**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 32 residents, with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to prevent sexual abuse when Resident (R)2 used topical pain medication as lubrication and penetrated cognitively impaired resident R1 anally and vaginally. On 07/11/25 at 03:05 PM, cognitively impaired R1 reported to LN G she felt nauseated, and LN G noted R1 to be anxious. R1 stated R2 utilized topical pain medication (Voltaren) during a sexual encounter, as lubrication, R1 felt sick, and reported hurting and bleeding. LN G asked R1 to clarify if it was used in her vagina or rectum, and R1 stated vagina. R1 reported R2 had put it on himself, and then it went in. R1 was unable to provide a date or time when the incident with R2 occurred, but stated it was a couple of days ago. R1 was tearful, voiced embarrassment, reported feeling ashamed, and said she told R2 to stop, but R2 did not stop. The Social Services Staff X took R1 to the hospital, where R1 reported sexual activity and bleeding. R1 told the emergency room (ER) doctors she was penetrated anally by R2. The examination revealed a small internal hemorrhoid and excoriation of the rectal tissue. R1 stated when R2 touched her, she felt afraid, helpless, and scared. R1 continued to have uncontrolled anxiety and tearfulness, was found shaking uncontrollably in bed, and was very difficult to calm. This deficient practice placed R1 in immediate jeopardy, and other female residents at risk for sexual abuse.Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of stroke, hemiplegia (paralysis of one side of the body) affecting the left non-dominant side, hypertension (high blood pressure), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), aphasia (condition with disordered or absent language function), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of eight, which indicated moderately impaired cognition. The MDS documented R1 had no behaviors, required set-up/clean-up assistance with eating, required moderate staff assistance with bathing, and was independent with all other activities of daily living (ADL).The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/29/24, documented R1 was at risk for a decline in cognitive status. The staff oriented R1 frequently, R1 required extra time to respond to questions, and the staff were to ask simple, direct questions which were easier for R1 to answer.The Communication CAA, dated 10/29/25, documented R1 was at risk for decline in functional communication. The CAA documented R1 was able to answer simple, direct questions if given the time.The Functional Abilities CAA, dated 10/29/25, documented R1 as at risk for a decline in functional ability with ADLs. The CAA documented R1 was mostly independent with her ADLs.R1's Care Plan documented R1 had a BIMS of eight and directed staff to speak about one topic at a time and wait on her response for understanding (10/28/24). The care plan documented R1 had a diagnosis of depression and directed staff to engage R1 in conversation when she felt sad and provide emotional support (02/19/25). The care plan documented R1 had anxiety attacks and directed staff to reassure R1 when she had negative thoughts that brought her stress and anxiety (06/25/25).The Nurses Note, dated 07/10/25, documented R1 reported she had moderate (about a tablespoon) of bright red blood after having a soft stool this evening. R1 stated she strained a little bit, denied a history of bleeding or hemorrhoids, stated she did not know if the bleeding was rectal or vaginal, and denied pain or discomfort. R1 declined an emergency room visit for evaluation but agreed staff could contact her provider in the morning and schedule an office visit. R1 agreed she would notify staff of further episodes and not flush before the nurse visualized.The Social Services Note, dated 07/11/25 at 02:18 PM, documented Certified Nurse Aide (CNA) M came to Social Services Staff X's office at about 02:09 PM and reported R1 was very tearful. Social Services Staff X went to R1's room, and R1 wanted her door shut during the visit. R1 stated a male resident had her cream and told R1 she was not lubricated enough. R1 admitted to having sex with the male resident [R2]. R1 was tearful because she noticed blood coming from her rectum. The note documented R1 expressed embarrassment. Administrative Staff A asked R1 if the sexual activities were consensual or not, and R1 replied, No, I did not want to do it. R1 was calming down and weeping less and agreed to get examined by a doctor, in case her sexual activity had harmed her in any way, especially using arthritis cream [as lubrication]. Social Services Staff X transported R1 to the emergency room, where a Sexual Assault Nurse Examiner (SANE) saw R1. R1 provided the nurse with her story and claimed she was a bad girl. The SANE nurse asked R1 if the sex was consensual, and R1 replied, Yes. The SANE nurse stated the exam would not be necessary and any evidence collected would most likely not be found since the event occurred two days to a week ago. The SANE nurse stated that this may be the case due to R1 showering, changing clothes, and so on. The emergency room doctor arrived, asked R1 about her rectal bleeding, and R1 did not mention anything about her sexual activity or any possible penetration wounds. The doctor examined R1's rectal area and noted she had obvious internal hemorrhoids. The hospital treated R1with a suppository and released the resident.The Nurses Note, dated 07/11/25 at 02:40 PM, documented R1 reported she felt nauseated and like she was going to be sick. The note documented R1 appeared anxious and displayed evidence of picking at several lesions on her left hand and abdomen. R1 asked LN G to go to her art table and get that tube. LN G retrieved a tube of diclofenac 1% gel (topical pain medication). R1 asked LN G, What is that for? LN G told R1 it was a topical medication used for pain. LN G asked R1 where she got the medication, and R1 replied, [R2]. LN G told R1 the medication was usually kept on the nurse's cart. R1 stated she had felt sick ever since she used it. LN G asked R1 where she had applied the medication, and R1 was hesitant to discuss but stated, [R2] got it out of his drawer. I was in his room, and we were messing around, and I was having a problem. I am so embarrassed. LN G provided R1 emotional support. R1 told LN G, [R2] got it out of his drawer and said we can use this, indicating the diclofenac gel, for lubrication. LN G asked R1 to clarify if she meant the gel was used for lubrication. R1 answered, Yes. R1 stated, Ever since then, it has been hurting and I have been bleeding. LN G asked R1 to clarify if she meant in her rectum or her vagina, and R1 stated, vagina. R1 stated, [R2] put it on himself, and then