8:00 AM documented, Resident #5 had an active diagnosis of generalized anxiety disorder.A review of Resident #5's record showed generalized anxiety disorder was not listed as an active diagnosis in the resident's medical record.On 5/29/26 at 10:03 AM, the ADON stated Resident #5's record did not include generalized anxiety disorder as an active diagnosis and confirmed the record would be updated to reflect the physician's documented diagnosis.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure immunizations were offered and/or provided as indicated. This was true for 1 of 5 residents (Resident #4) reviewed for pneumococcal immunization. This deficient practice placed residents at risk of developing pneumococcal pneumonia and developing serious, potentially life-threatening complications. Findings include:The CDC webpage titled, Pneumococcal Vaccination accessed on 6/1/26, documented there are two types of pneumococcal vaccines. They are Pneumococcal conjugated vaccines (PCV) and Pneumococcal polysaccharide vaccine. The CDC recommended pneumococcal vaccination for:-All adults 50 years or older.-Adults 10 through [AGE] years old with certain risk conditions.Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including aphasia, hemiplegia, and hemiparesis affecting right dominant side following a stroke.Resident #4's Immunization Information, documented he refused to receive the pneumococcal vaccine on 10/21/24.There was no documentation in Resident #4's record he/and or his representatives was offered and educated regarding the risk and benefits of having pneumococcal vaccines.On 5/26/26 at 2:52 PM, the MDS Nurse (previous IP) stated pneumococcal vaccine was being offered to residents upon their admission to the facility. The MDS Nurse stated she was unable to find documentation Resident #4 was offered or educated of the risks and benefits of the pneumococcal vaccination.

Based on record review, review of Incidents and Accidents (I&A's) reports, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 8 of 8 residents (#4, #5, #6, #7, #8, #9, #10, and #11) reviewed for medication errors. Resident #4 was harmed after being administered her roommate's opioid pain medication and required medical intervention. Resident #5 was harmed when her narcotic medication was omitted resulting in increased pain. There was potential for harm and adverse outcomes when Residents #6, #7, #8, #9, #10, and #11's medications were not administered following physicians' orders. Findings include:The online Nursing 2025 Drug Handbook accessed on 11/10/25, stated the eight rights of medication administration were: - Right drug- Right patient- Right dose- Right time- Right route- Right reason- Right response- Right documentation 1. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including dementia, chronic obstructive pulmonary disease, and hypertension. The facility's Medication Error Report documented a medication error occurred at 7:30 AM on 8/1/25 when the nurse administered Resident #4 another resident's medication. Resident #4 was noted to be suffering from increased lethargy and drowsiness and wasn't acting like herself as a result of the error.The medication administered to Resident #4 was: oxycodone 7.5 mg (opioid pain medication).A physician's order dated 8/1/25, documented, place IV (intravenous catheter), NS (normal saline) 500 ml bolus (the rapid administration of a single, concentrated volume of fluid directly into a patient's bloodstream through a vein) and then 100 ml per hour for 5 hours to treat patient who was noted to have increased drowsiness and lethargy after patient was administered 7.5 mg oxycodone in error.On 11/7/25 at 12:40 PM, the DON confirmed on 8/1/25, the nurse administered another resident's medication to Resident #4 in error, and she required medical intervention due to the error. 2. Resident #5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis including fractured vertebra (multiple broken bones in the spine), malignant neoplasm of the lung (lung cancer), and low back pain.Resident #5's physician's orders, dated 7/31/25, documented, oxycodone 7.5 mg tablet by mouth every 4 hours as needed for pain.The facility's Medication Error Report documented a medication error occurred at 7:30 AM on 8/1/25 when Resident #5 did not receive her PRN (as needed) pain medication as requested.Resident #5 experienced increased pain when she did not receive the pain medication until 12:40 PM on 8/1/25, 5 hours after it was requested. Resident #5's pain monitoring on 8/1/25 documented as follows:-7:28 AM pain level 8 out of 10-12:35 PM pain level 9 out of 10In response to the missed PRN pain medication, a physician's order on 8/1/25 documented staff were to provide Resident #5 non-pharmacological interventions for pain management and administer PRN pain medication.On 11/7/25 at 12:42 PM, the DON confirmed the nurse did not administer Resident #5's dose of oxycodone as requested for pain, which resulted in untreated and increased pain. 3. Resident #6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including dementia, hypertension, and fibromyalgia (a disorder characterized by widespread pain accompanied by fatigue, sleep, memory, and mood issues).Resident #6's physician's order's, dated 7/1/25, documented for Lyrica (an anticonvulsant drug used to treat neuropathic pain and fibromyalgia) 150 mg in the morning and Lyrica 200 mg at bedtime related to fibromyalgia.a. The facility's Medication Error Report, dated 10/21/25, documented a medication error occurred on 10/20/25 in the morning when the nurse administered the bedtime dose of Lyrica 200 mg to Resident #6 instead of the ordered of Lyrica 150 mg.b. The facility's Medication Error Report, dated 10/25/25, documented a medication error occurred on 10/24/25 at bedtime when the nurse administered the morning dose of Lyrica 150 mg to Resident #6 instead of the ordered 200 mg of Lyrica.c. The facility's Medication Error Report, dated 10/27/25, documented a medication error occurred on 10/27/25 when the day nurse failed to administer the morning dose of Lyrica 150 mg to Resident #6.On 11/7/25 at 12:47 AM, the DON confirmed on 10/20, 10/24, and 10/27, medication errors occurred involving Resident #6's Lyrica.4. Resident #7 was admitted to the facility on [DATE] with multiple diagnoses including osteomyelitis (a bacterial infection of the bone), diabetes, and kidney failure.Resident #7's physician's orders, dated 10/9/25, documented, daptomycin (an antibiotic) intravenous solution reconstituted, 1250 mg intravenously in the morning every other day for infection related to osteomyelitis.The facility's Medication Error Report documented a medication error occurred on 10/19/25 when nurse administered ceftriaxone (an antibiotic) 1 gm intravenously instead of the ordered daptomycin.On 11/7/25 at 12:54 PM, the DON confirmed the nurse administered Resident #7 the wrong IV antibiotic on 10/19/25. 5. Resident #8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including cerebral palsy (CP is caused by abnormal brain development or damage to the developing brain that affects a person's ability to control their muscles) and dysphasia (inability to use or understand language).Resident #8's physician's orders, dated 8/21/25, documented to give an enteral feed four times a day for nutritional needs, Vital AF 1.2 calorie nutrition formula - 250 ml, bolus feeds (a method of delivering nutrition directly into the stomach through a gastrostomy (G-tube) feeding tube using a large syringe and gravity. The bolus method involves infusing a set amount of formula, similar to a single meal, over a short period of time).The facility's Medication Error Report documented a medication error occurred on 10/13/25 when Resident #8 was not administered his enteral feeding as ordered.On 11/7/25 at 12:56 PM, the DON confirmed Resident #8 was not administered his ordered tube feeding on the evening of 10/13/25 in error. 6. Resident #9 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD is a disease that causes airflow blockage and breathing related problems), diabetes, and opioid dependence.Resident #9's physician's order, dated 7/9/25, documented fentanyl transdermal patch 25 mcg/hour, apply one patch every 3 days for pain. The facility's Medication Error Report documented a medication error occurred on 9/10/25 when Resident #9 was administered Fentanyl 37.5 mcg/hour transdermal patch. The mistake was reported on the evening of 9/11/25 when it was noted the narcotic count was not correct.On 11/7/25 at 1:00 PM the DON confirmed Resident #9 was administered the wrong dose of Fentanyl on 9/10/25 and it was not discovered until 9/11/25. 7. Resident #10 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including stroke and insomnia (a sleep disorder characterized by persistent difficulty falling or staying asleep).Resident #10's physician's order dated 7/18/25, was for zolpidem tartrate (Ambien) 10 mg, give 1 tablet by mouth at bedtime for insomnia.The facility's Medication Error Report documented a medication error occurred on 8/7/25 when Resident #10 was administered 20 mg of Ambien rather than the 10 mg ordered.On 11/7/25 at 1:02 PM the DON confirmed Resident #10 was administered double the ordered dose of Ambien on 8/7/25. 8. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses including respiratory failure, heart failure, and end of life care.Resident #11's physician's order, dated 7/18/25, documented an order for alprazolam (Xanax) 1 mg tablet, give 1 mg by mouth at bedtime for anxiety.Resident #11's physicians orders did not include an order for tramadol 50mg.The facility's Medication Error Report documented a medication error occurred on 7/22/25 when Resident #11 was administered another resident's tramadol 50 mg instead of the ordered Xanax.On 11/7/25 at 1:05 PM, the DON confirmed Resident #11 was administered another resident's tramadol by mistake.

Based on record review and staff interview, it was determined the facility failed to ensure a resident was free from abuse. This was true for 1 of 3 residents (Resident #50) whose incidents during transferring were reviewed. This failure resulted in actual harm when Resident #50 was injured during a transfer from her bed to a wheelchair against her will. Findings include: The Centers for Medicare and Medicaid (CMS) State Operations Manual (SOM), Appendix PP, dated 7/23/25, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful as defined in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Resident #50 was admitted to the facility on [DATE] with multiple diagnoses including dementia, history of stroke, history of fractures, and age-related osteoporosis (a bone disease that causes bones to become weak, fragile, and more likely to break).Resident #50's care plan included the following:- Initiated 3/1/24, Resident #50 is at risk for increased pain. Monitor/record/report to nurse any signs or symptoms of non-verbal pain: changes in breathing (noisy, deep/shallow, labored, fast/slow); vocalizations (grunting, moans, yelling out, silence); mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); eyes (wide open/narrow slits/shut, glazed, tearing, no focus); face (sad, crying, worried, scared, clenched teeth, grimacing); body (tense, rigid, rocking, curled up, thrashing).- Initiated 2/28/24, Resident #50 is at risk for increased pain. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease in [range of motion], withdrawal, or resistance to care.- Initiated 2/28/24, Resident #50 was at risk for falls. For fall prevention: nonskid footwear when transferring.- Initiated 6/20/24, Resident #50 had a stroke, activity as tolerated, out of bed in chair if tolerated.- Initiated 11/24/24, Resident #50 was at risk for activities of daily living (ADL)/mobility decline and required assistance related to limited mobility, with documentation she was dependent on 2 staff for assistance with stand pivot transfers and to use a mechanical lift if she was tired.- Initiated 12/1/24, Resident #50 had a diagnosis of osteoporosis, with the goal Resident #50 will be free from complications of chronic pain, injury, infection, and increase in impaired physical mobility symptoms to extent possible, with staff direction to handle gently when turning/repositioning and with daily care.