Every finding on record at Sanford Hillsboro Care Center

Based on record review, review of facility policy, and staff interview, the facility failed to provide appropriate care and services for 1 of 1 sampled resident (Resident #6) with a suprapubic catheter. Failure to provide the ordered catheter size and type placed the resident at risk for ineffective urinary drainage and other catheter-related complications.Findings include:Review of the facility policy titled Catheter: Care, Insertion & Removal, Drainage Bags, Irrigation, Specimen occurred on 08/19/26. This policy, dated 03/02/26, stated, . PROCEDURE: Reinsertion of Suprapubic Catheter . 1. Verify physician order. 2. Assemble equipment.Review of Resident #6's medical record occurred on all days of survey and identified a diagnosis of neuromuscular dysfunction of bladder and retention of urine. A physician's order, dated 03/11/26, stated, Change s/p [suprapubic] catheter every 4 weeks - 18 French 10 ml [milliliter] balloon . The nurses' notes stated the following:*03/13/26 at 11:17 a.m., . new SP [suprapubic] catheter placed via LPN [licensed practical nurse] x2 [two nurses]. 16Fr [French] coude [specialized urinary tube with a small, curved tip] placed and draining cloudy/yellow urine with a few blood clots noted.*04/10/26 at 10:11 a.m., . New suprapubic catheter placed via LPN x2. 16Fr coude placed and draining cloudy/yellow urine .*05/08/26 at 4:07 p.m., . New suprapubic catheter placed via LPN x2. 16 Fr coude placed and draining clear/yellow urine .*07/02/26 at 1:59 p.m., . Unable to remove current catheter, attempted x 3 [three times] . instructed to transport patient to [name of hospital] ER [emergency room].*07/30/26 at 10:53 a.m., . Catheter unable to be removed as it appears to be stuck in position. physician stated we need to send her to [name of city] ER, just as we did last time to have it changed.During an interview on 08/19/26 at 11:42 a.m., an administrative nurse (#3) agreed nursing staff inserted the wrong catheter size and type in March, April, and May.During an interview on 08/19/26 at 12:28 p.m., an administrative nurse (#2) stated she expected staff to follow the physician's order.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure food items were stored and monitored in a safe manner for 1 of 3 sampled residents with personal refrigerators (Resident #21). Failure to discard expired and spoiled food items may result in the consumption of unsafe food and place residents at risk for foodborne illness.Findings include:Review of facility policy titled Resident Refrigeration, Food (LTC [long term care]) occurred on 08/15/26. This policy, dated 02/24/26, stated, . staff is responsible to discard . any perishable foods after the appropriate time when it is considered unsafe .Observation of Resident #4's refrigerator on 08/17/26 at 11:45 a.m. showed the following:- small container of raspberries covered with mold- container of yogurt with expiration date of 07/28/26- container of guacamole with an expiration date of 07/24/26 During an interview on 08/18/26 at 8:48 a.m., an administrative staff member (#2) stated nursing staff are expected to check resident refrigerators daily to ensure expired and spoiled food items are discarded.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise the care plan to reflect the current status for 1 of 5 sampled residents (Resident #30) reviewed for unnecessary medications. Failure to revise the care plan limited the staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Plan occurred on 06/26/25. This policy, dated 12/02/24, stated, . The plan of care will be modified to reflect the care currently required/provided for the resident. Review of Resident #30's medical record occurred on all days of survey. Physician's orders identified Lasix (diuretic) 40 milligrams twice a day and Tramadol (opioid pain medication) 50 milligrams twice a day and as needed for pain. Resident #30's care plan failed to identify problems and interventions due to the use of diuretic and opioid pain medication. During an interview on 06/26/25 at 11:00 a.m., an administrative staff member (#1) confirmed staff failed to update Resident #30's care plan.

Based on observation, record review, review of facility policy, professional reference, and staff interview, the facility failed to follow professional standards of practice for medication administration for 1 of 1 supplemental resident (Resident #11). Failure to correctly administer and document medication administration may result in errors and/or adverse effects for the resident. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 832, stated, Practice Guidelines . Administering Medications . Administer only medications personally prepared. Review of the facility policy titled Medication: Administration Including Scheduling and Medication Aides occurred on 06/26/25. This policy, dated April 2025, stated . Purpose: . To administer medications correctly and in a timely manner . Medications are administered to the resident according to the 'Six Rights.' . Administer only those medications that you prepared. Do not ask anyone else to administer medications that you prepared. Do not administer medications prepared by anyone else. Observation on 06/26/25 at 9:20 a.m. identified a medication aide (MA) (#3) obtained a cup of medications and a cup of applesauce from the drawer of the medication cart and handed them to a nurse (#4). The nurse asked, Are these [Resident #11's name]? The MA (#3) replied Yes, and the nurse (#4) proceeded to Resident #11's room and administered the medications. The MA (#3) confirmed she dished Resident #11's medications earlier that morning and attempted to administer twice. Resident #11's electronic medication administration record (eMAR) identified the following medications documented as administered by the MA (#3) on 06/26/25 at 9:48 a.m.: *Aspirin 81 milligrams (mg) tablet *Bactrim DS (antibiotic) 800-160 mg tablet *Duloxetine (antidepressant) 60 mg capsule *Prevagen (memory loss) 10 mg capsule *Rivastigmine tartrate (memory loss) 6 mg capsule *Senna (laxative) 8.6 mg tablet *Seroquel (antipsychotic) 25 mg tablet *Vitamin B-12 1,000 micrograms (mcg) tablet *Vitamin D3 50 mcg tablet During an interview on 06/26/25 at 11:00 a.m., an administrative staff member (#1) confirmed she expected medication aides and nurses to administer medications they personally prepared.

Based on record review, review of facility policy, and resident and staff interview, the facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for 1 of 2 sampled residents (Resident #30) reviewed for falls. Failure to lock tub chair brakes placed residents at risk for falls and/or injury. Findings include: Review of the facility policy titled Fall Risk & Prevention: Standards of Care occurred on 06/26/25. This policy, dated February 2024, stated, . Procedure: Transfer/Locomotion: 2. Follow care-plan for level assistance required . 4. Lock brakes on wheelchair for pivot transfer. Review of the facility policy titled Falls Resource Packet occurred on 06/26/25. This policy, dated April 2025, stated, . Fall reduction efforts include . Safe and proper use of any assistive device (wheelchair, walker, etc.) and not to use moveable items, (furniture, etc.) for balance or transfers . During an interview on 06/23/25 at 5:30 p.m., Resident #30 stated he had fallen in the shower room. They were helping me to stand, and I wasn't quite out of the [tub] chair, and it rolled back. I fell on my right side. Review of Resident #30's medical record occurred on all days of survey. The care plan stated, . ADL [activities of daily living] Deficit r/t [related to] diagnosis of weakness . minimum of 1 assist with transfers and ambulation . [Resident] is at risk for falls due to: history of frequent falling prior to move-in . A Resident Event Review, dated 06/11/25, identified Resident #30 fell on [DATE] at 10:00 a.m. and stated, breaks [sic] were not locked on tub chair. Resident attempted to transfer from tub chair to wheelchair. Tub chair rolled out from under resident and resident fell. Education provided to CNA [certified nurse aide] by charge nurse at time of event. No residual injury occurred from fall. During an interview on 06/25/25 at 4:00 p.m., an administrative staff member (#1) confirmed the CNA failed to lock the tub chair.

