Every finding on record at Northgate Care Center

Based on observation, record review, and staff, doctor, pharmacist interview, and policy review the facility failed to have 4 of 7 nurses administer medications following the 6 rights of medication administration. The 6 rights are a process of verifying the right resident, right drug, right dose, right route, right time, and right documentation performed to systematically minimize medication errors, ensure patient safety, and maintain the efficacy of treatment. By verifying these key factors, healthcare providers prevent adverse events, protect residents, and adhere to safety protocols. Staff A, Licensed Practical Nurse (LPN), Staff B, LPN, Staff F, Registered Nurse (RN), and Staff G, LPN administered medications for residents who resided in the facility on the morning of 2/22/26 and morning of 2/27/26 without following the proper medication administration procedures by administering medications which were pre-set (set up in advance of being administered). The residents' medications included insulin, blood pressure, and anticoagulant (blood thinning) medications. This deficient practice resulted in an Immediate Jeopardy (IJ) to the health and safety of residents who resided at the facility as it was seriously likely receiving the wrong dose of insulin and/or medications could result in life-threatening complications. The facility also failed to prime an insulin pen for 1 of 1 resident prior to giving (Resident #43). The facility reported a census of 44 residents.The State Agency informed the facility of the Immediate Jeopardy (IJ) on 2/22/26 at 11:50 AM. The IJ began on 2/22/26, the day the first observation was made of staff not following the 6 Rights of Medication Administration.Facility staff removed the Immediate Jeopardy on 2/22/26 through the following actions:1. Pre-poured medications were immediately destroyed and disposed of appropriately. Destroyed medications will be reimbursed to the residents.2. Nurses and Certified Medication Aides (CMA) education initiated on 2/22/26 prior to working the next shift on medication administration and the 6 Rights of Medication Administration.3. Facility staff who administered medications including professional nurses and CMA's were educated on 2/22/2026 regarding passing medications that only that nurse or CMA has prepared themselves.Initially, the immediacy of the IJ was removed on 2/22/26 at 5:06 PM after verification all staff had received and acknowledged the training.However, on 3/2/26 at 4:57 PM the facility was notified the removal of IJ immediacy was rescinded due to an observation of ongoing failure occurring on 2/27/26. Video footage and staff interviews revealed nurses continued to not follow proper medication administration procedures (Staff F, RN and Staff G, LPN). Facility staff completed additional education and officially removed the Immediate Jeopardy on 3/3/26 through the following actions:1. On 3/2/26 re-education was completed with staff who pass medication regarding preparing medications at time of administration and reviewing the 6 Rights of Medication Administration.2. Administrative oversight remains in place and will continue to ensure understanding of medication administration process is followed.3. Facility staff who pass medications will complete medication administration competencies with direct in person oversight on 3/3/26. Any staff who are not available will complete medication administration competencies prior to next scheduled shift.4. All nursing staff will sign the Acknowledgment and Agreement of Proper Medication Pass Practice, including disciplinary action as indicated in the agreement.5. Daily random audits of medication administration will be completed.The immediacy of the IJ was removed on 3/3/26 at 4:21 PM after verification all staff received the training and had completed or were scheduled to complete the in person training prior to their next scheduled shift.The deficient practice was identified on 2/22/26 and the scope lowered from L to F on 3/3/26 after the facility implemented additional education and in person training. Findings include: 1. Observation on 2/22/26 at 7:17 AM revealed the facility had two (2) medication carts (South cart and North cart) in the building that contained all residents oral daily medications. The top drawer of the South medication cart contained 21 plastic med cups with pills placed inside them and white paper med cups placed on top of the pills with names written on the paper. The top drawer of the North cart also had 18 plastic med cups with medications inside them and white paper med cups with names written on them. Observation revealed 6 insulin pens with attached needles in an unlocked container that sat at the nurse's station pre-dialed to dosage amount. Three more insulin pens sat in the same container not dialed up without insulin needles on. On 2/22/26 at 7:25 AM, Staff B, Licensed Practical Nurse (LPN), stated she was the Charge Nurse on shift that day and she worked for a staffing agency. She revealed she started setting up all the residents' medications on the South medication cart around 5:00 AM for that day's morning medication pass. She revealed setting up resident medications ahead of time was just something they did at this facility and she did not do this at any other nursing home. On 2/22/26 at 9:53 AM, Staff A, LPN, stated she normally worked afternoons and dayshift not her normal shift. She said when she came in that morning all her residents' morning medications were set up on the North medication cart for her for the morning medication pass and she did not set them up herself. Staff A revealed she verified if the medications were correct when she checked the name written on the white paper medication cup on top and compared it with the Medication Administration Record (MAR), but she did not know for sure what meds were in the cup she passed. She verbalized she should have set up the medications at the time she was going to give them to a resident, she would notify the Director of Nursing (DON) in the future if another nurse set up her meds, she destroyed the meds in the drug buster (system designed to safely deactivate and dispose of medications), and she would not administer medications again that another nurse set up. Staff A said when the DON came in she directed her to destroy all the pre set up medications that were observed in the medication cart (18 residents morning medications) into the drug buster. In a follow up interview with Staff B, LPN, on 2/22/26 at 11:10 AM, she explained she worked at this facility 1-2 shifts a week and she came in at 4:00 AM. Staff B said she started setting up the residents' morning pills around 5:00 AM. Staff B revealed she was trained to prepare meds this way at this facility so they were able to take the medications with the morning breakfast trays or help with transfers and pretty much all the nurses pre-set up medications. Staff B stated if residents received narcotics she would retrieve them at the time she was going to give the resident their pills. Staff explained she did not normally check blister packs (pharmacy packing with each pill enclosed separately - used for secure, organized, tamper-evident packaging of medications which enhances medication adherence by organizing doses, prevent double-dosing, and allow for easy, visible monitoring), instead she would grab the medications she set up earlier with the residents name on it and go to give them. Staff B explained it was quicker but she knew she was not supposed to do it that way. Staff B reported the night charge nurse Staff C, RN, set up Staff A's residents' medications which she gave that morning for her to administer to the residents, and all the insulins on the North and South medication carts that were to be given in the morning, prior to her coming in at 4:00 AM. Staff B said it was just how they did it in the morning and she knew setting up medications was not allowed. On 2/24/26 at 11:17 AM, Staff C, RN, reported on 2/22/26 around 2:30 AM to 3:00 AM, she set up all residents' morning medications on the North med cart for Staff A, LPN, to pass and it included maybe around 20 residents' morning medications and one narcotic of Lyrica (a controlled substance used to treat pain). Staff C stated she looked at each medication when she was setting them up and went right on down the line. She revealed she put the meds in a plastic med cup with a white paper med cup on top and wrote the resident's name on them. Staff C said if more than one resident went by the same name she would put their last name initial on it. She revealed she did it because she thought they were going to be short a person so she thought she would help. Staff C reported she also set up all the insulin pens for Staff B, LPN, and Staff B was supposed to double check them before giving, and Staff C put the insulin pens all in one container. Staff C stated she primed the pens prior to dialing up the dosage and left them in the medication room sitting in the container for Staff B to give so she could have a jump start. Staff C revealed she did not usually do that and only did it because she thought they were going to be short staffed. Staff C said Staff A, LPN, did not ask her to set up the medications and she did not talk to Staff A to tell her what she did prior to leaving the facility. Staff C said she thought Staff A could verify by counting to make sure she had the right number of pills in the cup so this practice would have made it faster for Staff A. Staff C revealed she did not normally pass medications on her scheduled shift (overnight shift). Staff C verbalized the facility educated her on the 6 Rights of Medication Administration, the facility policy, and they were not to be setting up medications in advance. On 3/3/26 at 3:15 PM, the DON reported on 2/22/26 when she arrived to the facility, Staff B, LPN, told her the medications were set up and the State took pictures and looked at the med carts. The DON said she told Staff A, LPN, to not give any more medications that Staff C had set up for her and to destroy the meds in the drug buster. On 2/25/26 the facility provided an undated list titled, Morning Insulin, that listed the residents whose insulin pens were observed in the container together on 2/22/26 at 7:18 AM; Resident #30, #14, #43, #19, #2, and #4. Review of February Medication Administration Records (MAR) for Resident #30, #14, #43, #19, #2, and #4 revealed the following morning insulin orders: a. Resident #30 long acting insulin 16 units dailyb. Resident #14 long acting insulin 35 units daily and rapid acting insulin 0 - 18 units with meals depending on the blood sugar reading at the timec. Resident #43 rapid acting insulin 15 units daily and 0-7 units with meals depending on the blood sugar reading at the time. d. Resident #19 long acting insulin 30 units and rapid acting insulin 7 unitse. Resident #2 rapid acting insulin 7 units daily f. Resident #4 long acting insulin 38 units twice a day Review of an Order Listing Report provided by the facility on 2/22/26 revealed 25 residents received blood pressure medications the morning of 2/22/26. Review of an Order Listing Report provided by the facility on 2/22/26 revealed 22 residents received anticoagulant medications the morning of 2/22/26. Review of the February 2026 Medication Administration Records (MARs) for all residents in the facility (44 residents) revealed each individual resident's MAR documented they received all morning medications during the morning medication pass on 2/22/26. The Resident Listing Report dated 2/25/26 documented 5 residents in the facility had the same first name (Resident #2, #12, #20, #21, and #25). The document revealed Resident #20 and #21 also had the same first initial of their last name. Review of the February 2026 MARs for these residents revealed the following: a. Resident #2's February 2026 MAR revealed he took, in part, the following types of medication during the morning medication pass on 2/22/26: insulin, antihyperglycemic (diabetic medication to lower blood sugar), diuretics (water pill, gets ride of excess sodium and water), antifungal (antimicrobials used to treat and prevent infections), beta-blocker (lowers blood pressure), anticoagulant (blood thinner), potassium (supplement), non-ergoline dopamine agonists (used to treat restless leg syndrome), laxative, magnesium (supplement), and an antidepressant. b. Resident #12's February 2026 MAR revealed he took, in part, the following types of medication during the morning mediation pass on 2/22/26: gabapentinoid and anticonvulsant (controlled substance used for nerve pain), stool softener, antidepressant, angiotensin-converting enzyme (ACE) inhibitor (lowers blood pressure), cholinesterase inhibitors (for dementia), cholesterol absorption inhibitors (lowers bad cholesterol), laxative, alpha-1 adrenergic blockers (helps urine to flow more easily), anticonvulsant and mood-stabilizer (used to treat seizures, bipolar, and migraine prevention), and antipsychotic (primarily used to manage psychosis, including hallucinations, delusions, and schizophrenia). c. Resident #20's February 2026 MAR revealed he took the following types of medication during the morning mediation pass on 2/22/26: thiazide diuretic (used to treat high blood pressure and fluid retentions), ACE Inhibitor, non-opioid analgesic (pain reliever) and antipyretic (fever reducer), nonsteroidal anti-inflammatory drug (NSAID) (used to treat pain, fever, and inflammation), and anorectic (controlled substance for appetite suppression). d. Resident #21's February 2026 MAR revealed he took, in part, the following types of medication during the morning mediation pass on 2/22/26: antidepressant, antiplatelet (used to prevent blood clots), diabetic oral medications, opioid analgesic (controlled substance, narcotic), antihyperglycemic, proton pump inhibitor (reduces stomach acid), beta-blocker, antipsychotic, non-opioid analgesic, and anticonvulsant. e. Resident #25's February 2026 MAR revealed he took the following types of medication during the morning mediation pass on 2/22/26: Vitamin D (supplement), anticoagulant, and stool softener. On 2/22/26 at 11:26 AM, the DON reported all staff had been educated on not pre-setting up medications, she had completed audits on it in the past, and there hadn't been any issues. The DON revealed she instructed Staff A that morning to put the already set up medications in the drug buster. The DON reported Staff C had been educated in the past to not set up medications, and the DON thought it had been taken care of and that nurses were not presetting up medications anymore. The DON stated she felt the nurses had plenty of time to pass medications the correct way and she was not sure why they were presetting them up; it was not how they were trained. On 2/22/26 at 4:19 PM, the Administrator and DON reported they spoke with Staff C, RN, and Staff C confirmed she did set up all of Staff A's residents' morning medications for Staff A to pass on 2/22/26 because she was just trying to be helpful. The DON stated she instructed Staff C that could not be done. The Administrator and DON stated they provided education that day to all staff who pass medications in the facility, including agency staff, that they should only provide medications that they prepared themselves, only set up 1 resident's medication at a time, and medications should not be set up ahead of time for any reason. They reported everyone had acknowledge of the training and the importance of it. The Administrator and DON said they reviewed with the nurses the facility's Medication Administration - Medication Pass policy, last revised 5/2023, which contained the 6 Rights of Medication Administration and that they expected the policy to be followed that included: The right resident with 2 resident identifiers. The right medication, if its a stock medication or a blister pack (pharmacy packaging used as a tamper-evident method for storing medication using small plastic bubbles (blisters) with a foil or paper backing. Each dose is sealed in its own compartment). The right dosage of the medication by comparing the Medication Administration Record (MAR) and the medication label on the card. The right time and frequency of the medication. The right route (way to take the medication, such as by mouth or by an injection). Documentation after administering the medication. On 2/22/26 at 4:39 PM, Staff D, Certified Medication Assistant (CMA), confirmed she had been educated on not setting up medications and to follow the 6 Rights of Medication Administration and the facility's policy prior to her scheduled shift that day. On 2/22/26 at 4:55 PM, Staff J, LPN, confirmed she had been educated on the 6 Rights of Medication Administration and she was not to set up medications. Staff J revealed she heard nurses on the morning shift would pre-set up medications, but she had never observed it. 2. Observation with the Administrator on 3/2/26 at 1:23 PM to 1:55 PM of facility camera footage revealed on 2/27/26 from 5:35 AM to approximately 5:55 AM, Staff F, RN, and Staff G, LPN, stood at the North and South medication carts frequently opening drawers and it appeared the nurses were setting up morning medications for residents. On 3/2/26 at 2:02 PM, Staff H, Certified Nurse Aide (CNA), revealed on 2/27/26 she came to the facility for her morning shift around 5:45 AM and saw Staff F and Staff G setting up their morning medications. Staff H said she could not believe they were doing exactly what the facility just got in trouble for on 2/22/26. On 3/2/26 at 2:45 PM, Staff F, RN, revealed on 2/27/26 around 5:30 AM she was setting up medication for the North medication cart and it included about 20 residents. Staff F stated she was under the assumption if she set up medications on her cart she could pass those medications, but she knew it's wrong. Staff F revealed she did get education by the facility on 2/22/26, but she assumed if she set up the medication she could still pass them. Staff F said the reason she did that was so she could go in the medication cart and grab the cup that had a paper cup on top with the resident name on it, and deliver it to them. Staff F revealed when she gave the residents their med cup she knew they were getting the right medications because she set them up between 5:00 AM to 5:30 AM. Staff F explained she did this to save time, she just looked for the right name in the medication cart, was able to grab and go by verifying she had the right resident's name on the paper cup, but she did not verify the meds in the cup. Staff F further explained she typically sets up residents' morning medications around 5:30AM to 6:00 AM and residents' noon medications she set up between 9:00 AM to 10:00 AM. Staff F stated after she gave the meds she typically went to the MAR and signed them off, but sometimes she did not get back right away to do that. On 3/2/26 at 3:39 PM, Staff G, LPN, responded she worked the morning of 2/27/26 and did most of the nursing stuff while Staff F, RN, passed most of the medications. Staff G revealed the facility was always short CNAs and so she has to set up morning medications early to be able to get the job done. Staff G stated she set up medications on 2/27/26 for residents by using a plastic cup on bottom to hold the medications and a paper cup on top with the name of the resident the meds were intended for. Staff G said she did not pass any other nurses' medications they set up, but she set up her own meds so she was able to grab the resident's medications and go deliver them. Staff G stated she felt maybe other nurses at the facility could step up and come in to help so they could do it the right way, but she could not get done if she had to actually do it the right way, as she received too many interruptions. Staff G reported she had worked at the facility for 8 years and had always done it that way. In an interview on 3/4/26 at 8:40 AM with the Medical Director for the facility, he indicated he did not do the nurses job so it was hard to judge why the nurses were setting up medications in advance. He also verbalized economics only allows the facility to staff a certain way and if they had more staff then maybe some systems could work better. The Medical Director did not think setting up the insulin was good. He stated the system of setting up medications in advance did kind of bother him, but he was unsure how to help them to have a better solution to make it safe for the residents and meet the expectation with efficiency and not cause something that creates a totally new problem. In an interview on 3/4/26 at 10:07 AM with the Administrator, she stated she did not know why the nurses would be setting up medications in advance, there was a nursing standard of protocol, and the staff knew that it was a standard that should be followed at all times. Per the Administrator, should not be setting up medications early. She further explained it was not the nursing standard of practice from their education program and training and they all knew the right way it should be done. Per the Administrator, there was no excuse for not doing it the right way. She stated she felt it was very clear to them all right now and that it was not acceptable. Per the Administrator, they had all received the education, competency testing, signed contracts, and discipline. The Administrator reported hose that had been involved had received disciplinary action and all staff knew it was not acceptable; never trained or told that it was an acceptable process. In an interview on 3/4/26 at 4:13 PM, the facility's Pharmacist responded RNs and LPNs should administer meds to one patient at a time, punch out the medication, verify the med, and come back to sign them off in the MAR. The Pharmacist stated she would be most worried about anticoagulant medication (medication that thins the blood), as there was a narrow therapeutic window and worried for residents who received blood pressure med if they weren't prescribed any. The Pharmacist commented it was concerning if anyone ever got the wrong medications and it created extra work on the pharmacy end too. She went on to explain all insulin pens should be in the pharmacy labeled packaging, locked up when not used, and insulin should not be pre dialed to the dose until the time of administration. Review of an Order Listing Report provided by the facility on 3/4/26 revealed 12 residents received anticoagulant medications the morning of 2/27/26. Review of an Order Listing Report provided by the facility on 3/4/26 revealed 17 residents received blood pressure medications the morning of 2/27/26. Review of February 2026 MARs for residents who shared the same first name (Resident #2, #12, #20, #21, and #25) revealed the following residents took anticoagulant and/or insulin medication on the morning medication pass on 2/27/26: Resident #2 received insulin and anticoagulant medications. Resident #25 received anticoagulant medication. Review of the facility's policy Medication Administration - Medication Pass, last revised 5/2023 instructed the following: 1. Position medication cart in full view outside patient room or the dining room. 2. Perform hand hygiene. 3. Open Electronic MAR to the residents record and review physician medication orders against medication labels4. Read transcribed physician order on electronic MAR: patient name, medication name, dosage, route and interval ordered, remove medication from cart compare electronic MAR with medication label for accuracy.5. If medication is unfamiliar or physician order is questioned: read original physician order compare original physician order with the electronic MAR for accuracy remove medication from cart and compare with electronic MAR with the medication label for accuracy verify allergy status and contact physician for clarification, if needed 6. Read special medication administration instructions 7. Obtain vital signs, if applicable, and record results on electronic [DATE]. Prepare medications for administration 9. Administer medication, knock on door and request entrance, introduce self, explain medication administration need and provide privacy, administer medication in accordance with frequency prescribed by physician - within 60 minutes before or after prescribed dosing time. lock medication cart when not in direct view of nurse administering medication, take medication(s) and cup of liquid/food, if applicable, to resident, identify resident, describe name of medication and reason for use to patient and answer any questions if needed. Administer medication according to specific procedure such as oral, topical, injection, etc. remain with patient until administration of medication complete and document initials on electronic MAR for each medication administered, if administering a controlled substance it must be documented on controlled substance log and electronic MAR. 10. Patient Refusal, non-controlled medication, dispose of medication appropriately, document refusal on electronic MAR, notify physician/family of refusal as clinically indicated, controlled/narcotic medication refer to individual state regulations on how to dispose of controlled/narcotic medication document refusal on electronic MAR circle initials on Controlled Substance Charting Record and document refusal. Two licensed nurses sign form validating medication destruction notify physician of refusal as clinically indicated 11. Perform hand hygiene 12. Secure cart as required 3. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #43 documented a diagnosis of diabetes mellitus. Observation on 2/22/26 at 9:05 AM revealed Staff B, LPN. turned the dial on the insulin pen to 16 units without priming the insulin needle. Staff B indicated she was ready to administer the insulin (lispro) to Resident #43. After intervening (intervened prior to administration of the insulin due to safety), Staff B indicated she was not aware that she needed to prime the insulin pen needle to clear the needle of air. Review of Resident #43's Medication Administration Record (MAR) dated February 2026 revealed the following: a. Humalog (insulin) kwikpen (a device used for injecting insulin) give 15 units with breakfast. b. Humalog kwikpen give the following units depending on blood sugar readings 3 times a day; 150 - 200 milligrams per deciliter (mg/dL) give 1 unit; 201- 250mg/dL give 2 units; 251 - 300 mg/dL give 3 units, 301 - 350 mg/dL give 4 units; 351 - 400 mg/dL give 5 units; 401 - 450 mg/dL give 6 units, 451- 500 mg/dL give 7 units. In an interview on 2/22/26 at 9:12 AM, Staff B indicated that she had not primed any of the preset up insulins given that morning. In an interview on 2/22/26 at 9:14 AM, the DON responded she would have expected the insulin pen needle to be primed as the facilities standard procedure. Review of the Medication Administration: Injections revised 4/24 instructed the following for insulin administration: If the insulin pen appears cloudy, roll the pen in your hands, and turn it from side to side for one full minute. Do not shake pen Wipe the rubber stopper with an alcohol wipe Attach a new pen needle onto the insulin pen Prime the insulin per manufactures guidelines Select the dose of insulin prescribed by turning the dosage knob Cleanse injection site with alcohol wipe allowing area to dry prior to injection Remove needle protector; at injection site gently pinch tissue between thumb and fingers Quickly insert needle at a 90-degree angle and slowly push the knob of the pen, holding pen at the site 6-10 seconds and then pull the needle out Place needle in sharps container