- Initiated 6/4/25, Resident #50 had impaired skin integrity, with staff direction to allow Resident #50 to initiated and transfer herself slowly to reduce amount of agitation with transfers.Resident #50's electronic health record documented an interdisciplinary team note, dated 6/6/25. The note documented Resident #50's representative requested staff education on transfers to reduce agitation and due to her history of fractures, the staff were educated she preferred slow transfers where she could move herself and she would hold onto staff or grab bars for assistance. The note documented Resident #50 did not like for others to move her.The facility's incident investigation report summary documented, on 7/12/25, Resident #50 suffered a fracture of unknown origin.The report documented Resident #50 would not get out of bed and they were able to finally get her up at about 12 [PM] and got her cleaned up changed and put her in her wheelchair. The investigation report documented, after [Resident #50] was placed in her [wheelchair] she started having what looked like seizure activity, signs of left side drooping in her face, and it was determined to go ahead and send her out to the emergency room for evaluation.The incident report included a staff statement, dated 7/13/25, Licensed Practical Nurse (LPN) #6 documented, On 7/11/25, I witnessed [Resident #50] in her wheelchair at 7:30 PM. The statement continued, During the night, I did not hear anything out of the ordinary. There was not a reported fall or complaint of pain during the shift. [Resident #50] remained in bed from 10:00 PM to 6:00 AM. I did hear [Resident #50] complain during final rounds, though did not hear well enough to tell what she was saying, and it is common for her to be upset when disturbed when she is asleep in bed.The incident report included a staff statement, dated 7/15/25, Certified Nurse Aide (CNA) #3 documented, I worked [the night shift] 7/11/25-7/12/25. I did assist [CNA #14] to complete cares two times. [Resident #50] was agreeable with cares and did not yell or hit CNA's. We let [Resident #50] lead her cares and assisted. No complaining of pain with cares. Just complained of being cold.The incident report included a staff statement, taken by the Director of Nursing (DON), from CNA #14 about 7/11/25, it documented, I changed [Resident #50 on 7/11] and she yelled for her mom and dad, and seemed scared but then went right back to sleep. She did not seem like she was in any pain.The incident report included a nurses note, dated 7/12/25 at 1:38 PM, LPN #10 documented, [Resident #50] slept in this morning. Staff attempted to help her out of bed this morning, however, she refused.The incident report included a staff statement, taken by the DON from CNA #12, dated 7/12/25, documenting, I went in and asked [Resident #50] if she wanted to get up right before lunch and she stated no, so I went and told [CNA #17] then went [to assist another resident].The incident report included a staff statement, dated 7/12/25, CNA #17 documented, I worked on 7/12/25 with another aide, [Resident #50] expressing pain and not wanting to get up. [LPN #20] who was the nurse that shift gave some meds and [Resident #50] was still expressing pain, refusing cares, and to get up. Neither myself or [the other aide] had provided any cares to her on this shift as we attempted but she continued to refuse and would not allow us to get her up or change her. [RNA #1] was hoping to get [Resident #50] up but [CNA #8] stated that we were not to force her to do anything.The incident report included a staff statement, dated 7/17/25, CNA #9 documented, Before [Resident #50] went to the hospital, I was in the room with [CNA #8 and RNA #1]. [CNA #8] didn't want to get [Resident #50] up because she looked really tired, but [RNA #1] wanted to get her up. [Resident #50] was yelling for her mom and CNA #8 was trying to calm her down. I left the room while they were getting ready.The incident report included a staff statement, dated 7/12/25, LPN #20 documented, [Resident #50] was not wanting to get out of bed this morning, when asked why she would mumble and close her eyes. [Resident #50] did take her medication and I told her she could stay in bed. I communicated to [the CNA's] that it was okay to leave her in bed since that is what [she] wanted. [Restorative Nurse Aide (RNA) #1] was requesting [Resident #50] be up for exercise, I reaffirmed to leave her in bed.The incident report included a staff statement, dated 7/12/25, CNA #8 documented, Numerous times for the morning of my work shift, I asked what we should do if [Resident #1] refused care and stated to leave her alone and reapproach her at another time. We attempted 5 to 6 times. CNA #8's statement continued, [LPN #10] asked us [CNA #8 and RNA #1] to go get her up and get her changed as she was wet. [RNA #1] helped pull her up from a laying position to a sitting position and [Resident #50] got a bit combative, but this is normal for [her] as she gets very scared. The statement continued, she shortly after sat in her chair and her head shot up crooked towards the ceiling and she began to start blinking rapidly and trying to respond. I said that I was getting the nurse and that something was not right. I ran to get the nurse.The incident report included the records from Resident #50's hospitalization. The emergency department physician documented patient with history of advanced dementia, comes from skilled nursing facility with possible convulsions.The hospital records documented a diagnosis of displaced left femoral neck fracture (break in the bone that connects the hip to the thigh where the fractured segment is moved out of position).The hospital records documented a reported episode of possible convulsion and no corroborating evidence of seizure event following computed tomography (CT) scan (a medical imaging procedure that uses X-rays and computer technology to create detailed, cross-sectional images of the inside of the body) of her head with no acute findings.On 11/7/25 at 1:13 PM, CNA #8 stated he provided a written statement to the facility of his observation during the incident on 7/12/25 with Resident #50. CNA #8 stated the DON said his statement was unacceptable and shredded his original statement. CNA #8 reported, the DON typed up a second statement minimizing the severity of the situation and made him sign it, and the second statement is the one in the investigation report. CNA #8 provided a copy of his original statement dated 7/12/25. The original statement documented Numerous times for the morning of my work shift I was asked what the staff were supposed to do if [Resident #50] refused care. I stated we are to leave her alone and reapproach at another time. While the day went on, this resident had refused about 5-6 different times, when lunch was approaching around noonish- [LPN #10] stated it was neglect and abuse to leave her [soiled] so [RNA #1] and I were going to try to reapproach her. When we got to her room, the resident was already requesting to be left alone when [RNA #1] pulled her up from a laying position to sitting. When [RNA #1] did that, [Resident #50] started to fight against [RNA #1] and was swinging at her. I asked if I could help and maybe change her just in bed and [RNA #1] said she was wet and had to get up. [RNA #1] was focused on getting her out of bed and she did not put shoes on [Resident #50]. When she sat her in the wheelchair, her head shot up, crooked toward the ceiling and she began to stutter and blink rapidly, still trying to respond. I said, I'm going to get the nurse, something isn't right.On 11/7/25, at 1:25 PM, CNA #8 stated, Resident #50 had been approached multiple times that morning and continuously refused to get out of bed and LPN #20 had directed him to let her rest. CNA #8 stated RNA #1 was trying to get her out of bed for restorative activities and he reminded her of their training the month prior, that Resident #50 should not be transferred if she is refusing or combative to avoid injury. CNA #8 stated he observed RNA #1 picking up Resident #50 under her arms, without footwear on, while she was yelling and striking RNA #1. CNA #8 reported he was shocked RNA #1 was picking up the resident, and brought the wheelchair closer to try to keep her safe. CNA #8 stated, RNA #1 firmly placed Resident #50 into her wheelchair and he heard two snapping or cracking sounds. He stated, Resident #50 immediately threw her head back and began making full body jerking movements and yelling ow, 911 repeatedly through a garbled voice.On 11/7/25 at 1:48 PM, LPN #20 stated, I instructed the CNAs to leave [Resident #50] in bed if she wanted to rest, and [RNA #1] did not listen.On 11/7/25 at 3:14 PM, the DON stated the 2 CNAs involved did not report Resident #50 was transferred unsafely. The DON was asked, did the CNA's follow the care plan for transferring?, she responded, yes, because [Resident #50] would always refuse and become combative no matter what you were approaching her with.On 11/7/25 at 3:44 PM, the Administrator stated he was not employed at the facility at the time of the incident. He added, it seemed like they were in a tough spot and there is a fine line between neglecting someone by leaving them soiled or abusing them by transferring them when they're refusing.

Based on the Long Term Care State Reporting Portal, Incident and Accident (I&A) report, record review and staff interview, it was determined the facility failed to provide an environment free from accidental hazards over which the facility has control and provides supervision to each resident to prevent avoidable accidents. This was true for 1 of 4 residents (Resident #36) reviewed for accidents. Resident #36 was harmed when a CNA failed to notify the nurse Resident #36 was using a heating pad. Resident #36 was found to have a burn at the hospital. Findings include: Resident #36 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including surgical amputation of the left leg above the knee, diabetes, kidney disease, depression, anxiety, chronic pain symptom, and hypertensive heart disease without heart failure.An annual MDS Assessment, dated 7/16/25, documented Resident #36 was cognitively intact.Resident #36's medications included, but was not limited to:- Duloxetine (an anti-depressant, and also used to treat chronic pain) HCL capsule delayed release particles, dated 7/12/25, give 60 mg by mouth for neuropathy and depression.- Pregabalin (an anticonvulsant also used to treat nerve pain) Oral Capsule, dated 8/26/25, 150 mg 1 capsule by mouth three times per day for phantom limb pain.- Oxycodone (narcotic pain medication) HCL oral tablet 5 mg by mouth every 6 hours for chronic pain.A review of an I&A, dated 8/27/25, documented Resident #36 was found unresponsive at 3:45 AM when RN #1 attempted to wake her up to take her 2:00 AM medications. RN #1 felt hot compresses under Resident #36's gown. RN #1 was unaware Resident #36 was using a heating pad, or that it was on. The report stated RN #1 was unaware if Resident #36 was using a heating pad, and was never told it was on, or if Resident #36 was able to use it. RN #1 attempted to cool Resident #36 down by rolling her towards her and removing the heating pad. RN #1 did not visualize the resident's back as she was alone while rolling Resident #36 towards her. RN #1 was focused on getting Resident #36's vitals taken and applying cold compresses to the resident. Resident #36's temperature was documented at 100 degrees [F], and cold compresses did not wake the resident. Additional staff were called to assist to take Resident #36's vital signs, and Resident #36 remained unresponsive. RN #1 decided to contact emergency services. When RN #1 returned to Resident #36's room, her blood pressure was unreadable, and her oxygen levels were significantly low. Resident #36 remained unresponsive while life-saving measures were offered. Emergency services arrived soon after and Resident #36 was sent to the hospital.The facility investigation documented, CNA #1 stated she had cared for Resident #36 at 9:00 PM [on 8/26/25] and was aware Resident #36 had a heating pad with a green fabric cover on it. CNA #1 stated she was unaware Resident #36 was not allowed a heating pad. Resident #36 had told CNA #1 she was cold.The I&A report further documented the DON was informed by Resident #36's daughter, Resident #36 had a large burn and was being sent to [a nearby city] for burn care.There was no documentation in Resident #36's record CNA #1 notified the nurse on duty Resident #36 had a heating pad in her room or that the heating pad was placed behind Resident #36. Nursing progress notes, dated 8/26/25 at 1:40 PM, documented a Late Entry note where Resident #36 was concerned with an area on her buttocks. Resident #36 was examined, and it was documented her skin area was clear and there were no skin issues at that time.On 9/3/25 at 10:27 AM, the DON stated CNA #1 saw the heating pad was behind Resident #36's back, but did not check to see if it was on or off. The DON stated CNA #1 should have reported the heating pad to the nurse, but she did not.

Based on interviews of residents, resident representatives, and staff, and record review, it was determined the facility failed to ensure a resident's cultural/religious rights were honored. This was true for 1 of 1 resident (Resident #28) whose record was reviewed for resident rights. This failure resulted in psychosocial harm to Resident #28 when a certified nursing assistant (CNA) cut her hair without her consent. Findings include: Resident #28 was admitted to the facility on [DATE], for care following a stroke and had multiple diagnoses including chronic kidney disease and dementia. A facility incident report, dated 2/12/25, documented staff were pulling Resident #28's hair while brushing it, then cut her hair. The report documented CNA #1 stated Resident #28 was uncooperative with staff attempting to brush the knots out of her hair, and CNA #1 cut about an inch or inch and a half from Resident #28's hair. The report did not specify if Resident #28 was asked for her consent before CNA #1 cut her hair. On 4/3/25 at 5:00 PM, Resident #28 and her representative were interviewed together. Resident #28 stated, I don't cut my hair, my hair came from Jesus. She became upset and stated, If I cut my hair, I'll go to hell. Resident #28's representative stated Resident #28 chooses not to cut her hair for religious reasons, and she informed the facility of this on the day of Resident #28's admission. The representative stated Resident #28 was upset about her hair being cut when the representative visited her afterward. She stated she brought it to the administrator's attention that someone had cut Resident #28's hair without her consent. Resident #28's care plan, dated 11/24/24, documented she required assistance to complete her daily hygiene tasks, such as bathing and caring for her hair. The care plan did not document her preference to wear her hair long or her religious beliefs that her hair should never be cut. On 4/3/25 at 5:45 PM, the Administrator stated he was aware Resident #28 had religious beliefs and she chose not to cut her hair. He added CNA #1 was trying to be helpful by cutting the knots out of Resident #28's hair rather than upset her while brushing them out, and CNA #1 did not know Resident #28 did not cut her hair for religious reasons.

