Every finding on record at Sage View Care Center

Based on medical record review, staff interview, and facility incident review, the facility failed to ensure food was prepared in a form to meet resident needs for 1 of 9 sample residents (#1) reviewed. This failure resulted in actual harm to resident #1. Corrective measures were implemented prior to the survey and compliance was determined to be met on 1/9/26. The findings were:1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 had no long-term or short-term memory impairment and diagnoses which included cerebral palsy and esophageal obstruction. Further review showed the resident required a mechanically altered and therapeutic diet. Review of the Nutrition Hydration care plan last revised on 12/4/25 showed the resident required a mechanically altered diet and had swallowing problems. Further review showed interventions which included aspiration precautions and a minced and moist diet (diet of soft, moist foods that are easy to swallowed and requires minimal chewing). Review of the physician orders showed an order for a regular diet minced and moist texture dated 8/21/25. The following concerns were identified:a. Review of a progress note dated 8/21/25 and timed 10:11 AM showed Resident had a choking episode at lunch in the dining room, nurse responded to incident where [s/he] was found to be slightly cyanotic, having difficulty breathing and waving hand motions, foaming at the mouth. Nurse performed Heimlich maneuver multiple times until large chunk of pineapple projected from residents mouth. Resident was then able to breathe, skin color returned to pink and resident communicated that [s/he] was better. [S/he] was monitored for a time period after incident occurred with no respiratory complications/distress noted, and no further complications noted. Dr. [name] was notified, attempted to notify sister/POA [name], message was left. ST [speech therapy] eval and treat order was obtained, diet was downgraded to minced and moist. [S/he] was monitored every shift for any further choking incidents with none noted.b. Review of a progress note dated 1/2/26 and timed 5:39 PM showed Notified by visitor that [resident #1] needed help. [S/he] was putting fingers in mouth and choking. Heimlich maneuver was attempted several times. [S/he] was lifted out of chair and turned downward, Heimlich, back blows and finger sweeps performed. Finally chocolate was extracted. [S/he] was educated that [s/he] would eat snacks at nurses station or in DON room when [s/he] was there. [S/he] agreed. Noted scrape on stomach and redness r/t [related to] Heimlich.c. Review of a progress note dated 1/9/26 and timed 5:39 PM showed At approximately 1220, there was multiple staff in the main dining room assisting residents, another resident yelled out that [resident #1] needed help. [CNA #1], RNA tended to [resident #1] immediately, and someone in the dining room had also yelled out, not sure if it was another staff member or another resident, that [s/he] may be choking, [resident #1] was waving [his/her] hands and shaking [his/her] head. In appearance [his/her] lips did not appear blue and appeared as though [s/]he was still able to breath and still able to breathe air. [CNA #1] immediately initiated the Heimlich Maneuver for not longer than 30-45 seconds and was able to dislodge a piece of a grilled cheese sandwich. [S/he] was assessed for any injury with none noted, denied any pain. [S/he] was placed on alert charting to document any latent injuries r/t performing the Heimlich maneuver, and also to monitor for any symptoms of aspiration. Dr. [name] was notified of incident, speech order was obtained to evaluate and treat. [His/Her] guardian/sister/ was notified of the incident.d. Interview with CNA #1 on 1/15/26 at 11:22 AM revealed on 1/9/26 she heard a resident yell out, saying resident #1 needed help. The CNA was assisting another resident, and went to resident #1, who was waving his/her hands. The CNA revealed she began the Heimlich maneuver; however, after a couple unsuccessful thrusts, she attempted back thrusts, then she lifted the resident out of the chair and squeezed. The CNA revealed at that time, the resident expelled part of a sandwich. The CNA revealed the incident lasted 30 to 40 seconds. The CNA revealed the resident's diet order was to be soft and bite sized and s/he would not normally receive a sandwich for meals. The CNA revealed it was her understanding the resident was given the sandwich because s/he requested it. Further interview revealed following the incident, the resident was scared and relieved.e. Interview with cook #1 on 1/15/26 at 11:30 AM revealed on the day of the incident she was serving lunch and resident #1 requested a grilled cheese sandwich. She revealed the resident's diet was to be minced and moist and described it as soft and bite sized and for all breads to be pureed. The cook confirmed the grilled cheese sandwich was not a minced and moist item. She revealed she asked the dietary manager if the resident could have a grilled cheese sandwich and was told yes. She revealed the resident received the grilled cheese sandwich, started eating, and then starting choking. She revealed following the incident the staff was educated on following residents' diet orders. Further interview revealed she thought it would be appropriate to give the resident a grilled cheese sandwich because the resident's family gives him/her items s/he should not eat.f. Interview with the dietary manager on 1/15/26 at 11:10 AM revealed she expected staff to follow the spreadsheet based on each resident's diet order. She confirmed resident #1's diet order was for minced and moist and described it as a mixture of soft and bite sized and pureed. The dietary manager revealed she felt the choking incident on 1/9/26 was her fault because the cook asked if it was ok for the resident to have a grilled cheese sandwich per his/her request and the dietary manager said yes. She revealed she was passing drinks at the time and didn't think about it. She revealed she left the dining room and when she returned, CNA #1 was performing the Heimlich maneuver and resident #1 vomited. Further interview revealed following the incident, staff completed immediate education and she performed a tray card audit to ensure tray cards matched the physician orders. 2. Review of the facility's plan of correction dated 1/9/26 showed the following interventions were implemented as a result of the incident:a. All resident diets were audited for compliance by verifying that the diet order matched the meal ticket.b. Education was provided to all dietary staff on following the spreadsheet and matching the diet card to the spreadsheet. Nursing staff and managers on duty were educated on checking the meal ticket with the tray they were serving.c. Audits were implemented and were to be performed twice per week for 4 weeks then once a month for 2 months.3. The implementation of the plan of correction was verified during the survey.

Based on staff schedule review, daily staff posting review, time punch history review, and staff interview, the facility failed to ensure an RN was on duty for 8 consecutive hours per day, 7 days per week. The census was 533. The findings were: 1. Review of the February 2025 nursing schedule failed to show an RN had been scheduled for 2/8/25. 2. Review of the daily staff postings failed to show there was an RN on duty for 2/8/25. 3. Review of the time punch history for RN #1 showed on 2/8/25 she worked for 3.25 hours from 11:53 AM to 3:12 PM. 4. Interview with the DON on 2/12/25 at 1:49 PM revealed the RN on duty had been on-call and only worked 3.5 hours on 2/8/25. She stated she understood the nurse needed to be on duty for 8 hours; however, she confirmed the RN did not work 8 hours.