Based on observation, staff, and pharmacist interviews, and policy review the facility failed to store medications in the pharmacy labeled package for all residents on 2 of 8 days of the survey. The facility also failed to keep insulin pens in a locked container/cart/room and keep narcotic in a double locked container/cart/room. The facility reported a census of 44 residents. Findings include: An observation on 2/22/26 at 7:17 AM revealed the facility had two (2) medication carts (South cart and North cart) in the building that contained all residents oral daily medications. The South cart had 21 plastic cups with pill medications inside them and white paper cups with names written on them, in the top drawer of the cart. The North cart had 18 plastic plastic cups with medications inside them and white paper cups with names written on them, in the top drawer of the cart. There were also 6 insulin pens in an unlocked container sitting at the nurse's station pre-dialed up to dosages with insulin needles on. There were also 3 more insulin pens sitting in the same container not dialed up without insulin needles on. On 2/22/26 at 7:25 AM, Staff B, Licensed Practical Nurse (LPN), stated she was the Charge Nurse on shift that day and she worked for a staffing agency. She revealed she started setting up all the residents' medications on the South medication cart around 5:00 AM for that day's morning medication pass. On 2/22/26 at 9:53 AM, Staff A, LPN stated when she came in that morning all her residents' morning medications were set up on the North medication cart for her for the morning medication pass and she did not set them up herself.On 2/24/26 at 11:17 AM, Staff C, RN, reported on 2/22/26 around 2:30 AM to 3:00 AM, she set up all residents' morning medications on the North med cart for Staff A, LPN, to pass and it included maybe around 20 residents' morning medications and one narcotic of Lyrica (a controlled substance used to treat pain). Staff C stated she looked at each medication when she was setting them up and went right on down the line. She revealed she put the meds in a plastic med cup with a white paper med cup on top and wrote the resident's name on them. On 3/2/26 at 2:45 PM, Staff F, RN, revealed on 2/27/26 around 5:30 AM she was setting up medication for the North medication cart and it included about 20 residents. On 3/2/26 at 3:39 PM, Staff G, LPN, stated she set up medications on 2/27/26 for residents by using a plastic cup on bottom to hold the medications and a paper cup on top with the name of the resident the meds were intended for. In an interview on 3/4/26 at 10:07 AM with the Administrator, she stated she did not know why the nurses would be setting up medications in advance, there was a nursing standard of protocol, and the staff knew that it was a standard that should be followed at all times. In an interview on 3/4/26 at 4:13 PM with the facility's Pharmacist informed RN's and LPN's should do one patient at a time, punch out the medication, verify the med and come back and sign them off. She went on to inform all insulin pens should be in the pharmacy labeled packaging and locked up when not used, and insulin should not be pre dialed to the dose until the time of administration. Review of the facility's policy Medication Administration - Medication Pass, last revised 5/2023 instructed the following:3. Open Electronic MAR (Medication Administration Record) to the residents record and review physician medication orders against medication labels4. Read transcribed physician order on electronic MAR: patient name, medication name, dosage, route and interval ordered, remove medication from cart compare electronic MAR with medication label for accuracy.5. If medication is unfamiliar or physician order is questioned: read original physician order compare original physician order with the electronic MAR for accuracy remove medication from cart and compare with electronic MAR with the medication label for accuracy verify allergy status and contact physician for clarification, if needed.

Based on record review, staff interview, and policy review the facility failed to make a good faith attempt and ensure effective quality assurance processes regarding significant medication errors when a deficient practice with F760, Residents are Free of Significant Medication Errors, was cited at the facility for 3 of 4 onsite surveys, which included the current survey, since 9/1/2024. The facility reported a census of 44 residents.Findings include: 1.Review of Form CMS-2567 (the official document produced after a state or federal inspection (survey) that included survey results) for the survey ending on 9/22/2024 documented the facility was cited for F760 relating to 1 of 3 residents received 6 medications that were not prescribed for him and was hospitalized overnight for observation. 2. Review of Form CMS-2567 for the survey ending on 11/14/2025 documented the facility was cited for F760 relating for 2 of 3 residents who had significant medication errors. One resident received 5 medications that were not prescribed to them and another resident continued to receive medication that was discontinued. A deficient practice with F760 was identified on the current survey ending on 3/4/2026. In an interview on 3/4/26 at 10:07 AM with the Administrator explained the facility completed plans of correction on F760 tags prior and did audits, she explained the DON (Director of Nursing) worked the floor, and they did not find any cause for concerns from those audits. Review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan dated 10/3/25 instructed the following for recognizing problems and improvement opportunities: The QAPI plan address the element of systematic analysis and systemic action using the following processes and system: root cause analysis, use of continuous cycle to evaluate the effectiveness of he performance improvement initiatives, communication of performance improvement project efforts and re-evaluation of the center's QAPI plan annually. The Direction of QAPI Activities section of the Plan included the QAPI committee was responsible and accountable for ensuring corrective actions were effective.