Based on policy review, record review, review of the State Agency's Long Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to ensure a resident's right to stay in the facility and the right to appeal the decision for a facility-initiated discharge. This was true for 1 of 3 residents (Resident #1) reviewed for facility-initiated discharges. This deficient practice caused Resident #1 to experience psychosocial harm when he was discharged to a motel without the ability to check his blood sugar and safely administer insulin. Findings include: The facility's Notice of Transfer or Discharge policy, dated 4/2020, documented the notice of transfer/discharge shall be made 30 days prior to transfer/discharge unless the health and/or safety of the resident or residents residing in this center are endangered. Appendix PP, State Operations Manual, states there may be rare situations, such as when a serious crime (e.g., attempted murder or rape) has occurred, that a facility initiates a discharge immediately, with no expectation of the resident's return. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including Type 2 Diabetes Mellitus, Long term (current) use of Insulin, Depression, and Legal Blindness. Resident #1's care plan, initiated on 2/1/24, documented he had impaired visual function and was at risk for falls related to his visual impairment, legal blindness. Resident #1 care plan, initiated 2/2/24, documented that Resident #1 wished to remain in the facility. An admission MDS assessment, dated 2/2/24, documented Resident #1 was cognitively intact, vision was highly impaired, and physical and verbal behavioral symptoms directed towards others were not exhibited. A quarterly MDS assessment, dated 5/2/24, documented Resident #1 was cognitively intact, had adequate vision, able to see fine detail including regular print in newspapers/books, and physical and verbal behavioral symptoms directed towards others were not exhibited. The State Agency's Long Term Care Reporting Portal included a facility initial report, dated 6/25/24 at 1:15 PM, which documented an incident between Resident #1 and Resident #2. The report documented, LTC Residents, [Resident #1], [Resident #3], and [Resident #2] were outside in the designated smoking area. All Residents are alert and oriented x4. [Resident #1] and [Resident #3] are consented boyfriend and girlfriend. They were sitting on the bench outside and kissed. Based on statements from the residents, [Resident #2] yelled at [Resident #1] and [Resident #3] and said, 'get a room!' [Resident #1] responded by picking up the garden hose (used to water the flowers nearby) and sprayed [Resident #2] with water. [Resident #2] stated she is okay but not happy. [Resident #1] said, 'for what [Resident #2] said, that is the appropriate thing to do.' Residents were separated at this time. No injuries reported. Investigation started. The State Agency's Long Term Care Reporting Portal also included documentation of an immediate action plan, dated the same day and time as the initial report. The immediate action included notification for local police to talk with Resident #1 about using the garden hose to spray water on another resident, Resident #1 and Resident #2 were separated, and both residents stated they felt safe. A progress note, dated 6/25/24 at 2:04 PM, documented after the incident Resident #1 was placed on 1:1 supervision and was being closely monitored by facility staff. The note further documented Resident #1's provider gave approval to send him to the hospital for evaluation. A progress note, dated 6/25/24 at 9:35 PM, documented Resident #1 returned from the hospital after evaluation at approximately 9:15 PM via a non-medical ambulatory transport service and had no signs or symptoms of distress. The note documented Resident #1 was cooperative with the nurse and his cares. A progress note, dated 6/26/24 at 5:58 AM, documented Resident #1 slept through the night and remained in his room, with no problems. A progress note, dated 6/26/24 at 2:26 PM, documented Resident #1 stayed in his room throughout the day shift. He was assigned a 1:1 CNA to monitor him for safety reasons and no further episodes of this type of behavior was noted on that shift. A progress note, titled late entry, dated 6/26/24 at 9:15 PM, documented Resident #1 was in the DON's office with the Administrator and Social Services where options for discharge were discussed. Resident #1 was given three options including a hotel, with the power of attorney, or the homeless shelter. It also stated nursing staff would provide him with his medication list in large print due to difficulty with his eyesight. Medication organizers were also provided with labels in large print. A progress note, titled late entry, dated 6/26/24 at 9:16 PM, documented Resident #1 was able to give a return demonstration for administering his insulin on his own. A Social Services progress note, titled late entry, dated 6/26/24 at 5:49 PM, documented the DON, Administrator and Social Services Director spoke with Resident #1 on discharge options after he was given a discharge notice due to behaviors and threatening comments towards staff and residents. Resident #1 chose to be sent to a hotel paid by the facility. The Social Services Director made a three-night reservation at a local motel. A progress note, dated 6/26/24 at 6:31 PM, documented Resident #1 was discharged and was not allowed in the facility. The note documented if he came to the facility, to CALL THE POLICE IMMEDIATELY. This is trespassing and he will be arrested. The message was relayed by the DON. There was no documentation in Resident #1's record the facility discussed with Resident #1 he could remain in the facility for 30 days as stated on the discharge notice. Resident #1's record also did not include documentation the facility discussed with Resident #1 he had the right to appeal the facility-initiated discharge. On 7/1/24 at 11:20 AM, Resident #4 stated Resident #1 was his roommate and he heard that Resident #1 was kicked out because he sprayed a hose at a resident. He stated that he never had a problem with Resident #1, he was a nice guy. He also stated that he has never seen Resident #1 hit or strike out at another resident. During an interview with the surveyors at Resident #1's hotel on 7/1/24 at 12:30 PM, Resident #1 stated that he and Resident #3 were out by the smoking area kissing. He stated Resident #2 came outside and said, you guys are disgusting and that was when he sprayed Resident #2 with the hose. He stated, the day they kicked me out was the worst day of my life, worse than the day I lost my sight. I just want to die after what they did to me. Resident #1 did state to the surveyors he was not suicidal and could not kill himself. When asked, he stated he would go back to the facility if he could, I have nowhere to go. Resident #1 stated he did not receive a discharge notice. He was told the next day that he had to leave, they packed up my stuff, gave me my medications, and no way to check my blood sugar. When the surveyor asked if he was taking his insulin, Resident #1 stated just my Lantus (long-acting insulin), 25 units in the morning. He stated he could not take his Humalog (short-acting insulin) because he was not provided a way to check his blood sugar. When asked how he adjusted the insulin pen, Resident #1 stated I count the clicks because I can't see the numbers. Resident #1 allowed the surveyor to review the documentation that was provided to him at discharge. After review, the surveyor noted that the 30-day discharge notice was present in the documentation. When asked if he was able to read the notice, he stated no, the words are too small. The discharge notice was in small, newspaper style print. Resident #1 allowed the surveyor to visualize his insulin pen and it was observed to be set at 24 units, not 25 units as prescribed. During the interview with Resident #1, the surveyor observed he was emotionally distressed as evidenced by tearful moments throughout the interview. On 7/1/24 at 3:15 PM, Resident #3 stated she remembered the incident between Resident #1 and Resident #2. She stated she was outside on the bench smoking and visiting with Resident #1 when Resident #2 came out and starting yelling at them to get a room when she saw them kissing. Resident #3 stated she yelled back pay for it then Resident #2 went over to them in her wheelchair and kept screaming at them. Resident #3 stated I'm pissed he was kicked out and nothing happened with her. On 7/1/24 at 3:20 PM, Resident #2 stated she did not have issues with other residents anymore, now that Resident #1 was kicked out. [Resident #1] had a bad temper, and he took what I said seriously. I told them to get a room and he started calling me names and sprayed me with the garden hose. When asked how long Resident #1 sprayed her with the hose, Resident #2 stated not for long. On 7/1/24 at 4:11 PM, RN #1 stated she had not witnessed any other incidents between Resident #1 and Resident #2. RN #1 also stated she had not witnessed Resident #1 in any other physical interactions with other residents and had not witnessed him throwing anything or threatening other residents. On 7/2/24 at 10:52 AM, the Regional Ombudsman stated she was aware of the situation and had a conversation with the Social Services Director about Resident #1. She stated she made them aware if he was a safety concern then they could discharge him. She also stated she was not made aware of his diagnoses of legal blindness or that he was insulin dependent. On 7/2/24 at 1:43 PM, CNA #1 stated she provided cares to Resident #1, and he never yelled at or become aggressive with her. On 7/2/24 at 1:50 PM, CNA #2 stated she never saw or witnessed Resident #1 yelling or acting out. She stated she had not witnessed negative interactions involving Resident #1. On 7/2/24 at 2:30 PM, LPN #1 stated she had provided cares for Resident #1, and he could be hard to redirect. She also stated she had not witnessed Resident #1 physically put his hands on anyone in anger. She stated that he will get in people's faces. On 7/2/24 at 3:05 PM, the Social Services Director stated she was not in the facility on 6/25/24, the day of the incident. She was informed of the incident the next day and was instructed to begin finding placement for Resident #1. She stated Resident #1 became angry when he was given the 30-day notice of discharge and 3 options to go to after discharge. She stated the options given to Resident #1 were the motel, homeless shelter, or his friend's house. She stated he chose the motel as his option. On 7/2/24 at 6:02 PM, the Administrator stated due to Resident #1's behavior and statements, he felt they did the right thing. He also stated if Resident #1 had not accepted the hotel option, he would have kept Resident #1 in the facility.

Based on observation, policy review, record review, review of incident and accident reports, and resident and staff interview, it was determined the facility failed to ensure residents' safety during bed-to-wheelchair transfer and provide a designated, supervised smoking area with safety equipment for smokers. This was true for 1 of 6 residents (Resident #55) reviewed for falls, and 1 of 2 residents (Resident #17) reviewed for smoking. This resulted in harm to Resident #55 when she sustained a nose and a finger fracture during an assisted transfer; and Resident #17 was at risk of accident hazards when she was not provided with appropriate smoking equipment and a safe smoking area. Findings include: 1. The Drugs.com website, accessed on 1/17/23, How To Transfer A Person Safely, documented safety instructions after transferring a person, including Help the person sit with his or her back resting against the back of the chair. If the person is in a wheelchair, place his or her feet and arms on the chair rests. Resident #55 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure (weakness of the heart leading to buildup of fluid in the body) and type 2 diabetes mellitus and amputation of the right leg below the knee. A care plan for risk of falls, initiated 12/11/20, and revised 4/30/21, documented Resident #55 was at moderate fall risk. An I&A report, dated 4/19/21 at 9:30 AM, documented Resident #55 was cognitively intact and had a witnessed fall resulting in a nose and left pinky fracture. The report documented she was found on the floor on her left side with her left arm and leg underneath her. The pinky on her left hand was bent. Resident #55's left side of her face was on the floor, bleeding from her nose. Resident #55 was observed with a large bruise above her right eye. A Summary of Investigation for Fall with Injury, dated 5/19/21 at 9:30 AM, documented prior to the fall, 2 CNAs transferred Resident #55 from her bed to her power wheelchair with a slide board. The 2 CNAs did not put the right side armrest in the down position prior to and after the transfer for safety. After the transfer, Resident #55 leaned to the right, and she put her right hand down on the wheelchair's cushion to steady herself because the right armrest was not down. She then pushed down, forcing all her weight to shift left to move her bottom over, and she lost her balance. The report further documented the conclusion for the root cause of the fall as In every transfer staff must keep the far side power wheelchair arm down for safety. The facility initiated interventions to re- train staff on slide board transfers. On 1/13/23 at 4:30 PM, the DNS reviewed the I&A report and stated staff failed to put down Resident #55's armrest after the slide board transfer, resulting in a fall with fractures for Resident #55. Resident #55 was harmed when she sustained a nose and a finger fracture during an assisted transfer. 18947 2. The facility's Smoking policy and procedure, revised 3/2020, documented, It is the policy of [blank space] to provide a safe environment for residents, staff and visitors by limiting the use of smoking materials on its grounds. Residents who wish to smoke were evaluated by their ability to smoke safely. The policy stated the following were provided in the smoking areas: *A suitable number of noncombustible ashtrays *Metal containers equipped with self-closing covers to use solely for the disposal of cigarette butts and ashes *A trash can that can be used solely for trash *A portable fire extinguisher *A fire blanket This policy was not followed. Resident #17 was admitted to the facility on [DATE], with multiple diagnoses including memory deficit, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following stroke affecting right dominant side, and heart failure (progressive heart disease that affects pumping action of the heart muscles) A quarterly MDS assessment, dated 11/22/22, documented Resident #17 was moderately cognitively impaired. A Smoking Safety Evaluation report, dated 11/22/22, documented Resident #17 was safe to smoke independently. The assessment also documented Resident #17 had problems with dexterity (related to history of stroke and paresis of her dominant arm/hand). Resident #17's care plan, dated 12/6/22, documented she smoked off premises unsupervised. Interventions included to instruct her of smoking risks and hazards, and about smoking cessation aids that were available, instruct her about the facility's policy on smoking locations, times, safety concerns, monitor her ability to safely get to a smoking destination, and to notify the charge nurse immediately if it was suspected she had violated the facility's smoking policy. On 1/10/23 at 12:30 PM, Resident #17 was observed driving her power wheelchair down the access road at the back of the facility and around the side of the facility to the smoking area in the facility's parking lot. There were no observed sidewalks along the service road, and Resident #17 was observed to be driving down the middle of the road, dodging multiple potholes along the way. Resident #17's power wheelchair had a pole with a flag attached to it for safety related to oncoming traffic. She continued to the facility's smoking area, and smoked a cigarette. On 1/9/23 at 1:34 and 1/11/23 at 12:48 PM and 6:45 PM, Resident #17 was observed in her power wheelchair smoking a cigarette under a tree in the Off Campus Smoking area in the facility's parking lot in front of the building (which was part of the facility grounds). An open can was observed next to Resident #17 that appeared to be utilized for the disposal of cigarettes. There was no lid on the can and other debris, including paper was observed in the can. There was no fire extinguisher or fire blanket observed in the smoking area. Resident #17's power wheelchair did not have the required flag attached to the pole on her wheelchair to indicate safety while driving her wheelchair to the smoking area in the parking lot. On 1/11/23 at 9:50 AM, Resident #17 stated she did not feel safe driving her power wheelchair out to the smoking area, but she understood it was her choice to smoke and the facility allowed her to smoke as long as she smoked in the front parking lot area. Resident #17 stated she kept her smoking materials, including her cigarettes, in her room or on her person and she was never supervised by staff while smoking. On 1/12/23 at 9:45 AM, Resident #17 requested the surveyor to escort her to the back of the building to observe the sidewalk access immediately outside of the backdoor leading to the access road. There was no flag attached to the pole on her power wheelchair. Resident #17's roommate stated to her, Your flag is missing again. You should put your flag on your wheelchair before you go out to smoke. Resident #17 stated she did not know what had happened with her flag and would find it later. The access road was observed to have a large pothole in it and the area was very muddy. Resident #17 stated she had to use the access road when exiting the building to go out to smoke in order to get onto the road. She stated she had to drive down the road at the back of the building because there were no sidewalks in the area. Resident #17 stated she thought she might get stuck in the mud or have an accident while driving down the access area by tipping her wheelchair over in the pothole. The resident stated she knew she was not supposed to use the back door instead of the front door, but she had been having difficulty opening the front door (which was observed to not have handicapped access) due to her lower positioning in her power wheelchair and her inability to use her right dominant hand and arm related to her stroke. On 1/11/23 at 10:54 AM, the Administrator stated, We are a non-smoking facility, but a couple of the long-term care residents have smoked for years. The Administrator stated the current smokers had been grandfathered in when the facility decided to become a non-smoking facility and newly admitted residents were not allowed to smoke. The Administrator stated the residents who were allowed to smoke were required to leave the campus to do so. He stated the residents were supposed to check out with the nurse before leaving the building but indicated there was no documentation to show when the residents left the building to smoke or when they returned to the building after smoking. On 1/12/23 at approximately 10:00 AM, the DNS with the Administrator present stated, Resident #17 was not supposed to be using the back door to access the smoking area. He stated he had previous had multiple conversations with Resident #17 related to her needing to access the smoking area via the front door for safety reasons, but she continued to use the back door rather than the front door. He stated, She just won't listen and essentially does what she wants to do. The Administrator and DNS acknowledged the potential safety issues related to access to the back access road. The Administrator indicated he had been made aware of the safety issue with the back door road access the previous Monday and he was planning to put Quick-[NAME] down on the surface to fix the problem. The Administrator stated Resident #17 was supposed to be using the front door to access the smoking area and he had also had multiple conversations with the resident about this, but he stated, She just continues to use the back door. On 1/12/23 at approximately 10:10 AM, Resident #17 together with the DNS and Administrator stated, she did not like using the front door because it was difficult to access when coming back into the building due to her inability to use her right hand and arm to open the door and it was easier for her to open the back door by kicking it with her feet. She stated, I have to call staff to open the door and if no one is up here I have to wait to get in. Resident #17 was asked what she would do if she were out in the parking lot smoking and a fire was ignited by a cigarette, if a cigarette fell on to her clothing and she was unable to reach it, or if she were to have an accident in her wheelchair while driving down the access road in the back of the facility and she stated she thought she might holler, but she wasn't actually sure what she would do. Resident #17 stated, Honestly, I don't know what I would do. Resident #17 was asked about the use of the flag on her wheelchair for safety and she stated she did not know where the flag was. The administrator stated the resident's flag had gone missing and just been replaced the previous day and stated Resident #17 had been having a problem with losing the flag recently. The Administrator stated Resident #17 needed to have the flag on the pole on her wheelchair in order to remain safe when driving her wheelchair on the access road. The Administrator and the DNS acknowledged the lack of safety equipment, including a fire extinguisher, fire blanket and appropriate cigarette receptacle in the designated smoking area. The Administrator stated Resident #17 probably needed to be supervised while smoking.

