**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to protect the rights of one resident (#2) from sexual abuse by a visitor. The deficient practice resulted in the resident being sexually abused. Findings include: Resident #2 was admitted on [DATE] with diagnoses of cognitive communication deficit, Parkinson's disease, and anxiety disorder. The care plan with revision date of September 9, 2024 revealed the resident had actual and potential psychosocial well-being problem related to cognitive impairment, family discord and past history of physical and sexual abuse. Interventions included supervised visits with a family member and during visits, resident #2 and the family member had to be either in a public area or must be able to be viewed by staff while in her room. A communication note dated September 23, 2024 included that the resident's family member/POA (power of attorney) asked to get a report of a sexual abuse allegations from September 9; and that, the family member wanted to know what was in the report as he felt that he was being accused of something. Per the documentation, the family member reported that the resident's allegations were done to get attention; and that, the resident was molested when she was 7 and when she was married was abused by her husband. The documentation also included that the family member reported that the day the resident made allegations that she had been raped (September 9) was the day that the family member was not feeling well and only made a short visit. It also included that the short visit did not leave time for a rape and it does for inappropriate touching. The documentation also included that the family member was notified that eyesight visitations will be continued until the facility was told otherwise. The late entry mood note dated September 25, 2024 revealed the resident was more emotional and was crying out more lately. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 03 which indicated the resident had severe cognitive impairment. The alert note dated October 1, 2024 included that at approximately 3:30 p.m., the resident reported that she was suicidal as she was crying in the hallway. The facility visitor sign in-sign out sheet for October 14, 2024 revealed that the family member/POA visited and was at the facility from 11:00 a.m. through 12:13 p.m. The clinical record revealed no evidence found that the family/POA was supervised during his visit with resident #2 on October 14, 2024 from 11:00 a.m. through 12:13 p.m. The clinical record also revealed no evidence that the care plan for supervised visits were discontinued for the family member/POA. The alert note dated October 14, 2024 revealed that at approximately 2:00 p.m., two certified nursing assistants (CNAs) reported that resident #2 had abnormal vaginal bleeding that was found during showers; and that both CNAs reported that it was a lot of bleeding. Per the documentation, when the nurse approached the resident in the hall, the resident reported that she did not do anything wrong. It also included that the resident was assessed and external examination showed no bleeding, swelling or bruising and there was no blood in the resident's brief. Further, the documentation included that directions were given to send the resident to the hospital for examination. The alert note dated October 14, 2024 included that at approximately 2:15 p.m., a CNA who was upset reported to the social service director that the CNA was helping other CNAs with showers and was giving resident #2 showers. Per the documentation, the CNA reported that when the CNA was washing the resident's vagina, there was a lot of blood on the wash cloth; and that she grabbed a new wash cloth, washed the area again and there was still significant amount of blood. The documentation included that when the CNA asked the resident if she was ok, the resident yelled out that the family member/POA did not do anything to her. Further, the documentation included that the resident was assessed, EMS (emergency medical services) was called and resident was transferred to the hospital. Another alert note dated October 14, 2024 revealed that at approximately 2:25 p.m., the nurse was informed by a CNA who provided showers to resident #2 that that CNA witnessed a significant amount of vaginal bleeding; and that, the CNA used two rags which were both bloody. The documentation included that when the resident became aware of this, the resident reported that the family member/POA did not do it. The documentation included that a noninvasive assessment was conducted and the resident's brief was examined and there was no apparent blood or visible physical trauma observed. Per the documentation, instruction was given to proceed with hospital transfer and notification of the family member/POA. The transfer to hospital summary note dated October 14, 2024 revealed that at approximately 2:30 p.m., a CNA observed the resident was having vaginal bleeding; and that, the resident was post-menopausal. Per the documentation, both the nurse and the CNA reported that bleeding was initially frank-red with beginning of perineal care whilst in a shower after visit concluded. The documentation also included that when asked about the bleeding, the resident immediately responded that the family member (POA) did not do it. The note included that the resident was sent to the ER (emergency room) with explicit instructions to perform vaginal inspection via speculum. A health status note dated October 14, 2024 included the resident left the facility for evaluation at the hospital ER. The communication note dated October 14, 2024 included that at approximately 2:45 p.m., the family/POA was notified that the resident was transferred to the hospital for evaluation related to abnormal groin bleeding. Per the documentation, the family/POA responded by asking whether the bleeding was in the resident's private area and then ended the call. The sexual assault medical examination report dated October 14, 2024 revealed that the resident was frail, suffered from Parkinson's disease and had a difficult time communicating. Per the documentation, resident reported that the family member/POA had assaulted her earlier in the day but was not certain of the time. It also included that the resident reported that she and the family member/POA went to the mall and the family member/POA assaulted her in the care. The documentation included that the resident reported that the family member/POA took her shorts off, held her legs, placed his finger into her vagina, put his penis into her vagina and put his mouth and hands on both her breasts. It also included that the resident reported that she was slapped on the left side of the face-neck with the hand; and that, the family member/POA had assaulted her when she was a child. Physical examination included injuries noted in the lower extremities, external genital area and the labia minora. Description of the injuries included 0.5 cm (centimeter) x 1.5 cm red bleeding 1 o'clock to 3 o'clock at the edge of the vaginal orifice and 1 cm linear scratch 12 o'clock approximately 2 cm anterior to the vaginal orifice. Examiner's diagnosis included sexual assault by history and examination. The hospital report dated October 14, 2024 revealed that the resident was seen at 5:00 p.m. for evaluation for sexual assault. Per the documentation, facility reported that there were prior reports of sexual assault that were unsubstantiated. It also included that the resident reported lower abdominal pain, denied vaginal bleeding/discharge; and that, she was allegedly sexually assaulted by a patient from the facility yesterday. The documentation also included that the resident reported there were 3 discrete episodes of sexual assault that included touching and penile penetration. Continued review of the hospital report revealed that the police department informed the hospital that the resident told the police that she had been sexually assaulted 3 times while at the facility. The event note dated October 15, 2024 revealed that the nurse received a report from the hospital ED that the assessment and bruises were consistent with abuse; and that, the resident would need to have additional photos done. The event note dated October 15, 2024 included the resident arrived back to the facility, was agitated, crying and moaning. Per the documentation, the resident stated Why did he do this to me?, Was I bad? How could he hurt me, why did he do this to me? It also included that the resident kept crying and moaning, was given medications, and attention was diverted to watching a movie with the nurse until the resident fell asleep. A communication note dated October 15, 2024 included that the family/POA was informed that he would not be allowed into the building pending investigation. The administration note dated October 15, 2024 revealed that resident was restless and upset. The email correspondence from the facility's executive director (ED/staff #13) addressed to the provider and dated October 15, 2024 included that the resident was sent to the ER for vaginal bleeding; and that, clinical inspection was done at the ER and findings were consistent with sexual abuse. The administration note dated October 16, 2024 revealed that resident was agitated and was crying. The administration note dated October 17, 2024 included that the resident was crying and was asking the question What did I do wrong? over and over. An interview was conducted on October 17, 2024 at 2:04 PM with CNA (staff #20) who was working the day of October 14, 2024. The CNA stated that she assisted another CNA (staff #10) in getting resident #2 in the shower and then proceeded to the nurses' station. The CNA said that staff #10 came out of the shower and told her that she was washing the resident's vagina and that resident had blood in the area. The CNA said that staff #10 showed her the rag she used and asked her if it was normal for resident #2 to have that much blood. The CNA said that she asked staff #10 if resident #2 had hemorrhoids and staff #10 replied with a no. She stated that she then went with staff #10 back into the showers and had used the flashlight on her phone to check resident #2. The CNA said that she did not see any scratches or hemorrhoids and at that point, she gave resident #2 a towel to dry off and asked the resident if she had gotten hurt. The CNA said that looked at her and replied that family member/POA did not do anything to her vagina. The CNA said that she then reported the incident to the ED (staff #13) and registered nurse (RN/staff #6). Further, the