Based on medical record review, and resident, and staff interview the facility failed to provide rehabilitative services for 1 of 8 sample residents(#150). The findings were: 1. Review of the initial care plan dated 1/24/25 showed resident #150 had diagnoses which included hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, myocardial infarction, and weakness. Further review showed a physician's order dated 1/23/25 to evaluate and treat for physical and occupational therapy. The following concerns were identified: a. Interview with the resident on 2/11/25 at 8:40 AM revealed s/he had been in the facility for more than a week and had not received any therapy. b. Interview with the DON on 2/12/25 at 1:46 PM revealed she had been unaware that the resident had therapy orders and confirmed the resident had not received any therapy services. c. Interview with the DOR on 2/12/25 at 2:12 PM revealed she had been unaware the resident had therapy orders, and confirmed the resident had not received any therapy services.

Based on observation, medical record review, staff interview, and review of incident reports, facility documentation and manufacturer's instructions, the facility failed to provide adequate supervision to prevent an elopement for 1 of 2 sample residents (#1) reviewed for elopement. In addition, the facility failed to ensure the wander management system (wanderguard) was tested per manufacturer's instructions to ensure it was working. The facility had 11 residents with a wanderguard. The findings were: The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 7/5/24. 1. Review of the 6/24/24 admission Minimum Data Set (MDS) assessment showed resident #1 had a diagnosis of non-Alzheimer's dementia and wandered daily. Review of the 6/17/24 elopement/exit seeking evaluation showed the resident had a history of wandering and was at risk for elopement. Review of physician orders showed a 6/17/24 order for a wanderguard [bracelet that is worn and triggers an alarm when the resident is near an opened exit door]. Review of progress notes dated 6/22/24 to 6/29/24 showed the resident was exit seeking and had tried to leave out the front door on 6/28/24. The following concerns were identified: a. Review of an incident report dated 6/29/24 showed on 6/29/24 at 6:05 PM a Code [NAME] was initiated because the resident was unable to be located. The resident was last seen about 45 minutes prior walking the halls. Staff implemented their elopement protocol and the police were notified. The police department found the resident at his/her house about 30 minutes after the search began. The facility investigation showed a visitor of another resident had come to the facility, let resident #1 out, and gave the resident a ride home without the staff's knowledge. b. Interview with registered nurse (RN) #1 (nurse in charge at the time of the elopement) on 7/22/24 at 5:33 PM revealed on 6/29/24 about 6 PM she was notified resident #1 could not be located. She stated they started an inside and outside search and the police were notified. She stated the resident was found by police at his/her house. She stated a family member who had been outside the facility said she saw the resident get into a vehicle. The RN stated the resident's Wanderguard was working. She stated she and another nurse were in a resident's room doing a skin assessment when they heard the front door alarm. She stated licensed practical nurse (LPN) #1 responded to the alarm and shut it off. c. Interview with LPN #1 on 7/22/24 at 5:42 PM revealed she was working on the back hallway the day of the elopement. She stated she was in the middle of administering medications to a resident when she heard the front door alarm go off. She stated she finished giving the medications and went to the front door. She stated she looked outside and only saw a visitor sitting on the porch. She did not see any residents, so she turned off the alarm. Later, when staff realized the resident was missing, she called the visitor who had been sitting outside and was told she saw the resident leave with another person. Resident #1 asked the other person for a ride and the person agreed and they left in a vehicle. 2. Observation on 7/22/24 at 5 PM of the exit doors showed the facility used the Code Alert- 9450 wander management system (wanderguard). Review of documentation provided by the facility showed 11 residents currently utilized the wanderguard system, including sample residents #1 and #2. The following concerns were identified: a. Review of the July 2024 medication administration records (MARs) for residents #1 and #2 showed nursing staff checked placement of the wanderguard every shift. There lacked evidence the function of the wanderguard was checked. b. Documentation of resident Wanderguard checks to ensure function was requested. The facility provided evidence of weekly wanderguard checks for July 2024, but not earlier months. c. On 7/23/24 at 8:17 AM the administrator stated the maintenance staff was new as of 6/28/24. After the 6/29/24 elopement she asked him to find documentation of wanderguard checks from the previous maintenance staff, but he was unable to find any. She stated the facility did not have evidence of wanderguard checks for any of the residents prior to July. She stated weekly checks have been done since the beginning of July. d. Review of the RF Technology's Code Alert Wander Management Transmitters User Guide (https://www.rft.com/wp-content/uploads/2018/11/0510-1122-J_Code-Alert-Transmitter-User-Guide.pdf, accessed 7/26/24) showed weekly testing was required for transmitters in use on residents. 3. The following plan of correction was implemented by the facility by 7/5/24: a. Resident #1 was placed on 1:1 supervision until s/he was discharged to a facility with a secure unit. b. The facility implemented checks on all the wanderguards to ensure function, and continues weekly. c. The facility educated all staff on elopement prevention and elopement policy. This included a reminder to respond immediately to door alarms and the following instructions: If no resident is found, immediately investigate why the alarm went off. A head count needs to be completed on all residents. d. An elopement/wanderguard performance improvement project (PIP) was initiated 7/1/24. This includes audits for wanderguard testing and education to staff.