it went in. LN G asked R1 when this occurred, and R1 said a couple of days ago. R1 was tearful and voiced embarrassment. LN G continued to provide emotional support. LN G asked R1 if she felt threatened or unsafe by R2, and R1 said, No. The emergency room Provider Note, dated 07/11/25, documented R1 presented to the emergency room with the complaint of rectal bleeding and sexual assault. R1 presented with bright red blood per the rectum and reported constipation over the last several days since consensual penile penetration to the rectum. The exam showed a small internal hemorrhoid and excoriation of the rectal tissue. The staff administered Anusol (topical steroid used to treat hemorrhoids or rectal irritation) 25 milligrams (mg) via suppository, gave discharge instructions with supportive care, and encouraged R1 to avoid further activity.The Nurses Note, dated 07/12/25, documented the nurse found R1 sobbing in her recliner. When asked what was wrong, R1 stated, I'm so upset with myself. When asked why R1 was upset with herself, R1 stated, It was something that happened with another resident. It wasn't his fault. It was mine. When asked if she was upset about her sexual encounter, R1 nodded her head. R1 stated, I am just so ashamed of myself. It should not have happened. R1 stated, I am such a weak person, and I should not have given him the opportunity.I did tell him to stop, but he didn't. Everyone thinks [R2] is pure as snow, but he is not.I can't stop my mind from running, it's going and going and going. The Nurses Note, dated 07/13/25, documented R1 continued to have uncontrolled anxiety and tearfulness regarding a sexual encounter with another resident. R1 was able to come out for the morning meal but remained tearful. R1 was found shaking uncontrollably in bed and was difficult to calm.On 07/28/25 at 09:30 AM, observation revealed R1 sat in her recliner staring out the window. The room was dark, and the TV was off. R1 was wringing her hands, breathing hard, and was tearful.On 07/28/25 at 09:30 AM, R1 stated she had been more depressed lately. R1 stated she did a bad thing and let R2 take advantage of her. R1 stated she did not want to talk about R2 or think about R2. She just wanted to forget anything ever happened. R1 stated she did not want R2 to do the things he did to her, but she was an old lady, and he was a man. She did not know what to do. R1 stated R2 was gone, and she did not have to worry about him coming into her room anymore. R1 stated she still wanted her door shut all the time because she was afraid someone else would come into her room. R1 stated when R2 touched her, she felt afraid, helpless, and scared.On 07/28/25 at 11:00 AM, Administrative Staff A stated she thought something happened between R1 and R2, but was unable to prove what happened. Administrative Staff A stated by the time the investigation started, R2 transferred to a higher-level of care hospital for heart issues, so he was unable to be interviewed by her, but the police interviewed him, and R2 denied knowing R1. Administrative Staff A stated the local police ran a background search on R2 and said if Administrative Staff A would have run that, she would not have accepted R2 into the facility because R2 had a history of abuse of women in another state. The police stated they could not charge R2 with anything because R1 told them it was consensual.On 07/28/25 at 12:15 PM, CNA M stated R1 called her into her room and asked to talk to her. R1 was crying and anxious and told her that [R2] had touched her, and she was not feeling well. CNA M stated she was not sure how to handle it, so she told the social worker. CNA M stated [R2] threw up red flags because he was able to leave the facility and get drunk, so you never knew what he was going to do.On 07/28/25 at 12:30 PM, Social Service Staff X stated she wished she had done a better job representing R1 at the emergency room. Social Services Staff X stated she did not tell the SANE nurse or the doctor R1 had cognitive deficits, and she was not sure R1 even knew what consensual meant. Social Services Staff X stated she did not know how much she should tell the SANE nurse or the doctor because she did not want to skew the findings or anything, and she is not R1's responsible party.The facility's Reporting Abuse to Facility Management, Including Sexual Consent F600 Policy, dated August 2024, documented it is the responsibility of the employees, facility consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect, exploitation, or resident abuse. The community does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies, family members, legal guardians, sponsors, other residents, friends, or other individuals.On 07/28/25 at 03:15 PM, Administrative Staff A was provided the IJ template and notified of the facility's failure to ensure R1 was protected from sexual abuse, which placed R1 in immediate jeopardy.The facility identified and implemented immediate corrective actions, which were completed on 07/17/25 and included: R2 was placed on 1:1 on 07/11/25 at 03:00 PM and has since been discharged .All staff were re-educated on Abuse, Neglect, and Exploitation (ANE) after the incident, completed 07/17/25. The social worker will meet with R1 weekly for 4 weeks. The facility interviewed alert and oriented female residents regarding safety.Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliance at a J scope and severity.

The facility identified a census of 31 residents with three residents reviewed for medication errors. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free of significant medication errors. On 02/12/24 R1 returned to the facility from a cardiology appointment with a new order for metolazone, a diuretic (medication to promote the formation and excretion of urine), 2.5 milligrams (mg) that day, and another dose on 02/14/24. Licensed Nurse (LN) G incorrectly read the order as 25 mg and instructed LN H to administer five of R1's 5 mg metolazone from his PRN (as needed) stock. When the pharmacy delivered the medication to the facility a few hours later, LN G saw the dose was 2.5 mg. LN G called R1's cardiologist and received orders to monitor R1 for depleted fluid volume and to obtain a basic metabolic panel (BMP-laboratory blood test) the next day. On 02/13/24, R1's BMP showed R1's potassium level was critically low at 2.6 millimoles per liter (mmol/L) (normal range is 3.5 to 5.2 mmol/L). R1 admitted to the hospital and received intravenous fluids and potassium. R1's potassium remained critically low through 02/14/24 and low through 02/19/24 when he returned to the facility on oral potassium supplements. The facility's failure to ensure R1 remained free from significant medication errors resulted in R1 receiving ten times the ordered dose of metolazone which placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and chronic kidney disease. The Quarterly Minimum Data Set (MDS), dated 01/18/24, documented R1 had a Brief Interview for Mental Status score of fourteen which indicated intact cognition. The MDS documented R1 had shortness of breath at rest, with exertion, and while lying flat. The MDS documented R1 was on oxygen. The MDS documented R1 required substantial or maximal assistance with toileting, and partial or moderate assistance with bathing and lower body dressing. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/16/23, documented R1 was at risk for cognitive loss and had disorganized thinking. Staff frequently oriented R1 to the date, time, and events. The CAA documented R1's head of bed was elevated due to difficulty breathing when lying flat. The Activities of Daily Living (ADL) Functional Rehabilitation Potential CAA, dated 06/16/23, documented R1 was at risk for decline in his functional ability with ADL. The CAA documented R1 required one staff assistance with most of his ADL, R1 was able to make his needs known, and he used the call light for assistance. R1's Care Plan, dated 06/12/23, directed staff to administer R1's medications as ordered. The plan directed staff to elevate R1's head of the bed to prevent shortness of breath while lying flat. The plan directed staff to administer R1 oxygen as ordered by his physician. Staff were directed to monitor R1 for difficulty breathing, signs and symptoms of respiratory insufficiency, and anxiety. The Progress Note, dated 02/12/24 at 11:25 AM, documented R1 had an appointment with his cardiologist and new orders were received for metolazone 25 mg on Monday 02/12/24 and Wednesday 02/14/24. The facility was ordered to check R1's labs and call the cardiologist with the results on Thursday or Friday. R1's February 2024 Medication Administration Record (MAR) documented R1 received 25 mg of metolazone on 02/12/24. R1's Laboratory Report, dated 02/12/24, documented R1's potassium level was 3.9 mmol/L. The Progress Note, dated 02/12/24 at 12:45 PM, documented the facility received R1's metolazone from the pharmacy. The pharmacy sent metolazone 2.5 mg, but R1 had already received metolazone 25 mg. LN G called R1's cardiologist's nurse and left a message about the 25 mg dose staff administered to R1. The Progress Note, dated 02/12/24 at 12:52 PM, documented R1's cardiologist nurse called the facility with orders from R1's cardiologist to watch R1. R1 should have some urine output getting the fluid off. The office nurse directed if R1 started showing signs of depleted fluid volume the facility staff should contact R1's primary care physician. R1's cardiologist ordered a BMP to be drawn on Tuesday 02/13/24, and Wednesday 02/15/24. The facility was ordered not to give R1 2.5 mg of metolazone on Wednesday. The Progress Note, dated 02/13/24 at 11:08 AM, documented a BMP was obtained from R1 and sent to the lab. The Progress Note, dated 02/13/24 at 12:14 PM, documented the medication error occurred as a result of poor penmanship by the provider and staff not seeing the warning when entering the order into the EMR. The Progress Note, dated 02/13/24 at 02:04 PM, documented R1's primary care physician requested the facility send R1 to the emergency department due to R1's critically low potassium at 2.6 mmol/L. LN G's 02/14/24 Witness Statement documented on Monday, 02/12/24, R1 had a cardiologist appointment at 09:00 AM. R1 returned from his appointment with an orange piece of paper with handwritten orders. LN G read the order as metolazone 25 mg on Monday and Wednesday and to check labs and call the cardiologist's office with the results on Thursday or Friday morning. LN G called R1's responsible party to notify her of the new order. R1's responsible party stated she talked with R1's cardiologist and knew R1 would be getting extra water pills because R1 had lots of extra fluid he needed to get rid of. LN G then showed LN H the orders and LN H commented on the large dose. LN G told LN H R1's responsible party said R1 had a lot of fluid to get rid of. LN G then put the order into the computer EMR to be administered now and again on Wednesday. LN G asked LN H to pull five pills of R1's PRN 5 mg metolazone to equal 25 mg. R1 received the 25 mg of metolazone before noon. LN G stated at about 12:30 PM, the pharmacy delivered a bubble pack of metolazone 2.5 mg with directions to give 2.5 mg on Monday and Wednesday. LN G showed LN H the directions on the bubble pack and proceeded to call R1's cardiologist. R1's cardiologist's nurse answered, and LN G notified her the wrong dose was administered to R1. The cardiologist's nurse told LN G to monitor R1 and if he started showing signs of low fluid volume then R1 would need to go to the emergency department for fluids and to call R1's primary care physician with any other concerns over the next few days. Within two minutes R1's cardiologist's nurse called LN G with orders to not give R1 the metolazone 2.5 mg on Wednesday, and to draw a BMP on Tuesday and Wednesday. The cardiologist's nurse told LN G to monitor R1 for intolerance as the fluid may come off too quickly and if R1 had problems, he would have to go to the emergency department for fluids to replenish his electrolytes. LN G called R1's responsible party and told her the facility would monitor R1 for low fluid volume or signs he was not handling it well. LN H's Witness Statement, dated 02/14/24, documented on Monday, 02/12/24, R1 went to an appointment and upon return, LN G showed LN H the new orders. Upon reading the orders, LN H told LN G the dose was high, and said the physician must be trying to get that fluid off. LN G told LN H R1 had a lot of fluid. LN H told LN G she would have to wait until the pharmacy delivered the medication. LN G told LN H that R1 had PRN metolazone 5 mg. LN G said she would put in the orders and then LN H could get R1 his medication and not have to wait. LN G put the order in the EMR. LN H pulled up the MAR and it directed to give R1 five tablets of 5 mg metolazone. LN H gave R1 the medication as ordered. Later towards the end of LN H's shift, the pharmacy delivered R1's medication. LN G received the medication and the orders read to give R1 2.5 mg of metolazone. The updated Root Cause Analysis, documented the problem was R1 received the wrong dose of medication. The reason for the wrong dose administration was LN G read the order incorrectly, LN G did not use the template in the EMR to enter the order and did not pay attention to the alert from the EMR. LN H, who gave the medication, did not see the alert indicating a dose warning. LN G and LN H did not realize the dose was greater than what was acceptable, and LN G and LN H pulled the medication from R1's