Based on observation, interview, nationally recognized standards of practice, policy review, review of the facility list of COVID-19 positive testing results, and review of employee screening logs, work schedules, and timesheets, the facility failed to ensure infection control prevention practices were implemented and maintained to prevent and contain COVID-19. These failures placed all residents and staff at risk for exposure to COVID-19 with the likelihood of serious harm impairment, or death. Findings include: 1. The facility's policy for Coronavirus COVID-19, revised 7/28/20, documented staff and visitors were directed to an entry point and assisted with screening requirements. The facility's Emergent Infectious Disease Preparedness Plan, adopted 2/2019, documented the following: *To prevent risk of spreading disease in the facility, staff were screened for exposure risk and signs and symptoms of disease before they reported to work. * Staff screening prohibited sick staff members from work until cleared by appropriate medical authorities. The CDC Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID-19, dated 5/8/20, stated, HCP should self-monitor when they are not at work and be actively screened upon entering the facility. These facility policies and CDC guidelines were not followed. The facility's employee screening logs and timesheets, dated 8/1/20 through 8/2/20 were reviewed for all employees of the facility. There were inconsistencies between the timesheets and staff screening logs. a. The following staff were not screened prior to working their shift. * The screening logs and timesheets, dated 8/1/20, did not include screening for 1 CNA, 1 Housekeeper, and 1 Dietary Staff. * The screening logs and timesheets, dated 8/2/20, did not include screening for 1 Housekeeper and 2 Dietary Staff. b. The facility's employee screening logs included a section to document the employee's temperature, and 10 yes/no questions related to symptoms associated with COVID-19. At the top of the screening logs there was a statement that directed employees to notify supervisor for further guidance for any 'Yes' responses. There was no documentation of action taken when employees answered yes to potential symptoms of COVID-19 for the staff as follows: * The screening logs and timesheets, dated 7/30/20, documented 1 CNA worked when she answered yes to questions of symptoms associated with COVID-19. * The screening logs and timesheets, dated 8/1/20, documented 1 RN and 1 Dietary Staff worked and their symptom evaluations on the screening log were blank. * The screening logs and timesheets, dated 8/2/20, documented 1 LPN and 1 RN worked when they answered yes to questions of symptoms associated with COVID-19. On 8/4/20 at 1:10 PM, Activity Aide #1 stated there was no protocol for the screening process. She stated that she called the IP or another nurse if she had a concern about anyone who entered with symptoms. When asked for documentation that a nurse was notified and evaluated the symptoms, Activity Aide #1 stated it was done verbally on an as needed basis, and there was no documentation. On 8/4/20 at 2:35 PM, the DON and IP were interviewed together, and the DON stated there was no tracking method for symptoms. The IP stated she reviewed the screening log daily, but she did not sign it. The IP stated there was no documentation and no policy for evaluating staff or visitors. She stated there was no written process to support the evaluation of employees or visitors. On 8/4/20 at 2:42 PM, the Administrator stated the facility did not have documentation they were screened further for COVID-19 symptoms. 2. The facility's Hand Hygiene Policy, dated 4/2019, documented situations which required hand hygiene included before and after direct resident contact, before and after handling food, and after handling soiled equipment. This policy was not followed. a. On 8/3/20 at 12:05 PM, CNA #1 was in Resident #1's room and using her bare hands picked up Resident #1's fall mat and moved it aside. CNA #1 did not perform hand hygiene after moving the fall mat with her bare hands. CNA #1 then moved a stool closer to the bed and moved Resident #1's bedside table. She assisted Resident #1 to get a drink of water and to adjust her in her bed. CNA #1 did not perform hand hygiene after moving the furniture, before touching Resident #1, and after touching Resident #1. CNA #1 then moved the bedside table and stool away from the bed, returned the fall mat to its prior position on the floor, and then she washed her hands. On 8/3/20 at 12:48 PM, CNA #1 said she adjusted Resident #1 in her bed and held a cup of water for her to drink after she touched the fall mat on the floor. CNA #1 said she did not perform hand hygiene after touching Resident #1's fall mat or before touching Resident #1 and her items. On 8/3/20 at 5:00 PM, the IP said CNA #1 should have performed hand hygiene after touching the floor mat. b. On 8/3/20 at 12:50 PM, CNA #4 exited a resident's room who had a sign on their door indicating Special Droplet/Contact Precautions were in place She was not wearing gloves, and she removed her face shield and sprayed it with a pink disinfectant spray. She wiped off the face shield, and then she did not perform hand hygiene. CNA #4 then walked down the hall to room [ROOM NUMBER], where Resident #2 was sitting in her wheelchair outside the room. CNA #4 did not perform hand hygiene, and she placed both of her hands on the handles on Resident #2's wheelchair and moved her a short distance down the hall. On 8/3/20 at 1:02 PM, CNA #4 said she should have performed hand hygiene after she wiped off her face shield and before she touched Resident #2's wheelchair. On 8/3/20 at 5:05 PM, the IP said staff should perform hand hygiene after exiting a resident's room and after removing their face shield and mask. 3. The facility's policy for Environmental Cleaning, dated 1/19/19, documented The environment throughout the facility will be maintained in a state of cleanliness that meets professional standards to protect residents and healthcare personnel from potentially infectious microorganisms. This policy was not followed. On 8/3/20 at 1:05 PM, CNA #2 came out of a resident room with a Hoyer lift (a mechanical lift). CNA #2 placed the Hoyer lift against the wall across the hall, then entered another resident's room. CNA #2 did not sanitize the Hoyer lift after using it with a resident. On 8/3/20 at 1:33 PM, CNA #2 said the protocol for sanitizing the Hoyer lift was to spray it down after it was used. CNA #2 said the Hoyer lift should be sanitized in the hall. CNA #2 said he did not sanitize the Hoyer lift after using it in room [ROOM NUMBER]. On 8/3/20 at 5:00 PM, the IP said the Hoyer lifts were to be disinfected between residents. 4. The facility's policy for Coronavirus COVID-19, revised 7/28/20, documented the following steps to be taken for Special Droplet/Contact Precautions, including: * Special Droplet/Contact Precautions were implemented for residents with suspected or confirmed COVID-19. * After performing hand hygiene, staff were directed to don PPE, including a mask or a respirator. The CDC website, accessed 8/5/20, stated when putting on a respirator, do not allow anything to prevent proper placement or to come between your face and the respirator. The facility policy and CDC guidance were not followed. On 8/3/20 at 3:34 PM, CNA #3 prepared to enter room [ROOM NUMBER] which had a sign posted on the door indicating Special Droplet/Contact Precautions were in place. The sign directed everyone who entered the room to wear a face mask, when they entered the room. CNA #3 donned a gown and gloves, and she was already wearing a face shield and an N-95 mask over a blue procedure mask. CNA #3 then entered the room with a bag of adult briefs. CNA #3 exited the room, and she was wearing an N-95 mask and face shield, she was not wearing the face mask under the N-95 mask. CNA #3 said staff were to put on PPE including a gown, gloves, N-95 mask, and face shield prior to entering room [ROOM NUMBER]. CNA #3 said after she entered the room, she removed the blue face mask by pulling it off underneath the N-95 mask. She stated she disposed of it in the room because there was no trash can outside the room where she could dispose of it. On 8/3/20 at 4:55 PM, the IP said staff should remove their blue face mask prior to entering a resident's room, because pulling the blue mask off underneath the N-95 mask would break the seal of the N-95 mask. 5. The facility's Coronavirus COVID-19 policy, updated 7/28/20, documented during a COVID-19 outbreak, staff would wear a face shield upon entrance to the facility for the duration of their shift. It also documented all staff would use face masks and face shields when working in the facility. The CDC website, accessed 8/5/20, stated eye protection is to be worn upon entry to the patient care area. This facility policy and CDC guideline were not followed. On 8/3/20 at 11:26 AM, RN #1 was observed in the COVID-19 isolation unit wearing a surgical mask. She did not have a face shield on. When asked if it was the facility's policy to wear only a surgical mask, RN #1 said no she should also have a face shield on. On 8/3/20 at 2:35 PM, the IP stated staff should wear a mask and face shield in the COVID-19 Isolation Unit. On 8/4/20 at 4:02 PM, the Administrator, IP, and DON were informed of an Immediate Jeopardy determination for 42 CFR §483.80 (F880) via phone, and the Immediate Jeopardy template was subsequently sent via fax.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were free from physical restraints. This was true for 1 of 5 residents (#2) reviewed for restraints and resulted in psychosocial harm when Resident #2 experienced increased agitation and distress from being physically restrained. Findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was receiving hospice services as part of her treatment in the facility. Quarterly Minimum Data Set (MDS) assessments, dated 5/19/17 and 8/17/17, documented Resident #2 was severely cognitively impaired, dependent on 2 staff for all Activities of Daily Living (ADLs) and mobility, and required no physical restraints. The most recent Nurse Practioner (NP) Progress Note, dated 7/13/17, and Physician's (MD) Progress Note, dated 7/26/17, did not document the use of a physical restraint, or any concerns with rashes or itching. Resident #2's clinical record did not contain any documentation related to the use of physical restraints. Resident #2's care plan, reviewed and revised 8/22/17, did not document the use of physical restraints or that the resident experienced rashes or itching. Resident #2's MACC (temporary Managing Acute Change of Condition) care plan, located in a binder at the nurse's station and dated 10/23/17, documented the resident was scratching at her peri area, which had caused an open area to her skin. A third care plan, referred to by facility staff as a Bedside Care Plan and located on the inside of Resident #2's bathroom door, contained an undated, unsigned note at the top of the document notifying staff that Resident #2 was to have cotton gloves on when in bed. On 11/3/17 at 6:40 am, a facility incident report documented Resident #2 was found on the floor in her room next to her bed with lacerations to her left cheek and neck which required the resident to be taken by ambulance to a hospital for sutures. On 11/13/17 from 9:52 am to 10:10 am, and from 10:45 am until 11:08 am, Resident #2 was observed laying in bed with white cotton wrist-length gloves on both hands. During these observations, Resident #2 was laying still on her bed, eyes closed, snoring. The resident had minimal movement and a relaxed facial expression. On 11/13/17 at 4:30 pm, CNA #3 said she had been caring for Resident #2 the night before she fell , and the resident had been agitated and restless. CNA #3 stated it was not unusual for Resident #2 to be mildly agitated during the night. CNA #3 stated, I think she is trying to get out of the wraps. One of the things we do with (Resident #2) to stop her from digging (at her peri area) is tuck sheets around her tight. You know, 'wrap.' She tries to get out, that's one of the reasons she moves so much at night and day shift doesn't think she moves at all. CNA #3 stated the wrap consisted of a sheet folded in half and tucked tightly around the resident's body sometimes from just above her belly button to just past her peri area, but sometimes from her armpits to her mid-thigh. Everyone does it differently. CNA #3 stated she did not know if there was written direction for the use of the sheet but that she was told to do it from the time I started here about four months ago. On 11/14/17 at 5:04 am, Resident #3 was observed laying in bed. The resident was wearing a hospital gown, repeatedly moving her arms (right more than left) in a rubbing motion. A folded sheet was observed securely wrapped across her torso from mid-chest to her waist, where it was then covered by a blanket. Every few seconds, the resident's right hand would grasp and tug at the sheet, as if trying to remove it. The sheet was secured tightly enough that it did not move. At 5:08 am, Resident #2 reached behind her head with her right hand and lifted her head trying to look at her torso. The resident's eyes were fluttering open and closed. She was scowling and grimacing. Resident #2 dropped her head and began to tug at the sheet again. On 11/14/17 at 5:10 am, CNA #3 and CNA #4 stated they were about to perform peri care on Resident #2. CNA #4 stated after they changed the resident's brief, we 'burrito' her because she digs at her peri area. CNA #4 glanced at Resident #2 and stated, We did it earlier, but she has gotten it undone just a little bit. We need to tuck the sheet around her torso, roll her, then tuck it in around the other side so it's nice and tight. On 11/14/17 at 5:12 am, CNA #3 and CNA #4 were observed removing Resident #2's incontinence brief, providing peri care, applying cream to the peri area, and applying a new incontinence brief. The CNAs rolled the resident to her right side, placed a sheet that was folded in half under her right side, turned the resident onto her back, pulled the sheet across her body, from chest to knees, and tucked the sheet under the resident's left side. As the CNAs covered the resident with a top sheet and blanket, CNA #4 said, That's how we do it. On 11/14/17 at 5:30 am, CNA #5 stated Resident #2 was covered tight on night shift because of her itching. On 11/14/17 at 5:35 am, RN #1 stated she had been working in the facility about six weeks and had not worked since 11/3/17. RN #1 stated she was not aware Resident #2 had difficulty with itching, but