Based on observation, medical record review, staff interview, and review of facility policy and procedures, the facility failed to ensure appropriate disinfection of reusable equipment was performed before contact with 4 of 4 sample residents (#1, #3, #7, #11). In addition, the facility failed to implement appropriate hand hygiene practices during 1 of 4 meal observations. The census was 39. The findings were: 1. Review of the medical record for resident #11 showed s/he most recent admission was on 1/30/24 and had diagnoses which included pneumonia. The following concerns were identified: a. Observation on 2/20/24 at 3 PM showed resident #1 and resident #11 were in their room and resident #1 was coughing. CNA #16 entered the residents' room, with the vitals tower brought from the nurse's station, applied the blood pressure cuff to resident #11's left arm, applied the pulse oximeter to a finger on the right hand, removed the thermometer from the tower, and slid it across the resident's forehead. Without cleaning the vitals tower equipment, the CNA performed same procedures for resident #1. The CNA exited the room with the vitals equipment and returned it to the nurse's station to charge; however, no disinfection of the equipment was performed. Observation at 3:19 PM showed CNA #16 retrieved vitals equipment from the nurse's station, approached resident #7 in the common area, and applied the equipment to resident #7. The CNA placed the blood pressure cuff on the resident's right arm, the pulse oximeter on the resident's middle finger of his/her left hand, and slid the thermometer across the resident's forehead. No disinfection of the equipment was performed before or after contact with resident #7, and the CNA returned the equipment to the nurse's station. Observation at 4:04 PM showed CNA #16 obtained the vitals tower and entered resident #3's room. The CNA applied the blood pressure cuff to the resident's right arm, slid the thermometer across the resident's forehead, and put the pulse oximeter on a finger of the resident's left hand. The CNA returned the equipment to the nurse's station and no disinfection of the equipment was performed before or after resident contact. 2. Observation on 2/20/24 from 4:40 PM to 5:40 PM in the main dining room showed the maintenance supervisor coughed into his right shoulder, poured fluids into a plastic mug, and rested the mug on the table in front of a resident. The maintenance supervisor touched his own nose, kneeled down got a tea bag from the beverage cart with the same hand that touched his nose, put into a cup for another resident with hot water and provided it to the resident. The maintenance supervisor obtained 2 small glasses of juice, holding the cups by the lip where residents would drink from. The maintenance supervisor left the cart, grabbed an oxygen canula for another resident which was located over the resident's shoulder, and handed it to the resident. The maintenance supervisor returned to the beverage cart and provided a straw to a resident their beverage, after unwrapping the straw and touching the straw top with bare fingers. No hand hygiene was performed. At that time, CNA #20 entered the dining room, sat at the corner of a table between 2 residents, and assisted the resident on her right side with eating, using her right hand. The CNA touched the right side of her head with her right hand, turned, and used her right hand to assist the resident on her left side to eat. No hand hygiene was performed. 3. Interview with the executive director on 2/21/24 at 9:45 AM revealed she expected staff to follow cough hygiene, wash hands between resident contact, and to clean equipment between residents. 4. Review of the facility policy titled Cleaning and Disinfecting Resident Care Items and Equipment dated May 2015 showed .i. Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers .d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) .3. Durable medical equipment (DPE) is cleaned and disinfected before reuse by another resident . 5. Review of the facility policy titled Handwashing/Hand Hygiene dated March 2018 showed .2. Personnel follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .7. Use an alcohol-based hand rub .for the following situations .c. Before and after direct contact with residents .l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and m. After removing gloves .o. Before and after eating or handling food; p. Before and after assisting a resident with meals . 6. Review of the policy titled Standard Precautions dated May 2015 showed .b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned .

Based on observation, medical record review, staff interview, facility incident and employee record review, and review of facility policies and procedures and facility monitoring documentation, the facility failed to protect the resident's right to be free from verbal abuse and physical abuse by staff for 1 of 3 sample residents (#10) reviewed for abuse allegations. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 10/29/23. The findings were: 1. Review of a quarterly MDS assessment dated [DATE] showed resident #10 had a BIMS score of 6 out 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia, malnutrition, anxiety disorder, gastrointestinal hemorrhage, and diverticulosis of the large intestine without perforation, abscess, or bleeding. Further review showed the resident required moderate assistance (helper does less than half the effort) with eating, had weight loss which was not physician prescribed, and was on a mechanically altered diet. Review of the care plan related to the resident's refusal to eat, resistance to assistance with eating, and decreased appetite last revised on 8/3/23 showed interventions which included family provided snacks and favorite food items, allowing choices related to meal time, menu selection, and dining location, invitations to food related activities, and monitor/document circumstances surrounding mealtimes/refusals to eat. Review of the care plan related to a psychosocial well-being problem due to dementia and depression last revised on 9/13/22 showed interventions which included allowing the resident time to answer questions and verbalize feelings, perceptions and fears as needed. The following concerns were identified: a. Review of a facility incident report dated 10/21/23 showed CNA #1 allegedly told resident #10 take another bite or I will make you have 3 more and grabbed the resident's cheeks to put more food in the resident's mouth. The resident's response was to yell for help. Further review showed when another staff member stopped the interaction, CNA #1 yelled profanities and was acting inappropriately. CNA #1 was placed on leave pending investigation and terminated when the investigation was concluded. b. Review of a progress note dated 10/21/23 and timed 1:24 PM showed CNA reported alleged verbal and physical abuse against resident by another CNA during lunch. Reporting CNA witnessed alleged offending CNA pinched resident's cheek and tried to force [his/her] mouth open to take another bite. Reporting CNA then stated she used the spoon to try and keep the food in [his/her] mouth when resident tried to spit it out. This RN overheard alleged offending CNA state if you don't take a bite, I will put 3 more in there. CNA was told to leave the table away from resident and then removed from the building. Resident assessed for injury, no redness, swelling, or other injury noted to resident's face or mouth. Abuse coordinator, MD and family notified. c. Review of a progress note dated 10/22/23 and timed 2:11 AM showed Resident had no bruising to face at this time. No c/o [complaints of] pain to chin or cheek. Resident voiced being frightened r/t [related to] incident in dining room at lunch. I thought she was going to kill me Resident asked this writer to check on the resident frequently throughout the night. d. Review of a progress note dated 10/23/23 and timed 11 AM showed ED [executive director] and DON talked to resident and completed a safety survey. No concerns from the interview. When asked if [s/he] has ever felt uncomfortable or scared at any meals times, [resident] stated yes and that [s/he] could not remember what happened but [s/he] remembers a staff member making her feel scared. This staff reassured resident that the staff member who made [him/her] feel this way, would no longer provide [him/her] cares and that [s/he] would not have to see them as they no longer work here. [The resident] responded oh really? when asked how that made [him/her] feel, [s/he] said Much better, I feel safe here [the resident] stated [s/he] feels comfortable reporting concerns, staff treat [him/her] with respect, [s/he] currently feels safe and comfortable, and decline anyone inappropriately touching [him/her]. [The resident] will stay on increased monitoring to ensure physical and psychosocial well-being and safety. e. Interview with CNA #1 on 11/16/23 at 8:39 AM confirmed she was terminated from the facility for the allegation; however, she denied the incident occurred. f. Interview with RN #1 on 11/16/23 at 9:01 AM confirmed she was on shift the day of the incident and revealed she heard CNA #1 tell resident #10 I need you to take another bite or I'm going to give you 3 more. The nurse revealed as she was going to the dining room following the statement she heard CNA #2 tell CNA #1 what she was doing was not acceptable and to stop. The RN revealed CNA #2 reported CNA #1 was pinching the resident's face and the resident's mouth was full of food. The RN confirmed she told CNA #1 she needed to leave the facility at that time and the CNA responded by saying everyone fed the resident that way. The RN revealed the resident appeared shaky and upset following the incident. g. Interview with CNA #2 on 11/16/23 at 9:36 AM confirmed the incident happened during lunch and she observed CNA #1 hold resident #10's cheek and force food into his/her mouth. CNA #2 revealed she attempted to politely tell CNA #1 she couldn't force the resident to eat and the resident was yelling for help. The CNA revealed when she observed the resident's mouth was full of food, she attempted to get CNA #1 stop for a second time; however, the CNA told her to mind her own business. CNA #2 revealed at that time, she stood and asked the resident if s/he was done eating and the resident said yes. The CNA revealed she observed CNA #1 attempt to prevent the resident from spitting food out by placing a spoon in front of the resident's mouth to block the spitting. She revealed when she assisted the resident out of the dining room and back to his/her room, the resident told her thank you for saving his/her life. CNA #2 confirmed she reported the allegation to the charge nurse and CNA #1 was placed on suspension, then terminated from the facility. h. Interview with CNA #3 on 11/16/23 at 9:46 AM revealed she heard CNA #1 tell resident #10 to take another bite or she would shove 4 more down his/her throat. Further interview revealed she heard the resident yell which did not normally happen; however, when she turned around she did not observe anything abnormal. 2. Interview with the DON, ED, and divisional director of clinical operations on 11/16/23 at 10:07 AM confirmed the allegation of abuse was reported and investigated. They confirmed as a result of the investigation, CNA #1 was terminated from the facility. Review of the employee record verified the termination. They revealed resident #10 did not have a change in baseline feelings as a result of the incident. Observations during the survey showed no evidence of ongoing physical or mental outcome as a result of the incident. They revealed residents were interviewed for additional allegations of abuse and resident safety, and staff education was performed from 10/25/23 through 10/29/23 related to abuse and neglect. Review of the incident investigation verified resident interviews were completed and the education sign in sheet verified the completion of the training. They revealed the leadership team was conducting monitoring through manager on duty meal supervision, daily leadership rounding with documentation of rounding performed twice per week with notes related to safety, abuse observations, resident concerns, and random audits of staff knowledge of abuse through clinical scenarios which were reported to QAPI. They revealed monthly abuse reporting audits were also performed and reported to QAPI. Review of the meal monitoring schedule and training initiated on 2/28/23, leadership rounds for November 2023, and random staff audits for November 2023 verified the completion of ongoing monitoring. Observations during the survey verified meal monitors were present during meals. 3. Review of the facility policy titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation last updated October 2022 showed .Each resident has the right to be free from abuse, including verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, misappropriation of resident property, exploitation, and any physical or chemical restraint not required to treat the resident's medical condition. The Center implements policies and processes so that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members, and others who may have unsupervised access to residents. These policies address screening, training, preventions, identification, investigation, protection, and reporting/response .