Based on observation, staff interviews, and policy review the facility failed to implement infection control measures when 6 of 6 morning insulins were stored together in a container (Resident #30, #14, #43, #19, #2, and #4). The facility also failed to provide Enhanced Barrier Precautions (EBP) as the Centers for Disease Control and Prevention (CDC) (an infection control strategy for nursing homes and long-term care facilities to reduce the spread of multidrug-resistant organisms, It involves using gowns and gloves during high-contact care for residents with wounds, indwelling devices, or known multi-drug resistant organism colonization) directs during wound care (Resident #37). The facility also failed complete routine glove change and hand hygiene during pressure ulcer care after cleaning the wound for 1 of 1 residents (Resident #37). The facility reported a census of 44 residents. Findings include: 1. An observation on 2/22/26 at 7:18 AM at the nurses station revealed 6 insulin pens were being stored with their lids off and touching in a plastic unlocked container with a blood glucose machine. In an interview with Staff B, Licensed Practical Nurse (LPN) on 2/22/26 at 11:10 AM revealed she came in at 4:00 AM today and Staff C, Registered Nurse (RN) had already pre dialed up her insulin medications for her and placed them in a container together for her to give. She acknowledged they should have been locked up and stored separately and not touching. In an interview on 2/22/26 at 11:26 AM with the Director of Nursing (DON) informed the staff have been educated on not setting up medications in the past and she is not sure why they do it, and it was not how they were trained. In an interview with Staff C, Registered Nurse (RN) on 2/24/26 at 11:17 AM revealed she pre dialed six (6) insulin pens for Staff B on 2/22/26 around 2:00 AM to 2:30 AM and put them in the medication room sitting together in a plastic container. She informed she did this to help give Staff B a jump start when she would arrive to the facility. During an interview on 2/25/2026 at 1:06 PM the Infection Preventionist explained each resident's insulin pens should be stored in separate containers within the medication cart. The facility provided on 2/25/26 a undated list titled, Morning Insulins, for residents whose insulin pens were observed in the container together on 2/22/26 at 7:18 AM; Resident #30, #14, #43, #19, #2, and #4. Review of the facility's policy Medication Administration - Medication Pass, last revised 5/2023, instructed to remove medication from the locked medication cart, listed multiple steps on how to ensure verification of the medication and then to administer. 2. Resident #37's 11/20/25 Minimum Data Set (MDS) Assessment showed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. The MDS lacked documentation of pressure wounds to the heels. The MDS documented other open lesions on the foot; use of a pressure reducing device for the chair and the bed, nutritional intervention to manage skin problems, and application of dressing to the feet. A Physician Order signed by the Provider on 2/4/26 directed to apply a hillbilly hyperbaric (oxygen treatment to the pressure wound) to the left heel pressure ulcer wound for 2 hours twice a day. Apply a dressing change twice a day and as needed. Cleanse the pressure wound with hydrogen peroxide, light gauze over the wound when not in oxygen (treatment). The 12/2/25 Risk of Alteration in Skin Integrity Care Plan documented stage 4 pressure ulcers to both the right and left heels and directed the nursing staff to administer the treatment per the physician orders. The Care Plan lacked direction to utilize EBP due to pressure wounds of both heels. Observations on 2/25/26 at 8:48 AM revealed no CDC EBP sign on Resident #37's door. During an observation completed on 2/25/26 at 8:49 AM, Staff E, Licensed Practical Nurse (LPN) knocked, explained, washed hands and provided privacy. Staff E failed to apply a gown for EBP prior to initiating the wound treatment. Staff E opened a new package of oxygen tubing, attached the tubing to the oxygen concentrator and placed the tubing inside a plastic bag. Staff E then applied gloves without performing hand hygiene, removed Resident #37's left sock and gauze dressing to the left heel. Staff E changed her gloves without performing hand hygiene, placed a clean paper chux under left heel. Staff E proceeded to cleanse the left heel pressure wound, then changed her gloves without performing hand hygiene. Observation revealed a oblong triangular open wound bed to the left heel with an approximate quarter size of serosanguineous drainage to the old wound dressing. Staff E applied the plastic bag over Resident #37's left calf, secured the bag in place with tape, removed her gloves, turned on the oxygen concentrator and then placed another clean chux under Resident #37's left foot. Staff E washed her hands and turned the faucet off with her right wrist, then dried her hands with paper towel. During an observation on 2/25/26 at 11:11 AM Staff E applied gloves, removed the tape and plastic bag (hillbilly bariatric chamber device) from the resident's left foot. Staff E changed gloves without performing hand hygiene and placed a clean paper chux under the resident's left heel. Staff E cleansed Resident #37's left heel, then applied a clean gauze dressing without changing gloves and secured the dressing with tape. She removed the paper chux from under the resident's left heel. Removed her gloves. Staff E pulled the garbage up out of the garbage can, tied the garbage bag, then picked up Resident #37's clean sock from the bedside table and placed his sock on the left foot. Staff E washed her hands and turned off the faucet with her right wrist, then grabbed paper towel to dry her hands. Interview completed on 2/25/26 at 11:23 AM revealed Staff E reported she utilized a clean barrier for Resident #37's supplies and wore gloves. She further explained Resident #37 has never been on EBP as he does not have any infection in his pressure ulcer wounds. Staff E reiterated EBP would only be required if Resident #37's pressure ulcers had infection present. Interview on 2/25 26 at 1:01 PM revealed the Infection Preventionist (IP) reported they have a monthly list that lists all residents that require EBP. Resident #37's name should be on the list for EBP. They communicate EBP through nursing and then they let the aides know because any long-term wounds can be easily infected. EBP should be in the resident's care plan and the staff should also go to the communication book for the resident EBP list. The IP explained EBP for wound care would require the use of gown and gloves. The gowns and gloves should be kept in the resident's room. The nurses are supposed to dispose of gloves, perform hand hygiene and then apply new gloves during a wound treatment. They nurses should be washing their hands between the glove changes. When washing hands, it would not be appropriate for a nurse to turn off the faucet with their wrist. A clean paper towel should be utilized. On 2/25/26 at 1:14 PM Staff E explained each Certified Nursing Aide (CNA) report book had a resident EBP list in the front of the manuals. Staff E pulled the EBP resident list from the manual. The EBP list failed to have Resident #37's name listed. Staff E acknowledged the EBP list was undated and voiced two of the residents on the list were recent catheters so she knew the list had been revised the past few weeks. The EBP list at the bottom documented, remember (you) must wear a gown and gloves when providing cares. During an interview on 2/25/26 at 2:05 PM the Director of Nursing (DON) reported Resident #37 was not on EBP. She had thought they needed to place residents on EBP for long-term wounds. She explained staff were to perform hand hygiene when changing gloves either by using hand sanitizer or washing their hands. She also observed Staff E should have changed her gloves after she cleansed Resident #37's heel before applying the clean dressing. The DON further voiced staff should turn off the faucet with a clean paper towel versus using their wrist. Clinical Record review on 2/25/26 at 2:30 PM of the Physician Orders revealed Resident #37 developed the right heel pressure wound on 10/4/25 and the Progress Notes revealed the development of a left heel pressure ulcer measuring 6 centimeters (CM) x 4 CM on 11/25/25. The Enhanced Barrier Precautions Policy revised 3/2024 provided by the facility documented a purpose to minimize the risk of transmission of novel or targeted Multi-Drug Resistant Organisms (MDRO) during high contact resident care activities for residents requiring EBP. The Policy under Procedure directed EBP will be used in conjunction with standard precautions for residents with wounds even if the resident is not known to have infection or colonization with a targeted MDRO. Note: wounds include chronic wounds including but not limited to, pressure ulcers. The Policy directed for resident whom EBP indicate a gown and gloves should be used during high contact resident care activities that provide opportunity for MDROs to be transferred to staff hands and clothing. High contact resident care activities include: wound care, any skin opening requiring a dressing. The Policy included a table under EBP that directed during wound care requiring a dressing, gloves and a gown should be worn prior to the high contact activity.

Based on record review, staff interviews, and policy review the facility failed to complete a root cause analysis after each fall to ensure an intervention to prevent future falls was put in place, and failed to ensure the intervention was related to the reason the fall occurred for 1 of 1 resident reviewed for fall with major injury (Resident #7). The facility also failed to update the Care Plan timely related to falls for Resident #7. The facility reported a census of 44 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #7 documented a Brief Interview for Mental Status (BIMS) of 8 out of 15, indicating severe cognitive impairment. The MDS documented he was dependent on staff for walking and moving to desired locations in his wheelchair and was frequently incontinent of urine and bowel. The MDS also documented diagnoses of seizure disorder, anxiety, intellectual disabilities, and dementia with psychotic disturbances. Review of Resident #7's current Care Plan on 2/25/26 revealed the resident was at risk for unavoidable falls related to history of falls, Epilepsy, BPH (Benign Prostatic Hyperplasia), dementia, intellectual disability, anxiety disorder, impulsivity, and poor decision making. The following fall interventions, with date created in the computer, were on the current Care Plan: a. 10/28/24 call light within reach and assist with ambulation and transfers as needed.b. 9/23/25 hi/low bed and keep bed in lowest position when he is in it. c. 9/22/25 pressure alarm in bed and pull tab alarm when in wheelchair/recliner.d. 10/2/25 use body pillow when in bed for positioning and landing strip next to bed.e. 10/3/25 offer and assist with toileting frequently.f. 10/6/25 when anxious attempt to assist to the bathroom.g 11/18/25 ensure is place in a comfortable position and frequent reposition changes in place.h. 11/19/25 use distraction techniques with him during times of anxiety.i. 11/20/25 distract him during shift changes so he does not see staff leaving. j. 11/25/25 he may put himself on the floor and stay there if he is safe until he is ready to get up, staff are to ensure safety while on the floor. k. 12/11/25 toilet every 2 hours while awake.l.12/16/25 gait belt available on his wheelchair.m. 1/6/25 move to a quiet are when he becomes agitated. n. 1/9/26 monitor in dining room when play cares and assist so he is not stand up or reaching for objects.o. 1/27/26 non-skid footwear and assist to quieter environment when he is in a noisy environment and has signs of agitation, anti-tippers to wheelchair, bed is in a low position when resident is in bedp. 2/10/26 when attempting to get up assist with repositioningq. 2/23/26 assist to bathroom prior to meals.r. 2/10/26 assist to bathroom after supper meal. The facility provided by e-mail correspondence document titled Resident #7 Incident Reports, Notifications, and Neuros. The document included Resident #7's falls from 9/6/2025 to 2/25/2026, the document included paper Neurological Assessments that were completed after falls, Progress Notes, and Incident Reports. Review revealed, in part, the following: a. On 9/14/25 at 8:45 PM he had an unwitnessed fall in another residents room.b. On 9/19/25 at 1:37 PM he had a witnessed self transfer fall after using the hand pedal bike in the dining room.c. On 11/24/25 at 2:20 AM he had an unwitnessed fall in the dining room.d. On 11/27/25 at 3:30 AM he had a witnessed fall in the dining room when staff were attempting to assist.e. On 12/26/25 at 12:20 PM he had a witnessed fall at the nurses station.f. On 12/29/25 at 4:53 PM he had a witnessed fall in the dining room. Review revealed the following falls did not have root cause analysis and relevant interventions put in place to address the fall; 9/14/25 at 8:45 PM, 9/19/25 at 1:37 PM, 11/24/25 at 2:20 AM, 11/27/25 at 3:30 AM, 12/26/25 at 12:20 PM, and 12/29/25 at 4:53 PM. In an Email correspondence with Administrator on 3/2/26 at 11:14 AM revealed the following regarding Resident #7's falls: a. On 9/14/25 at 8:45 PM his fall intervention was a pad alarm at all times.b. On 9/19/25 at 1:37 PM his fall intervention was a mattress on the floor and a high-low bed.c. On 11/24/25 at 2:20 AM his fall intervention was that he may put himself on the floor and stay there until he is ready to get up and Staff are to check on him to ensure safety while he is on the floor. d. On 11/27/25 at 3:30 AM his fall intervention was to offer and assist with toileting frequently.e. On 12/26/25 at 12:20 PM his fall intervention was to take him to the bathroom and offer to lie down.f. On 12/29/25 at 4:53 PM his fall intervention was to place a pad alarm under his cushion in the wheelchair. The Incident Reports, Notifications, and Neuros document also informed the following falls resulted in him going to the emergency room (ER) and resulted with treatment for fractures: a. On 11/4/25 at 4:00 PM he had an unwitnessed fall in the dining room, alarm was going off, staff ran to answer the alarm but he was on the floor. The resident was sent to the ER for evaluation for left wrist pain and swelling. Review of Resident #7's Progress note on 11/4/2025 at 4:27 PM documented he returned from the ER (Emergency Room) and had a traumatic closed fracture of ulnar styloid with minimal displacement, left initial encounter (crack in the small bony bump on the outside of left wrist (near the pinky side) caused by a sudden injury) and Traumatic closed torus fracture of metaphysis of left distal radius with minimal displacement, initial encounter (wrist fracture where the bone has slightly buckled or compressed after a fall, rather than breaking all the way through). A wrist splint was placed on his left hand and was to remain on for 6 weeks. b. On 1/8/26 at 2:58 PM he had a witnessed fall in the dining room and was sent to the ER for evaluation due to pain in his right elbow, right hip and left shoulder. Review of Resident #7's Progress Note on 1/8/2026 at 9:42 PM documented he returned from the ER at at 7:30 PM and has a closed fracture of his distal ulna (a break in the forearm bone) located on the pinky-finger side, right near the wrist) and was to wear a splint to the affected arm for now and family may be interested in surgical repair. He also needed to wear an arm sling to his right arm for comfort and keep right his arm elevated when possible. In an interview on 3/4/26 at 8:40 AM with Resident #7's Doctor/Medical Director revealed Resident #7 entered the facility with a seizure disorder and his intellect was also vastly declining. Nurses would ask for the past year as he to declined if it was related to pain or what was going on. His fractures did not slow him down. His vascular dementia probably started about 2 years ago and his rapid decline started in February 2026, with a failure to thrive and became anorexic and would not drink anything. The Doctor/Medical Director revealed attempted to get him into to a geriatric psychiatric nursing facility but nothing was available. He could be very violent, and then became more frail as he declined. His falls were 100% percent unavoidable, and could not even make him a one to one with staff because if one person was in his face all the time that would make him even more aggressive. Per the Doctor/Medical Director, could have put 6 alarms on him but no matter what he was still going to take the first 2 steps and fall, and just couldn't catch him. The Doctor/Medical Director explained thought the facility did the best they could. In an interview on 3/3/26 at 3:15 PM with the Director of Nursing (DON) explained Resident #7 really started to have changes in September 2025, and were unable to do a lot because his behaviors were so extreme. Per the DON, thought he might of started to have some terminal restlessness in January 2026. He was a very busy guy and resistive to cares. Per the DON, reviewed falls daily at Interdisciplinary Team (IDT) meetings, and the Administrator took notes, but she did not have a formal tracking sheet regarding each one of Resident #7's falls and finding the root cause analysis. Review of the facility's Fall Occurrence policy, revised 2/2024 instructed, in part, the following: 2. Based on assessment, interventions are implemented and placed on the resident Care Plan .6. Additional intervention(s) will be implemented post fall. The IDT team may the the intervention(s) if the IDT investigation identifies a more appropriate intervention for the individual fall .7. The Resident's Care Plan will be updated with any new or revised interventions(s).

