Based on record reviews, observations, and interviews with staff and the Medical Director, the facility staff failed to utilize a resident's assigned blood glucose meter (glucometer) and instead used a loose, unassigned, and unlabeled glucometer located in the medication cart to check Resident #8's blood glucose (sugar) level. In addition, the staff member did not disinfect the glucometer before or after obtaining Resident #8's blood glucose level and would have had no way to know if another staff member had previously disinfected the loose, unassigned, and unlabeled glucometer. This occurred while there were 11 residents identified with a known bloodborne pathogen in the facility with 4 of the 11 residents requiring blood glucose levels. Loose, unlabeled glucometers can be contaminated with blood and must be disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer of the glucometer has the high likelihood to expose residents to the spread of bloodborne infections. Care must also be taken by personnel handling and storing glucometers to protect the glucometers against cross-contamination via contact with other meters or equipment. The deficient practice occurred for 1 of 3 residents observed to have his blood glucose (sugar) level checked (Resident #8). Immediate jeopardy began on 5/15/25 when Nurse #1 was observed to perform blood glucose testing for Resident #8 using a loose, unlabeled, unassigned glucometer without disinfecting the glucometer. Immediate jeopardy was removed on 5/16/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) for the facility to complete agency and employee staff training with monitoring to ensure appropriate interventions are put into place. Findings included: The facility's policy and procedure titled Obtaining a Fingerstick Glucose Level that did not contain a date read under the title Steps in the Procedure always ensure the blood glucose meter intended for reuse is clean and disinfected between resident use following the manufacturers instructions and the current infection control standards of practice. The manufacturer instructions for cleaning and disinfecting the (Brand Name) glucometer used at the facility were summarized in a Technical Brief (Revised 9/24). The Technical Brief read in part, To minimize the risk of transmitting bloodborne pathogens, the cleaning and disinfecting procedures should be performed as recommended in the instructions below. The (Brand Name) meter may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed. The meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of bloodborne pathogens .Clean and disinfect the meter following step-by-step instructions in the Quality Assurance (QA) / Quality Control (QC) Reference Manual. Cleaning and Disinfecting Procedures specified in the glucometer's QA/QC Reference Manual (Revised 10/24) included, in part: --Cleaning: Step 1 (of 7): Wear appropriate protective gear such as disposable gloves. Step 3 (of 7): Wipe the surface of the meter to clean blood and other body fluids . Step 4 (of 7): If blood is visible on the meter, it should be cleaned prior to each disinfection step. --Disinfecting: Step 5 (of 7): Pull out 1 new towelette and wipe the entire surface of the meter horizontally and vertically to remove bloodborne pathogens. Carefully wipe around the test strip port by inverting the meter so that the test strip port is facing down. Step 6 (of 7): Treated surface must remain wet for recommended contact time. Please refer to wipe manufacturer's instructions. The manufacturer's Technical Brief for the glucometer listed the disinfectant wipes used at the facility as one of the EPA-registered wipes recommended to clean and disinfect the (Brand Name) glucometer. The instructions on the label of the disinfectant wipes read in part: To clean and disinfect and deodorize hard, nonporous surfaces: Wipe surface to be disinfected. Use enough wipes to treat surface to remain visibly wet to the contact time listed. Let Dry. Special instructions for cleaning and decontamination against human immunodeficiency virus (HIV), hepatitis B and hepatitis C indicated, Allow surfaces to remain wet for one minute, let air dry. For all other organisms, see directions for contact time. The Director of Nursing provided education for Nurse #1. The education was dated 2/4/25 with a return competency completed on 2/5/25. The education titled glucometer testing included how to store, disinfect before and after each use, and using the resident's designated glucometer. A continuous observation from 5:10am to 5:25am occurred on 5/15/25 in the 100 Hall hallway. The observation revealed Nurse #1 walking away from her medication cart (lower 100-hall medication cart) with a glucometer in her hand. Nurse #1 entered Resident #8's room, stood on the left side of the bed, lifted the cover exposing Resident #8's left hand, the nurse wiped one finger on Resident #8's hand with an alcohol pad, used a lancet device to prick Resident #8's finger, and then held the glucometer (with the test strip already in the machine) to the resident's finger obtaining his blood sugar. Nurse #1 was observed to walk out of the resident's room, place the used lancet into the secure needle container, throw her gloves into the trash receptacle, and place the glucometer on top of the medication cart. The glucometer was observed to not have any label. At 5:15am, Nurse #1 was observed to place the glucometer in the top