1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure an environment free of accident hazards for 1 of 1 sampled resident (Resident #27) who experienced a burn related to hot coffee. Failure to ensure appropriate coffee/water temperatures resulted in Resident #27 sustaining a burn and placed all residents at risk for serious burns/injuries. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 05/28/24 at 6:20 p.m. The IJ resulted from temperature readings obtained from the coffee/hot water machine, a lack of temperature monitoring by staff, and an injury to a resident. This finding placed residents in immediate danger due to hot temperatures and the potential for serious burns. *05/28/24 at 6:50 p.m. The survey team notified the administrator and director of nursing of the IJ situation, provided the IJ template, and requested a plan for removal of the immediate jeopardy. *05/29/24 at 10:15 a.m. The survey team reviewed and accepted the facility's removal plan for the IJ. The removal plan contained the following: *Immediately disconnected power to coffee machines, coffee and hot water with temperatures at or below 150 degrees were made available in carafes *Implement focus audit to monitor coffee and hot water temperatures twice daily in carafes *Education was provided to dietary and nursing staff currently working and staff not present will be trained on their next scheduled shift *Message sent to nursing staff to review the policy related to hot liquids *06/05/24 The survey team verified the implementation of the removal plan as of 05/28/24 and the IJ removal. The deficient practice remained at an G scope and severity following the removal of the immediate jeopardy. Findings include: Review of the facility policy titled Hot Liquids - Food and Nutrition Services occurred on 05/29/24. This policy, revised 04/19/24, stated, . When self-service of hot liquids are available in the dining room: a. Consider serving liquids at temperatures at or below 150 degrees Fahrenheit . When serving hot liquids to residents with behavior or medical conditions that put them at increased risk for spills: . Allow hot liquids to cool before serving to reduce the risk and/or severity of burns. c. Add ice to hot liquids before serving, if resident agrees . Review of Resident #27's medical record occurred on 05/28/24. Nursing progress notes included the following: * 05/24/24 at 5:47 p.m. Resident was sitting in dining room eating her meal and drinking coffee. Resident spilled her hot coffee into her lap. Nurse observed the incident and immediately pulled her polyester pants away from her legs and got her back to her room and took the pants off. Cold washcloths were placed over her legs for about 10 minutes. Right inner thigh, labia, and left inner thigh were affected. Red tissue is observed with no blistering. Resident c/o [complained of] the cold washcloths but has since denied c/o pain since the initial incident. Burn boundaries outlined with a sharpie. Burn areas to [NAME] for measurement. On-call provider [Doctor's name] notified @ [at] 1710 [5:10 p.m.] and new orders were received: 1. Daily dressing changes to affected areas with Silvadene and Telfa until resolved. 2. Monitor for blistering and s/s [signs and symptoms] of complications; call provider if they appear. Silvadene obtained from hospital. Son/POA [power of attorney] (name) was notified of incident and verbalized understanding of new POC [plan of care] @ 1720 [5:20 p.m.]. RRVH [Red River Valley Hospice] notified @ 1755 [5:55 p.m.]. DON [Director of Nursing] notified @ 1725 [5:25 p.m.]. * 05/27/2024 12:14 p.m. Resident has 2nd degree burns to right and left inner thighs, and 1st degree to the right labia. Right inner thigh has a ruptured bullae [blister] measuring 2 cm [centimeters] in diameter and is 0.1 cm deep. Intact continuous serous filled bullae trace the inferior border of the right inner thigh burn. Small ruptured bullae measuring 1 cm x 0.3 cm x 0.1 cm to the left inner thigh is observed. Temperatures obtained by the survey team on 05/28/24 showed the following: *At 2:30 p.m. in the first floor dining room, the temperature of the coffee (dispensed from an automatic machine) was 178 degrees Fahrenheit (F). A sign posted on the coffee/hot water machine identified staff were to add one teaspoon of ice or wait three minutes before serving coffee/hot water to residents in order to avoid burns. *At 5:23 p.m. in the second floor dining room, the coffee and hot water (dispensed from an automatic machine) measured 180 degrees F and 181 degrees F, respectively. A sign posted on the coffee/hot water machine also indicated to add a teaspoon of ice or wait three minutes before serving. Observation showed an unidentified dietary aide brought two cups of coffee and one cup of tea to residents, but failed to add ice and/or wait three minutes to serve the hot liquids. During an interview on 05/28/24 at 6:05 p.m., a dietary supervisor (#6) verified staff do not complete routine or random temperature checks on the hot water/coffee machines. 2. Based on observation, record review, policy review, and staff interviews, the facility failed to provide adequate assistance for 1 of 4 sampled residents (Resident #27) observed during a sit-to-stand mechanical lift transfer. Failure to ensure staff properly used assistive devices placed residents at risk for accidents and injury. Findings include: Review of the facility policy titled Mobility, Support and Positioning occurred on 05/30/24. This policy, dated 05/06/24, stated, . Sit-to-Stand For residents who demonstrate leg strength for weight bearing and are able to hold their torso in an upright position . must have some upper body strength. Must be able to cognitively follow cues and cooperate with procedure. Review of Resident #27's medical record occurred on all days of survey and included the diagnoses of dementia. The current care plan stated, [Resident #27's name] has a history of falling. Assist x2 w/ [with] pivot transfer. Standing lift/Hoyer [mechanical lift] assist of 2 per nurse's discretion. Observation on 05/29/24 at 10:55 a.m. showed a certified nurse aide (CNA) (#5) and a licensed nurse (#3) transferred Resident #27 from the wheelchair to the bathroom using the sit to stand mechanical lift. The resident had a difficult time holding onto the lift handles and hung from the harness in a semi-seated position. During the transfer the harness sling slid up the resident's back to the axilla area causing the resident's elbows to bow outward above the shoulders. During an interview on 05/30/24 at 12:03 p.m., an administrative nurse (#1) agreed residents should be able to bear weight while using the sit-to-stand lift. 40489