was told we were supposed to give her very good peri care at night. RN #1 was not aware Resident #2 was being wrapped tightly in a sheet to prevent her from scratching herself. RN #1 stated, That would be a restraint, wouldn't it? On 11/14/17 at 5:45 am, Resident #2 was observed laying in her bed, covered with a blanket and top sheet. RN #1 removed the blanket and top sheet from Resident #2. Resident #2 was wearing a hospital gown, with a folded sheet wrapped securely from the mid-chest to her mid-thigh area. RN #1 gasped audibly and took a quick step back from the resident's bedside while covering her mouth with her hand. RN #1 stated, That shouldn't be like that. She couldn't move. RN #1 attempted to roll Resident #2 to remove the sheet from her torso, then stopped and stated, That's tight. That's really tight. I have to get a second person to help me. RN #1 stepped into the hallway and asked CNA #3 to help her remove the sheet. On 11/14/17 at 8:35 am, Resident #2's Power of Attorney (POA) stated she was aware Resident #2 had a history of [REDACTED]. The POA noted she was not aware itching was a current problem for the resident, and stated she had been told by a CNA the previous week that the facility was wrapping the resident's peri area at night rather than using a brief to prevent skin breakdown. The POA said she believed this was a new treatment for [REDACTED]. They told me (Resident #2) pushes and tugs at night, but I had never seen that (tightly wrapped sheet). That must be why she does it. On 11/14/17 at 10:55 am, the Director of Nursing (DNS) for Resident #2's hospice agency stated wrapping the resident in a sheet at night was not part of the hospice plan of care, and they did not have rashes or itching in the peri area listed as a current concern for Resident #2. On 11/14/17 at 12:40 pm, Resident Care Manager (RCM) #1 stated he added the intervention of white cotton gloves to Resident #2's care plan to prevent her from scratching herself while she was in bed. RCM #1 stated nursing staff could provide [MEDICATION NAME] if the resident was scratching herself, and we do tuck the sheet in. RCM #1 stated the facility initiated the use of gloves and the sheet because she was itching and scratching to the point of being excoriated or opening her skin. RCM #1 could not recall when or if Resident #2's physician had been notified of the itching or scratching, or what caused the rash and itching. RCM #1 stated the facility used anti-fungal cream in August of 2017 to treat a yeast issue that had resolved within a few days of treatment and the cream was discontinued. RCM #1 stated the facility did not have a physician's orders [REDACTED]. On 11/14/17 at 12:45 pm, the MSW stated she was unaware staff were physically restraining Resident #2. On 11/14/17 at 1:45 pm, the DNS stated she had only become aware that morning that staff were applying a physical restraint to Resident #2. The DNS stated the facility did not have a physician's orders [REDACTED]. The DNS stated the facility removed the restraint as soon as it was discovered by the survey team, and she would educate staff to ensure another physical restraint did not take its place. Resident #2 was harmed when the facility failed to address her physiological symptom of itching and instead physically restrained the resident to prevent her from scratching herself. Resident #2 experienced increased agitation and restlessness when the restraint was in place and her itching was unrelieved.

Based on observation, interview, and record review, it was determined the facility failed to provide adequate supervision and assistance to prevent falls. This was true for 1 of 3 residents (#2) reviewed for falls and resulted in harm to Resident #2 when she fell from bed and sustained lacerations to her left cheek and neck which required 11 sutures. Findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was receiving hospice services as part of her treatment in the facility. The quarterly Minimum Data Set (MDS) assessment, dated 8/17/17, documented Resident #2 experienced severe cognitive impairment and was dependent on 2 staff for all Activities of Daily Living (ADLs), transfers, and bed mobility. Resident #2's care plan, revised 8/22/17, did not document the level of assistance Resident #2 required for ADLs, transfers or bed mobility. The care plan directed staff to check for airbed placement and inflation as needed. A hospice Clinical Summary, dated 9/3/17, documented Resident #2 had an air mattress. A Bedside Care Plan, provided to surveyors on 11/13/17, contained an undated intervention documenting Resident #2 required the assistance of 2 staff for positioning. On 11/3/17 at 8:37 am, Resident #2's Nurse's Notes (NN) documented, . CNA came into nursing station (and) stated that she found resident on the floor . on her left side next to the bed with her head noted under the bed and her lower body out from the bed . had a fresh pool of blood present under her, her left hand and hair were also bloody . source of bleeding noted to (be) a half circular laceration with what appeared to be a puncture to her left cheekbone and an 8 (centimeter long) deep laceration to left jawline/upper neck area . Paramedics arrived and resident transported via 911 ambulance with 2 attendants . On 11/3/17 at 3:06 pm, a NN documented Resident #2 returned to the facility with 3 sutures to her left cheek and 8 to the left side of her neck. On 11/3/17 at an undocumented time, CNA #3's staff statement regarding the incident documented, I have seen her move by pushing with hands. Her right hand was out and so was her left hand. She was on her right side facing the wall, her hips were out a little more towards the side of the bed. On 11/3/17, Resident #2's care plan was updated to inform staff she could neither understand the call light's purpose nor how to use it. Staff were directed to conduct enhanced rounds and to remove the call light from Resident #2's room to avoid any injury. The call plan also documented 2 staff were to provide assistance with bed mobility/repositioning and incontinence care. On 11/10/17, a facility Investigations Summary documented: * .(CNA #3) reported she turned (Resident #2) four times total while providing peri care, twice to remove the old attend and (absorbent pad) then two more times to put the new items underneath her. She reports that (Resident #2) is generally easy to roll with one person assist and during cares she rolled well without difficulty . * .Through demonstration .(CNA #3) said/showed she (Resident #2) had her upper body directly in the center of the bed with her head on the pillow but her buttocks area was at an angle (buttocks angled outward towards the side of the mattress . * .(due to) the air mattress surface being more slippery potentially could have caused her to slide off the bed. The resident is unable to stop any momentum of her body falling which probably caused her to fall off the bed. * Conclusion .no call light to be placed as resident cannot understand/use and will reduce any future injury; Enhanced rounding which staff will check on her more frequently due to no call light; will always use 2 staff assist with bed mobility and incontinent care . On 11/13/17 at 3:40 pm, CNA #2 stated she was the staff member who discovered Resident #2 on the floor the morning of 11/3/17. CNA #2 stated she entered Resident #2's room at approximately 6:40 am to get the resident up from bed and ready for breakfast, but did not see the resident in her bed. CNA #2 stated she initially presumed the night shift aides had already awoken Resident #2 and taken her to the dining room for breakfast when she heard Resident #2 jabbering. CNA #2 noticed Resident #2 laying on the floor on her left side with her head and neck under the bed. CNA #2 stated there was blood coming from Resident #2's neck and shoulder, and she quickly left the room to get a nurse. On 11/13/17 at 4:20 pm, CNA #3 stated she had been assigned to care for Resident #2 the night before her fall. CNA #3 stated Resident #2 required assistance to change her brief twice that night. CNA #3 stated 2 CNAs changed the resident's brief on the first occasion, and that she (CNA #3) changed Resident #2's brief the second time without assistance. CNA #3 stated she rolled Resident #2 back and forth in the bed several times to change the brief, then positioned the resident on her right side in the bed. CNA #3 stated she was told Resident #2's position on the bed caused her to fall to the floor when the air mattress fluctuated. CNA #3, however, stated, But I don't think that's what happened. CNA #3 stated Resident #2 was wrapped tightly in a blanket at night to prevent her from scratching her peri area, which caused the resident to become restless and agitated. CNA #3 stated, I think she was trying to get out of the wrap and pushed herself out of the bed. On 11/14/17 at 10:55 am, a hospice nurse familiar with Resident #2 stated, (Resident #2) did not fall out of bed by rolling herself. She couldn't have done that in July, and hospice patients don't get better and more independent. There is no way she had that ability in November. On 11/14/17 at 1:45 pm, the Director of Nursing Services (DNS) stated she was the first licensed nurse (LN) on the scene when Resident #2 was discovered on the floor. The DNS stated she did her best to recreate the scene before the fall, and determined Resident #2 most likely fell due to her positioning on the bed. The DNS stated when Resident #2 was positioned on her right side in the air bed, her hips and buttocks would have been angled towards the edge of the bed. The DNS stated Resident #2's functional status would not have enabled her to stop her momentum when the alternating pressure of the air bed likely led to the resident's hips and buttocks sliding off the edge of the bed. The DNS stated the facility had recently changed MDS nurses, and she was unaware Resident #2's MDS assessment documented 2 staff were required to assist the resident with bed mobility, positioning, and incontinence care. The DNS stated the facility updated Resident #2's care plan after the fall to require the assistance of 2 staff for all cares. On 11/13/17 at 9:52 am, Resident #2 was observed laying on her back in bed on an Air Dyne Pro air mattress. The resident's body alignment was straight and she was in the center of the bed, which was in the corner of the room with the headboard and right side each against a wall. The bed was not visible from the hallway and required an observer to take several steps into the room before it could be seen. From 9:52 am to 10:10 am, the resident did not move or open her eyes. The bed had bolsters at the head and foot of the mattress on both sides, with an approximate one-foot gap in the bolsters that aligned with Resident #2's hips and buttocks. There was no odor in the room, and no staff or visitors entered the room during the 18 minute observation. On 11/13/17, from 10:12 am to 11:05 am, the following was observed: * Between 10:12 am and 10:30 am, CNA #8, who was charting while standing at a kiosk in the hallway several doors down from Resident #2's room, stated he was assigned to care for residents on the hall, including Resident #2. When asked about enhanced rounding, CNA #8 looked puzzled and stated, That doesn't mean anything to me. I've never heard of it. * At 10:12 am, a nurse aide student entered Resident #2's room, retrieved a used water mug, brought it into the hallway, filled it with fresh water, and returned it to the resident's room. The student was in the room for 15 seconds. *No staff or visitors entered or approached the resident's room from 10:12 am to 10:49 am. *At 10:43 am, CNA #6, who was at the end of the hallway where Resident #2's room was located, stated she guessed enhanced rounds meant you double check the resident. *At 10:45 am, Resident #2 remained in bed, in the same position she had been since 9:52 am and the room now had a strong odor of urine and feces. *At 10:49 am, Resident #2's roommate entered the room in her wheelchair, went to her own side of the room, and activated her call light. * At 10:50 am, CNA #1 and CNA #7 entered Resident #2's room in response to the roommate's call light. For the next 10 minutes, the 2 CNAs assisted Resident #2's roommate to transfer onto the toilet with a sit-to-stand mechanical lift before leaving the room without approaching or speaking to Resident #2. The odor of urine and feces remained. * At 11:05 am, an unknown staff member entered the room to speak to Resident #2's roommate in the bathroom, but did not come far enough into the room to see Resident #2. CNA #s 1 and 7 entered the room as the unidentified staff person was leaving, went into the bathroom and assisted Resident #2's roommate off the toilet. At 11:08 am, both CNAs left the room, along with Resident #2's roommate; neither CNA #1 nor CNA #7 approached or spoke to Resident #2. On 11/13/17 at 11:10 am, CNA #1 said she was just now told Resident #2 required enhanced rounds. CNA #1 stated she was told enhanced rounds included ensuring Resident #2 was in the center of the bed and not on the floor. CNA #7 said, And her call light is in reach. CNA #8, who was standing nearby at the charting kiosk, said, No call light. She's care planned for no call light. CNA #8 stated, I check on (Resident #2) every time I go in to take care of her roommate. All three CNAs present stated they checked on Resident #2 every 20 minutes and had done so that morning. On 11/13/17 at 12:25 pm, the DNS stated she had initiated enhanced rounds after Resident #2's fall on 11/3/17 and directed staff to remove the resident's call light. The DNS stated there was no documented policy or protocol for enhanced rounds. The DNS stated she expected staff to observe Resident #2 hourly. When informed of the 10:12 am to 11:10 am observation, the DNS stated, The problem is, if they don't know what (enhanced rounding) means, it's hard to do. The DNS said the amount of time that staff did not check on Resident #2 was too long. On 11/13/17 at 4:30 PM, CNA #3, who was assigned to care for Resident #2 the night of the fall, stated she had worked many times with the resident since the fall. When asked about enhanced rounds as directed in Resident #2's care plan, CNA #3 stated, I have no idea. I've never heard that term before. On 11/14/17 at 12:40 pm, Resident Care Manager (RCM) #1 stated he had all staff sign an educational inservice directing staff to provide enhanced monitoring after Resident #2 fell . RCM #1 stated though there was no policy, procedure, or written direction as to what enhanced monitoring entailed, he presumed all staff understood they should check on Resident #2 at least hourly.