PRN dose instead of waiting for the medication to come from the pharmacy. The Progress Note, dated 02/16/24 at 06:45 PM, documented R1 re-admitted to the facility post-hospitalization for low potassium. The Hospital Discharge Summary, dated 02/16/24, documented R1 admitted to the hospital for low potassium on 02/13/24 after nursing staff accidentally gave R1 metolazone 25 mg after his cardiologist ordered metolazone 2.5 mg. R1's BMP on 02/13/24 showed a potassium level of 2.6 mmol/L. R1 admitted to the hospital and received two liters of normal saline with 20 milliequivalents (mEq) of potassium. On 02/14/24 R1's potassium level was 2.4 mmol/L after administration of 40 mEq of potassium intravenously (IV-administered directly into the bloodstream via a vein) and 40 mEq of potassium by mouth. On 02/15/24, R1's potassium level was 3.0 mmol/L despite continued potassium replacement. R1 received an additional 40 mEq of potassium IV in addition to his oral dosing. On 02/16/24, R1's potassium level was 3.1 mmol/L. R1 received a total of 80 mEq of potassium orally and 40 mEq of potassium by IV. A potassium level check in the afternoon showed R1 had a potassium level of 5.0 mmol/L, a normalized potassium level, and discharged back to the nursing home. The Facility Incident Report, dated 02/19/24, documented at approximately 11:42 AM LN H gave R1 25 mg of metolazone instead of 2.5 mg. R1 returned from a cardiology visit and had a new handwritten order for 2.5 mg of metolazone. LN G and LN H interpreted the order as 25 mg. LN G entered the order as 25 mg metolazone and LN H gave the medication dose that was entered into the MAR. LN H gave the medication from R1's PRN card. When the local pharmacy delivered the prescription at approximately 12:40 PM, LN G noticed the pharmacy sent a dose of 2.5 mg of metolazone. LN G immediately called the cardiologist and requested to speak to his nurse. LN G told the nurse what happened. The nurse instructed LN G to monitor R1 for any signs of low fluid volume because R1 would need to go to the emergency department and call R1's primary care physician with any concerns. Approximately two minutes later, R1's cardiologist's nurse called LN G back and ordered LN G to monitor for signs and symptoms of hypovolemic (abnormally low circulating blood volume) shock (an acute medical condition associated with a fall in blood pressure), in which case R1 would need to go to the emergency department, and not to give R1 the 2.5 mg of metolazone on Wednesday, and to draw a BMP on Tuesday, 02/13/24, and Wednesday, 02/14/24. R1 was monitored for low fluid volume. A BMP was drawn as ordered and showed a potassium level of 2.6 mmol/L. The clinic staff notified the facility of the critical lab value and gave the order to transport R1 to the emergency department. On 03/13/24 at 10:30 AM, R1 laid in bed with his oxygen on watching TV. R1 wore pajama pants and slippers. On 03/13/24 at 10:30 AM, R1 stated when he found out he had received the wrong dose of medication, he was scared. R1 stated he was still uneasy about his medication being wrong. On 03/13/24 at 09:45 AM, Administrative Staff A stated the medication error should never have happened because if the nurse putting in the medication had paid attention to the alerts in the EMR, instead of clicking through them, the medication would not have been given. Administrative Staff A stated all the nurses had been trained to pay attention to the alerts and adhere to the alerts. On 03/13/24 at 01:00 PM, LN H stated she thought the dose of metolazone was high and she questioned LN G about it. LN G told her R1 had a lot of fluid that needed to come off and LN G was going to put the order in for now, for 25 mg of metolazone. LN H stated she listened to her charge nurse and administered 25 mg of metolazone. On 03/13/24 at 01:15 PM, LN G stated when she received the order for metolazone she thought the order read 25 mg. LN G stated she knew R1 had as needed metolazone 5 mg tablets, so she put the order in for five 5 mg tablets (metolazone) to be given now. LN G stated she did not wait for the pharmacy to deliver the medication because metolazone was a diuretic and she did not want R1 to be up all-night urinating. LN G denied that she had clicked through the alerts in the EMR when she input the order. The Physician Medication Orders, and Documentation of Medication Administration Policy, revised September 2023, documented medications shall be administered only upon written order of a person duly licensed and authorized to subscribe medications. The facility shall maintain a medication administration record to document all medications administered. The facility's failure to ensure R1 remained free from significant medication errors resulted in R1 receiving ten times the ordered dose of metolazone which placed R1 in immediate jeopardy. On 02/13/24 the facility completed education which included The Rights of Medication Administration, Face to Face Order Entry (using EMR template - if dose is not available get a double check), Pay Attention to Alerts (medication allergy/maximum dose exceeded), and Transcribing Orders and Order Entry into PCC. All corrective actions were completed prior to the onsite survey therefore the deficient practice was deemed past noncompliance. The scope and severity remained at a J.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 32 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure residents remained free from abuse including physical restraint when staff manually restrained Resident (R) 1 to administer medications. On 11/10/23 at around 06:30 PM, Certified Medication Aide (CMA) R asked Certified Nurse Aide (CNA) M and CNA N to help administer eye ointment to R1. CMA R, CNA M, and CNA N went into R1's room and CMA R climbed on top of R1, straddled him, and pinned his arms under the blankets while R1 attempted to resist. CNA M told CMA R the actions were inappropriate, but CMA R ignored CNA M. The facility staff failed to ensure R1 remained free from abuse when staff physically restrained him. This placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. The MDS documented R1 had impairment to one side of his upper and lower extremities. The MDS further documented R1 required the use of a wheelchair, was totally dependent on staff for transfer, bed mobility, oral hygiene, toileting, bathing, and dressing. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/07/23, documented R1 had short-term and long-term memory loss and exhibited behaviors of inattention, disorganized thinking, and altered level of consciousness. The Communication CAA, dated 07/07/23, documented R1 as at risk for social isolation due to only being able to answer mostly yes and no questions; it usually took R1 a little bit of time for him to answer questions. Staff were directed to anticipate R1's needs. The Activities of Daily Living Function/Rehabilitation Potential CAA, dated 07/07/23, documented R1 required assistance of two staff for all activities of daily living and required the use of a sit-to-stand lift for transfers and toileting. R1's Care Plan, revised 04/29/21, directed staff R1 often said no when he meant yes (for example immediately questioning staff why they were leaving and not doing something after R1 had just declined cares). Staff were directed to encourage R1 to allow cares such as incontinence care, going to meals, taking medications, and going to bed per R1's routine. Staff were to provide education to R1 to assure he would understand what he was saying no to. The care plan directed staff to re-approach R1 after refusal of care and take the time to explain cares, medications, and procedures. If R1 refused medications, staff were to provide clear, concise education on the use of each medication. R1 usually took the medications if staff told him what the medication was for. The Progress Note, dated 10/24/23, documented R1 continued to have purulent (producing or containing pus) drainage from both eyes. R1 did not tolerate the gentamycin (antibiotic) eye drops and stated that [expletive] burns. As a result, staff was only able to get one or two drops in once or twice daily. The note recorded the inquiry to the physician asking if erythromycin (antibiotic) ophthalmic (relating to the eyes) ointment, given in the evening or night while R1 was sleeping, would be more effective. The October 2023 Treatment Administration Record (TAR), documented a new order for erythromycin ophthalmic ointment. Instill one centimeter (cm) in both eyes one time a day for conjunctivitis (eye infection). Give when the resident was sleeping soundly. The Progress Note, dated 10/25/23, documented nursing attempted to apply erythromycin ointment to R1's eyes and R1 refused and became very aggressive and combative with both the CMA and charge nurse. R1 said no and started pinching and hitting staff. Staff were unable to instill the ointment. The Progress Note, dated 10/27/23, documented R1 continued to be on erythromycin ointment to both eyes. R1 would not allow the medication to be placed in his eyes and administration must be done when R1 was asleep. The nurse was able to get the ointment on R1's eyes and R1 rubbed his eyes as the ointment was applied. The facility's Incident Report, documented CNA M sent Administrative Nurse D a text message on 11/11/23 at 06:18 AM asking Administrative Nurse D to give her a call. Administrative Nurse D called CNA M at 07:45 AM and CNA M asked Administrative Nurse D if she spoke to CMA R because CMA R had done it again. Administrative Nurse D asked CNA M Did what again? and CNA M replied that CMA R administered eye ointment to R1 in a way that she held his eyes open while R1 resisted. Administrative Nurse D told CNA M that she would talk to CMA R about the situation. Administrative Nurse D spoke to CMA R on the afternoon of 11/14/23 and told her that residents had the right to refuse medication and treatments and the action CMA R took to administer R1's eye ointment could not happen again. On the morning of 11/15/23, Administrative Nurse D reported the incident to Administrative Staff A and an investigation was started. CMA R was suspended. During the investigation, the facility noted CNA M's witness statement said she reached out to Administrative Nurse D because of recurrence. CNA M was asked when the other occurrence happened, and CNA M reported she was unsure. When Administrative Staff A asked CNA M if she reported it the first time, CNA M stated, I think I told [Administrative Nurse D] but I can't remember if it was in text or phone message. Administrative Nurse D stated she did not get a text or message about it. CNA M explained she witnessed (twice) CMA R crawled in the bed and straddled R1 to hold him down in order to get his eye ointment in. CMA R admitted this happened on 11/10/23. Both CNA M and CNA N admit the incident happened on 11/10/23 and from the camera footage, the facility believed the incident happened at approximately 06:30 PM. CNA M reported she had alerted Administrative Nurse D after the event of 11/10/23 because she knew of the need to report. CNA N did not report the event on 11/10/23 because she believed CNA M notified Administrative Nurse D. The root cause analysis documented a failure of staff to ensure management was notified immediately to the events and failure of management staff to get enough information to decide how to proceed. The Social Services Note, dated 11/15/23, documented the facility social worker notified R1's responsible party and explained the incident when CMA R forced R1 to accept his eye ointment. The facility social worker explained to R1's responsible party the method was unacceptable and was considered abuse. CMA R was suspended for the time. Police were called and the facility filed a report. According to administration and other staff, R1 had no injuries. R1's responsible party verbalized understanding and stated he did not plan to press any formal charges. CNA N's Witness Statement, dated 11/16/23, documented CNA N heard CMA R ask CNA M if she was ready to help her give R1 his eye drops. CNA M and CNA N followed CMA R into R1's room. CNA M stood next to R1's head as he laid in bed and CMA R was next to CNA M by the bed. CNA N stated she stood back and was there just in case CNA M and CMA R needed help. CMA R proceeded to climb on top of R1, straddle him like she was sitting on a saddle, with the covers pulled tightly over R1's arms. CNA M told CMA R that she was not supposed to do that. CNA M stated it numerous times, but CMA R said that is what she always did with her kids. R1 tried to move his arms in a motion of trying to fight. CNA N did not hear R1 say anything. Once CMA R had they eye drops in R1's eyes, she climbed off of R1 and CNA N heard CNA M tell CMA R she was going to contact Administrative Nurse D about the incident. CMA R kept telling CNA N that was how she always did her kids and that it always worked. CNA N stated CMA R went back to her medication cart to continue giving medications to the other residents. CNA N stated she did not report the incident to Administrative Nurse D because she knew CNA M was going to. CMA R's Witness Statement, dated 11/17/23, documented CMA R was trying to give R1 his eye ointment and he was resisting so CMA R asked the aides to help. CMA R stated she decided to straddle R1 in the bed in order to get the ointment in his eyes. CNA M's Witness Statement, dated 11/22/23, documented CNA M was unsure of the date, but one evening CMA R asked CNA N and her to help her administer R1's eye ointment. CMA R kept