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure all forms of communication related to code level status accurately reflected the resident ' s wishes for 1 of 14 sampled residents (Resident #23) reviewed for advance directives. Failure to ensure the medical record and other forms of communication accurately reflected the resident's code status limited the facility's ability to communicate to direct care staff and emergency personnel the resident's choice in the event of a medical emergency. Findings include: Review of the facility policy titled Advance Care Planning occurred on 05/30/24. This policy, dated 11/13/23, stated, . Residents . have the right to make decisions concerning medical care, including the right to accept or to refuse medical or surgical treatment. Review of Resident #23's medical record occurred on all days of survey. The Uniform Code Level Directives for Cardiopulmonary Resuscitation, signed by the resident on 01/04/22, indicated Code Level 1: All available reasonable technology is used in the event of cardiac or respiratory arrest but would require transfer out of facility. *Wants chest compressions. No intubation. Observation on 05/28/24 at 5:39 p.m. showed a red dot on the spine of the resident's chart. During an interview on 05/28/24 at 5:39 p.m., an administrative nurse (#1) stated a green dot indicated a full code and a red dot indicated do not resuscitate (DNR). The administrative nurse (#1) confirmed that staff would identify Resident #23 as DNR based on the red dot on the resident's chart, and the facility would need another color circle to indicate resident's wishes of do not intubate (DNI).

Based on record review, staff interview, and review of facility policy, the facility failed to provide the resident or the resident's representative a written notice of transfer for 1of 1 resident (Resident #9) reviewed for hospital transfer. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: A review of the facility policy titled Transfer to Hospital Guide occurred on 05/30/24. This policy, dated, 02/19/23, stated, . Notify the resident, family member or legal representative of the transfer in a timely manner. Document completion in the Medical Record. Review of Resident #9's medical record occurred on all days of survey and identified a hospital transfer on 11/07/23. The medical record lacked documentation the facility provided the resident and/or representative with a written transfer notice. During an interview on the afternoon of 05/29/24 an administrative staff member (#1) confirmed the facility failed to provide written notice of a transfer to the family/representative.

Based on observation and review of facility policy, the facility failed to follow professional standards of practice for 1 of 1 resident (#17) observed for insulin preparation and administrations. Failure to prime the insulin pens correctly may result in residents receiving an inaccurate dose. Findings include: Review of the policy Medication: Insulin Administration, Insulin Pens, Insulin Pumps occurred on 05/30/24. This policy, revised December 2023, stated . Insulin Pen . Turn the dosage knob to '2' units to prime the pen. Holding the pen with the needle pointing upwards, press the button until at least a drop in insulin appears. Observation on 05/29/24 at 11:30 a.m. showed a nurse (#3) prepared Resident #17's Humalog insulin pen for administration. The nurse (#3) dialed the insulin pen to the prescribed units without priming the insulin pen. The nurse (#3) failed to prime the insulin pen as per facility policy. During an interview on 05/29/24 at 4:52 p.m., an administrative staff member (#1) confirmed it is her expectation that staff prime insulin pens per policy.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 3 of 14 sampled resident's (#17, #21, and #27) observed during medication administration, resident cares, and wound cares. Failure to follow infection control standards related to hand hygiene and glove use has the potential to transmit infections to residents, staff, and visitors. Findings include: Review of the facility policy titled Hand Hygiene occurred on 05/30/24. This policy, dated 03/29/22, stated, . Policy: . All employees are responsible for maintaining adequate hand hygiene by adhering to specific infection control practices. All employees in patient care areas . will adhere to the '4 Moments of Hand Hygiene and 2 Zones of Hand Hygiene'. 1. Entering . After contact with a patient's non-intact skin, wounds . If gloves are used to perform a clean/aseptic procedure, hand hygiene must be completed before donning gloves . - Observation on 05/28/24 at 5:35 p.m. showed a certified nurse aide (CNA) (#4) donned gloves and assisted Resident #21 off the toilet with a sit to stand lift. The CNA stood the resident, performed perineal cares, removed gloves and without performing hand hygiene donned new gloves. The CNA (#4) applied a clean brief, pulled up the resident's pants and removed the gloves. Without performing hand hygiene, the CNA positioned Resident #21 in the wheelchair, offered the resident a drink of water, and pushed the resident's wheelchair to the dining room. The CNA (#4) failed to remove gloves and perform hand hygiene after performing perineal cares and before performing other tasks. - Observation on 05/29/24 at 10:55 a.m. showed a nurse (#3) donned gloves and performed perineal care for Resident #27. The nurse removed the gloves and without performing hand hygiene donned new gloves and removed the soiled dressing from the wound on the resident's left leg. Without changing gloves or performing hand hygiene, the nurse cleansed the wound, and applied the new dressing. The nurse removed the glove on the right hand and without performing hand hygiend, placed another glove on the right hand, applied a prescription ointment to the glove and applied the silvadene cream to the resident's right and left thighs and right perineal area. The nurse then removed both gloves and performed hand hygiene. The nurse (#3) failed to remove gloves and perform hand hygiene before and after incontinent cares, dressing change, and applying an ointment. - Observation on 05/29/24 at 11:30 a.m. showed a nurse (#3) donned gloves, and scanned Resident #17's Dexcom (wearable device that tracks blood glucose levels). Without removing the gloves, the nurse exited the room, placed the monitor back into the medication cart, and typed on the computer. With the same gloves on, the nurse (#3) gathered supplies for Resident #17's insulin administration from the medication cart, and administered the insulin. The nurse exited the room, placed the insulin supplies back into the medication cart, removed the gloves, and without performing hand hygiene, typed on the computer. The nurse (#3) failed to remove the gloves and perform hand hygiene prior to exiting the room, after performing the blood sugar scan, and before and after the insulin administration. During an interview on 05/30/24 at 10:45 a.m., an administrative nurse (#1) stated she expected staff to follow infection control guidelines regarding hand hygiene and glove use.

Based on review of daily staffing information and staff interview, the facility failed to post daily staffing data for all shifts on 9 of 15 days reviewed (May 14-28, 2024). Failure to post accurate staffing data does not allow residents and visitors to be aware of the number of licensed and unlicensed staff on duty each shift. Findings include: Review of daily staffing data from May 14-28, 2024 showed on nine of the days, staff failed to post the number of staff working on six day shifts, six evening shifts, and one night shift. During an interview on the afternoon of 05/29/24, an administrative staff member (#1) confirmed staff failed to post staffing data for each shift on some of the days.