Based on observation, medical record review, resident and staff interview, and policy and procedure review the facility failed to develop comprehensive care plans for 1 of 12 sample residents (#39). The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #39 had an admitted [DATE], a BIMS score of 7 out of 15, which indicated severe cognitive deficits, and diagnoses which included non-Alzheimer dementia, anxiety, and depression. The following concerns were identified: a. Observation on 11/13/23 at 4:17 PM showed the resident was packing his/her bags. At that time, s/he stated s/he was getting discharged and was ready to go home. Observation on 11/15/23 at 9:53 AM showed the resident was located in the front hall by the main entrance and had just got his/her nails painted. At that time, the resident stated the bracelet on his/her left wrist was an alarm and would go off if s/he goes out the door. b. Review of the physician orders showed Device: Wander guard every shift with an active date of 8/14/23. c. Review of the Elopement/Exit-Seeking Evaluation dated 8/18/23 for the resident showed -Wanders, verbalizes desire to go home, has dementia and attempts to leave the facility at times in belief she is okay to go home. There were no interventions identified and no indication of the wander-guard use. d. Review of the care plan last revised on 11/1/23 showed the resident had dementia and confusion; however, there was no care plan developed for wandering or elopement. 2. Interview with DON on 11/16/23 at 8:24 AM revealed anyone with dementia and is at risk of elopement or exit seeking, or verbal exit seeking would get a wander-guard and the facility would care plan it. 3. Review of the policy and procedure Devices hand delivered by the DON on 11/16/23 at 9:10 AM showed .2. e. Are addressed on the care plan and updated appropriately .

Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure appropriate hand hygiene and glove use to prevent cross-contamination for 1 of 2 sample residents (#19) observed during perineal care. The findings were: 1. Review of the annual MDS assessment dated [DATE] showed resident #19 had a BIMS score of 12 out 15, which indicated the resident was cognitively intact, and diagnoses which included non-traumatic brain dysfunction, depression, Wernicke's encephalopathy, muscle weakness, and other symptoms and signs involving cognitive functions and awareness. Further review showed the resident was dependent on staff for toileting hygiene. The following concerns were identified: a. Observation on 11/15/23 at 4:16 PM showed CNA #4 removed the resident's brief and performed perineal care on the resident, who was incontinent of urine, by wiping front to back. The CNA assisted the resident to roll to his/her left side, placed a clean brief under the resident, and performed perineal care to the resident's buttocks by wiping front to back. After finishing perineal care, the CNA attached the brief tabs, then pulled up the resident's pants and blanket. No glove change was performed before touching the clean items. b. Interview with CNA #4 on 11/15/23 at 4:23 PM confirmed the resident was incontinent of urine and revealed staff should remove gloves after performing perineal care, prior to touching anything else, to prevent cross contamination. 2. Interview with the DON on 11/15/23 at 4:32 PM revealed staff should perform glove changes when going from dirty to clean, including after perineal care to a resident who was incontinent of urine. 3. Review of the policy titled Standard Precautions provided by the DON on 11/15/23 at 4:40 PM showed .e. Change gloves, as necessary, during care of a resident to prevent cross-contamination from one body site to another(when moving from a dirty site to a clean one) .

Based on review of daily staffing records, and staff interview, the facility failed to accurately post daily nurse staffing data. The census was 40. The findings were: 1. Review of the Daily Staffing for Nursing sheets for 10/6/22 through 10/18/22 failed to show the actual hours worked by the registered nurses, licensed practical nurses, and the certified nurse aides responsible for resident care per shift. 2. Interview with the administrator on 10/19/22 at 12:05 PM confirmed the daily staff posting failed to include the actual hours worked by the resident care staff.

Based on observation, review of the menu, staff and resident interview, and medical record review, the facility failed to follow the controlled carbohydrate (CCHO) diet menu for 9 of 9 residents (#1, #4, #5, #6, #7, #10, #12, #13, #16) observed who required that diet. The findings were: 1. Review of medical records showed the following diet orders: a. Resident #1 had an order for a CCHO diet dated 9/15/22. b. Resident #4 had an order for a CCHO diet dated 10/16/19. c. Resident #5 had an order for a CCHO diet dated 7/26/22. d. Resident #6 had an order for CCHO diet dated 9/2/22. e. Resident #7 had an order for a CCHO diet dated 8/18/22. f. Resident #10 had an order for a CCHO diet dated 7/21/17. g. Resident #12 had an order for a CCHO diet dated 10/11/22. h. Resident #13 had an order for a CCHO diet dated 7/6/22. i. Resident #16 had an order for a CCHO diet dated 3/15/22. 2. During an interview on 10/18/22 at 9:15 AM resident #5 stated the facility did not always follow his/her diabetic diet during meals. 3. Review of the menu for the lunch meal on 10/19/22 (signed by the certified dietary manager and registered dietitian on 9/14/22) showed the main meal consisted of a chicken filet sandwich, sweet potato fries, cucumber tomato salad, and a fruit tart. Review of the menu for the CCHO diet showed sweet potato fries were not to be served, and canned fruit was to replace the dessert. The following concerns were identified: a. Observation of the trayline in the kitchen on 10/19/22 from 11:51 AM until 12:21 PM showed cook #1 served sweet potato fries to the nine residents who had CCHO diets (#1, #4, #5, #6, #7, #10, #12, #13, #16). b. During an interview on 10/19/22 at 12:26 PM cook #1 and the certified dietary manager (CDM) both confirmed that sweet potato fries were served to residents with a CCHO diet. The CDM stated the menu did show that sweet potato fries should have been omitted for the CCHO diet. The CDM further stated this was a new menu and this was the first time this meal had been served, but acknowledged that staff should have reviewed and followed the menu.