asking CNA N and her if they wanted to see how she did eye medications on her kids. CNA M stated she politely declined and stated R1 was not a child, he was a resident. CMA R then proceeded to crawl on top of R1 and straddle him. CMA R attempted to pull his arms down under her legs to which R1 fought and would not allow. CMA R struggled for a minute with R1 before getting the eye ointment in his eyes. CMA R, CNA M, and CNA N exited the room and went about their shift. CNA M stated she thought she contacted Administrative Nurse D but could not remember how she contacted her. The next shift CNA M worked with CMA R, on 11/10/23, CMA R again asked CNA M and CNA N to help her with R1's eye ointment. CNA M told CMA R that he had been refusing a lot and other medication aides had a much gentler approach. CMA R proceeded to state, This is how I do my kids, and climbed on top of R1 and straddled him again. CNA M stated she told CMA R she should not be doing that, and CMA R ignored her. CNA M stated she stayed until CMA R was finished to ensure no harm to either CMA R or R1 occurred. CNA M stated that she then immediately contacted Administrative Nurse D to inform her of the re-occurrence of the incident via text message. Administrative Nurse D's Witness Statement, dated 11/22/23, documented Administrative Nurse D was alerted via text message to call CMA M on 11/11/23 at 06:18 AM. Administrative Nurse D returned CNA M's call at approximately 07:54 AM. CNA M stated that CMA R had administered eye ointment to R1 in a way that CMA R held R1's eyelids open and R1 was resisting administration. Administrative Nurse D told CNA M she would talk with CMA R. On 11/14/23 in the afternoon, Administrative Nurse D talked to CMA R and told her that every resident had the right to refuse medications and treatments and this action could not ever happen again. Administrative Nurse D stated on 11/15/23, during the morning stand up meeting, she notified Administrative Staff A of what happened. Administrative Staff A immediately educated Administrative Nurse D of the abuse reporting policies and the investigation began immediately. LN G's Witness Statement, dated 11/22/23, documented Licensed Nurse (LN) G stated on 11/10/23, at the end of the shift at 10:00 PM, CMA R told her that she was able to administer R1's eye drops by straddling his leg. On 12/07/23 at 09:30 AM, observation revealed R1 sat in a Broda chair (specialized wheelchair with the ability to tilt and recline) at the breakfast table and ate breakfast. R1 was slow to acknowledge verbal greeting. On 12/07/23 at 10:30 AM, Administrative Staff A stated as soon as she heard about the incident in the morning meeting on 11/15/23, she told staff this was an abuse allegation and an investigation was needed. Administrative Staff A stated she started an investigation and called CMA R in order to suspend her and get her witness statement. Administrative Staff A stated she did not understand why CMA R thought that what she did was appropriate. CMA R was terminated on 11/21/23. Administrative Staff A stated that abuse and neglect and reporting policy education was started for all staff on 11/15/23 and finished on 11/16/23 and a QAPI meeting was held on 12/15/23 with the medical director. On 12/07/23 at 11:00 AM, Administrative Nurse D stated the incident never should have happened and when CNA M reported it to her, she did not think it was as bad as it turned out to be. Administrative Nurse D said she should have done some more investigating and asked questions about the incident to ensure R1's safety. On 12/07/23 at 11:30 AM, CNA M stated this was the second time she saw CMA R crawl up on top of R1 to administer eye ointment. CNA M stated she knew she had told Administrative Nurse D about it, but maybe she did not. CNA M stated R1 struggled and fought both times CMA R gave him eye ointment. CNA M confirmed she did not text Administrative Nurse D until the following morning. The facility Abuse and Neglect Policy, revised August of 2022, documented all residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, exploitation, and involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical condition. Upon hire and annually, covered individuals will be notified of their obligations to report suspicion of abuse and neglect. The facility through the Administrator or their designee will report alleged violations related to mistreatment, exploitation, neglect, or abuse including injuries of unknown origin and misappropriation of resident property the results of all investigations to the proper authorities in appropriate time frames. The facility staff failed to ensure R1 remained free from abuse when staff physically restrained him. This placed R1 in immediate jeopardy. On 11/16/23 the facility completed the following corrective actions: The facility had a Quality Assurance and Performance Improvement (QAPI) meeting with the facility medical director. Staff completed an assessment of R1 on 11/15/23. All employees were educated on abuse, neglect, restraints, and reporting policies which was completed on 11/16/23. CMA R was suspended on 11/15/23 and then terminated on 11/21/23. All corrective actions were completed prior to the onsite survey therefore the citation was issued as past noncompliance at the scope and severity of J.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 30 residents. The sample included three residents reviewed for medication errors. Based on observations, record review, and interviews, the facility failed to prevent a significant medication error for Resident (R) 1 when facility staff prepared and wrongly administered R2's medications, including psychotropic (any drug that affects brain activities associated with mental processes and behavior) and antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medications, to R1 on 11/16/22. Certified Medication Aide (CMA) R prepared R1's medications, then realized R1 was in the shower. CMA R labeled the medication cup with R1's name, placed the cup back in the cart, and began to prepare R2's medications. CMA R then observed R1 in the dining room and gave R1 the medications she had prepared for R2. As a result, R1 had a significant change in condition which required transfer to the local hospital where she was intubated (tube inserted down the throat to secure the airway) and transferred to a larger hospital for intensive care. CMA R failed to implement the standards of practice regarding medication administration when she failed to verify the right medication for the right resident, prior to administration, which placed R1 in Immediate Jeopardy. Findings included: - R1 admitted to facility on 09/06/18. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling) of right lower limb, generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder), orthostatic hypotension (blood pressure dropping with change of position), and mild intermittent asthma (disorder of narrowed airways that caused wheezing and shortness of breath). The Annual Minimum Data Set (MDS) dated 04/05/22, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 was independent with activities of daily living (ADL) and required setup help only with eating. R1 received antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), anticoagulant (medication used to prevent blood from thickening or clotting), and diuretic (medication to promote the formation and excretion of urine) medications seven days in the seven-day lookback period. The Quarterly MDS dated 10/17/22, documented R1 had a BIMS score of 15, which indicated intact cognition. R1 was independent with ADLs and required setup help only with eating. R1 received antidepressant, anticoagulant, antibiotic (medication that inhibits or destroys microorganism that cause infections), and diuretic medications seven days in the seven-day lookback period. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 04/19/22, documented R1 was at risk for decreased functional ability to perform ADLs. R1 was dependent with most ADLs with assist of staff as needed. The Psychotropic Drug Use CAA dated 04/19/22, documented R1 was at risk of adverse side effects for antidepressant medication use and nursing monitored R1 for adverse side effects of antidepressant medication daily. The Care Plan, initiated 01/08/21 and revised 02/04/22, documented R1 was at risk for adverse effects of medications because she took medications that had a Black Box Warning (BBW- warnings required by the Food and Drug Administration for certain medications that carry serious safety risks), psychotropic medications, and had medication allergies. The Care Plan documented an intervention, initiated 05/01/21, that directed nursing monitored for adverse effects and side effects of all medications and reported changes in condition to provider in timely manner. The Care Plan documented interventions, initiated 02/04/22, that directed R1 received citalopram and nursing monitored for side effects/adverse effects and efficacy of treatment; and nurse monitored all new prescription for drug interactions and potential allergies. The Care Plan, initiated 01/08/21, documented R1 was at risk for respiratory distress related to asthma and directed staff gave medications as ordered and monitored/documented side effects and effectiveness. The Orders tab of R1's EMR documented an order with a start date of 11/12/22 for Zyvox (antibiotic) 600 milligram (mg) two times a day for wound infection/cellulitis for 10 days. The facility's Investigation, not dated, documented on 11/16/22 at approximately 09:45 AM, CMA R was passing medications and had placed R1's medications into a medication cup. She then realized R1 was in the shower. CMA R labeled the medication cup and placed it in the top drawer of the medication cart then proceeded to prepare R2's medications. CMA R finished preparing R2's medications when R1 walked out of the shower. CMA R handed R1 the cup of pills that she had just prepared. When CMA R went to give R2 her medications, she realized she gave R1 the wrong medications and immediately notified LN G. LN G notified the clinic at 09:55 AM and sent a fax detailing the medications R1 received at 09:58 AM. LN G advised the clinic nurse that there was some urgency because R1 was taking Zyvox and had ingested psychiatric medications as well as an antiparkinsonian agent. R1 went to the dining room at approximately 10:00 AM, ate breakfast, then joined group activities. At 10:25 AM, the activity director notified staff that R1 nodded off which was not unusual for her. LN G asked staff to check R1's vital signs and staff reported R1 was not acting normal. LN G assessed R1 and noted a decreased level of consciousness, muttering speech, was stuporous (a state of near-unconsciousness or insensibility), but responded to verbal and tactile cues. R1 was pale and declined as LN G assessed her. LN G called the clinic and was put on hold, at that time she hung up and called 911 instead. Emergency Medical Services (EMS) arrived at the facility at 10:35 AM. R1's oxygen saturation was 90% on room air, she was placed on supplemental oxygen at 2 liters per minute (lpm). A peripheral intravenous (IV- infusion administration of fluids into a vein by means of a steel needle or plastic catheter) catheter was placed in R1's right forearm and normal saline (saline water solution) infusion was started. R1's blood glucose was checked and was 44 mg per deciliters (mg/dL). The Emergency Medical Technician (EMT) pushed Dextrose 5% in water (D5W- IV solution used to replace lost fluids and limited carbohydrates in the body) via IV. R1 left the facility with EMS at approximately 10:55 AM. LN G gave report to the emergency department (ED) provider and notified R1's family. Consultant GG was in the facility for the Quality Assurance (QA) meeting and informed staff that R1 was intubated and was being transferred to a larger hospital. The root cause analysis of the event was determined to be CMA R did not inquire if R1 was ready for her pills before preparing medications. CMA R was working a task that was not her routine assignment. A Nursing Note on 11/16/22 at 10:01 AM documented CMA R reported to LN G that around 09:30 AM, she gave R1, R2's medications. The medications ingested were: Carbidopa-levodopa (medication used to treat Parkinson's [slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness] disease or Parkinson's like symptoms) 50 mg/200 mg two tablets, cephalexin (antibiotic medication) 500 mg, cholecalciferol (vitamin supplement) 1000 mg, clozapine (antipsychotic medication)100 mg, famotidine (medication used to treat acid reflux and stomach ulcers) 20 mg, magnesium oxide (mineral supplement) 400 mg, venlafaxine extended release (antidepressant) 150 mg, and vitamin B12 (vitamin supplement) 1000 mg. R1 had not had her usual morning medications yet and was currently on Zyvox for treatment of a wound infection. Zyvox had several drug interactions. R1's Medical Record revealed a Hospitalist History and Physical on 11/16/22 that documented R1 was accidentally given medications that belonged to another patient that included carbidopa-levodopa, clozapine, and venlafaxine. R1 was taken to an outlying hospital where she was noted to have acute encephalopathy with a low Glasgow Coma Scale (GCS- a tool used to assess and calculate a patient's level of consciousness) of around seven (patients with a GCS score of seven or less were considered comatose) and was intubated to protect her airway. R1's hypoglycemia was treated with dextrose and her hypotension responded to IV