CNA said that earlier in the day of the incident, during lunch, resident #2 appeared to be uncomfortable. An interview was conducted on October 17, 2024 at 3:01 p.m. with another CNA (staff #22) who stated that she was familiar with resident #2 but was not working with her on October 14, 2024. Staff #22 stated that the family member/POA would visit resident #2 often; however, she does not know where these visits take place or if there were any safety precautions in place during these visits. In an interview with a licensed practical nurse (LPN/staff #14) conducted on October 18, 2024 at 9:08 a.m., the LPN stated he was working on October 14, 2024 and was familiar with resident #2. He said that resident #2 had one visitor on October 14, 2024 and it was the family member/POA; however, he said that he was not sure where the visit took place. The LPN stated that at one point, the family member/POA was at the nurses' station for approximately 15 minutes because resident #2 was being changed in her room; but, he lost sight of the family member/POA after that. He stated that during his shift the CNA (staff #10) reported that resident #2 had blood on her washcloth during a shower. The LPN said that he had reported the incident to the Assistant Director of Nursing (ADON/staff #4) and RN (staff #6). An interview was conducted with the CNA (staff #10) on October 18, 2024 at 9:18 a.m. The CNA said that she was scheduled to be on the rehab unit on October 14, 2024 but the long term care unit needed help so she was assisting residents with showers. The CNA said that resident #2 was her first shower of the day since she was up and around; and that, resident #2 does not do her own washing so staff was doing it for her. The CNA said that she was washing the resident's privates with soap and a washcloth when she noticed a good amount of blood and she was not sure where it was coming from. She reported that she was able to get another CNA (staff #20) to assist her in locating the source of the bleeding and both she and staff #20 saw the blood coming out of the resident's vagina. The CNA said that she and staff #200 reported the incident to the RN (staff #6) and the ED (#13). Regarding resident #2, the CNA said that the resident's agitation usually gets worse after her visits with the family member/POA. During an interview with the Director of Nursing (DON/staff #18) conducted on October 17, 2024 at 3:58 p.m., the DON said that she was somewhat familiar with resident #2 as she had just recently started working at the facility on October 2, 2024; and she was not working on October 14, 2024 which was the day of the incident. The DON said that the visits between resident #2 and the family member/POA were to take place within the staff's line of sight; and that, she only became aware of this on October 14, 2024 when the incident took place. The DON said that the visits of the family member/POA with resident #2 were put on hold pending the outcome of the abuse investigation; and that, if a staff sees the family member/POA on the premises, the staff were to inform her, the ADON or the ED immediately so they could intervene. Further, the DON said that allowing family member/POA to continue to have unsupervised visitation with resident #2 would have the risk of abuse to continue. In an interview conducted with the ED (staff #13) conducted on October 17, 2024 at 4:12 p.m., the ED stated that visits between resident #2 and the family member/POA were to take place either on the front porch, the front lobby, or the sitting area by the ice cream parlor. The ED said that she was working on October 14, 2024 and was approached by the RN (staff #6) and two CNAs (staffs #10 and #20). She said that she was told that the resident was being provided with showers by the CNA and there was blood on the washcloth when the CNA did the peri care. The ED stated that the two CNAs reported that they got on their knees with a flashlight, saw that there were no cuts but the bleeding appeared to be coming from the resident's vagina. The ED said that she instructed the RN (staff #6) and another nurse to do an exam to determine the cause of the bleeding. The ED further stated that the risk to the resident if someone, who was accused of sexually assaulting them continued to have unsupervised visits depended on whether the allegation was substantiated or unsubstantiated. The facility's policy on Abuse - Protection of Resident was last reviewed on July 18, 2023 revealed that the facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation. The policy also revealed that to ensure the protection of residents during an investigation included removal of access by the alleged perpetrator to the alleged victim and assurance that ongoing safety and protection is provided for the alleged victim and, as appropriate, other residents. The facility policy on Visitor Management reviewed on June 17, 2024 included that all associates are responsible for ensuring the safety and well-being of residents, associates and visitors. Reasonable clinical and safety restrictions include a facility's policies, procedures or practices that protect the health and security of all residents and staff; and, these may include, but are not limited to denying access or providing limited and supervised access to