Based on medical record review and staff interview, the facility failed to provide a written notice of transfer to 1 of 4 sample residents (#17) reviewed for a facility-initiated transfer. The findings were: 1. Review of the medical record for resident #17 showed the resident was hospitalized on [DATE] for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Interview with the DON on 10/19/22 at 5:24 PM revealed the facility was unable to locate the form for the discharge/ transfer. Further, she stated the resident knew about the discharge/transfer and wanted to go.

Based on observation, staff interview, and review manufacturer's instructions, the facility failed to ensure medications available for use were not expired in 1 of 3 medication storage units (rehabilitation hall cart). The findings were: 1. Observation on 10/19/22 at 11:22 AM of the rehabilitation hall medication cart showed 2 [MEDICATION(S)] 100 units/milliliter (ml) kwikpens without a written open date. Interview with RN #1 at that time confirmed the medications were not dated and were for resident use. 2. Interview with the DON on 10/19/22 at 11:29 AM revealed it was the facility's expectation for the nurses to put an open date on insulin pens when they were removed from the refrigerator and then dispose of them when the medication expired. Further, she revealed the facility did not have a policy of medication expiration. She stated .the nurses are to follow what the pharmacy says. 3. Review of manufacturer's instructions for [MEDICATION(S)] KwikPens found at http://www.[MEDICATION(S)].com/taking-[MEDICATION(S)]/using-u100-u200-kwikpen#storage-and-disposal-kwikpens, retrieved 10/20/22, showed .Opened [MEDICATION(S)] prefilled pens must be thrown away 28 days after first use, even if they still contain insulin .

Based on employee record review and staff interview the facility failed to ensure competencies and skills were evaluated and documented for 5 of 5 CNAs reviewed (CNA #1, CNA #2, CNA #3, CNA #4, CNA #5). The findings were: Review of the employee education files showed education related to resident cares and abuse prohibition had been completed upon hire and annually. However, there were no records available to show the CNAs had been assessed by the facility demonstrating competency in skills and techniques necessary to care for residents' needs. The following concerns were identified: a. Review of the employee records showed CNA #1 was hired 2/1/2013, and there was no documented evidence of skills competency determination. b. Review of the employee records showed CNA #2 was hired 9/30/2016, and there was no documented evidence of skills competency determination. c. Review of the employee records showed CNA #3 was hired on 9/17/21 and there was no documented evidence of skills competency determination. d. Review of the employee records showed CNA #4 was hired 7/13/21, and there was no documented evidence of skills competency determination. e. Review of the employee records showed CNA #5 was hired 5/1/21, and there was no documented evidence of skills competency determination. f. Interview with the administrator and the DON on 9/23/21 at 11:34 AM verified documentation of skills competency was not available. The administrator stated the facility was transitioning to an electronic record system for competency determination. The DON stated a skills fair was being planned in the next few weeks.

Based on medical record review and staff interview, the facility failed to ensure the physician provided a rationale for contraindication to a dose reduction for 1 of 5 sample residents (#17) reviewed for [CONDITION(S)] medications. The findings were: Review of the 7/30/21 significant change MDS assessment showed resident #17 used an antipsychotic and an anti-depressant medication during the last seven days. The assessment further showed there had not been a gradual dose reduction (GDR) attempted or documented by a physician as contraindicated for the assessment time frame. Review of the 5/20/21 revised care plan for the resident showed s/he used the [CONDITION(S)] medications [MEDICATION(S)] and [MEDICATION(S)], related to the diagnoses of [CONDITION(S)], depression, and [CONDITION(S)] disorder. The following concerns were identified: a. Review of the 6/30/21 consultant pharmacist recommendation to the physician showed The resident has been using [MEDICATION(S)] 30 mg BID [twice daily] since 7/12/2017 and most recently a GDR request was denied 7 month ago in November 2020 without rationale. If this therapy is required to prevent future depressive episodes, please document to that effect in your progress notes. The physician responded on the form with an undated signed note that showed No GDR at this time. A rationale was not provided. b. Review of the 7/25/21 consultant pharmacist recommendation to the physician showed The resident has been using [MEDICATION(S)] 30 mg BID [twice daily] since 7/12/2017 and most recently a GDR [gradual dose reduction] request was denied 9 month ago in November 2020 without any rationale. If this therapy is required to prevent future depressive episodes, please document to that effect in your progress notes. The physician responded on 9/7/21 by check marking the box with the following typed statement: Continue THIS antidepressant therapy; dose reduction contraindicated. See progress note below or in chart. There was no rationale documented with the recommendation, or identified in the resident's chart. c. Interview with the DON on 9/22/21 at 4:09 PM confirmed there was no documentation from the physician providing a rationale contraindicating the dose reduction.

Based on review of facility policies and procedures, employee timecards, and staff interview, the facility failed to develop and implement COVID-19 policies regarding travel based on national standards. One of one staff (CNA #1) reviewed who traveled internationally did not quarantine per the CDC recommendations prior to returning to work. The findings were: 1. During an interview on 6/9/21 at 3:29 PM administrator #1 stated CNA #1 was not fully vaccinated when she traveled internationally in March. Review of a typed statement from the administrator dated 6/3/21 and review of employee timecards showed CNA #1 traveled March 1 to March 22, 2021. Further review showed the CNA returned to work on 3/24/21 (two days after international travel). The CNA did have a negative COVID-19 test on 3/24/21. 2. Review of the facility's COVID-19 Policy and Procedure (revised 2/10/21) showed procedures for returning to work after travel were not addressed. During an interview on 6/9/21 at 5:36 PM administrator #1 stated the facility did not have a policy on travel, including international travel. 3. Review of the CDC's International Travel During COVID-19, revised June 10, 2021 (https://www.cdc.gov/coronavirus/2019-ncov/travelers/international-travel-during-covid19.html, accessed 6/14/21) showed Recommendations for Unvaccinated People .After you travel: Get tested with a [CONDITION(S)] test 3-5 days after travel AND stay home and self-quarantine for a full 7 days after travel. Even if you test negative, stay home and quarantine for the full 7 days.