Based on record review, review of facility policy, and staff and resident interview, the facility failed to provide necessary supervision to prevent accidents for 1 of 1 sampled resident (Resident #1) with a burn. Failure to ensure placement of a barrier between the resident's skin and the heating pack and monitor the resident resulted in a burn to Resident #1's shoulder. Findings include: Review of the facility policy titled Heat Applications occurred on 11/02/23. This policy, dated 11/29/22, stated, . Procedure: Microwave Heating Packs . Place pack in microwave and follow manufacturer's recommendations for setting and length of heating time. Cover pack with towel and place on treatment area of resident . Check area in one minute for any redness of skin . Check area again every five minutes for any redness of skin or discomfort . Review of Resident #1's medical record occurred on 11/02/23. A physician's order, dated 10/19/23 and discontinued 10/31/23, stated, Ice/heat pack 3x [times]/day. If pt [patient] doesn't have preference between ice or heat, can alternate each throughout day for 10 minutes at a time. A nurse's note, dated 10/31/23 at 9:29 a.m., stated, . L) [left] shoulder wound: Resident is currently getting heat packs TID [three times per day] for L) shoulder pain. Upon entering residents room to give heat pack for today, some burning and blistering was noted in residents left shoulder. Most superior red area: Reddened area measures 2.3 cm [centimeters] x 2 m [sic, centimeters] in size. Within the reddened area there are 2 fluid filled blisters both smaller than 0.5 cm in size. Middle red area: Reddened area measures 5.3 cm x 4 cm in size. Located within the reddened area there are 2 fluid filled blisters at this time. Most inferior red area: The final reddened area measures 2.3 cm x 2 cm in size. It appears as though there were once 2 fluid filled areas than [sic] have since burst or fully drained. The two breaks in the skin are each around 2 cm x 1 cm in size. Bacitracin and Telfa bandage applied to open skin areas . Ice was given to resident instead of heat. During an interview on 11/02/23 at 10:18 a.m., Resident #1 stated, She [the nurse] had it [the heating pack] pretty hot. I just put it on though, didn't think much of it. The resident then stated, It hurt a little bit, but I'd rather have that than the arthritis pain, and usually they wrap it in a towel or something but not this time. I'm not sure why. During an interview on 11/02/23 at 9:45 a.m., an administrative nurse (#1) stated the night nurse brought the heating pack to the resident on the evening of 10/30/23. The nurse did not wrap the hot pack with a barrier and left it with the resident, telling the resident to wait to apply it for a few minutes so it could cool off. The administrative nurse (#1) stated the night nurse did not return to remove the heating pack or check on the resident.

Based on observation, facility policy review, and staff interview, the facility failed to follow standard infection control practices for 2 of 2 sampled residents (Resident #3 and #281) on isolation. Failure to follow infection control practices related to proper procedure for personal protective equipment (PPE) usage and isolation signage may result in the spread of infection to residents, staff, and/or visitors. Findings include: Review of the facility policy titled Emerging Threats-Acute Respiratory Syndromes Coronavirus (COVID) occurred on 02/17/22. This policy, revised 02/08/22, stated, . Upon identification of any resident with suspected or positive COVID-19, a COVID-19 precautions sign indicating precaution type and PPE will be posted on the outside of the resident's room. The resident will be isolated in their room with the door closed as safety allows . Reusable eye protection will be cleaned and disinfected according to manufacturer's recommendation. - Observation on 02/14/22 at 3:04 p.m. showed Resident #3's door closed with an isolation cart by the room but no sign on the door to indicate what type of isolation the resident required or PPE to be worn by staff. Observation on 02/15/22 at 8:47 a.m. showed a medication assistant (MA) (#4) donned PPE and entered Resident #3's room to administer medication. The MA removed her gloves and gown in the room prior to exiting and removed the N95 mask outside the room. The MA failed to clean her goggles after exiting the room, but continued to wear the goggles. Resident #3's door lacked a sign regarding the type of isolation or PPE to be worn by staff. Observation on 02/15/22 at 9:25 a.m. showed a certified nursing assistant (CNA) (#7) donned a gown and gloves without first performing hand hygiene, removed her surgical mask and goggles, and tucked the surgical mask into her uniform pocket under the gown and the goggles into the collar of her gown. The CNA failed to dispose of the surgical mask or store it in an acceptable way, i.e. in a clean paper bag. Without performing hand hygiene, the CNA donned an N95 mask and the goggles and took a breakfast tray into Resident #3's room. The CNA (#7) exited Resident #3's room, and after appropriately removing all PPE, donned the contaminated surgical mask from her uniform pocket, disinfected the goggles, and without performing hand hygiene donned her goggles. Observation on 02/16/22 at 8:49 a.m. showed Resident #3's door closed. The door lacked a sign regarding the type of isolation or PPE to be worn by staff. - Observation on 02/14/22 at 3:12 p.m. showed Resident #281's door closed with a sign on the door for droplet precautions, including the type of PPE to use, and an isolation cart by the door. Observation on 02/15/22 at 8:43 a.m. showed a nurse (#5) donned PPE and entered Resident #281's room to check her vital signs. Upon exiting the room, the nurse removed her gloves, gown, N95 mask, and donned a new surgical mask. The nurse failed to clean her goggles and continued to wear them. When asked if she does anything with the goggles once leaving the resident's room, the nurse stated, No. During an interview on 02/16/22 at 8:30 a.m., an administrative nurse (#6) stated she expected staff to disinfect or change eye protection after leaving an isolation room and before entering a non-isolation room. She expected staff to utilize appropriate doffing/donning technique for isolation rooms and she expected appropriate signage to be posted on the outside of the resident's door identifying what type of isolation precautions and the type of PPE to be worn in the room.

Based on record review and staff interview, the facility failed to document required COVID-19 test documentation for 3 of 3 sampled residents (Resident #3, #5, and #281). Failure to document COVID-19 testing results in each resident's medical record may lead to a lack of further required interventions and/or an incomplete medical record. Findings include: Review of resident medical records occurred on 02/15/22 and showed Resident #3, #5, and #281's records failed to contain documentation of negative COVID-19 test results. During an interview on 02/15/22 at 10:42 a.m., an administrative nurse (#1) confirmed the facility failed to ensure all resident medical records contained documentation of negative COVID-19 test results.