an individual if that individual is suspected of abusing, exploiting, coercing a resident until an investigation into the allegation has been completed or has found to be abusing, exploiting or coercing a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, review of facility documentation, facility policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure there was a physician order for a narcotic medication that was administered to one resident (#2). The deficient practice could result in residents receiving unnecessary medication. Findings include: Resident #2 was admitted on [DATE] with diagnoses of paroxysmal atrial fibrillation and Alzheimer's disease. A care plan dated [DATE] included that this resident was at risk for falls related to cognitive impairment and hypotension. A physician's order dated [DATE] included acetaminophen (analgesic) Tablet 325 milligrams, give 2 tablet by mouth every 4 hours as needed for temperature above 101 degrees, not to exceed 3 gram/24 hours. An admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. A review of the clinical record revealed no evidence of any physician order for morphine (opioid) for resident #2. Review of the MAR revealed no transcribed order for morphine for resident #2. A progress note dated [DATE] included the nurse writing the note was called into resident #2's room to assess the resident with night shift (NOC) nurse and that when a Certified Nursing Assistants (CNA) were changing resident #2, he took one last breath and then did not seem to be breathing. This note included that upon assessment of the resident, vitals were absent, no apical pulse auscultated, no pulses or respirations noted at time 6:45 P.M. Review of the intake information submitted by the facility to the SA complaint tracking system on [DATE] revealed that an allegation was made that the former Director of Nursing (DON) was informed by a Registered Nurse (RN/staff #59) that resident #2 was not doing well and seemed to be in pain on [DATE]. The information also included that staff #59 allegedly asked the former DON if they could get an order for comfort medications and the former DON responded, No, I have some morphine here and you can give him this. Per the documentation, the former DON then was said to pull a bottle of Morphine out of her locked cabinet, where she keeps discontinued Narcotics to be destroyed. The information also revealed that staff #59 stated that former DON drew up the morphine and handed it to the RN, and instructed the RN to go give the medication to resident #2. Further, the information revealed that the former DON admitted to giving the morphine orally to resident #2 at around 4:00 P.M. and at 6:45 P.M. the resident #2 was found deceased . The information noted that in review of medical records there were no physician order for morphine. The facility's 5-day investigative report submitted to the SA on [DATE] revealed a written statement by the former DON dated that she gave the RN (staff #59) the 0.25 of morphine from a bottle that had not yet been destroyed and that the former DON did not instruct the RN to check if there were orders in. The report also revealed that former DON wrote that she should not have given the medication to the the RN and that it was a mistake. Continued review of the facility's investigative report revealed a witness statement dated [DATE] written by staff #11 that sometime in April she was in the former DON's office when staff #59 (RN) walked in with concerns about a resident needing pain pills but did not feel comfortable with giving him the pill due to possible chocking since he was not doing well. The statement noted that the former DON pulled out a box of morphine and said she had that to give to the resident. Per the statement, the RN (staff #59) was very hesitant and looked at both the former DON and staff #11 and told staff #11 she better not say anything to anyone or else. Further, the statement revealed that the RN (staff #59) asked what does she tell the resident's family member since she was right next to him, the former DON stated to tell the family that it was liquid tylenol. Per the statement, the RN (staff #59) was very scared, walked out, and came back with a syringe that she washed. The statement noted that the former DON instructed the RN (staff #59) to throw it away because she had more. Per the statement, the former DON told the RN (staff #59) that she drew up, I think .5 something close to that. The facility investigation also included an email written by an RN (staff #59) dated [DATE] that stated she went to the former DON with her concern of patient condition and the former DON gave her 0.25 ml (milliliter) of morphine and left the room. The documentation included that the RN (staff #59) wrote that this was a mistake and not a common practice. Further review of the facility's investigative report revealed a letter by the Medical Director of the facility dated [DATE] that stated the physician (staff #3) was informed that resident #2 was given morphine on [DATE] and did not recall giving an order for the patient. The facility investigation report concluded the facility substantiated the allegation of misappropriation of a controlled substance and administering medication without a physician's order. Despite the lack of