Based on observation, review of product information, and staff interview, the facility failed to ensure food preparation equipment in the kitchen was in good condition, and that perishable drinks were marked with expiration dates in 3 of 4 refrigerators (Memory care, Frontier, Rehab). The findings were: 1. Observation on [DATE] at 11:30 AM showed the memory care unit refrigerator contained 3 cartons of health shakes. There were no dates marked on the cartons to show when they were thawed or when they expired. According to the instructions on the cartons, the health shakes expired 14 days from when thawed. Interview with CNA #1 at that time revealed she was unsure when the health shakes expired. 2. Observation on [DATE] at 11:43 AM showed in the Frontier station refrigerator there were 2 cartons of Sysco Med Plus 2 a nutritional drink usually provided with medication passes. One of the cartons was marked with the date ,[DATE] the other was about ,[DATE] full and had no date marked to show when it was opened. According to the carton, the product expired 3 days after it was opened. 3. Observation on [DATE] at 12:16 PM showed the Rehab station refrigerator had 1 opened carton of Sysco Med Plus 2 with no date marked. According to the carton, it expired 3 days after it was opened. Interview with LPN #2 at that time revealed she knew it was good for 3 days once opened, however did not know when it had been opened. She further stated the carton is usually gone quickly related to how many people receive it. 4. Observation on [DATE] at 11:53 AM in the kitchen showed the clean plastic measuring cups were hanging from a rack. The water had not been allowed to dry after washing and 2 were stored face up with water remaining inside the cups. In addition, 3 of the measuring cups had cracks and fissures in the plastic. Also stored on the rack was a large fry pan with very little non-stick coating remaining. There were visible scratches on the surface where the coating had been scraped away from use. 5. Interview with the Certified Dietary Manager (CDM) on [DATE] at 12:10 PM revealed the health drinks should not be stored in the refrigerators without dates to show expiration. The CDM also verified the measuring cups should be stored face down to dry, and equipment with condition issues needed to be replaced. 6. According to Food Code (YEAR), U.S. Public Health Service ,[DATE].11: Materials that are used in the construction of UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be .(E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.

Based on observation, staff interview, and review of manufacturer's recommendations, the facility failed to ensure expired medications were not available for resident use in 1 of 3 medication storage units (Frontier medication cart). The findings were: 1. Observation on 9/24/19 at 5:23 PM during the medication pass showed 2 [MEDICATION NAME] 100 unit/milliliter multiple use vials with no written open date. Interview with LPN #1 at that time revealed the medication was for resident use and confirmed there was no written open date on the vials. 2. Interview with the DON on 9/25/19 at 11:28 AM revealed it was the expectation of the facility for staff to label the insulin with an expiration date when the insulin was placed into the medication cart. 3. Review of [MEDICATION NAME] safely storing diabetes medication found at https://www.rapidactinginsulin.com/[MEDICATION NAME]/using-[MEDICATION NAME]/storage-and-handling.html (retrieved 9/30/19) showed [MEDICATION NAME] stored at room temperature could be used up to 28 days.

Based on observation, medical record review, family interview and staff interview, the facility failed to ensure interventions to prevent and heal pressure ulcers were followed for 1 of 4 sample residents (#1) with pressure ulcers. The findings were: 1. Review of the annual MDS assessment with an ARD of 6/26/19 showed resident #1 was at risk for developing pressure ulcers, but none were present at the time of the assessment. Review of the quarterly MDS assessment with an ARD of 9/24/19 showed the resident had developed two stage 2 pressure ulcers during that look-back period. Interview with the resident's spouse on 9/23/19 at 5:09 PM revealed the resident had developed a wound on his/her back related to the oxygen tank on the back of the resident's wheelchair. S/he stated the nursing staff were providing wound care and there had been no changes s/he was aware of related to the wheelchair. Review of the 9/9/19 weekly skin evaluation showed the resident had a stage II pressure ulcer to the [MEDICATION NAME] spinal area measuring 0.6 cm by 0.6 cm. The note showed it was from oxygen tank on w/c (wheelchair). The physician was notified and review of the 9/9/19 untimed physician order [REDACTED]. Review of the 9/12/19 untimed physician order [REDACTED]. Review of the 9/18/19 skin evaluation showed PU (pressure ulcer) has decreased in size. No s/sx (signs/symptoms) infection. Staff continues to encourage res (resident) to lay down in between meals with not much success. Will continue to encourage. Also, therapy is looking at alternatives for res' (resident's) w/c (wheelchair) back to assist in reducing pressure d/t (due to) res (resident) will fall asleep in his w/c (wheelchair) leaning against the w/c (wheelchair) back. MD notified. The following concerns were identified: a. Observation on 9/23/19 at 6:03 PM showed the resident was seated in the wheelchair at the dining table. It appeared the back of the wheelchair was at a height of the resident's mid-back. It was noted when the resident leaned back in the chair the oxygen canister valve/nozzle was positioned where it contacted the resident's back. There was no additional cushioning placed between the resident and the chair back which was curved downward due to the tank hanging on the chair back. b. Observation on 9/24/19 at 1:41 PM showed the resident was seated in the wheelchair in his/her room. At that time the MDS nurse provided an amplifier to use to ask the resident questions. The resident indicated yes by a head nod that his/her back was bothering him/her. At that time, there was no additional cushion or padding between the resident and back of the wheelchair. c. Observation on 9/25/19 at 8:53 AM and at 10:37 AM showed the resident was seated in the wheelchair with nothing between the resident and the back of the wheelchair. d. Observation on 9/25/19 at 2:35 PM with RN #1 and RN #2 showed when the resident's shirt was lifted, there was an elongated, curved reddened area about an inch wide stretching from the bottom of one shoulder blade to the other shoulder blade. This reddened area had lightened by the time the observation had concluded. e. Review of the 9/25/19 weekly skin evaluation timed at 1:13 PM showed the redness that was noted at the beginning of the evaluation from the resident leaning against the wheelchair back had started to subside as the resident leaned forward. The evaluation further showed Pillow put in place between res (the resident) and w/c (wheelchair) back and res (the resident) likes this. f. Review of the (MONTH) 2019 treatment administration record showed please evaluate for a pressure relieving device for back of wheelchair dated 9/12/19. The need for this wheelchair evaluation was shown as an FYI with no documentation related to completion or progress. g. Review of the care plan showed the resident had a stage 2 pressure ulcer to the spinous process. This was initiated and last revised on 9/10/19 and failed to include specific interventions related to the wheelchair and oxygen tank positioning. h. Review of the Care Directive Form showed it was last updated on 7/9/19 and did not include any interventions related to the wound, oxygen tank, or positioning in the wheelchair. i. Interview with the DON on 9/26/19 at 10:47 AM revealed there was no documented or formal evaluation done related to the wheelchair. She stated the position of the oxygen (O2) canister was changed and there was an order made for a new oxygen canister holder which would be applied to the resident's wheelchair once it was received. She further stated the CNAs used the care directive form that was kept in the resident's room to provide care. She verified there were no care interventions related to preventing wounds from the wheelchair and O2 canister. 2. Review of the annual MDS assessment with ARD of 6/26/19 showed resident #1 was at risk, but did not have any pressure ulcers. Review of the 9/24/19 quarterly MDS assessment showed the resident had 2 stage 2 pressure ulcers during that look back period. Review of the 9/20/19 timed at 7:17 PM nurse's note showed the resident had a area that was bleeding on the top of the right ear. Upon assessment the resident's O2 tubing was resting on ear, when it should be up secured to top backside of (his/her) head D/T (due to) resident has HX (history) of pressure sores similar to this in the past. The note went on to show the area was cleansed and skin prep was applied, the tubing was secured appropriately and all staff were educated related to the tubing placement and history. Review of the 9/23/19 at 12:21 PM nurse's note showed the resident had a stage 2 to the top of the right ear where the O2 tubing sits. The note included approximate measurements of 0.2 cm by 0.2 cm and skin prep treatment applied and ear foam protectors applied to O2 tubing. The MD was notified at that time. Review of the 9/23/19 untimed physician order [REDACTED]. Review of the 9/25/19 timed at 1:13 PM weekly skin evaluation showed the resident had a stage 2 pressure ulcer to the right ear, it was shown to have decreased in size with measurements of 0.2 cm by 0.2 cm. The plan was to continue to offload pressure on the ear from the O2 tubing with foam ear protectors. The following concerns were identified: a. Observation on 9/24/19 at 1:41 PM, 9/25/19 at 10:37 AM, 9/25/19 at 2:30 PM, and 9/25/19 at 3:26 PM showed there was no foam protection on the O2 tubing the resident was wearing over his/her ears. b. Interview with LPN #2 on 9/25/19 at 3:26 PM revealed the foam was expected to be on the oxygen tubing, and the resident sometimes took it off. The nurse went to the supply closet to find the foam. c. Review of the care plan showed on 9/20/19 the skin impairment to the right ear was added. The interventions failed to include the foam protectors to be applied to the tubing, or any special instruction to secure the tubing behind the resident's head and not over the ears. d. Review of the Care Directive Form showed it was last updated on 7/9/19 and did not include any interventions related to the ear wound or oxygen tubing.