Based on observation, record review, staff interviews and policy review the facility failed to provide restorative programs as directed for 2 of 2 residents reviewed for restorative and develop/implement a restorative treatment policy for the facility to follow (Resident #36 and #7). The facility reported a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #36 documented a Brief Interview for Mental Status (BIMS) of 12 out of 15, indicating moderate cognitive impairment. The MDS also revealed she needed supervision/touching assistance to walk 10 feet but could not walk greater than 50 feet due to medical condition or safety concerns and needed partial to moderate assistance by staff when she used her manual wheelchair for distance greater than 50 feet. The resident had impairment on one side to her upper and lower extremity that interfered with daily function or placed her at risk for injury. The MDS documented diagnoses of cancer, hypertension and dementia. An observation of Resident #36 on 2/22/26 at 3:12 PM revealed she appeared to have limited Range of Motion (ROM) in both of her arms and legs. Review of Resident #36's January 2026 and February 2026 Documentation Survey Report V2 revealed she had 2 restorative programs in place: a. Restorative AROM (Active Range of Motion) Program: [Brand Name Redacted of Recumbent Cross Trainer Machine], level 3 for 15 minutes OR active range of motion exercises to arms and legs, all motions. (arm exercises using green theraband, leg exercises using a one-pound weight, rest breaks as needed. Repetitions/Durations: 20 repetitions. OR active range of motion to arms and legs (arm exercises using the arm bike, light resistance for 5-8 minutes, leg exercises using a one-pound weight, 20 repetitions x 2, standing exercises, and choice of task: sort cards, weighted clothes pins, large pegs.) 15 minutes per day as tolerated 3 times a week and as needed.b. Restorative Walking Program (includes minutes only): Ambulate with front wheeled walker, one staff assist, and gait belt distance as tolerated everyday. In January 2026 the report revealed she did not complete/facility did not offer her Restorative AROM Program 6 times and Restorative Walking Program 1 time.In February 2026 the report revealed she did not complete/facility did not offer her Restorative AROM Program at all for the whole month (12 times) and Restorative Walking Program 5 times.Review of Resident #36's Progress Notes lacked nursing review of her Restorative Program and progression or decline from 3/1/25 to 3/4/26. Review of Resident #36's Care Plan on 2/25/26 documented a goal that she will improve/maintain her current ROM to arms (goal date initiated 2/20/25), with interventions to encourage her to participate in restorative programs, follow therapy recommendations as applicable, and provide resident with required assistive devices such as wheelchair and walker.2. The MDS dated [DATE] for Resident #7 documented a BIMS score of 8 out of 15, indicating severe cognitive impairment. The MDS documented he was dependent on staff for walking and moving to desired locations in his wheelchair and was frequently incontinent of urine and bowel. The MDS also documented diagnoses of seizure disorder, anxiety, intellectual disabilities, and dementia with psychotic disturbances.Review of Resident #7's January 2026 and February 2026 Documentation Survey Report V2 revealed he had 1 restorative program in place: a. Restorative AROM (Active Range of Motion) Program: [Brand Name Redacted of Recumbent Cross Trainer Machine], level 4 for 15 minutes per day as tolerated. In January 2026 the report revealed he did not complete/facility did not offer his Restorative AROM Program 10 times and he refused it 3 times. In February 2026 the report revealed he did not complete/facility did not offer his Restorative AROM Program 10 times and he refused 1 time. Review of Resident #7's Progress Notes lacked nursing review of his Restorative Program and progression or decline from 2/20/26 to 2/25/26. Review of Resident #7's Care Plan on 2/25/26 instructed he was on a Restorative Nursing Program to help achieve and maintain optimal physical, mental, and psychosocial health (date initiated 2/20/25), with intervention to encourage him to participate in restorative programs and follow therapy recommendation as applicable (intervention dates 2/20/25). In an interview on 2/24/26 at 2:33 PM with the Administrator revealed the restorative programs for all residents are in their Electronic Health Record (EHR) and are documented under the task section. She informed the facility did not have a formal restorative program, it was strictly to maintain the resident's current functional ability. In an e-mail correspondence with the Administrator on 3/2/36 at 1:05 PM revealed the facility did not have a policy related to restorative programs, because they did not have a formal Restorative Program in which they captured restorative minutes on the MDS. The person who did the restorative was a Certified Nurse Assistant (CNA). In an interview on 3/3/26 at 3:15 PM, the Director of Nursing (DON) explained the MDS Coordinator put the Restorative Programs into the EHR and then she made a copy so people could see them and she lets Staff I, CNA know. She explained she did not complete monthly or quarterly progress notes and neither did the MDS Coordinator. In an interview on 3/4/26 at 12:23 PM with the MDS Coordinator explained she put Restorative programs in the EHR for the staff to do and if the program changes or was discontinue she updated the Care Plan but did not complete routine progress notes or evaluation of the restorative programs. In an interview on 3/4/26 at 12:49 PM with Staff I, Certified Nurse Assistant (CNA) explained Resident #7 would ride the bike depending on his mood and she felt she had enough time to complete restorative programs. She informed if she saw a decline in a resident she would tell the nurse on duty or the DON, but she really hasn't had to do that for anyone recently. She also informed in the past a nurse used to watch her complete so many residents programs a month, but no one had done that for awhile.

Based on observation, and resident and staff interviews the facility failed to provide care routine skin monitoring to cancerous lesions on the scalp and resident requested assessment/treatment for 1 of 3 residents reviewed for skin conditions (Resident #36). The facility also failed to maintain documentation that Neurological assessments (often called neuro checks) were performed after unwitnessed falls for 3 of 7 falls that indicated a need for neuro assessment monitoring (to detect serious, hidden brain injuries that might not be obvious right away, because bleeding or swelling in the brain can develop slowly over hours or even days, these tests are repeated to monitor for changes in a person's condition) for 1 of 1 resident reviewed for fall with major injury (Resident #7). The facility reported a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #36 documented a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. The MDS documented diagnoses of cancer, hypertension and dementia. Review of Resident #36's Medication Review Report signed by her Doctor/Medical Director on 1/22/25 instructed a twice a day treatment of hydrogen peroxide to her scalp, order date 5/22/24. An observation and interview on 2/22/26 at 3:03 PM with Resident #36 revealed she had been asking the nurse for 2 hours for them to take care of a skin site on her head. The scalp on the top of her head appeared to measure approximately 3 inches x 1 inch of loose dry skin with red beefy skin underneath.Observation of the nurses station revealed two nurses were sitting at the desk. They were made aware of Resident #36's complaint, and Staff B, Licensed Practical Nurse (LPN) came over and informed Resident #36 she would look at it when she was done giving report. An observation on 2/23/26 at 2:21 PM of Resident #36's scalp revealed the loose dry skin measuring 3 inches by 1 inch was no longer present on her scalp, and a large red scab present which measured approximately 3 inches by 1 inch. Review of Resident #36's Progress Notes from 2/21/26 to 2/24/26 lacked documentation and treatment regarding what happened to the loose skin on her scalp. Review of Resident #36's Care Plan on 2/25/26 revealed she had a history of an open areas on her scalp related to skin cancer on scalp and a scalp infection (created on 10/28/24 and last revised on 2/13/26). In an interview on 3/3/26 at 3:15 PM the Director of Nursing (DON) revealed Resident #36 had no active skin sheets, she had skin cancer on (her) head, previously they used a cream and put on the spots, and it changed recently due to it almost getting worse. Per the DON, stopped the treatment and the treatment changed to hydrogen peroxide. She revealed the facility planned on starting a skin sheet for her. In an interview on 3/4/26 at 8:40 AM, Resident #36's Doctor/Medical Director informed she had skin sites on her scalp since at least 2021 and right now they were consistent with squamous cell carcinoma. The Doctor/Medical Director further explained over the past few years he had ordered chemotherapy cream treatments. He explained it would probably never cure but are trying to minimize the impact it had on her life. He further explained the facility had completed labs in the past and she had completed courses of antibiotics and antifungal, but this had been an ongoing issue. He also explained she had no pain to the site, he looked at it usually every month when he visited, however it might not be documented. He further explained she (resident) is usually in the dining room and he could observe it. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #7 documented a Brief Interview for Mental Status (BIMS) of 8 out of 15, indicating severe cognitive impairment. The MDS documented he was dependent on staff for walking and moving to desired locations in his wheelchair and was frequently incontinent of urine and bowel. The MDS also documented diagnoses of seizure disorder, anxiety, intellectual disabilities, and dementia with psychotic disturbances. The facility provided by e-mail correspondence a document titled Resident #7 Incident Reports, Notifications, and Neuros, the document included Resident #7's falls from 9/6/2025 to 2/25/2026. The document included paper Neurological Assessments that were completed after falls, Progress Notes, and Incident Reports. The following falls did not have Neurological (neuro) assessments and/or documentation of completed neurological assessments: a. On 9/6/25 at 1:31 AM he had an unwitnessed fall and a neuro assessment was started.b. On 9/8/25 at 10:17 AM he had a fall that was witnessed and he hit his head and a neuro assessment was started.c. On 11/24/25 at 2:20 AM he had an unwitnessed fall and a neuro assessment was not started. In an Email correspondence with Administrator on 3/2/26 at 11:14 AM revealed the following regarding Resident #7 falls: a. On 9/6/25 at 1:31 AM, neuros were completed per progress notes, but they were unable to locate the paper copy of neuro sheet.b. On 9/8/25 at 10:17 AM, neuros were completed per progress notes, but they were unable to locate the paper copy of neuro sheet.c. On 11/24/25 at 2:20 AM no neuro assessments completed. In an interview on 3/3/26 at 3:15 PM with the Director of Nursing (DON) explained usually once the neuro sheets were complete they got filed away, but she could not find them. Review of the facility's Fall Occurrence policy, revised 2/2024 instructed, in part, Neurological assessment will be initiated for unwitnessed falls and/or falls that are witnessed and the resident hits their head (neuros completed as directed on neuro flowsheet).

Based on record review and staff interviews the facility failed to code 1 of 2 residents catheter (Resident #38), 1 of 1 resident pressure ulcer (Resident #37), and 1 of 2 residents Preadmission Screening and Resident Review (PASRR) outcome (Resident #8) on the Minimum Data Set (MDS) assessment to reflect their current status at the time of the MDS assessment. The facility reported a census of 44 residents. Findings include:1. Resident #38's Medication Review Report signed by his doctor on 1/28/26 revealed an active order to continue use a of his catheter that started on 8/15/25. The MDS assessment dated [DATE] for Resident #38 documented a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating no cognitive impairment. The MDS documented a diagnosis of obstructive uropathy (a blockage in the urinary tract that hinders urine flow, causing it to back up into the kidneys and leading to potential damage), and that he did not have a catheter. 2. Resident #37's Wound Evaluation, dated 12/2/25 documented an assessment of a right heel unstageable facility acquired pressure ulcer that was identified at the facility on 10/4/25.The MDS assessment dated [DATE] for Resident #37 documented a BIMS of 15 out of 15, indicating no cognitive impairment. The MDS documented he did not have a pressure ulcer.3. Resident #8's current Preadmission Screening and Resident Review (PASRR) (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) dated 5/27/24 revealed he had a PASRR [NAME] II outcome (a determination that confirms an individual has a serious mental illness, intellectual disability, or related condition, and decides whether nursing facility placement is appropriate and if specialized services are needed).The MDS assessment dated [DATE] for Resident #8 documented a BIMS of 15 out of 15, indicating no cognitive impairment. The MDS documented he has diagnoses of anxiety and schizophrenia and did not have a PASRR Level II outcome.In an interview on 3/03/26 at 3:15 PM with the Director of Nursing (DON) revealed the MDS Coordinator had been doing MDS for approximately 2 years now she did them previously before. She informed Resident #38 has a catheter, Resident #8 was a PASRR level II, and Resident #37 had a pressure ulcer and should have been coded accurately to reflect each resident's status. In an interview on 3/4/26 at 12:23 PM with the MDS Coordinator explained Resident #38 did have a catheter, Resident #37 did have a pressure ulcer, and Resident #8 was a PASRR Level II. She revealed she had a system in place to complete MDS so they should not be coded inaccurately and had a Corporate staff member she could talk to if she would have question.