Based on interview and record review, it was determined the facility failed to follow professional nursing standards regarding medication administration, and failed to respond appropriately to a medication error. This was true for 1 of 8 residents (#1) sampled for nursing standards. Resident #1 was harmed when the facility administered an extra dose of the muscle relaxant [MEDICATION NAME], resulting in the resident receiving more than the recommended total daily dose in a 12 hour period. The resident required hospitalization for respiratory depression, a known symptom of [MEDICATION NAME] overdose. Findings include: The American Nurses Association, (2015), Nursing: Scope and Standards of Practice, 3rd Edition pp.4-5 Silver Spring, MD: ANA, The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse ' s decision-making .Assessment .the registered nurse collects pertinent data and information relative to the consumer's health or the situation Implementation .the registered nurse implements the identified plan. The facility's Medication Error policy and procedure, revised June 2016, documented if a medication error was made, the resident's physician should be notified, and the facility should place the resident on alert (increased monitoring). The 2018 Nursing Drug Handbook documented for [MEDICATION NAME]: *The maximum daily dosage of the oral form of the medication should not exceed 80 milligrams (mg). *The time for the medication to take effect and the duration of effectiveness was unknown, with peak effectiveness at 2-3 hours, and half-life of 2 1/2 to 4 hours. *Adverse reactions included difficulty breathing. *Signs and symptoms of overdose included drowsiness and respiratory depression. Resident #1 was admitted to the facility on [DATE] for a five day hospice respite stay, with [DIAGNOSES REDACTED]. Resident #1's 8/16/17 physician's admission orders [REDACTED]. No other [MEDICATION NAME] doses were ordered. Resident #1's Medication Administration Record [REDACTED]. Resident #1's Nurse's Notes (NN) dated 8/17/17, documented Resident #1 was given a second 40 mg dose of [MEDICATION NAME] at 2:00 am, and the dose was a medication error. The NN did not document an assessment of Resident #1's condition, or that the resident's physician was notified of the error, for the next 6 hours. On 8/17/17, no time documented, the facility initiated a medication error report, which documented the 2:00 am administration of the [MEDICATION NAME] was a medication error. On 8/17/17 at 7:58 am, Resident #1's Nurse's Notes (NN) documented the resident's physician was notified of the medication error, but no acknowledgement or response was documented. On 8/17/17 at 8:00 am, Resident #1's Vital Signs Log documented a blood pressure of 138/70, temperature as 98.4 degrees, pulse 70, respirations 18, and oxygen saturations of 97% on room air. Resident #1's clinical record did not document any further assessments or progress notes until 12:00 noon. Resident #1's MAR indicated [REDACTED]. The resident had received a total of 100 mg of [MEDICATION NAME] (20 mg more than the maximum allowable daily dose, and 40 mg more than she normally received daily) in less than 12 hours. On 8/17/17 at 12:00 noon, Resident #1's NN documented the resident was awake but sleepy. On 8/17/17 at 1:36 pm, Resident #1's NN documented a decline in her level of consciousness and hospice was called. On 8/17/17 at 2:05 pm, Resident #1's NN documented the resident was responsive only to painful stimuli, and per hospice direction 911 was called and the resident taken to the hospital. On 8/17/17, Resident #1's hospice Transfer Summary documented Resident #1 was taken to the hospital after becoming unresponsive, and admitted for respiratory depression and a urinary tract infection. On 9/19/17 at 10:45 am, the Director of Nursing Services (DNS) stated Resident #1 had been in the facility less than 24 hours when the medication error occurred. The DNS stated the facility had a scheduled computer update, causing the main system to be down, which took place on the night shift between 8/16/17 and 8/17/17. The DNS stated it was during this time the medication error occurred. The DNS stated the facility had a back up system to accurately track medication administration during the computer down time, but for some reason RN #1 had not utilized that system. The DNS stated it was her understanding that Resident #1 requested her bedtime dose of [MEDICATION NAME] in the middle of the night, and since the resident was new and on hospice, RN #1 administered the medication to the resident without first checking that a dose was scheduled. The DNS stated, (RN #1) failed to actually look at the back up computer to ensure the medication had not been given (at bedtime). On 9/20/17 at 1:00 pm, RN #1 stated she first recognized the medication error on 8/17/17 when the computers came back up at approximately 4:00 am. RN #1 stated she thought she called the physician and left a message on his answering machine regarding the error, but did not get a response. After reviewing the documentation that the physician had actually been notified at 7:58 am, almost 4 hours after she recognized the error, RN #1 stated he had been busy with other tasks and did not realize so much time had passed. RN #1 stated she took Resident #1's vital signs at the time she realized the medication error, but did not document them. RN #1 stated she had done no further assessments of the resident prior to the end of her shift, and had not given the oncoming nurse details of the medication error at shift change (approximately 6:00 am). RN #1 stated she had given the 2:00 am dose of [MEDICATION NAME] because the resident stated she did not get her bedtime dose. Resident #1 was harmed when the facility administered an extra dose of [MEDICATION NAME], which was not ordered by the physician, then failed to notify the physician or monitor the resident's reaction to the additional medication. The resident later became sleepy, then unresponsive. The resident transported emergently to the hospital, where she was admitted for respiratory depression, a known symptom of [MEDICATION NAME] overdose.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure a resident who was at risk for pressure ulcers (PU) and had a history of [REDACTED]. This was true for 1 of 3 sample residents (#1) reviewed for PU. Resident #1 was harmed when he developed recurrent stage II PU on his left buttock, left upper buttock, and coccyx; and, a stage III PU on the left buttock. Findings included: Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's significant change MDS assessment and two most recent quarterly MDS assessments, dated 9/13/12, 12/7/12, and 3/2/13 respectively, coded, in part: * Moderate cognitive impairment with short and long-term memory problems; * Total assistance of 2 people for bed mobility, transfers, and bathing; * Total assistance of 1 person for dressing and personal hygiene; * Functional limitation in range of motion in both upper extremities; * Frequent incontinence of bowel and bladder; * No healed or unhealed PU/venous or arterial ulcers; and * Moisture associated skin damage (MASD). The aforementioned 9/13/12 and 3/2/13 MDS assessments also coded total assistance of 2 people for toileting while the 12/7/12 MDS assessment coded total assistance of 1 person for toileting. Resident #1's PU CAA, dated 9/13/12, documented, in part, extrinsic risk factors - pressure, needs special mattress or seat cushion, friction and shear, and maceration; [MEDICATION NAME] risk factors - immobility, altered mental status, and incontinence; and, history of healed PU. The analysis of findings documented, "...multiple risk factors for development of pressure areas. He will remain at risk." The resident's recapitulation (recap) of Physicians Orders for May 2013 included the following orders and the order date for each: * Multi vitamin 1 by mouth (PO) daily as a supplement - 12/30/08; * Magic cups 2 times daily inbetween meals as a supplement - 11/16/12; * Three-in-one vitamin, once daily PO as a supplement and for wound healing - 3/1/13; * Barrier cream to peri area and buttocks as needed for protection - 9/20/12; and * Zinc oxide topical ointment to open areas on coccyx and gluteal folds every shift and as needed until healed - 3/15/13. Resident #1's Care Plan Problem List, dated 3/12/13, included: * "I am at risk for...pressure ulcers and impaired skin integrity R/T (related to) my incontinence..." and "5/1 open area on compromised (L) (left) buttocks (sic)..." Approaches included, "Tx (treatment) as ordered...monitor me after meals for toileting needs and need to lay down...assist me to reposition Q 2 hrs (every 2 hours) PRN (as needed) when in bed. Be aware: I likes (sic) to lay on my back. Encourage me to stay on my sides to take pressure off my buttocks. I have an air overlay (and) pressure reducing cushion in my w/ch (wheelchair)...I need barrier cr(eam) to my buttocks PRN for protection/report redness to LN...I have a tendency to get open areas on my buttocks because of previous injury to skin-use [MEDICATION NAME] or sacral Allevyn or barrier PRN to encourage healing, and keep my buttocks (open) to air at night..." * "I have a self care concern...I require assistance with my ADLs, mobility and transfers." One approach was, "I need peri care after each incont(inent) episode (and) PRN. 2/28 Not a candidate for a toileting program..." * "I have an alteration in elimination - I am incontinent of B&B (bowel and bladder)..." Approaches included, "I wear adult sized incont(inence) products. Assist me w/ (with) changing and peri care PRN...I have barrier cr(eam) to my buttocks PRN for protection..." Resident #1's medical record included the following: * A Braden Scale (tool for predicting pressure ulcer risk) which documented the resident's PU risk as 14, or moderate risk, on 12/7/12 and 3/7/13. Both Braden Scales included: sensory perception = 3, slightly limited; moisture = 3, occasionally moist; activity = 2, chairfast; mobility = 2, very limited; nutrition = 3, adequate; and, friction and shear = 1, problem. * A Wound/Skin Record with a stage II PU at the left inner buttock and a stage II PU at the left upper/inner buttock, both on 3/14/12. Both of these were documented as healed on 3/28/12. This Wound/Skin Record also included a stage II PU on the coccyx on 4/30/12 which was documented as healed on 5/7/12. * A Wound/Skin Record with a stage II PU on the coccyx and a stage II PU on the left upper buttock, both on 9/20/12. The coccyx PU measured 0.5 centimeters (cm) by 0.6 cm by less than 0.1 cm. The left upper buttock PU measured 0.8 cm by 0.8 cm by less than 0.1 cm. Both of these PU were documented as healed on 10/4/12. This Wound/Skin Record also documented a stage II PU on the left buttock that measured 3.6 cm by 2.6 cm by less than 0.1 cm on 10/8/12, it was noted as healed on "10/2." (The date "10/2" may have been incomplete, or an error). * Another Wound/Skin Record documented a stage III PU on the left buttock that measured 3.6 cm by 2.6 by "unknown" depth on 10/5/13. This PU was documented as healed on 10/23/12. * A Wound/Skin Record with a stage II PU on the left inner upper buttock that measured 2.6 cm by 1.1 cm by less than 0.1 cm on 5/1/13. NOTE: It was unclear why there was documentation on 10/5/13 of a stage III left buttock PU and on 10/8/13 of a stage II left buttock PU. In addition, all of the Wound/Skin Records included 4 body diagrams in which to note the location of PU on the body. The diagrams represented the anterior (front), posterior (back), and lateral (left and right sides) perspectives of the body. However, only the 3/14/12 Wound/Skin Record documented the location of the PUs on the posterior body diagram. All of the other aforementioned Wound/Skin Record body diagrams were blank. Resident #1 was observed in bed on his back on an air mattress on: * 5/7/13 at 8:35 a.m., the head of the resident's bed was at about 40 degrees elevation, while CNA #7 fed him; and, * 5/9/13 at 9:35 a.m., 10:30 a.m., and 11:30 a.m. On 5/8/13 at 11:10 a.m., Resident #1 was observed lying on an air mattress on his right side. With CNA #6's assistance, the Wound Nurse (WN) turned the resident farther onto his side and examined the resident's buttocks and peri area. Two superficial open areas were noted on the resident's left inner buttock. Both of the open areas, one superior (above) the other, were about 1.0 cm in diameter. When asked about the open areas, the WN stated the superior wound was related to moisture and the inferior (lower) wound was related to moisture and pressure. The WN pointed out that the inferior wound was over the ischium (hip bone). She stated, "Stage II pressure ulcers come and go about every other month." On 5/9/13 at 12:10 p.m., when asked what treatments and interventions were implemented regarding the recurrent PU to Resident #1's buttock and coccyx areas, the WN stated she alternated between barrier cream and [MEDICATION NAME] and different types of dressings, such as [MEDICATION NAME], and Allevyn. At 3:20 p.m. that day, the WN was also asked about the aforementioned conflicting documentation on 10/5/12 regarding a stage III PU and 10/8/12 regarding a stage II PU, both on the left buttock. The WN only stated, "I'm not sure why I documented that way." When asked if the resident's voiding pattern had been monitored, such as a 3 day voiding diary, to determine when the resident may be wet and if more frequent incontinence brief changes were needed, the WN stated, "No." When asked if turning the resident more often than every 2 hours had been considered, the WN indicated, "No." When asked if the physician had documented that any of the PU were unavoidable, the WN stated, "No." Resident #1, who had a history of [REDACTED]. On 5/9/13 at 6:10 p.m., the Administrator and DON were informed of the PU issue. On 5/10/13 at about 4:00 p.m., the WN provided more documentation regarding the care and treatment Resident #1 received related to PU; however, the documentation did not resolve the issue.