Based on medical record review and staff interview, the facility failed to ensure the care plan was revised and individualized for 1 of 17 sample residents (#1). The findings were: Review of the annual MDS assessment with an ARD of 6/26/19 showed resident #1 was at risk for pressure ulcers, but did not have any pressure ulcers. Review of the quarterly MDS assessment with an ARD of 9/24/19 showed the resident had 2 stage 2 pressure ulcers during that look-back period. Review of the 9/12/19 un-timed physician order [REDACTED]. Review of the 9/9/19 weekly skin evaluation showed the resident had a stage 2 pressure ulcer on the spine area and the oxygen tank on the wheelchair was a contributing factor. Review of the 9/23/19 un-timed physician order [REDACTED]. Review of the 9/20/19 timed at 7:17 PM nurse's note showed the resident had an area that was bleeding on the top of the right ear, and the nurse educated all staff of the need for the oxygen tubing to be secured off the resident's ear. The following concerns were identified: a. Review of the care plan showed the resident had a stage 2 pressure ulcer to the spinous process. This was initiated and last revised on 9/10/19 and failed to include specific interventions related to the wheelchair and oxygen tank positioning. b. Review of the care plan showed on 9/20/19 the skin impairment to the right ear was added. The interventions failed to include the foam protectors to the tubing or any special instruction to secure the tubing behind the resident's head not over the ears. c. Review of the Care Directive Form showed it was last updated on 7/9/19 and did not include any interventions related to the back wound, oxygen tank, positioning in the wheelchair, or the need for securing the oxygen tubing off the ears and using foam protectors. d. Interview with the DON on 9/26/19 at 10:47 AM revealed the CNAs used the care directive form that was kept in the resident's room to provide care. She also confirmed there were no care interventions included on the care plan or the care directive form related to the wound from the wheelchair and O2 canister, or the need to apply foam to the oxygen tubing.