Based on record review, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to ensure timely electronic data submission of a required Minimum Data Set (MDS) assessment for 1 of 1 sampled resident (Resident #5) whose MDS did not get transmitted. Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.17), page 2-32 stated, . The MDS must be transmitted (submitted and accepted into the MDS database) electronically no later than 14 calendar days after the MDS completion date (Z0500B + 14 calendar days)., and page 5-1 stated, . All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS ' [Centers for Medicare and Medicaid Services] Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. Review of Resident #5's MDS occurred on 02/15/22. The quarterly MDS, dated [DATE], showed the MDS had been accepted as an Optional State Assessment (OSA) by the state, but the facility failed to submit the MDS to CMS. During an interview on 02/15/22 at 4:49 p.m., an administrative nurse (#1) reviewed the CMS Submission validation reports and confirmed the quarterly MDS dated [DATE] had not been submitted to CMS.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 01/27/21. Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to complete Minimum Data Sets (MDSs) that accurately reflected the residents' status for 2 of 12 sampled residents (Resident #19 and #24) and 1 closed record (Resident #280). Failure to accurately code the MDS may negatively affect the development of a comprehensive care plan and the care provided to the residents. Findings include: Section J: Falls The Long-Term Care Facility RAI Manual, revised October 2019, page J-33, states, . If this is not the first assessment . the review period is from the day after the ARD [assessment reference date] of the last MDS assessment to the ARD of the current assessment. Determine the number of falls that occurred since . prior assessment . and code the level of fall-related injury for each. Code each fall only once. If the resident has multiple injuries in a single fall, code the fall for the highest level of injury. - Review of Resident #280's medical record occurred on 02/16/22. A discharge return anticipated MDS, dated [DATE], showed section J1900 coded for two or more falls with no injury, two or more falls with injury (except major), and one fall with major injury. Documentation in the medical record identified only one fall with major injury since the previous MDS completed 09/08/21. During an interview on 02/16/22 at 3:55 p.m., an administrative nurse (#1) agreed staff failed to code Section J1900 of the 11/03/21 MDS correctly. - Review of Resident #24's medical record occurred on all days of survey. Review of the resident's progress notes identified a hospitalization on [DATE] with a return date of 12/28/21. A significant change MDS, dated [DATE], identified J1800 coded for the resident having a fall since return to the facility. Review of Resident #24's progress notes failed to identify a fall since 12/28/21. During an interview on 02/16/22 at 04:57 p.m., an administrative nurse (#1) confirmed staff coded section J1800 incorrectly. Section P: Physical Restraints The Long-Term Care Facility RAI Manual, revised October 2019, page P-1, stated, . DEFINITION PHYSICAL RESTRAINTS Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. and page P-5 stated, . Coding Instructions: Identify all physical restraints that were used at any time (day or night) during the 7-day lookback period. After determining whether or not an item listed in (P0100) is a physical restraint and was used during the 7-day lookback period, code the frequency of use. Review of Resident #19's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], identified section P0100 H coded for restraint used in chair or out of bed less than daily. The medical record did not identify the use of a restraint. Observations on all days of survey of Resident #19 failed to show the use of a restraint. During an interview on 02/15/21 at 3:34 p.m., an administrative nurse (#1) confirmed staff coded section P for restraints incorrectly.

Based on observation, record review, review of facility policy, and resident and staff interview, the facility failed to ensure staff reviewed and revised comprehensive care plans to reflect the residents' current status for 3 of 12 sampled residents (Resident #7, #13, and #22). Failure to review and revise the care plans limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Plan, LTC [Long-Term Care] occurred on 02/16/22. This policy, dated 11/01/21, stated, . As changes in resident condition occur, the care-plan must be updated in a timely manner to reflect the current plan of care . - Review of Resident #7's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician's orders included long-acting insulin, daily blood glucose monitoring, and a daily anti-depressant. Resident #7's current care plan lacked information related to diabetes mellitus and depression. During an interview on 02/17/22 at 10:00 a.m., an administrative nurse (#8) agreed Resident #7's care plan lacked a problem and interventions used to address depression and failed to address interventions for diabetes. - Review of Resident #13's medical record occurred on all days of survey. A physician's order, dated 11/09/21 and renewed 01/11/22, for [MEDICATION(S)] [anti-anxiety medication] stated, Special Instructions: Give prior to appointments every 1 hour as needed. A progress note, dated 02/16/22 at 12:33 p.m., stated, . She has been getting increased anxiety with any treatments, dressing changes and accuchecks [measures blood sugar] or lab draws. She will yell out 'help' even when you are right there in front of her helping her with whatever she may need. She prefers to stay in her room for everything except going to appointments. Resident #13's current care plan stated, . Assess environmental factors that may hinder activity involvement. [Resident #13's name] becomes anxious if asked to go outside or go on an outing so she states that she doesn't want to be asked to go to activities outside of the facility . Nursing staff failed to include a problem and/or non-pharmacological interventions related to Resident #13's anxiety. During an interview on 02/16/22 at 12:39 p.m., an administrative nurse (#1) stated Resident #13 received [MEDICATION(S)] as needed prior to appointments to the (type of specialty) clinic to reduce anxiety. This nurse reviewed the care plan and agreed staff should include anxiety and related interventions in the care plan. - Review of Resident #22's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS), dated [DATE], indicated pain almost constantly but unable to rate the worst pain over the last five days on a 0 to 10 scale. The quarterly MDS, dated [DATE], indicated intact cognition, experienced pain occasionally, and rated the worst pain at a seven. Physician's orders showed Resident #22 received five different medications for pain control and/or muscle spasms. During an interview on 02/14/22 at 1:14 p.m., Resident #22 stated both knees have been swollen, wears compression sleeves on knees, has pain in legs at night, and takes pain medications. On 02/15/22 at 10:36 a.m., Resident #22 stated had pain in his thighs. Observation on 02/16/22 at 9:42 a.m. showed a nurse (#3) completed cares to Resident #22's lower extremities. The resident complained of pain with moving legs during this process. Resident #22's current care plan showed staff failed to include a problem, goals, or interventions related to pain. During an interview on 02/16/22 at 12:39 p.m., an administrative nurse (#1) agreed Resident #22's care plan failed to address pain.