Based on record review, staff interviews and policy review the facility failed to ensure non-pharmacological interventions were in place and anti-psychotics were used to treat relevant diagnoses and not a behavior (agitation) for 1 of 3 residents reviewed (Resident #38). The facility reported a census of 44 residents. Findings include: 1. The MDS assessment dated [DATE] for Resident #38 documented Brief Interview for Mental Status (BIMS) of 13 out of 15, indicating no cognitive impairment. The MDS documented he admitted to the facility on [DATE] and had diagnoses of non-Alzheimer's dementia with other behavioral disturbances, anxiety, and unspecified depression. Per this assessment, the resident had no hallucinations, no delusions, no physical or verbal behavioral symptoms directed towards others, no other behavioral symptoms not directed towards others, no rejection of care exhibited, and no wandering exhibited. Review of Resident #38's Medication Review Report signed by his Doctor on 1/28/26 indicated he had been taking seroquel (an antipsychotic medication used to treat schizophrenia, bipolar disorder, and major depressive disorder) 50 mg (milligram) daily for agitation and anxiety disorder since 10/24/2024. Review of Resident #38's Progress Notes from 1/1/2025 to 2/22/2026 revealed a Gradual Dose Reduction had not been completed for his seroquel medication, and his most recent gradual dose reduction on 8/27/25 at 9:50 AM revealed a request was denied by his Doctor for his anti-depressant, anti-anxiety medication and anti-psychotic medication with a rationale the benefits of the medications outweigh the risk and the medications enhance his ability to function at his highest functional level. Review of Resident #38's Care Plan on 3/3/26 revealed he was on an anti-psychotic medication and to attempt non-pharmacological intervention prior to use of psychotropic medications as of 10/21/24, but lacked non-pharmacological interventions. In an interview on 3/3/26 at 3:15 PM with the Director of Nursing (DON) explained Resident #38 did not have behaviors or psychotic episodes and his seroquel was being used to treat his anxiety. She also revealed he started on it after he was admitted to the facility, when he was a lot more agitated, but was not currently. In an interview with Resident #38's Doctor, the facility's Medical Director, on 3/4/26 at 8:40 AM revealed Resident #38 could do some gradual dose reduction on his medications, as he was not as aggressive anymore like he was in the past. Review of the facility's policy Usage for Psychotropic Medications Guidance, last revised 3/2025, instructed when prescribing new medications and/or increasing dosage the facility should, document non-pharmacological approaches used and their outcome. The policy also instructed to ensure and document psychotropic medications are necessary to treat specific, diagnosed, and documented conditions causing distress.

Based on record review, staff interviews and policy review the facility failed to provide informed consent regarding the risk and benefits for as needed psychotropic medications (medications that affect brain activity, influencing mood, thoughts, behavior, and perception to treat mental health conditions) for 1 of 3 residents reviewed for antipsychotic medications (Resident #7). The facility reported a census of 44 residents.Findings include: Review of Resident #7's Progress Notes written by his Doctor on 12/17/25 documented he continues to benefit from his medication ziprasidone (an antipsychotic given by a shot called an Intramuscular (IM) injection) and ABHR (ativan, benadryl, haldol, reglan) gel (a compounded gel medication that goes on the skin, containing Ativan/lorazepam (anti-anxiety medication), Benadryl/diphenhydramine (anti-histamine medication), Haldol/haloperidol (antipsychotic medication), and Reglan/metoclopramide (anti-dopaminergic) (a medication that blocks dopamine receptors, preventing dopamine from binding and reducing its activity)). Review of Resident #7 Medication Administration Record (MAR) documented current orders starting on 2/10/26:a. Ziprasidone 20 milligram's (mg) give IM every 12 hours ase needed for severe agitation related to his unspecified dementia, with psychotic disturbance for fourteen (14) days, then discontinue. b. ABHR gel (lorazepam 1mg, diphenhydramine 12.5 mg, haldol 2mg, reglan 20 mg per milliliter (ml), apply 1 ml of the gel to the skin every 4 hours as needed for aggression and anxiety related to his unspecified dementia, with psychotic disturbance and anxiety disorder for fourteen (14) days, then discontinue. Review of Resident #7 Progress Notes from 12/1/25 to 2/25/26 lacked documentation of family consent and education of adverse side effects regarding the risk and benefits of receiving as need antipsychotic medications of ziprasidone and ABHR gel. Review of Resident #7 current Care Plan on 2/25/26 instructed he is receiving antipsychotic, antidepressant and antianxiety medications to manage his impulsivity and keep him calm. In an interview on 3/3/26 at 3:15 PM with the Director of Nursing (DON) revealed psychotropic medication consents are completed in Assessment on the residents Electronic Health Record (EHR) and Resident #7 did not have ones completed for his ziprasidone and ABHR gel. Review of Resident #7 Assessments in his EHR (electronic health record) on 3/4/26 revealed he did not have an Assessment for completed for psychotropic medication consent for his ziprasidone and ABHR gel. In an interview on 3/4/26 at 10:07 AM with the Administrator informed Resident #7 family was very hard to get in contact with. Review of the facility's policy Usage for Psychotropic Medications Guidance last revised, 3/2025 instructed the facility will obtain informed consent from resident and/or their representative before initiating or increasing psychotropic medication use. Informed the resident, family, or representative of the benefits, risks, and alternatives, including black box warnings, before initiating or increasing medication.

Based on clinical record review, staff interview, facility video, and facility policy review the facility failed to properly assess and intervene for 2 of 3 residents reviewed, (Residents #3 and #8). The facility identified a census of 45 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 7/24/25 indicated Resident #3 had diagnosis that included Non-Traumatic Brain Dysfunction, Alzheimer's Disease, Non-Alzheimer's Dementia and a Retinal Vascular Occlusion. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 (cognitively impaired), with delusions, ambulated with a walker, required supervision to touch assistance with transfers and ambulation and with two (2) falls since reentry to the facility on 2/25/25. A Care Plan included the following Focus and Interventions: a. I have impaired visual function related to (r/t) blindness in my right eye. b. The resident required assistance with activities of daily living (ADL's). 1. Ambulation - Supervision with assistance of one (1) staff member. c. At risk for falls. 1. Resident fell 2/21/25, 2/23/25, 7/9/25, 7/22/25, 8/26/25 and 10/17/25. d. At risk for pain r/t generalized pain verbalized by the resident. 1. Evaluation of her pain level as ordered. 2. Monitored for factors/activities that precipitated or aggravated the pain. e. Resident required an indwelling catheter. Review of the facilities video footage revealed the following instances occurred on 10/17/25 at the approximate times listed below: a. At 7:31:52 until 7:32:04 p.m. (according to the video time stamp) - The resident stood from her recliner took five (5) steps towards a dining room table, tripped over her catheter tubing, fell on her left side and hit her head on the recliner all the while Staff A, Licensed Practical Nurse (LPN) and Staff B, Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA) stood at the nurse's station. b. 7:31:59 p.m. - Staff A remained at the nurse's station while Staff B walked around the front of the station with her head positioned down as she looked at an item in her and and walked down the North hallway. The resident in site. c. 7:32:08 p.m. - The resident stood from the reclined electric chair d. 7:32:13 thru 7:32:23 p.m. - Staff A casually walked to the resident positioned on the floor and held out her hand towards the resident. e. 7:32:31 - Staff B arrived and both Staff A and Staff B sat the resident up on her buttocks. f. 7:33:13 - Both staff members placed their hands/arms under the resident's bilateral arms/axilla (armpit) area and stood the resident while her left leg presented internally rotated, her foot dragged behind and she refused application of pressure to the area. g. 7:33:31 - The staff sat the resident in a dining room chair. h. 7:33:38 - Staff B pushed the dining room chair across the carpet approximately 10 feet to the same electric recliner she stood from prior. i. 7:34:08 - Staff again transferred the resident as described above from the dining room chair to an electric recliner. j. 7:34:19 - The resident held her left leg/hip while positioned in her chair. k. 7:34:30 thru 7:35:25 - Staff covered the resident with a blanket, reclined the chair and walked away. l. 8:43:54 p.m. - Staff A and Staff C, CNA stood resident from recliner chair without the use of a gait belt assistive device and ambulated the resident attempted to take approximately 10 steps to a dining room table, limped during the process and failed to bare weight on the left leg. m. 8:45:09 p.m. - The resident remained in a standing position at the dining room table as she leaned her head down (chin to chest type position) and rested her arms on the table. n. 8:45:27 p.m. - The resident stood back up straight. o. 8:46:03 p.m. - The resident remained standing but leaned to the left and on Staff A. p. 8:46:29 p.m. - Staff A assisted the resident into a dining room chair. q. 8:47:04 p.m. - Staff C brought a piece of paper and writing tool to the resident as a means of communication. r. 8:53:05 - The resident remained positioned in the dining room chair as she moved around frequently as Staff A and C periodically stayed and left the resident's side. s. 8:55:54 - Staff A and Staff C stood the resident as stated above and again without the use of a GB assistive device. t. 8:56:11 - The staff sat the resident back down in the dining room chair. u. 9:21:25 - The ambulance crew arrived. v. 9:27:25 - Transferred the resident per GB and the assistance of 2 ambulance crew members. A Progress Note entry identified as a late entry dated 10/17/25 at 7 p.m. included the following information: Resident #3 had been administered the medications for Resident #6 which consisted of Melatonin (hormone that regulated sleep) 3 milligrams (mgs), Mirtazapine (antidepressant) 15 mg, Alprazolam (antianxiety) 0.375 mgs and Apixaban (anticoagulant) 2.5 mg. A Progress Note entry identified an Incident Report as a late entry dated 10/17/25 at 7 p.m. included the following information: The resident sat in a recliner in the day room, stood up and immediately fell to the floor next to the recliner. The nurse witnessed the fall from across the room and observed her as she landed on her left side on the floor while the pressure alarm sounded. Staff assisted the resident to her feet and helped her back into the recliner. The resident complained of pain to her left leg with no deformity noted and no pain as the nurse palpated the upper leg. Vital signs included a blood pressure (B/P) of 156/80, Pulse (P) 83, Respirations (R) 20, Temperature (T) 97.2 degrees Fahrenheit (F) and an oxygen saturation rate (O2) of 95%. The resident continued to complain of leg pain so Staff A and Staff B, CNA stood the resident and walked her as the resident refused placement of weight on her left leg. Staff sent the resident to the emergency room (ED) by ambulance. An X-ray showed a closed, traumatic, minimally displaced fracture of the trochanter of the left femur. The family chose no surgical intervention and the hospital sent the resident back to the facility on Hospice care. According to an email dated 10/31/25 at 11:12 a.m. the Director of Nursing (DON) indicated Staff A made the Progress Notes entries from 10/17/25 on 10/20/25 at a time unknown and under the directive of management. According to an email dated 10/31/25 at 12:02 p.m. the DON indicated she had not been sure where Staff A obtained the information she documented above because she had been unable to answer questions that pertained to her assessment rather she stated she could not have recalled. An Ambulance service Patient Care Report dated 10/17/25 indicated the ambulance crew had been dispatched at 8:22 p.m., arrived at the scene at 8:28 p.m. and departed the facility with the resident at 8:43 p.m. The Narrative portion included the following information: Upon arrival the patient had been located in the commons area accompanied by 2 nursing home staff. The staff stated the patient was seated in a chair then for an unknown reason fell forward to the ground and landed on her left side. The staff then approached the patient and attempted to assist her to a standing position and ambulatory but it caused the patient to much pain so the ambulance crew had been activated. An ED Provider Note form dated 10/17/25 at 8:51 p.m. indicated the resident presented at the ED following a fall out of a recliner as she landed on her left hip and complained of left hip pan. At 9:17 p.m. the nursing facility called the ED and informed them the patient received 2.5 mg of Eliquis not prescribed to her that night. (The facility failed to notify the ED related to the other 3 medications administered in error. The ED described the Impression as a mildly impacted and angulated intertrochanteric left femur fracture. A Hospice Certification and Plan of Care form with the start of care dated 10/18/25 indicated the top 3 admission diagnosis in the following order: Alzheimer's Disease, Fall and a Trochanteric Fracture of the Left Femur. The Discharge Instructions directed the facility staff the patient planned to return to facility enrolled in Hospice for pain control, nonsurgical pain control and end of life care. During an interview 10/21/25 at 4:55 p.m. Staff D, CNA confirmed she worked the night the resident fell but not present in the area she fell. When Staff C told her of the fall she knew right away it had been this resident because she became restless at that time of night and refused to stay positioned in the recliner. The staff member indicated when a resident fell she had been told staff left the residents on the floor until the nurse assessed the resident. During an interview 10/22/25 at 4:42 p.m. Staff B confirmed worked 10/17/25 from 3 until PM med pass was over approximately 9:30 p.m Staff B Confirmed the resident had been positioned in recliner chair in dining/lounge area when she passed her HS meds to her and then returned to medication cart and continued to pass meds to other residents. Staff B then dished up the medications for Resident #6, who had been positioned right past resident #3, but in the course of that medication administration, Resident #3 quickly scooted down the foot rest of her recliner so the staff member approached the resident with the medications for Resident #6 still in-hand and assisted her back into the chair. Staff B stated at that point lost her mind and gave Resident #3 the medications of Resident #6. Staff B did not recall if she lifted her up in the chair or scooted her back but thought the alarm had been positioned under the resident. Staff B then went and found Staff A and reported the medication error. Staff B suggested Staff A should have completed a medication error report and Staff A voiced she had not planned to do so. Staff B confirmed she had not observed the resident as she fell, had been unable to recall if the pressure alarm sounded but she had notified Staff A about the fall. At that point, the staff members walked to the resident and helped get her up off the floor. Staff A asked the resident if she had pain on her head or any other place and the resident stated nope. When the staff members stood the resident she complained of terrible leg pain as she grabbed her left leg. The staff members then positioned the resident in the recliner in the lounge/dining area at which time the staff member had been corrected due to the actual video footage so at that point she indicated she had no recollection of the event and staff members interventions at that time. Staff B confirmed Staff A failed to assess the resident and per policy and procedure they are required to do so prior to having moved a resident who had fallen. During an interview 10/22/25 at 11:44 p.m. Staff A confirmed she worked as the charge nurse on 10/17/25 from 4 p.m. to 4 a.m. and just prior to the fall the resident attempted to stand when Staff B redirected the resident. Shortly after the redirection the staff members stood at the nurse's station when she heard the alarm sound so she looked up and witnessed the resident as she fell and landed on her left side. The staff member indicated she performed a hit and miss assessment for injuries and directed an unknown CNA to have performed an assessment of the resident's vital signs. Staff A indicated the resident had not complained of pain on the floor and/or when the staff stood her and positioned her back into the recliner however after a short time later complained of pain so she decided to send her to the ED. The staff member confirmed she failed to perform thorough range of motion (ROM) exercises and vitals per facility policy. The staff member confirmed the resident had been known to self transfer and that had been why staff kept her positioned in a visible area in the facility and not in bed. During an interview 10/23/25 at 9:02 p.m. Staff A now confirmed she had been in the general area of the fall but had not observed her as she stood the first time due to the chaos rather she knew what Staff B reported to her was the resident's pressure alarm sounded so Staff B responded and made sure the resident sat in the chair. Staff B then informed her of the medication error which had been right around the time the resident's alarm sounded again. Staff A indicated both staff members were about to respond when the resident fell and it took longer to respond, because the staff members were in the midst of discussion about the medication error. At that time she had not known but she was muddled and confused. The staff member indicated in hindsight Staff A and B should have ended their discussion on the medication error and responded to the resident more quickly. Staff A confirmed when the staff stood the resident they sat her in the recliner for comfort. Again the staff member stated, the resident never complained of pain until after she sat in the recliner for 5-10 minutes but she had been unable to pinpoint the location of the pain at that time until later when she verbalized the left leg. When the staff member pressed on hip the resident expressed no pain. The staff member indicated she observed her hip for bruising and that had been when she stated the area hurt so bad. At that point the staff member debated whether to send her to the ED but she wondered if her current condition had been her normal level of care so she decided ambulation of the resident would have been an effective assessment because the staff member had been aware she ambulated. When the staff ambulated the resident she failed to place any weight at all on her left leg so that is when Staff A decided something had been wrong, called the physician and ambulance crew for transportation to the ED. After the resident left with the ambulance crew had been when the staff member called the ED and informed them the resident received Eliquis and that she should have informed them of all 4 of the medications administered in error. When asked Staff A what she failed to do she stated, number 1, I failed to get to her quicker, #2 I failed to do a complete evaluation before we got her up and #3 she failed to tell the physician about all the incorrect medications administered. When asked why she had not told the truth in the beginning Staff A responded by stating because I knew I was wrong. During an interview on 10/22/25 at 12:42 p.m. Staff E, CNA indicated she had not been present when the resident fell however when she came to the conference room and planned to chart a little after 7:30 p.m. she overheard the resident as she stated ouch my leg. When Staff E originally came to conference room the resident had been positioned in a recliner in the lounge/dining area and when Staff E came out of the conference room the resident had then been positioned in a dining room chair approximately 15-25 feet away from the recliner with staff present. When Staff E exited the conference room she heard the resident as she verbalized ouch I want an ambulance and my leg hurt as she rubbed her hip. Staff A stated lets try some pain meds but approximately 20 minutes later the resident continued verbalization of pain. Staff E confirmed the resident had not been supposed to self transfer as she required one staff assistance. Staff E described the facility policy following a resident's fall as the nurse's were required to thoroughly assess a resident when on the floor. Had heard Staff A failed to properly assess other residents after they fell as well. During an interview 10/22/25 at approximately 1:50 p.m. the DON confirmed the nurse's assessment had not been as thorough as she would have expected after review of the video and nurse failed to assess the resident's vital signs. During an interview on 10/28/25 at 10:17 a.m. Staff D, RN MDS Coordinator and the DON confirmed the facilities policy following a resident fall consisted of the following: In the event of a witnessed or unwitnessed fall staff went right to the resident/person while positioned on the floor, assessed vital signs, performed ROM, assessed for abnormalities and stopped bleeding if applicable. Staff D confirmed the staff members failed to have performed neurological assessments. During an interview 10/23/25 at 12:05 p.m. Staff C, CNA indicated Staff A notified her of the resident's fall and asked her if she would check her out with a plan to ambulate the resident as an assessment to see if she could walk. Staff A and Staff C stood the resident without a gait belt as the resident complained of leg pain and barely placed weight on her leg, she barely put it on the ground and lifted it back up again. The staff member confirmed the resident stood on one leg and they sat her down in a dining room chair because she could not walk. The staff member indicated the nurse had been required to have assessed the resident on the floor with no movement with a potential injury. During an interview 10/29/25 at 1:07 p.m. a Hospice staff member confirmed staff having moved the resident would have affected and/or worsened her fracture and caused her harm and increased pain and a non-repaired fall and fracture would have hastened the resident's death. During an interview 10/29/25 at 1:47 p.m. the Hospice staff member indicated she had spoken with the Hospice Medical director who indicated he had been unable to state the cause of death without the death certificate but 9 times out of 10 when the elderly sustain a fall and fracture they throw an emboli which caused death. The Hospice Medical Director felt because she called out in pain when she fell staff should not have moved her and the continued movement could have caused a worsening fracture. More than likely with a femur fracture occurred with the initial fall and worsened with each transfer/movement. Staff A signed acknowledgement of the facilities LPN Floor Nurse job description form on 5/12/25 which indicated she understood her job duties which included the following: a. Promotion of quality nurse care to guests in an environment that promoted their rights, dignity and freedom of choice. b. Carried out direct contemporaneous charting on your shift. c. Responsible for all nursing care of assigned guest while on duty. Notification of appropriate persons of a significant change in a guest's condition. d. Assurance that guest care plans were followed and assessed each guest's status in accord with their care plan. e. Completed medical records documenting care provided and other information in accordance with nursing policies. f. Maintained the comfort, privacy and dignity of guest and interacted with them in a manner that displayed warmth, respect and promoted a caring environment. During an interview 10/29/25 at 1:59 p.m. Staff F, CNA indicated it had been the charge nurse's responsibility when a resident fell to have to have made sure the resident safe, staff were not to move the resident until the nurse completed a thorough assessment which included vital signs, range of motion and complete follow up. During an interview 10/29/25 at 2:08 p.m. Staff G, CNA indicated when a resident fell direct care staff had been directed to call for the nurse, leave the resident where they fell for the nurse to have completed a through assessment of the resident and to have made sure nothing broken. During an interview 10/21/25 at 4:55 p.m. Staff H, CNA confirmed when a resident fell the nurse's responsibility began with an assessment of the resident vital signs. The staff member indicated upon hire she had been directed all residents remained positioned on the floor following a fall until the nurse completed her assessment. A Fall Occurrence policy and procedure revised 2/2024 indicated the Purpose as the assurance the residents were evaluated for fall risks and implemented interventions which minimized the risk for falls and/or the risk for injury from falls. The Procedures included the following: a. An Incident Report completed by the nurse with each fall. b. Residents assessed by a licensed nurse prior to having been moved after a fall. c. Neurological assessment initiated for an unwitnessed fall and/or falls witnessed and the resident hit their head. d. Notification of a physician and resident representative. d. Documentation and monitoring completed for 72 hours post a fall. 2. A Minimum Data Set (MDS) assessment form dated 9/22/25, (follow up to his 9/15/25 readmission to the facility) indicated Resident #8 had diagnosis that included Heart Failure (HF), Diabetes Mellitus (DM), Non-Alzheimer's Dementia, altered mental status, adult failure to thrive and abnormal weight loss. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 (cognitively intact), required partial/moderate assistance with toileting, personal hygiene and non-ambulatory. The assessment identified the resident without any skin issues and as not on a repositioning program. The Care Plan included a Focus area of at risk for alteration in skin integrity related to a potential risk for development of a pressure ulcer. The Interventions included the following: a. Provision of preventative skin care. A Nursing - Admission/readmission Assessment form dated 9/15/25 at 12:39 p.m. indicated the resident as readmitted to the facility with a right trochanter blister and no further assessment provided (i.e. measurements, surrounding skin, drainage, odor). According to an email dated 11/30/25 at 10:34 a.m. the Director of Nursing (DON) confirmed the facility staff failed to assess the resident's blistered area between 9/15/25 and 9/29/25 and she had been unsure of the etiology of the blistered area. A Progress Notes entry dated 9/29/25 at 9:30 a.m. indicated the resident with an intact blister on his right hip that measured 6.5 centimeters (cm) by (x) 2.2 cm with no further assessment completed. According to the facilities Timeline of Events form (not dated) included the following entries which pertained to the resident's blistered area as dated:a. 10/4/25 - 6 cm x 3 cm x 0.0 cm, a scant amount of serous drainage, wound bed dark pink/red tissue with the blister opened and pain noted. b. 10/15/25 - 2.3 cm x 1.5 cm, purulent drainage, slough noted in the wound bed and surrounding skin red. The physician started the resident on Cephalexin 500 milligrams (mg's) three times a day (TID) for 7 days.