Based on medical record review, resident and staff interview, and review of the facility's incident report and investigation, the facility failed to ensure residents were free from non-consensual sexual contact for 1 of 1 sample residents (#1) with allegations of sexual interactions with staff. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #1 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Further review showed the resident had a brief interview for mental status (BIMS) score of 13 out 15 (indicating the resident was cognitively intact) and required extensive assistance of 1 person for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. Review of an Interdisciplinary Note for the resident dated 2/26/19 showed the facility's interdisciplinary team reviewed an allegation of sexual abuse involving the resident. The resident reported CNA #1 had been sexually inappropriate with him/her during the resident's shower the evening of 2/19/19. Further review of the 2/26/19 Interdisciplinary Note showed an investigation was initiated, the resident presented with no change in baseline behavior, and the resident's care plan was updated. Review of the resident's care plan showed the item Resident alleges inappropriate sexual contact with staff member was initiated on 2/22/19. Interventions included the following: monitor for resident making inappropriate sexual comments towards staff, monitor for signs and symptoms of infection, monitor times 3 days for tearfulness, fearfulness, and changes in behavior, notify physician of any changes in behaviors related to allegation, and will refer to counseling as appropriate. The following concerns were identified: a. Review of the facility's investigation showed the resident was interviewed by the facility on 2/20/19 at 6:30 PM, and told the facility CNA #1 had sucked on his/her nipple, and washed the resident's genitals. The resident stated .(CNA #1) told me I am the only one (s/he) is doing this with. b. Review of the facility's investigation showed the resident was interviewed by the facility again on 2/22/19 at 2:10 PM. At that time, the resident reported the sexual contact began in his/her room, when CNA #1 rubbed up on him/her, then continued in the shower where the CNA sucked on the resident's nipple and told the resident s/he wanted to have further sexual contact with the resident. The resident stated s/he expressed concern they would be caught, and asked the CNA .how many other (guys/girls) are you doing this with? The CNA responded, You're the only one here. You're the only one I've found. The resident stated the CNA then took the resident's hand and put it down his/her pants. c. Interview with resident #1 on 3/12/19 at 12:40 PM revealed a CNA at the facility tried to make the resident aroused and french-kissed the resident in the shower. The CNA asked the resident to engage in sexual intercourse and the resident stated s/he couldn't. Continued interview revealed the CNA licked the resident's nipple and tried to perform oral sex; however, the CNA was unable to due to the resident's catheter. The resident revealed s/he allowed the interaction to continue and touched the CNA a few times as s/he didn't know what else to do. The resident stated s/he told the CNA to quit and the CNA wouldn't. The resident stated the CNA stuck his/her hand down the CNA's pants and the resident felt the CNA's genitals. Further interview revealed the resident didn't enjoy it, but let (the CNA) think (s/he) did and the resident .did not want it to happen. d. Interview with resident #2 on 3/12/19 at 1:50 PM revealed resident #1 was his/her roommate, and resident #1 had told resident #2 about the interaction in the shower. Resident #2 revealed s/he was told CNA #1 was kissing, fondling, and rubbing on resident #1 in the shower. e. Review of the facility's investigation showed CNA #1 was interviewed by the facility on 2/20/19 at 6:50 PM. The CNA reported the resident was grabbing at him/her everywhere. However, further review showed the CNA stated s/he did not report this behavior to a nurse or discuss it with his/her co-workers. f. Further review of the facility's investigation showed the facility interviewed CNA #1 again on 2/21/19 at 4:30 PM. The CNA confirmed s/he gave resident #1 a shower. The CNA reported the resident was moving (his/her) hands over the CNA and tried to get up the CNA's shirt. The CNA stated s/he told the resident no, we aren't going to do that, finished the resident's shower, took the resident to his/her room, and assisted the resident into bed. When asked if the resident actually got (his/her) hands down into your pants the CNA stated Just an effort, I kept moving (his/her) hands aside and was like no, don't do that. The CNA stated s/he did not report this interaction with the resident because s/he did not want to get the resident in trouble too. g. Interview with CNA #1 on 3/12/19 at 1 PM revealed the CNA provided a shower to resident #1 and during the shower the resident was putting (his/her) hands all over the CNA. Further interview revealed during a transfer of the resident, the resident felt the CNA's genitals and the CNA did not report this due to feeling embarrassed. h. Review of the facility's investigation showed CNA #1 was an experienced CNA, with more than 9 years of nursing home experience. i. Review of the facility's investigation showed a list of 11 staff members were asked between 2/20/19 and 2/25/19 if they had ever been grabbed at or touched in an inappropriate way by resident #1. All staff members denied resident #1 had touched or grabbed at them in an inappropriate way. j. Interview with the administrator on 3/12/19 at 2:48 PM revealed resident #1 reported CNA #1, by name, as being a sex fiend. The resident reported that the CNA was sucking on (his/her) nipples and wanted to do stuff. The resident reported the CNA had stuck the resident's hands down his/her pants, and the resident felt the CNA's genitals. The administrator revealed when CNA #1 was interviewed, the CNA reported resident #1 was trying to stick his/her hands down the CNA's pants and the CNA would not allow it. Further interview revealed the resident had no history of sexually inappropriate behaviors with staff. The administrator further stated the CNA's employment at the facility was terminated for a rule violation of not reporting alleged inappropriate behaviors.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure appropriate management of medical conditions for 2 of 2 sample residents (#38, #48) with diabetes who experienced low blood sugar levels. This failure resulted in emergency interventions and transfer to the hospital for resident #48. The findings were: 1. Review of the April 2017 Medication Administration Record [REDACTED]. The resident received fingerstick blood sugar tests every morning, [MEDICATION NAME] (antidiabetic) 25 mg by mouth at bedtime, and [MEDICATION NAME] (a hormone that raises the level of glucose) 1 mg/ml as needed for [DIAGNOSES REDACTED] (low blood sugar). The following concerns were identified: a. Review of the April 2017 MAR indicated [REDACTED]. The resident had 6 out of 16 documented blood glucose levels (on 4/3, 4/4, 4/6, 4/10, 4/11, and 4/17) which were below 80 mg/dl (milligrams per deciliter). Further, medical record review showed no evidence the physician was notified of the low blood glucose levels, or that the resident's blood glucose levels and medication regimen were assessed until 4/16/17. b. Review of a facsimile transmission dated 4/16/17 showed the facility communicated the resident's low blood glucose levels to the physician on 4/16/17 and stated the resident was symptomatic. c. Review of a nurse's note dated 4/17/16 (sic) and timed 6 AM showed the nurse went to residents (sic) room, to check blood sugar (glucose) (scheduled), called resident (s/he) didn't responded (sic), sternal rub given (s/he) opened (his/her) eyes, noted to be snoring (with) harsh breath sounds, blood glucose 50 mg/dl no [MEDICATION NAME] shots available. Attempted to rub glucose in mouth but was not much help, Oxygen 68% on RA (room air) commenced 10 L (liters) of oxygen (five via nasal cannula and 5 face mask) Oxygen saturation went up to 91%. Patient remains unresponsive. d. Review of a nurse's note dated 4/17/16 (sic) and timed 6:30 AM showed Fire department on scene, attempts made to site (sic) IV access, unsuccessful. B/S (blood sugar) 36 mg/dl. e. Review of a nurse's note dated 4/17/16 (sic) and timed 6:30 AM showed EMS team arrive, placed IO (intraosseous: the process of injecting directly into the marrow of a bone) gave 50 cc (cubic centimeters) [MEDICATION NAME] (50%) patient became responsive in 3 minutes. B/sugar 246 mg/dl. f. Further review of the 4/16/17 facsimile to the physician showed the physician response on 4/17/17 was to discontinue the [MEDICATION NAME], however the resident had already been hospitalized . 2. Interview with the DON on 4/28/17 at 8:10 AM revealed the nurse should not have administered oral glucose to an unresponsive resident. The DON confirmed that, while administering a [MEDICATION NAME] injection might have improved the resident's condition sooner, the [MEDICATION NAME] injection was not available at the time because it had been discarded a couple of days prior to the incident. The DON further confirmed the facility should have followed its policy on physician notification of out-of-range blood glucose levels. 3. Review of the policy title Blood Glucose Monitoring Protocol last updated May 2016 showed Policy Statement: Blood glucose levels are monitored per physician orders. The physician is notified when levels are below 80 or above 350 unless otherwise specified by physician . 4. Review of the medical record showed resident #38 required daily medication for diabetes mellitus. Review of the April 2017 medications form showed the physician ordered blood glucose levels three times a day and sliding scale insulin based on the blood glucose levels. Further, the resident had physician orders [REDACTED]. Review of the MAR indicated [REDACTED]< (less than) 80.00 or > (greater than) 350.00 Notify MD. The following concerns were identified: a. Review of the April 2017 MAR indicated [REDACTED]. Further review of the medical record showed no evidence the physician was notified of these out-of-range blood sugar levels until 4/28/17.