Based on policy review, review of the Centers for Disease Control and Prevention (CDC) guidelines and recommendations, record review, and staff interview, the facility failed to assess each resident's pneumococcal status and provide education to residents and/or their legal representatives regarding the benefits and potential side effects of receiving the vaccination for 3 of 5 sampled residents (Resident #6, #19, and #281) reviewed for immunization status. Failure to offer pneumococcal vaccine to all residents, provide education to residents and their legal representatives, and document the administration or refusal has the potential for non-immunized residents to contact pneumonia and spread the infection to other residents, visitors, and staff. Findings include: Review of the facility policy titled Immunizations/Vaccinations for Residents, Pneumococcal, Influenza, COVID-19, Other-Infection Control occurred on 02/17/22. This policy, revised 10/06/21, stated, . Upon admission, each resident and/or resident representative will receive the Vaccination Information Statements (VIS) for . pneumococcal vaccines. Discuss the benefits and potential side effects of vaccinations with the resident and/or resident representative. Obtain written consent . If the resident and or resident representative chooses not to be vaccinated . select refused in the consent given field . Assess the resident's current immunization status for pneumococcal vaccination . If the resident is eligible to receive the pneumococcal vaccine . and an order was not received at the time of admission, obtain a physician's/practitioner's order for vaccination . Review of CDC's Pneumococcal Vaccine Timing for Adults www.cdc.gov/pneumococcal/vaccination.html, reviewed 06/25/20, stated, . For those who have not received any pneumococcal vaccines, or those with unknown vaccination history . if patient and provider decide PCV13 [13-valent pneumococcal conjugate vaccine] is not to be given administer 1 dose of PPSV23 [23-valent pneumococcal polysaccharide vaccine]. If patient and provider decide PCV13 is to be given administer 1 dose of PCV13. Administer 1 dose of PPSV23 at least 1 year later. For those who have previously received 1 dose of PPSV23 at >[AGE] years and no doses of PCV13 if patient and provider decide PCV13 is not to be given series is complete. If the patient and provider decide PCV13 is to be given administer 1 dose of PCV13 at least 1 year after the dose of PPSV23. - Review of Resident #6's medical record occurred on 02/16/22. The resident was admitted in 2018. The record lacked evidence the facility assessed the resident's pneumococcal immunization status on admission and provided education to the resident and/or their legal representative. - Review of Resident #19's medical record occurred on 02/16/22. The resident was admitted in 2020. The record showed Resident #19 received the PCV13 vaccine on 10/13/18 (prior to admission). The record lacked evidence the facility assessed the resident's pneumococcal immunization status for the PPSV23 immunization and/or provided education to the resident and/or their legal representative. - Review of Resident #281's medical record occurred on 02/16/22. The resident was admitted 2022. The record showed Resident #281 received the PPSV23 vaccine on 06/15/16 (prior to admission). The record lacked evidence the facility assessed the resident's pneumococcal immunization status for the PCV13 immunization and/or provided education to the resident and/or their legal representative. The facility failed to follow their policy and the CDC recommendations for pneumococcal vaccine administration. During an interview on 02/16/22 at 12:53 p.m., an administrative nurse (#1) verified the facility failed to assess residents for pneumococcal immunization and/or follow the CDC recommendations for the pneumococcal vaccinations.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), and staff interview, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for 5 of 12 sampled residents (Resident #13, #14, #18, #26, and #27). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs, and has the potential to affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION H: BLADDER AND BOWEL The Long-Term Care Facility RAI Manual, revised October 2018, pages H-3-6 , . Steps for Assessment: H0200A, Trail of a Toileting Program . Review the medical record for evidence of a trial of an individualized, resident-centered toileting program. A toileting trial should include observations of at least 3 days of toileting patterns with prompting to toilet and of recording results in a bladder record or voiding diary. Simply tracking continence status using a bladder record or voiding diary should not be considered a trial of an individualized, resident-centered toileting program. - Review of Resident #13's medical record occurred on all days of survey. The care plan stated, . Toileting schedule: c/c (check and change) repo (reposition) every 2 hours. The resident's current MDS, dated [DATE], identified a current toileting program. Review of Toileting/Reposition Sheet, dated January 2021, identified the continence status and the changing of pads/wet garment for the resident. During an interview on the morning of 01/27/21, a certified nursing assistance (CNA) (#3) stated Resident #13 does not use the toilet and is a check and change. - Review of Resident #18's medical record occurred on all days of survey. The care plan stated, . Resident is an assist of 1 with ADL's (activities of daily living). Independent in room, Independent with meals. Toileting schedule, prompt upon arising and before meals, at HS (bedtime snack) and offer green brief. Urinal at bedside, check and empty. The resident's current MDS, dated [DATE], identified a current toileting program. Review of Toileting/Reposition Sheet, dated December 2020 - January 2021, failed to show prompts upon rising and before meals. - Review of Resident #26's medical record occurred on all days of survey. The care plan stated, . Toileting schedule as per resident assessment & schedule, I am to be check and changed every 2 hours while awake . Check and change at 0600 . The resident's current MDS, dated [DATE], identified a current toileting program. Review of Toileting/Reposition Sheet, dated January 2021, identified the continence status and the changing of pads/wet garment for the resident. Review of Urinary Incontinence Assessment, dated 01/17/21, Resident #26 is incontinent all the time. The facility failed to implement an individualized/resident specific toileting program based on an assessment of the resident's unique voiding pattern and evaluate the resident response to the toileting program. SECTION J: HEALTH CONDITIONS The Long-Term Care Facility RAI User's Manual, revised October 2018, pages J-24-25 stated, . Review the medical record for documentation by the physician that the resident's condition or chronic disease may result in a life expectancy of less than 6 months, or that they have a terminal illness . - Review of Resident #27's medical record occurred on all days of survey. A Hospice Initial Certification, dated 12/01/20, stated, Based on the patient's [DIAGNOSES REDACTED]. The resident's current MDS, dated [DATE], failed to identify Resident #27 as terminally ill a SECTION K: NUTRITION The Long-Term Care Facility RAI User's Manual, revised October 2018, pages K-5-6 stated, . Code 0, no or unknown: if the resident has not experienced weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is not available . Code 2, yes, not on physician prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days and the weight loss was not planned and prescribed by a physician . - Review of Resident #14's medical record occurred on all days of survey. The resident was admitted on [DATE]. The current MDS, dated [DATE], identified a weight loss without a prior weight to compare to. During an interview on 01/27/20 at 10:00 a.m., a dietary manager (#2) agreed Resident #14's medical record lacked pre-admission weights and she incorrectly coded section K for weight loss. - Review of Resident #26's medical record occurred on all days of survey. The resident's current MDS, dated [DATE], showed a weight of 166.7 lbs (pounds) and failed to identify a weight loss. Six months prior, on 07/21/20, Resident #26's weight was 188.6 lbs (a loss of 11.7%, significant). During an interview on 01/27/20 at 10:00 a.m., a dietary manager (#2) agreed she failed to code section K for weight loss accurately on MDS. SECTION O: SPECIAL TREATMENT, PROCEDURE, AND PROGRAMS The Long-Term Care Facility RAI User's Manual, revised October 2018, page O-5 stated, . O0100K, Hospice Care . Code residents identified as being in a hospice program for terminally ill person where an array of service is provided for the palliation and management of terminal illness and related conditions. Review of Resident #27's medical record occurred on all days of survey. A Hospice Initial Certification, dated 12/01/20, stated, Based on the patient's [DIAGNOSES REDACTED]. The resident's current MDS, dated [DATE], failed to identify hospice services.