Based on a complaint from the general public received by the Bureau of Facility Standards on 3/28/11, record review, resident, family, and staff interviews, it was determined the facility failed to protect a resident from potential sexual abuse. Staff members were uncertain of the relationship between a resident and a male visitor, and did not immediately stop nor report witnessed sexual activity. This failed practice resulted in the potential for serious harm, constituting immediate jeopardy to 1 of 4 residents, (Resident #1) reviewed for possible abuse/neglect. Specifically, the facility failed to: a) determine the resident, who had suffered a significant [MEDICAL CONDITIONS] with residual right sided paralysis, and loss of speech, was cognitively intact to make complex decisions related to her ability to consent to sexual activity with a male visitor. (Refer to F278 as it addressed failure to accurately assess the resident's cognitive status); b) immediately protect the resident from sexual contact by the male visitor after a staff witnessed the male visitor fondling the resident's breast while in a public setting within the facility; c) immediately contact law enforcement, the resident's responsible party, and the BFS of the incident. The facility notified a family member, who was not the responsible party, two days after the incident. (Refer to F157 as it addressed the immediate notification requirement); d) immediately initiate an investigation to determine if other staff on duty witnessed the incident. The facility did not interview all staff to determine if they had witnessed any previous sexual contact by the male visitor towards the resident while she resided in the facility. (Refer to F225 as it addressed the facility's failure to conduct a thorough investigation, and F226 related to failure to ensure policies and procedures for prevention of abuse were implemented.) The complainant alleged the following: On 3/21/11 an identified resident, who is alert but not cognitively intact, was sexually assaulted by a male visitor; The resident was not immediately protected from further contact with the male visitor; Family and law enforcement were not immediately notified; The facility only informed a family member two days later on 3/23/11 when the family member came to visit and was informed of the incident by the Social Worker and the Nurse Unit Manager; The male visitor had been making "conjugal visits" with the resident in the facility over a three year period; Staff members were aware of this because on one occasion staff entered the resident's room while the resident was "masturbating" the male visitor; The resident's family was told that staff assumed the male visitor had lived with the resident as her significant other, prior to her stroke. The facility's failed practice was brought to the attention of the facility's Administrator and DON on 3/30/11 at 1:40 pm, and the facility was provided with specific details of the failure to ensure the resident was not being sexually abused. The facility did not assess her ability to consent to sexual activity with a male visitor. Staff had knowledge that the resident and visitor were engaging in sexual activity over a period of three years. Direct care staff, during interviews, stated they assumed the sexual activity was consensual. On 3/30/11 at 1:50 pm, the DON was informed the facility needed to ensure Resident #1's immediate safety. The DON stated she would write a communication notice that each staff was to read and sign. before start of shift, as an acknowledgement of understanding and compliance. At 2:15 pm, the DON provided a copy of the typed notice. It directed: "This notice must be read and signed by all staff who work at (name of facility.) (Name of Resident) cannot have any visitors by the name of (name of male.) If a male visitor comes to visit (Resident #1) you need (to) direct them to the supervisor and ask for identification. If this visitor is (name of male) you need to escort him out of the facility and if he will not leave the (name of local police department) must be called at (telephone number.)" At approximately 3:00 pm, the DON provided a second copy of the notice to staff which contained signatures of 19 staff currently on duty. On 3/31/11 at 11:35 am, the facility presented the complaint survey team with an acceptable plan of correction and the immediate jeopardy was abated. The plan of correction was as follows: "Resident #1 will have no visitation or contact with (name of male visitor) until such time that a determination of her cognitive capabilities is determined. The facility with this resident's primary care Physician will have a qualified person determine if she can engage in consensual sexual activity. The Ombudsman will visit Resident #1 today (3/31/11) and will be an advocate for this resident. This deficient practice could affect any cognitively impaired resident at this facility. All residents who have cognitive impairment will be assessed for possible abuse. Care plans will be reviewed and revised accordingly. Staff will be re-educated on issues to report regarding any form of abuse. This will be done by 11:00 am, 3/31/11, for all staff on duty today, and will continue so each staff member receives this re-education during their next working shift. All staff will sign a master staffing list after receiving the inservice. DON and Administrator will investigate any reported incidences of abuse or potential abuse immediately. (Name of Corporation) will provide ongoing consulting services on a monthly basis for 6 months beginning 3/31/2011. Completion date 4/2/2011." The DON also provided the signatures of 20 additional staff who came on duty after the immediate jeopardy was called, and who signed the notice regarding Resident #1, dated 3/30/11. Findings include: The survey team entered the facility on 3/29/11, at 8:45 am. The surveyors informed the DON that the BFS received a complaint regarding care issues. The surveyors did not identify the resident nor the complainant to her. The DON stated, "I think I know why you're here." She informed the surveyors that the SW was on vacation for the current week. The surveyors requested all the facility's Incident/Accident (I/A) reports and abuse/neglect investigation reports for the past two months. The DON returned a short time later with the I/A reports and stated, "We don't have any investigations regarding neglect or abuse." Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly MDS, (3.0), dated 12/28/10, identified, "Moderately impaired. No short or long term memory problems." The MDS definition of "Moderately impaired" is, "Decisions poor; cues/supervision required." Social Service Progress Notes, written by the SW, documented in part: *4/24/08: "Initial assessment. Is alert and oriented to self. Seems to know family...Seems to recognize staff...difficult to accurately assess..." *5/1/08: "14 day assessment. Cont (continues) to be alert (with) some confusion - diff (difficult) to accurately assess (secondary) [MEDICAL CONDITION] - inconsistency according to ST (with) nodding of head -picture board may vary (with) fatigue level...No beh(behavior) noted..." *5/21/08: "30 Day. No significant change noted...Is diff, to accurately assess cog (cognitive) status (secondary to) [MEDICAL CONDITION] - seems to be familiar and comfortable (with) staff, room, routine..." *6/19/08: "No significant change noted in cog status. Communication - ST working on use of picture board, Can make own dec (decisions) by nodding yes/no - is fairly reliable..." *7/14/08: "90 day...Needs cueing and reminders at times..." *10/11/08: "Quarterly assessment. Is alert and oriented to self. Seems to recognize family, staff...Cont non-verbal. (Specialty Clinic) notes 80% accuracy (with) yes/no questions noted by nodding her head...(Specialty Clinic) has recommended cont therapy - 3 disciplines did an evaluation. Only OT (occupational therapy) will be involved for therapy on hand..." *1/9/09: "Quarterly assessment. No significant change noted. Cont. to be aphasic - Appears to be familiar (with) staff, routine room, activities - knows family ..." *4/15/09: "Annual assessment: Is alert - oriented to self and family. Seems to be familiar and comfortable (with) staff...Diff to accurately assess cog status (secondary) being aphasic - inconsistent (with) nodding head, comm (communication) board - is able (to) comm (with) commun(ication) board, eliminating options, giving choices...Seems to be content with placement, care..." *7/15/09: "Quarterly assessment. Cont to be alert - oriented to self, family...Inconsistent (with) nodding her head...Needs reminders/cueing at times - Family is involved in dec (decision) making..." *10/12/09: "Quarterly assessment: "No significant change noted - Is alert and oriented to self, family, is familiar and comfortable with staff, room, routine. Cont to be aphasic - can nod yes, no...Not able to accurately assess knowledge of place, complete date..." *1/08/10: "Quarterly assessment: "No significant change noted from above note. Will respond to questions by nodding her head with a fair amount of accuracy..." *4/8/10: "Annual (assessment.) No significant change noted. Is alert - recognizes family...Can nod her head yes - no - however, yes/no responses are inconsistent - not reliable. Needs reminders, cueing; family helps (with) dec making..." *7/8/10: "Quarterly assessment. Is alert - knows self and family. Appears to know staff, room, that she is in a NH (nursing home.)..Will nod her head in response to questions. Face does not appear to be as expressive as it was - mouth open - not smiling as distinctly as she did..." *9/23/10: "Quarterly assessment. Is alert-oriented to self and family. Is familiar and comfortable with staff, room, routine. Reviewed Cog patterns (with)...They indicated she knew all the items...season, room, staff, NH. Also indicated she could make her own decision when questions are phrased correctly. PHQ-9 (MDS, section under "MOOD" to determine if the resident had any problems or behaviors) Answered no to all of them. This is supported by (Resident's) smile, level of activity, intraction..." *12/28/10: "Quarterly assessment. Is alert - appears to be oriented to her self, family. Appears to be comfortable, familiar (with) staff...Responds to questions (with) nod of head - is not always consistent...Staff indicates she needs supervision, cueing..." *3/23/11: "Reported inappropriate sexual behavior between (Resident #1) and longtime male friend. Reviewed behavior (with name of family member with) Unit Manager. (family member) spoke to (Resident with) writer present. (Resident) was asked several times and was consistant (sic) that she wanted the behavior to stop. (Family member) will inform male friend and writer will re-enforce the decision - Staff will be informed." NOTE: This entry was made two days after the incident, reported by Employee (A) on 3/21/11. There was no documented evidence in the resident's record or in any facility report that staff immediately initiated an investigation on 3/21/11, the day of the incident. In addition, the SW's entry documented the family, "will inform male friend." Notification to the male visitor was the facility's responsibility. *3/24/11: "Conversation (p/c) (unknown abbreviation) (with) family. Requested male friend not be allowed in the facility for now. Staff notified. Writer will inform male friend when he visits." NOTE: The facility failed to immediately ensure the male visitor did not return to the facility. *3/25/11: "(Name of police officer) here. Meeting (with) DNS (DON), writer and (Employee (A). Discussed concern expressed by (resident's family member). Discussed concern expressed by (family member) about above. For now, it is (family member's) desire that male friend not visit. He (family member) is acting as POA. Will encourage male friend not visit until matter is resolved. Will call Ombudsman to be involved to protect (Resident's) rights." NOTE: Based on this documentation, it could not be determined if the male friend had yet been prohibited from visiting the resident. *3/25/11: "Met (with family member) - given copy of POA. Requested male friend not see (Resident). Staff inform (sic). Will wait for Ombudsman's report." NOTE: This was the first documentation, four days after the incident, that staff received some form of communication and direction from management regarding the incident. At 10:00 am, the DON asked the surveyor, "Do you want to interview any staff?" The surveyor stated, "Yes." The DON indicated one staff member, not on duty today, but in the facility, was available for interview. The surveyor informed the DON that all staff interviews needed to be conducted in private, without management team present. NOTE: The survey team had not yet discussed any specifics of the complaint to the DON or staff. On 3/29/11 at 10:05 am, the survey team interviewed Employee (A). The Employee stated she assumed surveyors were in the facility regarding Resident #1 and the male visitor. She stated she had already been questioned by the police. She stated the male visitor was the "boyfriend" of Resident #1, and, "visited quite often. They lived together." Employee (A) was asked to describe the incident she witnessed. She stated that last Monday, 3/21/11, at approximately 11:00 am, she observed Resident #1 and the boyfriend in the dining room. She witnessed the boyfriend with his hand down Resident #1's shirt. The boyfriend was standing behind the resident and was touching her breasts. They were the only two people in the dining room. She stated Resident #1 always sat at a table close to the door so she was able to observe the front of Resident #1 when she walked into the dining room. She stated she quickly backed out of the dining room and went to the nursing station where she reported what she observed to the DON and UM. The Employee identified the names of both these staff. The Employee said that she reported it because the public setting for the sexual activity was not appropriate. The Employee stated she knew sexual activity between the two had been occurring in the resident's room for a long time. Employee (A) stated that approximately 10 to 15 minutes after the incident she again entered the dining room and the boyfriend still had his hand down the front of Resident #1's shirt. The Employee said "Hello" and he stopped caressing Resident #1, and asked the Employee to see the gift of jewelry he bought the resident. Employee (A) was asked by the surveyor what she further observed after she had been noticed. She stated the boyfriend removed his hand from the inside of the resident's shirt. He sat next to the resident then the resident placed her hand on his leg. The boyfriend asked Resident #1 if she wanted to go back in her room. She took her left hand and rubbed it into his upper inner thigh. "She made a nod and a giggle." They then returned to her room. Employee (A) stated the resident giggled as she does when she is happy, and the resident was able to let staff know when she is upset. "She flutters her hand, and by her facial expression." Employee (A) was asked if she received any immediate direction from the DON and UM after the first observation. She stated the DON asked her to write a statement of her observation. The Employee confirmed she wrote a statement and gave it to the DON. The Employee stated the DON told her it was time to talk to the family. Employee (A) stated the police came to the facility on Friday, 3/25/11. The police officer interviewed her and she reported what she witnessed between Resident #1 and the boyfriend. Employee (A) was asked how Resident #1 usually expressed herself. "She gets expressive in her face, we can tell if she's happy or upset. She nods for 'yes' as she doesn't say 'yes.' She does a kind of half laugh." The surveyor asked the employee if the resident shook her head to indicate, "No." She stated, "Umm, she gets mixed up in her nodding." She indicated that it was not always consistent when the resident shook