Based on observation, facility video review, resident interview, staff interview and facility policy review, the facility failed to follow appropriate infection control practices during direct resident cares for 3 of 3 residents reviewed. (Resident #1, #3 and #4) The facility identified a census of 45 residents.Findings includeAn observation of the facilities video coverage dated 10/17/25 revealed Staff J, Licensed Practical Nurse (LPN) as she washed and gloved her hands prior to the removal of a supportive boot and wound dressing on the left foot/leg of Resident #4. The staff member then performed the prescribed physician treatment to the resident's upper left heel and the tips of her toes with the same gloved hands. Following completion of the treatment Staff J placed the non-used and/or prescribed treatment supplies in a plastic bag and placed the plastic bag back into the resident's treatment supply basin without sanitization of the surface areas. During an interview on 10/28/25 at 4:20 p.m. the Director of Nursing (DON) confirmed the above documented observation. Review of the facilities video footage dated 10/17/25 revealed the following as timed: a. 7:36:40 p.m. - Staff A, performed the treatment to the left leg/foot of Resident #1 in the dining/lounge public area with six (6) residents present. The staff member failed to place a barrier between the table and resident treatment supplies that consisted of creams, bandages, scissors, tape and etc. Following completion of the treatment the staff member placed the remaining supplies directly into the treatment cart without sanitization. b. 8:26:17 p.m. - As Resident #3 remained positioned in a recliner in the dining/lounge area, Staff A approached her, pulled out the resident's sweat pants as she palpated the residents left hip with her bare hands and proceeded to touch the resident's person, the furnishings and herself without having washed her hands. Review of the facilities video footage timeline of events revealed the following; a. 7:26:41 thru 7:48:31 - Staff A walked to Resident #1 in the dining area and completed the dressing change while her leg had been positioned on a chair directly across the dining area from Resident #3. b. 7:49:40 p.m. - Staff A pressed on the resident's left hip area. c. 7:50:34 p.m. The nurse looked under the residents pajama bottoms as if she looked for any bruising or injury and pressed on the resident's hip. d. 7:51:30 p.m. - The nurse finished with the resident and walked away. e. 7:52:42 p.m. - The nurse walked back to the resident after she applied gloves at the medication cart and again palpated or rubbed the resident's left hip. During an interview on 10/22/25 Staff A confirmed she failed to place a barrier between the table and treatment supplies and she failed to sanitize the items when she replaced them into the treatment cart.

Based on clinical record review, staff interview, a Licensed Practical Nurse (LPN) Job Description form and facility policy review, the facility failed to maintain complete and accurate resident records for 2 of 3 residents reviewed. (Resident #3 and #5) The facility identified a census of 45 residents.Findings include: A Progress Note entry identified an Incident Report as a (late entry) dated 10/17/25 at 7 p.m. included the following information: The resident sat in a recliner in the day room, stood up and immediately fell to the floor next to the recliner. The nurse witnessed the fall from across the room and observed her as she landed on her left side on the floor while the pressure alarm sounded. Staff assisted the resident to her feet and helped her back into the recliner. The resident complained of pain to her left leg with no deformity noted and no pain as the nurse palpated the upper leg. Vital signs included a blood pressure (B/P) of 156/80, Pulse (P) 83, Respirations (R) 20, Temperature (T) 97.2 degrees Fahrenheit (F) and an oxygen saturation rate (O2) of 95%. The resident continued to complain of leg pain so Staff A and Staff B, CNA stood the resident and walked her as the resident refused placement of weight on her left leg. Staff sent the resident to the emergency room (ED) by ambulance. An X-ray showed a closed, traumatic, minimally displaced fracture of the trochanter of the left femur. The family chose no surgical intervention and the hospital sent the resident back to the facility on Hospice care. According to an email dated 10/31/25 at 11:12 a.m. the Director of Nursing (DON) indicated Staff A documented the above stated information on 10/20/25 at a time unknown and under the directive of management. Review of the facilities video footage dated 10/17/25 from 7:31:52 thru 9:27:25 revealed Staff A failed to assess the resident while positioned on the floor which included any physical abnormalities and vital signs. Staff A and Staff B stood the resident while her left foot leg appeared internally rotated and the resident failed to place any pressure on the foot/leg. According to an email dated 10/31/25 at 12:02 p.m. the DON indicated she had not been sure where Staff A obtained the information she documented above because during their interview process Staff A had been unable to answer questions that pertained to her assessment as she told the DON she could not have recalled. A Fall Occurrence policy revised 2/2024 included the following Procedures: a. An incident report completed by the nurse each time a resident fell.b. Residents assessed by a licensed nurse prior to having been moved after a fall.c. Neurological assessment initiated when a resident hit their head. 2. An Individual Resident's Controlled Substance Record form dated 9/29/25 indicated Resident #6 had a physician's order for Xanax 0.25 milligrams (mgs)1.5 tablets and on 10/17/25 at 6:36 p.m. the medication had been destroyed. During an interview 10/23/25 at approximately 1 p.m. the Director of Nursing (DON) confirmed the medication as not destroyed rather administered to Resident #3. Staff A signed acknowledgement of the facilities LPN Floor Nurse job description form on 5/12/25 which indicated she understood her job duties which included the following: a. Promotion of quality nurse care to guests in an environment that promoted their rights, dignity and freedom of choice. b. Carried out direct contemporaneous charting on your shift. c. Completed medical records documenting care provided and other information in accordance with nursing policies.