Based on record review, review of facility policy and staff interview, the facility failed to ensure acceptable parameters of nutritional status and adequately monitor weights for 1 of 3 sampled residents (Resident #5) identified with weight loss. Failure to adequately monitor and evaluate weights, and promptly implement interventions may have contributed to Resident #5's significant weight loss. Findings include: Review of facility policy titled Nutrition Interventions (weight loss) occurred on 01/27/21. This policy, revised 01/17/21 stated . 1. Identify significant weight loss: a) 5% weight loss in one (1) month b) 7.5% weight loss in three (3) months c) 10% weight loss in six (6) months 2. Re-weigh to assure accurate weight . 14. LRD (Licensed Registered Dietitian)/CDM (Certified Dietary Manager) to monitor weights monthly in weight log . The Bath Checklist - Body Audit- Weight Log record was blank for Resident #5 in the month of January. The weight log record stated, . re-weigh if 3# (pounds) weight difference - Chart the re-weigh - Notify charge nurse . Review of Resident #5's medical record occurred on all days of the survey. [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS), dated [DATE], identified weight loss. Review of the resident's care plan 01/27/21 failed to identify the weight loss and interventions. The updated care plan stated, . Nutritional Status Actual/potential alteration in nutrition related to MS (multiple scerlosis), dysphagia, and constipation . Dietician to monitor weights . The care plan lacked interventions addressing the weight loss. Resident #5's weights included the following: * 07/25/20 191.0 pounds (Lbs) * 08/29/20 189.4 Lbs * 10/24/20 186.7 Lbs * 01/07/21 164.4 Lbs * 01/14/21 167.6 Lbs (12.5% weight loss in six months) * 01/21/21 157.0 Lbs (17.80% weight loss in six months During an interview on 01/27/21 at 2:00 p.m., a dietary manager (#2) provided a Nutrition Assessment Form for Resident #5. The assessment dated [DATE], showed data collected from 01/11/21 to 01/17/21. The document showed the following: * 1 month weight - 171.8 2.4 % loss * 3 month weight - 184.4 9.1% loss * 6 month weight - 191.0 12.3% loss The assessment lacked interventions to address Resident #5's weight loss. Review of dietary and nursing progress notes showed the following: * 01/20/21 at 7:52 a.m. : Completed Nutritional Quarterly Assessment. Will continue to monitor for he has had significant weight loss in the last 6 months but it's slowed down. Dietician and CDM will continue to monitor weights monthly. * 01/21/21 at 12:40 p.m. : According to weight taken today, Resident is down 10 pounds in a week. No physical changes have been noted in Resident. This is thought to be from inaccurate scales. Writer will pass off to try and get a re-weight at some point tonight or tomorrow. No concerns. Nursing will continue to monitor. * 01/26/21 at 3:56 p.m. : Dietician and CDM are reviewing weights and noticed resident has a significant weight loss more than we anticipated so having nursing re weight (sic) him but last weights shows he lost 10 pounds in one week so requested a reweigh. Intakes are still good. He eats well. Will Continue to monitor. During an interview on 01/27/21 at 1:03 p.m., a dietary manager (#2) agreed Resident #5's care plan lacked interventions to address his significant weight loss and needed to be re-weighed. During an interview on 01/27/21 at 3:35 p.m., two administrative nurses (#1) and (#4) stated they would expect staff to reweigh the resident immediately if greater than 3 pounds difference in weight from the last recorded weight and then to notify the Interdisciplinary Team if weight loss is noted.