her head or nodded in order to express herself. Employee (A) stated she had witnessed sexual touching between the resident and boyfriend when she entered the resident's room one time. There were other staff who had also witnessed this at times. She stated she had not reported the room incident as it was in the privacy of the Resident's room. She mentioned it to someone but could not remember who she told. She said she was told, "It happens." The surveyor asked the Employee if this sexual activity was an expectation by the staff. "Yeah, but just by other CNAs and RNs...To all of us it seemed consensual." The Employee said, "They had a long-time relationship. They travelled together. (Resident #1) was very happy when he showed up." Employee (A) was asked when she had first learned of the resident's sexual encounters. She said it was not until approximately last year. The boyfriend visited about four times a week. The surveyor asked if she received any instruction on how to maintain their privacy. She said, "No." The Employee was asked if Resident #1's care plan identified the resident was sexually active and if so, did it direct staff to allow privacy for sexual encounters with her boyfriend in her room. She stated she did not know if any such direction was on the care plan. Employee (A) was asked if Resident #1's roommate was ever in the room during the sexual encounters between Resident #1 and the boyfriend. She said to her knowledge the roommate had not been present and for a time Resident #1 did not have a roommate. Employee (A) said that sometimes there were young residents admitted to the facility. She gave an example of a young man that used to be in the facility and liked to masturbate. "You just found out don't go in when the door is shut or you may see something you don't want to see." At 11:15 am, the surveyor requested the DON to arrange for further staff interviews with the survey team. She stated, "Yes, there are two staff that have knowledge." The surveyor asked her to clarify her statement. She stated, "They've seen it." At 12:35 pm, the survey team interviewed Employee (B.) She said she had just written a statement "today" regarding Resident #1 and a male visitor. She had been asked to write a statement earlier in the week but did not have time "until today." Employee (B) stated she had "seen things several times." She stated she could not give a period of time, "but it has been going on for a long time. I have walked in her room and he has his hands down her shirt." The Employee said the first time she saw this, "I thought they were husband and wife. I asked her if he is her husband and she said, 'yes.'" Later a family member visited and clarified for the Employee that the male visitor was not the resident's husband. The Employee said, "I just saw it as two adults. It was none of my business so I gave them privacy." The Employee said it never seemed to her like Resident #1 was not happy with what was occurring. "He (male visitor) usually comes in at noon." Employee (B) said she had never seen a different side of the Resident #1, but "you can tell if she is frustrated." Employee (B) said there had been married couples in the facility and it was, "just known that they were married." She indicated it was known to knock before entering the room as, "It's common courtesy." Employee (B) said she had never witnessed Resident #1 and her male visitor engage in sexual touching in public. She had never been told by any staff, prior to her own observations, that sexual encounters occurred between Resident #1 and the male visitor. At 12:50 pm, the survey team interviewed Employee (C.) She stated she knew why the surveyors were in the facility. Employee (C) said she had witnessed Resident #1 with the male visitor in her room, "a couple of months ago." The Employee said she had knocked on the door and when she entered the room the male visitor was touching Resident #1's breasts. The Employee thought Resident #1 "looked embarrassed." The door to Resident #1's room was not closed but the resident and the male visitor could not be seen from the hall. The Employee said it was the first time she had ever, "came on it." The Employee named the UM as the person she told. The Employee stated the UM said, "she would look into it." The Employee also said Resident #1 and the male visitor had lived together before the resident was admitted to the facility. When the Employee was asked how she knew this, she said, "He has her car, and from staff discussion. He visits her and has coffee with her all the time." The Employee said that after the incident last week the male visitor was not allowed in the facility. The Employee was asked how she knew this. She stated, "It was on the 24 hour board that he could not come to the facility." On 3/29/11 at 1:24 pm, the surveyors interviewed the SLP per telephone. She stated she worked with the resident when she was first admitted , "a very long time ago. I have no recollection of what I wrote in the chart. What I can remember, she was coming out of what I call a stroke fog." She had [MEDICAL CONDITION] and was unable to make any gains with speech therapy. The SLP stated," I interact with her so know how she is cognitively. In my view, she is very cognitively intact and aware of her surroundings. Her speech is the only thing holding her back." She indicated the resident did a good job with expressions, body language and gestures. The SLP stated, "She's pretty consistent with her 'yes' and 'no' responses when I see her." The SLP said she performed no formal cognitive assessment on Resident #1 and had never used a standardized test for cognition on anyone who was non verbal. The SLP did not think the resident used alternative devices for communication. The SLP said her interactions with Resident #1 did not include ADL care and interactions were limited to when the she and the resident were in the dining room during meals. At these times the SLP thought the resident was very clear about her needs. The SLP acknowledged her current interactions with the resident were "minimal." At 1:40 pm, the DON was interviewed. She was asked about the "communication board" that staff were instructed to read regarding the male visitor who was not allowed in the facility. The DON clarified that the communication clipboard had 24 hour notes and all staff on each shift were to read it prior to start of shift. Also, when staff did walking rounds at the beginning of each shift they would be informed. If staff had been off duty for several days they were responsible to read the 24 hour report for the time they had been off duty. The DON stated, "(SW) talked to everyone about (Resident #1's family member's) wishes of (name of male visitor) not coming into the building until further notice, (family member) made that decision." The DON was asked which staff were told this. "I think all the staff on duty Friday." She was asked how the SW inserviced the staff. "I don't know how he accomplished this." She indicated it was not until 3/26 that the SW told all staff that the male visitor "could not come in here yet." The DON was asked if the SW wrote an entry on the communication clipboard. "No, I don't think he did." The DON stated she wrote on the communication clipboard that the resident's male friend could not visit until further notice. The DON said that in her opinion the family member had no right to determine Resident #1 could not be visited by the male friend. NOTE: A copy of the The "24 Hour Charge Nurse Communication Log" was requested prior to the exit conference on 3/31/11, and contained the following entry on 3/25/11: "(Name of male visitor - Resident #1's) friend cannot visit her until further notice - If he comes direct him to a supervisor. (First name of DON). (Not to visit at all under any circumstance.)" The statement in parentheses was written in red, and the words, "cannot visit" were underlined multiple times in red ink. The notation was entered four days after the incident. The DON stated, "We called the Ombudsman but he was not available. We wanted a third party to get (Resident #1's) wishes." The DON also said, "I called (name of Resident #1's family member,) Friday evening and I called her Wednesday also...The (family member) thought (male friend) could stay in (Resident #1's) life." NOTE: The DON did not call the resident's responsible party. The DON said the family member indicated Resident #1 and the male visitor had taken some trips together. When asked if the Resident and male visitor had ever lived together the DON said she did not know. The surveyors informed the DON that documentation in the resident's record revealed family had attended care conferences for Resident #1, but there was no documented discussion about the male visitor or their sexual relationship. The DON indicated the family did not know of the sexual relationship between Resident #1 and the male visitor. "The issue never came up before. They (family) never knew about the sexual aspect. Some of us did." The DON was asked what she knew of the resident and male visitor's relationship. "I found out a little. I was under the impression they lived together, but I don't think the kids knew that." The DON was asked who was the resident's responsible party. "She's her own person." The DON stated that when she spoke with the family member on Friday, (3/25/11) she told the family member, "We really need the POA for health care." The DON stated, "(Name of a second family member) wants him (male visitor) charged as a sexual predator but the police said, 'No charges here.'" The DON stated, "We all felt an admiration for (male visitor) after (name of Resident #1's) stroke, to care about her and be there for her." The DON was asked, once she found out about the sexual relations did the staff determine that the resident had given consent to this. The DON stated, "No." The DON was asked if the staff arranged for privacy. "No, that wasn't done." When the DON was asked if she had spoken to the resident after the 3/21 incident, the DON stated, "I haven't talked to (Resident #1) about it." She stated she was not sure who the best person would be to interview the resident, or how to approach the resident about such a personal issue. The surveyor read to the DON the SW's note, dated 3/23/11: "Reported inappropriate sexual behavior between (Resident #1) and longtime male friend. Reviewed behavior (with name of family member with) Unit Manager. (Family member) spoke to (Resident with) writer present. (Resident) was asked several times and was consistant (sic) that she wanted the behavior to stop..." The DON made no comment about the statement read to her. The DON indicated she did not witness any staff inservices by the SW and did not see any staff sign-in sheets. The DON was asked if she called the incident into the BFS's Hotline. "I thought to call the Hotline, but it wasn't abuse." She said she made this determination after she got statements from two staff and from a third staff today, (3/29). She determined there was no abuse. NOTE: The DON determined there had been no abuse before she received all staff's written statements. The written statement by Employee (A) was not dated, and the statement by Employee (C) was dated 3/29/11. The resident had not been interviewed. At 2:15 pm, the DON was again interviewed and was asked, once the staff member told her about the 3/21 dining room incident, how did she proceed. She stated, "I told her to report it to (name of SW.) The DON was asked if she had intervened to stop the incident. "Well, it was in private, but not really." At 2:22 pm, the UM was interviewed. She indicated she had been involved in the meeting on Wednesday, 3/23, with a family member and the SW regarding an incident that had occurred between Resident #1 and a male visitor. She said that there had been two meetings that day with the SW and family member but she was only present at one. The UM stated that when the family member was told of the incident, "(name of family member) was surprised but said, 'Well they were practically living together' then she said 'oh boy is my (sibling) going to be mad.' (Name of family member) indicated (name of sibling) does not like (male visitor)." The UM said the family member indicated she would speak with the resident. "I asked her if she wanted me present. She said 'No.'" The UM stated the incident was the first time she had heard that the resident was having sexual relations with the male visitor. The UM was asked if the resident seemed all right after the incident. "(Employee (A)) said 'Oh yeah.'" The UM was asked if CNAs were able to asses the emotional state of a resident. "Our CNAs can." The UM was asked if, after the incident in the dining room, a psychosocial assessment was performed on the resident. She stated, "I'm not aware if anyone did an emotional assessment." She stated they had a history of [REDACTED]. Resident #1's response to the male visitor was very endearing. "In retrospect, things should have been done quicker, or go to (Resident #1) and say, 'Are you okay?'" The UM stated, "I was not aware that some staff knew about their relationship." The UM denied she was told by any staff member that the resident was engaging in a sexual relationship with the male visitor. NOTE: During the interview with Employee (C), she stated she reported her observation to the UM. The UM was asked what system was in place for staff to communicate with the resident. She said there was a picture board at one time but the resident did not want to use it. At 2:52 pm, shortly after the interview with the UM, the DON came to the surveyors and stated, "I was not in the nursing station when (Employee (A)) came in the first time and told (name of UM) (about the dining room incident.)" The DON also stated that she had just spoken with the UM who "validated this just now." NOTE: This statement conflicted with Employee (A's) verbal and written statements. At 3:15 pm, the DON and UM spoke with the surveyors. They stated they had just spoken privately with Resident #1. The DON stated, "We asked her did she want (name of male visitor) to continue to visit with her. She nodded 'Yes' and said.'Yes.'" We offered her a private place, She shook 'No'. What if staff knock first, 'No.'" The DON stated, "We've known her a long time and know when she's upset. We talked about possibly calling in (name of Psychiatrist.)" The DON and UM were asked if the resident could make these decisions by herself. The DON stated, "That's not determined. (Name of family member) is listed as closest family to call...I'm still not clear that she (Resident #1) should be making these decisions." The survey team informed the DON and UM that the relationship between the resident and the male visitor should have been established at the time of her admission. In addition, the facility had not determined the resident was her own representative at the time of her admission. At 3:40 pm, the surveyors attempted to interview Resident #1 but were unable to ascertain if she understood questions or was nodding 'yes' appropriately. On 3/29/11 at 7:19 pm through 7:39 pm, a surveyor interviewed the family member identified by the facility as the person the SW and UM spoke with on 3/23/11. During the interview the family member agreed to provide a written statement. On 4/1/11 at 11:11 am, the BFS received the notarized statement. It documented in part: "...When I arrived (at the facility) I was told by 3 or 4 of the caregivers that (SW) wanted to see me as soon as he could...(SW and UM) opened the conversation by apologizing for what they had to share, and (SW) stated that as frequently as he provides in-service to his staff sometimes these things still happened. He then told me that a staff member had observed some sexual activities in the dining room between (Resident #1 and a male visitor) one evening when the two of them were in the dining room alone. (UM) apologized and told me that the staff had seen activities on a few occasions also and these encounters were OK, but only if (Resident) were