order for morphine; and documentation that the morphine was administered to the resident, there was no evidence that an order was requested from the physician. A phone interview with the the Registered Nurse (RN/staff #59) who administered the Morphine was attempted on [DATE] at 12:21 P.M. but was unsuccessful. The RN did not answer or returned the call. An interview was conducted on [DATE] at 2:43 P.M. with the physician (staff #3) who stated that resident #2 was a cardiac and memory patient; and, had diagnoses of atrial fibrillation and hypotension. The physician further stated that he did not prescribe morphine; and that, his records did not reflect that this resident was on hospice. In an interview conducted with the former DON (staff #36) on [DATE] at 2:48 P.M., the former DON stated that resident #2 received morphine on [DATE]; but, the resident had no physician orders for morphine. She said that she believed this resident was on hospice already because she had been speaking to the family about it. The former DON also stated that the RN (staff #59) came to her office that day and requested for comfort medications for resident #2. The former DON said that she then took a bottle that was not yet destroyed, had not been used and gave this to the RN (staff #59) to administer 0.25 ml dose to resident #2. Further, the former DON stated that the RN (staff #59) administered the morphine to resident #2. An interview was conducted on [DATE] at 3:24 P.M. with a former certified nursing assistant (CNA/staff #11) who stated that she did not remember the resident's name but on that day of the incident, a nurse walked in the former DON's office; and that, the nurse informed the former DON that a resident needed pain medications but that the resident will choke if she gave him the pain medication. The former CNA also said that the nurse told the former DON that there was no liquid Tylenol available. The former CNA said that the former DON pulled out a morphine box and told the nurse to just give the resident some of this and tell the resident's daughter that the nurse gave the resident liquid Tylenol. The former CNA said that the nurse just stood there so the former DON said that she would be drawing up the dose so if anything happens it will fall on the former DON. The former CNA said that the nurse looked at her and the DON told the nurse and the former CNA not to say anything. The former CNA stated that the dose that was prepared by the former DON was more than 0.25 milliliters (ml) of morphine and the nurse left and administered it to the resident. Further, the former CNA said that the nurse washed the syringe, brought it back and gave it to the former DON who told the nurse to dispose of it; and that, the former DON told the former CNA that resident #2 was going home the next day on hospice care. The former CNA further stated that when she found that resident #2 passed the DON told her again that she (referring to former CNA) better not say anything. An interview was conducted on [DATE] at 5:00 P.M. with a Licensed Practical Nurse (LPN/staff #10) who said that when administering medications, the LPN would check the right patient, the full name, the date of birth , and double check the physician's order and the medication provided by the pharmacy. She said that she cannot give a resident a medication that the resident did not have order for; and, when another nurse gave her a medication to administer because she did not perform the necessary checks. The LPN said that the physician have to be notified when a nurse give a medication that a resident does not have an order for. Further, the LPN said that the narcotic medication, morphine was not kept in stock at the facility; and that, morphine is ordered for each individual resident. During an interview was conducted with the Regional Director of Clinical Services (RDCS/staff #23) on [DATE] at 5:33 P.M., the RDCS said that the nurse (staff #59) went to the former DON's office and reported to the former DON (staff #36) that resident #2 was in pain; and that, the resident was going on hospice but was not yet in hospice at that time. The RDCS said that former DON (staff #36) then drew the morphine from the bottle and gave it to the nurse (staff #59) who then gave it to resident #2. The RDCS said that the former DON (staff #36) admitted to being wrong and should have called the doctor for orders prior to giving the morphine the nurse who administered it to the resident. The RDCS said that she did not know whose morphine bottle/medication the former DON used; but, the nurse (staff #59) who was present at the time of the incident reported that the morphine bottle was taken by the former DON from the file cabinet where the facility kept medications that needed to be disposed of. Further, the RDCS said that a search was made of the file cabinet and an open bottle of Morphine liquid was found; and that, the facility's 5-day investigation substantiated that resident #2 received morphine that was not prescribed to him. A policy titled Physician/Prescriber Authorization and Communication of Orders to Pharmacy revised [DATE] included the facility should not administer medications or biologicals except upon the order of a Physician/Prescriber lawfully authorized to prescribe for and treat human illnesses.