Based on information provided by the complainant, record review, review of facility policy and procedure, and staff interview, the facility failed to ensure a safe environment for 1 of 1 sampled resident (Resident #2) who was subjected to sexually inappropriate advances by another resident (Resident #1). Failure to ensure residents are free from the sexual advances of other residents resulted in Resident #2's being fondled, placed Resident #2 at risk of continued sexual abuse, and placed other vulnerable, cognitively impaired residents at risk of potential sexual abuse. Findings include: Information provided by the complainant indicated the facility failed to protect Resident #2 after receiving reports Resident #1 made sexually inappropriate advances towards her. Review of the facility policy "Abuse and Neglect" occurred on 11/05/14. The policy, dated December 2013, stated, ". . . All Residents . . . have the right to be free from . . . sexual . . . abuse . . . Residents must not be subjected to abuse by anyone, including . . . other residents . . . SEXUAL ABUSE: Includes, but is not limited to, sexual harassment, sexual coercion, or sexual assult. . . . PREVENTION: . . . All residents . . . will be considered vulnerable and susceptible to abuse related to institutionalization and dependence on staff to meet daily needs. . . . Residents . . . who display abusive . . . behaviors will have such behaviors monitored by staff and these behaviors will be addressed on the care plan with appropriate approaches. . . . IDENTIFICATION: . . . If the abuse suspect is a resident . . . special security and/or possible transfer to an appropriate facility may occur. . . . Facility staff, the physician, and family will be involved with transferring residents. . . ." - Review of Resident #2's medical record occurred on 11/05/14. The resident's medical [DIAGNOSES REDACTED]. The current care plan stated, ". . . Problem: ADL (Activities of Daily Living) . . . Approaches: . . . (Resident #2) uses feet to propel w/c (wheelchair) (Start Date 06/19/13) . . ." - Review of Resident #1's medical record occurred on 11/05/14. The resident's medical [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], identified intact cognition and unclear speech. During an interview on 11/05/14 at 1:45 p.m., a social services staff member (#7) described Resident #1 as "being very competent," even though he has "a hard time verbalizing." The current care plan stated, ". . . Problem: ADL . . . Approaches: Independent with . . . locomotion, ambulation with FWW (front wheeled walker) (Start Date 04/25/14) . . . Problem: Behavioral Symptoms . . . Resident also has a history of sexual behavior towards other female residents at times . . . Approaches: 1:1 education on appropriate vs (versus) inappropriate behavior, Monitor resident(')s behavior in public areas, Social Services visits with resident as needed (Start Date 04/22/14) . . . behavior log (Start Date 04/25/14) . . . All disciplines to monitor resident for inappropriate touching to other residents, resident is not (to) be 1:1 with female residents in facility. Redirection will be provided as necessary (Start Date 10/13/14) . . ." The "Mood/Behavior Monitoring Sheets" showed staff identified Resident #1 as having no "inappropriate sexual behaviors" from April-November, 2014. The "Live Event" forms identified the following: * 04/19/14 at 2:15 p.m., ". . . resident (#1) was sitting near resident (#2) who is unable to verbalize needs on a regular basis. . . . Resident (#1) was sitting out in corridor . . . near (Resident #2), CNA (certified nursing assistant) walked passed the residents observing (Resident #1's) hands in (Resident #2's) shirt touching her breasts and areas under her shirt. As the CNA walked passed the resident (#1) his hands were removed. CNA immediately reported event to the Charge Nurse . . . Staff were informed to monitor resident (#1) . . . resident (#2) did not awaken while the other resident (#1) was touching her midsection and breasts. Immediately (Resident #2) was removed from the area resident (#1) was in. . . . The plan at that time included: educating resident (#1) . . . of our expectations - touching other residents in a sexual nature is unacceptable and will not be tolerated. Staff were informed to avoid putting resident (#2) in close proximity to (Resident #1) to prevent further incidents from occurring. . . . Met with resident (#1) relating to event on 04/21/14 . . . Explained to resident (#1) that when residents are not alert, have confusion, etc. they are considered vulnerable adults and that kind of behavior is considered sexual abuse. Resident stated that was the first and only time he has done that here. . . ." * 10/11/14 at 9:50 a.m., ". . . (Resident #1) was sitting in hallway . . . When (Resident #2) was done with breakfast, staff had her sitting in the hallway. When . . . CMA (certified medication assistant) (#3) looked out into hallway, (Resident #1) had 1 hand between (Resident #2's) legs and was rubbing. (Resident #2) removed his hand from her and started to back her w/c away. (CMA #3) moved (Resident #2) from situation. Updated (Director of Patient Services). She will follow-up on situation. . . . (Resident #1's) care plan was updated to reflect changes to prevent incident and similar incidents from recurring. All disciplines to monitor resident for inappropriate touching to other residents, resident is not (to) be 1:1 with female residents in facility. Redirection will be provided as necessary. . . ." On 10/13/14, the facility obtained written statements from three CNAs (#3, #4 and #5) who witnessed the incident that occurred on 10/11/14. One of the CNAs (#3) stated, ". . . (Resident #1 took) his hand and rub on top of (Resident #2's) leg. (Resident #2) took his hand and placed it back on his lap. (Resident #1) once again placed his hand between (Resident #2's) legs. (Resident #2) once again removed his hand and told him 'No.' (Resident #2) then started backing away from (Resident #1). . . ." Another CNA (#4) confirmed what the first CNA (#3) had said by stating, ". . . (Residents #1 and #2) began to hold hands, I'm not sure who held whose hand first. (Resident #1) then began to put his hand on (Resident #2's) upper thigh and was rubbing her leg. . . . She grabbed his hand and moved it away. (Resident #2) then began to scoot away in her wheelchair. . . ." The social services progress notes identified the following: * 10/13/14 at 2:21 p.m., "SS (Social Services) met with DON (Director of Nursing) this morning RE: (regarding) an incident that was witnessed by staff and visitors. There is concern for (Resident #2) as some witness' (sic) report that she was being fondled outside of her clothing, near the vaginal area by a male resident (#1) who is on the same floor as her (different wing). . . . The police have been contacted . . . SS attempted to call daughters of (Resident #2) with no answer. Full details will not be given to the family as the investigation needs to develop on it's own course. . . . this is a repeat situation that is being taken seriously. . . ." * 10/13/14 at 2:48 p.m.,"SS received verbal report (two days after the incident occurred) from supervisor, (name of Nurse), regarding a staff report of a male resident (#1) fondling a female resident (#2) in the commons area outside of the dining room on second floor of (the facility). . . . (Resident #1) was directed to not be near the female resident (#2)'s room, talk to her, or appropach her in the dining room or commons area. . . . His family will not be contacted out of respect for his privacy. . . . All staff (volunteers and housekeeping as well) that work directly with the resident (#1) need to be aware of the incident in order to protect other residents." A care conference note, dated 10/20/14, identified, ". . . Reports (Resident #2) and a male resident (#1) were in close proximity. . . . Due to the fact that this has been a concern in the past, and (Resident #2) is a vulnerable adult, the cops were notified. . . . Due to the PD (Police Department) conducting an external investigation, and that not being complete at this time (9 days after the incident), specific details are not available. Defer to PD for further questions . . . (Licensed Social Worker (LSW)) put in (Resident #2's) care plan that the male resident (#1) is not to be in the same area as (Resident #2). . . . Staff have been made aware. The ombudsman was also notified. Family notified on Tues (Tuesday) (three days after the incident occurred) as attempts to reach them prior (the day before) were not successful. . . . (Resident #2's daughters asked) Can the gentleman who did this be moved to another floor? (LSW) stated that it's a possibility . . . (LSW) will call family when this happens (. . . it was agreed to wait for the investigation finding prior to moving male resident (#1) down to first floor.). (Director of Patient Services) generated good and valid points about transferring at this time, which is why it is on hold for now. We also discussed that (LSW) will seek out placement at other facilities to see if a male unit is available. A unit with less vulnerable adults . . . may be beneficial. Again, these are options. No major decisions will be implemented until the investigation findings are provided. . . ." A social services progress note, dated 10/22/14 at 9:39 a.m., stated, "Investigation complete (eleven days after the incident) . . . (Officer) concludes that (Resident #2) was not victimized and that her interaction with a male resident (#1) was consensual. (Resident #2's daughters) were both notified regarding the findings. . . . (Resident #2's daughter) inquired about a room change for the male resident (#1) and I let her know that it was not warranted due to the findings of the relationship being consensual. . . ." It is unclear why/how the facility concluded it was appropriate for a cognitively intact resident to make sexual advances towards a vulnerable resident with severely impaired cognition. During an interview on 11/05/14 at 12:30 p.m., the Director of Patient Services (#6) acknowledged Resident #2 is severely cognitively impaired, considered a vulnerable adult, and would be considered unfit to give consent in a court of law. During an interview on 11/05/14 at 1:45 p.m., a social services staff member (#7) reported the officer instructed facility staff to keep quiet about the incident. He felt there was "no point in alarming (Resident #2's) family if it was consensual, and didn't want to get (her) family upset over nothing." She further indicated staff have been re-educated regarding Resident #1's care plan interventions. The social services staff member (#7) stated, "It makes it so disconcerting, because (Resident #1's) so competent," but "the officer and ombudsman assured us we were doing the right thing." She also indicated she felt Resident #1 should have been "moved from the facility." Review of an email dated 10/23/14 at 10:28 a.m., provided by the LSW, showed Resident #2's family contacted the facility regarding the "frustration" and continued "concerns." Resident #2's family asked why the facility considered the problem resolved as this was the second incident involving (Resident #1 and #2), how the facility came to the conclusion the incidents were consensual as one resident was cognitively intact and the other was demented, why (Resident #1) could not be transferred to another floor within the facility, how "keeping a [MEDICAL CONDITION] eye on (Resident #2)" would protect her from (Resident #1's) advances, and what would happen if there is a third incident. The facility failed to: * protect Resident #2 from abuse, as staff allowed Resident #1 and #2 to be in close proximity on 10/11/14 in the commons area/hallway where the inappropriate touching occurred, * record any of Resident #1's inappropriate sexual behaviors on the behavior log (Medical records and staff interviews show both incidents were witnessed first hand.), * consider Resident #2's severely impaired cognition when drawing the conclusion the incidents were consensual, * and, protect Resident #2 during the investigation.