Based on the facilities video footage review, clinical record review and staff interview the facility failed to assure 2 of 3 residents remained free of significant medication errors. (Resident #3 and #5)Findings include: The facilities Investigative Report form included the following timeline of events per their review of the video footage: a. 7:10:25 p.m. (camera time) - Staff B, Certified Medication Aide (CMA) administered the physician prescribed medications for Resident #3. b. 7:30:06 p.m. - The CMA wrongfully administered medications prescribed for Resident #6 to Resident #3. According to a computer generated form the CMA administered the following medications prescribed to Resident #3 on 10/17/25 at 6:21 p.m. a. Buspirone Hydrochloride (anti-anxiety) 5 milligram (mg) tablet. b. Acetaminophen (pain) 325 mg tablet. c. Alprazolam/Xanax (anti-anxiety) 0.25 mg tablet. d. Melatonin (sedative/hypnotics) 5 mg tablet. e. Pepcid (H2-receptor (decreases acid in the stomach) 20 mg tablet.According to a Medication Event - Wrong Medication form dated 10/17/25 at 7 p.m. Staff A, Licensed Practical Nurse (LPN) documented Staff B had been in the middle of her medication pass and just answered a telephone call amidst other interruptions when a resident's pressure alarm went off. The CMA rushed to assist the resident back into her recliner because she scooted herself to the edge of the recliner and tried to stand up. The CMA had another resident's medications crushed in a cup with a spoon during that time and erroneously gave this resident Melatonin 3 mgs, Mirtazapine (anti-depressant) 15 mg, Alprazolam 0.75 mgs and Apixaban (anti-coagulant) 2.5 mg. According to a written statement (not dated) the Director of Nursing (DON) confirmed Resident #3 received the medications prescribed for Resident #6 at approximately 6:36 p.m.2. An Incident Report-Medication Event form dated 9/10/25 at 4:28 p.m. included the following information: Staff discovered on rounds that Resident #5 continued to receive Seroquel 12.5 mgs in addition to Seroquel 25 mg in the morning when the Physician changed the order on 8/28/25 for Seroquel 25 mgs in the morning and 12.5 mg at noon and supper.

Based on staff interview, resident interview and facility policy review the facility failed to answer resident call lights in a timely manner, within 15 minutes and provide enough staff to meet the individual needs of the residents for 2 of 2 residents reviewed. (Resident #2 and #4) The facility identified a census of 45 residents. Findings include: During an interview on 10/28/25 at 11:03 a.m. Resident #2 offered she felt the facility failed to staff the appropriate amount of staff to meet the individual needs of the residents. The resident indicated she timed her call light as on for 2 1/2 hours as she used the clock on the wall which caused her anger. The resident also offered recently staff left her in bed in the morning because it took 2-3 staff for transfers and the facility failed to provide enough staff to get her up for the day that morning which she wanted to do. During an interview on 10/28/25 at 1:06 p.m. Resident #4 confirmed she waited for an extended period of time for staff to have responded to her call light and no time of day had been worse than the other. During an interview on 10/29/25 at 1:59 p.m. Staff F, Certified Nursing Assistant (CNA) confirmed staff as unable to answer resident call lights within 15 minutes because they got stuck in resident rooms somewhere and there had been no way to get to resident's fast enough. The staff member felt the facility failed to provide enough staff because she felt people had not wanted to work healthcare. The current healthcare staffing crisis had been contributed to the fact the care in nursing facilities had not been like the [NAME] days, its not grandma's and grandpa's anymore it had been so many more types of residents they cared for now. During an interview on 10/29/25 at 2:08 p.m. Staff G, CNA indicated staff answered resident call lights 95% of the time but felt the staff had been staffing challenged the past year because of management having capped staff wages which made Staff G sad. During an interview on 10/29/25 at 2:49 p.m. Staff I, CNA indicated staff tried to answer resident call lights within 15 minutes but she could not confirm it occurred every single time. A Call Light Policy form revised 9/2023 described the Purpose as an assurance of prompt responses to a resident's call for assistance.

Based on clinical record review, staff email and a Skin Quick Reference form, the facility staff failed to maintain complete and accurate Care Plans for 1 of 3 residents reviewed. (Resident #8) The facility identified a census of 45 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 9/22/25, (follow up to his 9/15/25 readmission to the facility) indicated Resident #8 had diagnosis that included Heart Failure (HF), Diabetes Mellitus (DM), Non-Alzheimer's Dementia, altered mental status, adult failure to thrive and abnormal weight loss. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 (cognitively intact), required partial/moderate assistance with toileting, personal hygiene and non-ambulatory. The assessment identified the resident without any skin issues and as not on a repositioning program. A Nursing - Admission/readmission Assessment form dated 9/15/25 at 12:39 p.m. indicated the resident as readmitted to the facility with a right trochanter blister and a scabbed area on his coccyx and no further assessment provided (i.e. measurements, surrounding skin, drainage, odor). The form indicated the resident had a history of pressure ulcers and at risk for further development of ulcers. The Care Plan failed to address the resident's active skin issues and expected interventions. According to an email dated 11/14/25 at 2:40 p.m. the Director of Nursing (DON) sent the following explanation which pertained to the Care Plan policy: Per the Care Plan Policy - The facility puts in place person centered care plans outlining care for residents. These are reviewed and revised by the interdisciplinary team after completion of MDS assessments, when applicable and with changes that warrant a care plan revision.Review of a Skin Quick Reference Guide revised 11/2023 provided by the facility included the following Components of a Wound Evaluation:a. A completed head to toe body assessment upon admission and a confirmed re-check within 24 hours of admission. b. Completed documentation required as noted above. c. Initiated Care Plan interventions.

Based on clinical record review, staff interview, family interview, hospital staff interview and facility policy review the facility failed to notify 1 of 3 resident family members/representatives which pertained to a condition change and/or medication error. (Resident #3) The facility identified a census of 42 residents. Findings include: A Progress Note entry identified as a late entry for the following event dated 10/17/25 at 7 p.m. included the following information: Resident #3 had been administered the medications for Resident #6 which consisted of Melatonin (hormone that regulated sleep) 3 milligrams (mgs), Mirtazapine (antidepressant) 15 mg, Alprazolam (antianxiety) 0.375 mgs and Apixaban (anticoagulant) 2.5 mg. Staff A, Licensed Practical Nurse (LPN) asked the emergency room (ED) Physician Assistant to have notified the family. The facility notified the family on 10.20.25 at 4:30 p.m. During an interview on 10/21/25 at 1:50 p.m. the resident's family indicated just prior to her fall the resident received four (4) wrong medications, Mirtazapine, Alprazolam, Melatonin and Eliquis prescribed for a separate resident and the facility failed to notify the family. The family indicated they were alerted to the mistake on 10/20/25 when they received the hospitals History and Physical report but the facility failed to notify them directly. The family indicated the facility only told the hospital she received Eliquis that was not prescribed to her on 10/17/25 but not the other 3 medications.Staff A signed acknowledgement of the facilities LPN Floor Nurse job description form on 5/12/25 which indicated she understood her job duties which included the following: a. Promotion of quality nurse care to guests in an environment that promoted their rights, dignity and freedom of choice. b. Responsible for all nursing care of assigned guest while on duty. Notification of appropriate persons of a significant change in a guest's condition. A Notification for Change of Condition policy and procedure form revised 6.2023 indicated the Purpose as a provision of care to residents and notification of resident change in status. The Procedure included the following: a. Immediately informed the resident, consult with the resident's physician and if known, notification of the resident's legal representative or an interested family member when there had been the following: 1. An accident which involved the resident which resulted in injury with a potential for physician intervention. 2. A significant change in the resident's physical, mental or psychosocial status (i.e., a deterioration in health, mental or physical status).

Based on observation, video footage review, clinical record review, staff interview and review of the facilities Resident [NAME] of Rights, the facility failed to maintain the dignity and respect during cares for 2 of 3 residents reviews. (Resident #3 and Resident #4). The facilities identified a census of 45 residents. Findings include: 1. Review of the video footage revealed the following: a. 8:26:17 p.m. - As Resident #3 sat positioned in a recliner chair in the dining/lounge area, Staff A, Licensed Practical Nurse (LPN) approached the resident, pulled out her sweat pants at the waist band area, placed her hands inside the sweat pants and palpated the resident's left hip area following a fall as another resident sat approximately12 feet right across from Resident #3 in direct view. Review of the facilities timeline of events provided from the video footage included the following: a. 7:49:40 p.m. - Staff A pressed on the resident's left hip area. b. 7:50:34 p.m. The nurse looked under the resident's pajama bottoms as if she looked for any bruising or injury and pressed on the resident's hip. c. 7:51:30 p.m. - The nurse finished with the resident and walked away. d. 7:52:42 p.m. - The nurse walked back to the resident after she applied gloves at the medication cart and again palpated or rubbed the resident's left hip area. 2. Review of the facilities timeline of events from their own video footage included the following: a. 7:36:41 p.m. - The nurse walked to Resident #4 positioned in the dining room and completed a dressing change while the resident's leg rested on a chair directly across the dining/lounge area from Resident #3. During an interview 10/22/25 at a time unknown Staff A confirmed she performed the resident's foot treatment in the dining on 10/17/25. The staff member indicated she had not been aware of the facilities policy and procedure related treatments and privacy. Staff A signed acknowledgement of the facilities LPN Floor Nurse job description form on 5/12/25 which indicated she understood her job duties which included the following: a. Promotion of quality nurse care to guests in an environment that promoted their rights, dignity and freedom of choice. b. Maintained the comfort, privacy and dignity of guest and interacted with them in a manner that displayed warmth, respect and promoted a caring environment. The facilities Resident Rights - Dignity and Respect form revised 4.2024 indicated the Purpose as the foundation for the treatment of all residents with dignity and respect. The Procedure included the following: a. Each resident had the right to considerate and respectful care and to have been treated with honesty, dignity, respect and with reasonable accommodation of individual needs. b. Each resident had the right to have been free from physical, verbal, sexual or mental abuse.

Based on record review and staff and resident interviews the facility failed to give 1 of 3 residents the correct medications and inadvertently gave him another residents medications that included anti-psychotic medication resulting in over sedation and admission to the hospital for observation (Resident #1). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) for Resident #1 dated 8/15/24 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented he did NOT take anti-psychotic medication and had no neurological diagnoses. The MDS also documented his psychiatric/mood disorder was depression. Record review of an emergency room (ER) note dated 9/18/24 for Resident #1 documented he received the following wrong medications at the facility: Zonisamide 100 milligrams (mg) - anti-convulsant Zofran 4 mg - anti-emetic Sucralfate 1 gram (g) - ant-acid Seroquel 200 mg - anti-psychotic Propranolol 20 mg - beta blocker Tylenol 1000 mg - analgesic The ER note also documented he was minimally arousal all afternoon according to family and the facility, and had a blood sugar of 52. He was sedated likely due to the Seroquel he received in error, Poison Control suggest six (6) hours of observation. His low hypoglycemia (blood sugar) was likely due to being sleepy and sedated. Plan is to admit to the Hospital for accidental Seroquel administration and hypoglycemia. The facility will admit him for close monitoring and anticipated metabolism of the inadvertently provided Seroquel. Record review of a document titled, Action Plan for Medication Event on 9/18/24 instructed the following: a. Resident was assessed and physician was notified. b. A full investigation was completed. c. Effective immediately a sign will be placed on the medication cart while medication pass is in progress to deter interruptions. 4. On 9/19/24, re-education of the six (6) rights of medication pass was provided to all nurses and CMA's. 5. Medication Pass audits will be completed two (2) times a week on all shifts for one (1) month. The frequency of audits thereafter will be determined by outcomes. Record review of a Progress Note dated 9/19/24 at 3:02 PM by Resident #1 Doctor documented, he had a minor event on 9/18/24 and given several wrong medications which were intended for another resident. Most notable was an anti-psychotic Seroquel 200 mg. He ultimately settled in for the afternoon and slept, which was expected. He did experience an episode of hypoglycemia that was not directly related to the medication. However, Resident #1 is a gentleman who typically snacks all afternoon, and he did not do that, but rather slept, and that led to hypoglycemic episode that resulted in his transport to the emergency department for evaluation. It was a predictable event, not directly caused by the medication, but caused by his sleeping. During an Interview on 9/20/24 at 6:40 PM with Resident #1 revealed he recently went to the hospital because his blood sugars tanked. He informed everything went fine and he got to come back home to the facility. During an interview with the Administrator on 9/20/24 at 6:47 PM revealed Resident #1 was given the wrong residents medications this week on 9/18/24 and they sent him the hospital for evaluation and he ended up staying the night for observation. During an interview on 9/20/24 at 7:48 PM with the Director of Nursing revealed Staff A, Certified Medication Aide (CMA) received an upsetting personal call prior to the noon medication pass on 9/18/24 and she did all her correct checks but walked to the wrong resident. She informed she immediately put an action plan in place so this would not occur again. During an interview with Staff A, (CMA) on 9/22/24 at 12:58 PM informed she was on break and received a phone call that was upsetting, and got distracted and accidentally gave Resident #1 another resident's medications. She informed as soon as she got back to the cart she identified the error right away and his Doctor and the DON were updated. She informed after this happened she had a conversation with the DON about how it could have been prevented.