fluids. R1 was transferred to a larger hospital for further care. The Intensive Care Unit (ICU) team was consulted and R1 was likely to be extubated (standard procedure to remove a tube that was placed in a patient's airway) the next day if she was doing well. In a Witness Statement on 11/18/22, CMA R stated she prepared R1's medications, unaware she was in the shower at the time. CMA R labeled the medication cup and put them in the top drawer of the med cart. CMA R was working on R2's medications when R1 came out of the shower. She finished R2's medications and handed the wrong cup to R1. CMA R realized what happened and went to R1 to see if she had taken the medication. R1 had just taken them. CMA R went straight to the charge nurse to report what happened. On 11/21/22 at 10:59 AM, R1 sat in her chair in her room and played a game on her phone. She stated on 11/16/22, she had taken her medications before breakfast and had somehow received the wrong medications. On 11/21/22 at 11:45 AM, CMA R stated she did not know that R1 was in the shower before she prepared her medications. CMA R labeled the med cup and placed in med cart then moved on to R2. R1 came out of shower and went to the dining room. CMA R stated she did not know how she did not manage to grab the cup out of the cart, but she gave R1 the medications she had just prepared for R2. CMA R stated she went down the hall to obtain R2's blood pressure when she realized she gave R1 the wrong medications and ran back to the dining room to see if R1 had taken the medications yet. CMA R stated R1 had just taken the medications, so she reported the medication error to the nurse. CMA R stated to prevent med errors, she was to follow the rights of medication administration, which included right resident, medication, dose, route, and time and was to make sure the resident was directly in front of her when preparing medications. On 11/21/22 at 11:54 AM, LN G stated she was charting around 09:40 AM to 09:45 AM when CMA R told her she made a mistake and had given R1, R2's medications. She stated CMA R held R1's pills in the drawer after realizing she was in the shower and continued to pass medications. CMA R was pulling R2's meds and accidently gave R1 the medications. At that point, because R2 had a lot of psychotropic medications and R1 was receiving Zyvox, which had a lot of drug interactions, she pulled both residents' Medication Administration Records (MAR) and printed them out. She stated she went through R2's med list with CMA R to determine what meds she gave to R1. LN G stated she called the doctor at 09:50 AM and faxed a list of medications R1 received at 09:58 AM. She told all staff to watch R1, because if she anything was to happen, it would be around 10:30 AM. R1 finished breakfast and joined exercise group around 10:10 AM and fell asleep, which was not uncommon for her. At 10:25 AM, CMA was sent to check vitals and came back later saying LN G needed to look at R1 as she was not herself and was acting weird. LN G went to dining room, R1's oxygen saturation was 89% on room air, which was not uncommon due to her respiratory status as an asthmatic. LN G had Administrative Nurse D take a peek at R1, because LN G wanted to send her to the emergency room. LN G called the provider and spoke to the receptionist, but hung up and decided to call 911. EMS arrived and they checked R1's blood sugar, which measured 44 mg/dL. D5W was given through right forearm, oxygen had been applied at 2 lpm, and R1 was stable for transport to the hospital. LN G stated she gave report to the ER provider and later the hospital's pharmacist had called for a report on what medications R1 received. She stated she prevented medication errors by following the five rights of administration, checking the MAR against the medication card, recognizing what medications were placed in the cup, and not pulling medications ahead of time. She stated staff stayed with the residents to make sure medications were taken and nobody left pills with R1. On 11/21/22 at 12:00 PM Administrative Nurse D stated she was informed by LN G there was a medication error on the floor. She stated CMA R had popped R1's pills and went to give them to her, but R1 was in the shower. CMA R then labeled the medication cup and placed it in the medication cart drawer then moved on to next resident. R1 came out of the shower and in CMA R's mind, she had R1's pills and handed her the medications that were in her hand. LN G contacted primary care to see how to proceed, informed him of R1's allergies and what medications she took. They were instructed to monitor R1, which they did. Administrative Nurse D stated because R1 was on Zyvox and it had a lot of drug interactions, staff were concerned. She stated R1 had a noticeable change in condition about an hour after ingestion and was transferred to the ER via EMS. Administrative Nurse D stated education was conducted on the policy of administering oral medications. The facility's Administering Oral Medications policy, last revised [DATE], directed staff checked the label on medication and confirmed medication name and dose with the MAR, confirmed the identity of the resident, allowed resident to swallow oral tablets at his/her own pace, remained with the resident until all medications had been taken. The facility's Identifying and Managing Medication Errors and Adverse Consequences policy, last revised April 2017, directed staff followed relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication. The facility failed to prevent a significant medication error when facility staff wrongly administered R2's medications, including psychotropic and antipsychotic medications, to R1 on 11/16/22. R1 had a significant change in condition which required transfer to the local hospital where she was intubated and transferred to a larger hospital for care. CMA R failed to implement the standard of practice regarding medication administration when she failed to verify the right medication was given to the right resident. This placed R1 in Immediate Jeopardy. The facility completed the following corrections by 11/18/22: The medication error was reviewed in Quality Assurance and Performance Improvement (QAPI) on 11/16/22 and immediate corrective actions were put into place. A medication drop lock box was ordered on 11/16/22 for discontinued narcotics All CMA and nurses were trained on the facility medication policy, five medication rights, and timely medication dispensing on 11/16/22 to 11/17/22 The facility replaced R2's medications on 11/17/22 Medication administration audits were completed by Administrative Nurse D on 11/17/22 Both medication carts and medication room were audited by Administrative Nurse D on 11/18/22. The deficient practice was cited as past non-compliance.