Based on observation, policy review, and staff interviews the facility failed to keep bare hands off the drinking surfaces of glasses in order to serve meals under sanitary conditions for 1 of 1 meals observed. The facility reported a census of 39 residents. Findings include: An observation of the noon meal on 4/22/24 from 11:05 AM to 11:42 AM revealed Staff A, Cook, served 28 glasses to 19 residents while touching the drinking rim surfaces with her bare hands. Staff A picked up the glass with one hand, poured juice or milk with the other hand, and set the glass back on the table to serve the resident. Staff A also pushed the beverage cart throughout the dining room with her bare hands. The cart handle was not observed to be sanitized throughout meal service. Staff A was not observed to perform hand hygiene during the meal service. In an interview on 4/24/24 at 12:01 PM Staff B, Dietary Manager explained the facility provided training on appropriate serving techniques upon hire. She explained she expected staff to touch silverware only by the handles, never the tines of silverware. Staff must never touch the drinking rims of any glasses or mugs. Plates must be held by the edge and base; no fingers are allowed on food surface areas. (During the ongoing observation in the kitchen of the noon meal on 4/23/24, multiple staff members were observed grabbing the milk jugs by the handle during meal preparation and service. Hand hygiene prior to touching the jugs was not observed.) The facility lacked a policy regarding dining services and appropriate hand placement during food service.

Based on record review, staff and resident interviews, the facility failed to ensure each resident was free from sexual abuse for one of four residents reviewed. (Resident #2). This constituted immediate jeopardy to Resident #2's health and safety. The facility reported a census of 48 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment tool dated 10/26/16, Resident #2 displayed intact cognition and was independent with transfers, ambulation, dressing, personal hygiene and toilet use. The MDS documented Resident #2 required staff supervision with bathing. The plan of care with a target date of 1/24/17 revealed Resident #2 admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The plan of care identified the resident tended to be a loner and needed reminders from staff to participate in activities he/she enjoyed. The plan of care documented the Resident #2 liked to be naked in his/her room at times and directed staff to provide privacy and pull the privacy curtain. Interventions related to Resident #2's behaviors included providing Resident #2 a private place if staff found Resident #2 disrobing or stimulating him/herself in a public area. The nurse's notes revealed a follow-up assessment dated [DATE] at 10:56 a.m. The nurse documented Resident #2 had been (previously) sexually assaulted by another resident. That shift, Resident #2 had been walking around the facility with his/her nephew. The resident showed little or no emotion related to assault, but stated it was an awful thing that happened. In an order note dated 11/2/16, The Nurse Practitioner wrote: (Resident #2) may return to facility and resume previous orders. Place Resident #2 away from (Resident #1) to prevent further complaints since Resident #1 has been known for the behavior displayed tonight. In the nurse's notes dated 11/3/16, a third shift nurse documented Resident #2 slept well this shift with no complaints. It was reported when I got here last night Resident #2 kept turning his/her call light on and shutting it off him/herself as if he/she was testing it. During an interview on 11/8/16 at 12:48 p.m., Resident #2 was asked how things were going. Resident #2 reported there had been an incident in the past when he/she was in bed and Resident #1 came to his/her side of the room and grabbed Resident #2. The Resident stated his/her pants had been partially undone. When asked where Resident #1 had grabbed him/her, Resident #2 demonstrated around his/her neck and groin. When asked if Resident #1 had grabbed his/her private/genital area, Resident #2 responded in the affirmative. Resident #2 stated he/she pulled his/her call light. Resident #1 had not done this before. During an interview on 11/8/16 at 12:24 p.m., Staff B stated when Resident #2 activated his/her call light the night of 11/1/6, she immediately went to his/her room. Staff B stated both privacy curtains were pulled and she went toward the top of the curtain on Resident #2's side of the room. Staff B stated she observed Resident #2 in bed with his/her pants partially down with crease of buttocks visible, and Resident #1 with his/her underwear pulled down, standing beside Resident #2 making thrusting motions to Resident #2's buttocks. Staff B reported she couldn't see Resident #1's genitalia from that angle because she was behind and to the left of Resident #1. Staff B reported she immediately asked Resident #1 what he/she was doing. Resident #2 did not respond, so Staff B asked again. Resident #1 jumped and quickly replaced his/her clothing, put his/her privates back into their underwear, then attempted to exit Resident #2's side of the room. Staff B asked the resident if he/she was ok and Resident #2 replied yes and handed her the call light which he/she had pulled completely out of the wall outlet. During an interview on 11-08-16 at 11:12 a.m., Staff A reported during the overnight shift, staff had always kept an eye on Resident #1 due to his/her heterosexual tendencies. Resident #1 would visit the snack bar usually several times a night, but at least once at midnight. Staff A stated Resident #1 at times would expose him/herself, but on the night of the incident there had been not been behaviors reported to her. Staff A stated about 11:45 p.m. on 11-01-16, the call light in Resident #2's room was activated. Staff A stated she had not known Resident #2 to ever activate his/her call light, so she and Staff B hurried to Resident #2's room. Staff A stated Staff B came out of Resident #2's room very upset and reported to her what she had observed. Staff A stated she immediately responded to Resident #2 to ensure his/her safety. Staff A stated she asked Resident #2 if he/she was okay. Resident #2 responded affirmatively. Staff A stated she asked Resident #2 if he/she liked what Resident #1 was doing, Resident #2 responded negatively. Staff A asked Resident #2 if he/she wanted Resident #1 to do what he/she was doing and Resident #2 responded negatively. Finally, Staff A stated she asked Resident #2 if Resident #1 had forced him/her to do what Resident #1 wanted and Resident #2 responded affirmatively. During an interview with the Administrator on 11/8/16 at 10:00 a.m., she reported Resident #1 remained at the facility with 1:1 supervision after the incident and continues to deny anything happened with his/her roommate. The Administrator indicated Resident #1 denied everything, even actions he/she was almost caught in the act of doing. When asked, the Administrator stated staff had not seen a change in Resident #2 after the incident with Resident #1. Resident #2 has always been a very private person. During an interview on 11/3/16 at 12:52 p.m., the Director of Nursing (DON) reported Resident #2 was a very private person. She also reported when Resident #2 activated his/her call light that night, he/she had actually pulled the cord completely out of the outlet in the wall. The DON stated the facility is providing 1:1 supervision for Resident #1 after the assault, and the plan is to continue this level of supervision until they can find alternate placement for him/her. 2) The Medication Review Report dated 11/3/16 revealed Resident #1 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment form dated 8/10/16, Resident #1 experienced moderate cognitive decline and was independent with transfers, ambulation (walking), dressing, personal hygiene and toilet use. The MDS documented Resident #1 required staff assistance with bathing. The facility's individual plan of care addressed Resident #1 and his/her history of exhibiting inappropriate sexual behavior toward staff and other residents. The plan of care documented the resident had been placed on medication for inappropriate sexual behavior and for delusions and hallucinations. Staff were directed to implement the following interventions: * If staff suspect Resident #1 is exhibiting sexual preoccupations or if Resident #1 misconstrues the treatment plan, it is important that staff protect themselves from Resident #1. * Staff will be honest in setting limits and boundaries by clarifying their roles. When dealing with Resident #1's behaviors, honesty is the best policy. Inform resident a relationship with him/her would be illegal, unethical, and unprofessional and would never be considered. * Staff will set limits by telling Resident #1 the consequences of his/her behavior. Staff will carry out what they say the consequences will be. * Staff will use a flat affect and firm matter-or-fact tone of voice, labeling sexually inappropriate behavior and directing Resident #1 to cease. * Staff will immediately report Resident #1's behavior and have it logged in Resident #1's behavioral record/general medical notes if Resident #1 continues to respond inappropriately. * Staff will ensure that Resident #1 is at a safe distance away from female residents. Staff should intervene and redirect Resident #1 to another area of the building if Resident #1 is bothering female residents. *The facility plan of care also addressed Resident #1, at times, liked to be naked in his/her room. The plan of care directed staff to provide privacy and pull the privacy curtain. Additional interventions related to Resident #1's behaviors directed staff to provide Resident #1 a private place if staff found Resident #1 disrobing or stimulating him/herself in a public area, and staff will counsel the resident if he/she engages in inappropriate behavior. A Psychology Note dated 6/30/16 documented staff reported Resident #1 had an increase in impulsive behaviors including some of a sexual nature. The nurse's notes dated 7/1/16 documented Resident #1 found roaming after dinner in the dining room with his/her pants around their ankles, exposing genitalia. Another resident told Resident #1 to put their pants on. When asked, the other resident denied it bothered him/her. Staff pulled the resident's pants up and took the resident to his/her room. The nurse's notes dated 7/2/16 documented Resident #1 asked a CNA, What (do I) need to do to get a boner around here? CNA told the resident the question was inappropriate and told him/her not to ask those types of questions. The nurse's notes dated 7/3/16 documented the resident was in his/her room naked and exposing themselves to the female residents across the hall. Staff assisted the resident with dressing and escorted the resident up the hall. The female resident was very upset. The [MEDICAL CONDITION] Medication Assessment Progress Note dated 7/7/16 indicated Resident #1 had many sexual behaviors this past month. Behaviors included exposing his/her genitalia on 6/13, 6/24, 6/26, & 7/1. On 7/2, Resident #1 made verbalizations which were sexual in nature. The nurse's notes dated 7/30/16 documented resident walking in hallway wearing t-shirt, underwear and socks and found by staff in another resident's room. Staff redirected the resident back into his/her own room and the resident got dressed and came to the dining room. Staff told resident this behavior was inappropriate. An entry in the nurse's notes dated 8/4/16 documented the resident was found in another resident's room with his/her pants down. The female resident was in the room also. The resident stated, I'm on the wrong hall. Staff redirected the resident back to his/her room and informed him/her the behavior was inappropriate. The [MEDICAL CONDITION] Medication Assessment Progress Note dated 8/10/16 indicated Resident #1 showed an improvement in behaviors with one incident of exposing him/herself and would continue with the present medication regimen. The medication was clinically appropriate to decrease libido which could cause mental distress to others and also used to decrease hallucinations. A Social Service Note dated 8/19/16 documented staff gave Social Worker a note that reported the resident continued to expose him/herself in common areas. Resident denied he/she did this. Social Worker told the resident he/she must be fully dressed in common areas and if he/she is not fully dressed, he/she must be in their room or bathroom with the privacy curtain pulled. The resident continued to deny inappropriate behavior. A Psychology Note dated 8/24/16 documented clinician discussed an incident with Resident #1 that occurred in the facility last week. The resident denied remembering it. The clinician documented she discussed Resident #1's cognitive testing results with him/her, and the likelihood that he/she couldn't remember; the tests measured Resident #1's memory as cognitively intact. The resident continued to deny any event. The clinician stated if it happened again, she would ask staff to take the resident aside and ask him/her why he/she felt like exposing him/herself. Resident #1 again denied and stated that would have been a horrible thing but I do not remember doing it. Active listening and rapport building provided. The clinician documented the resident would be seen 1-2 times per week. A Psychiatric Progress note completed by an MD documented the resident still dropping their pants in public. The resident is very sexually inappropriate still and will try him/her on [MEDICATION NAME] 300 mg twice daily and recheck in two weeks. Documentation in the nurse's notes dated 8/25/16 revealed Resident #1 met with the psychiatrist who recommended adding [MEDICATION NAME] 300 mg (milligrams) twice daily due to sexually inappropriate behaviors. Documentation in the nurse's notes also revealed the facility received a fax back from the physician regarding resident's sexually inappropriate behaviors. The faxed contained an order that directed staff to administer [MEDICATION NAME] 300 mg twice daily. The nurse's notes dated 8/29/16 documented the resident remained on [MEDICATION NAME] as ordered, and revealed he/she was found spying on his/her roommate through the curtains. Staff redirected the resident. A Psychology Noted dated 9/21/16 documented Resident #1 had issues taking medication as staff found pills that he/she did not take and are taking steps to monitor mediation more effectively. The [MEDICAL CONDITION] Medication Assessment Progress Note dated 10/12/16 indicated Resident #1 had no changes in medications or functional changes in the past month. He/she remains on [MEDICATION NAME] for high risk sexual behaviors. The resident was overheard on 9/19/16 asking a female resident if she could take it all in? Documentation in the nurse's notes dated 11/1/16 at 11:45 p.m. staff observed Resident #1 sexually assaulting his/her roommate. Staff intervened and implemented one on one supervision. Documentation in a follow up Psychiatric Progress note dated 11/3/16 at 8:19 p.m. revealed Resident #1 sexually assaulted another resident. Resident #1 denied all the assault and allegations. During an interview attempted on 11/8/16 at 3:10 p.m. Resident #1 responded that he/she would visit (talk), but Resident # 1 did not open his/her eyes. In addition Resident #1's speech was extremely slurred and difficult to understand. Although Resident #2 did not express his/her fear and trauma as a result of the sexual assault, interviews and review of the care plan reveal he/she had always been a very private person and a loner. When Resident #1 assaulted him/her, Resident #2 pulled the call light completely out of the wall outlet to get the staff to come to his/her aid. Although the resident expressed little to no emotion related to the assault, he/she stated it was an awful thing that happened. He/she was also observed by staff turning his/her call light on and then off as if testing it to see if it worked. On 11/1/16, the facility abated the Immediate Jeopardy when they implemented the following: 1. Both residents were immediately separated by staff upon discovery of behavior. 2. Resident #1 was immediately taken to the dining area and placed on 1:1 supervision with assigned staff person. Staff removed his/her possessions from the room and the items were placed in a private room at the end of a different hallway. He/she remained and will remain on 1:1 supervision until alternate placement is obtained. 3. Nursing assessment was completed and emotional support given to Resident #2 immediately following incident. 4. Social Worker began seeking alternate placement for Resident #1 on 11/1/16 and facility will continue to do so until alternate placement is obtained. 5. Resident #2 was placed on 15 minute checks by staff on 11/1/16 following the incident until transferred to emergency room . 6. Law enforcement was notified immediately and they initiated an investigation upon notification. 7. On call physician and responsible parties for both residents were notified on 11/1/16. 8. Resident #2 was transported to local emergency room upon direction of law enforcement on 11/1/16. 9. Resident #2 will be seen daily by social worker. Frequency will decrease based on resident's needs. Crisis intervention services will be obtained for resident as available/appropriate.