drawer of the medication cart without disinfecting it. Nurse #1 was observed for another 10 minutes with no other residents receiving blood sugar checks. Nurse #1 an agency nurse who worked the 7:00pm to 7:00am shift was interviewed on 5/15/25 at 5:25am. Nurse #1 discussed every resident having their own glucometers that were kept in the top drawer of the medication cart in a plastic container. Nurse #1 opened the top drawer of her medication cart and there was an individual plastic container labeled with each resident's name. There was also a loose unlabeled glucometer in one of the compartments on the left side of the drawer. Nurse #1 confirmed she had just obtained a blood sugar from Resident #8 with the loose unlabeled glucometer that was on the left side of the drawer. Nurse #1 showed the surveyor that Resident #8 had his own glucometer. She stated she had obtained the loose unlabeled glucometer from the bottom drawer of the medication cart. Nurse #1 explained she did not know why she had not used Resident #8's dedicated glucometer I don't know, I just saw this one and used it. She discussed not knowing if the glucometer was disinfected before she used it and stated she had not disinfected it herself prior to obtaining Resident #8's blood sugar. Nurse #1 also confirmed she had placed the glucometer back into the top drawer of the medication cart in the left compartment without disinfecting it. The nurse explained she did not disinfect it because she was going to take it to the nursing station to throw it away. She explained she was going to throw it away because Resident #8 already had his own. Nurse #1 stated she had received education on the proper care/disinfecting glucometers before and after use but said I'm agency. I don't work here all the time. She confirmed there was no visual cues on the medication cart to help her remember how/when to disinfect the glucometers and stated, I have never seen anything on the cart. Upon request, the facility provided a Diagnosis Report for its current residents (dated 5/15/25 at 9:42am). The Diagnosis Report indicated 11 residents were identified as having at least one bloodborne pathogen, which included hepatitis C and HIV. Upon review of the 11 residents, it was discovered that 4 of the residents required blood sugar monitoring with one (1) of the 4 residing on hall-100. The Quality Assurance Nurse/Infection Preventionist was interviewed on 5/15/25 at 8:33am. The Nurse explained that she was responsible for having staff sign an acknowledgement form on the computer that staff would adhere to all the facility's rules, expectations, and procedures. She stated the Unit Managers were responsible for any specific training for the nurses/staff. The Quality Assurance Nurse/Infection Preventionist confirmed Nurse #1 had signed the acknowledgement form. Observation of the lower 100-hall medication cart with Nurse #6 occurred on 5/15/25 at 9:43am. A loose unlabeled glucometer was observed in the bottom drawer of the medication cart in a small white basket. The observation also revealed there were EPA wipes present in the bottom drawer, but there was no visual cue cards present on the medication cart for disinfecting the glucometers. Nurse #6 was interviewed on 5/15/25 at 9:44am. Nurse #6 explained he worked the 7:00am to 7:00pm shift. The nurse confirmed there was a non-labeled loose glucometer in the bottom drawer of his medication cart. He explained the glucometer was for emergencies only and used only on non-diabetics. Nurse #6 discussed not knowing if the glucometer had been disinfected but stated, it should be cleaned before using. He was unable to answer how long it took to clean the glucometer. He stated he had never had to use the loose unlabeled glucometer. Nurse #6 stated he had received education on storing/disinfecting glucometers and stated he thought it was in February 2025. Nurse #6 confirmed there was no visual cues on the medication cart to help him remember how/when to disinfect a glucometer and said he did not remember ever seeing a visual cue on the medication cart. A telephone interview occurred with the Medical Director on 5/15/25 at 10:21am. The Medical Director discussed being aware of staff not disinfecting glucometers a few months ago but nothing recently. She stated the concern of not disinfecting glucometers before and after use was the spread of diseases. The Medical Director explained she expected staff to follow infection control practices when using glucometers. The Director of Nursing (DON) was interviewed on 5/15/25 at 11:31am. The DON explained during the facility's last annual survey in February 2025 there had been an issue with staff not disinfecting shared glucometers before and after use between residents. She stated when that occurred the facility began monitoring/auditing glucometer use to ensure staff were disinfecting as required, placed visual cue cards on the medication carts to help staff remember the steps in disinfecting the glucometers, and provided education to all the staff including agency staff. The DON also stated the facility purchased plastic cases and assigned each resident their own glucometer. The DON discussed the facility was continuing to do monitoring and audits of the medication carts for visual cue cards and ensuring each resident had their own glucometer. She stated this was being done by the Unit Managers and/or the Quality Assurance Nurse. She explained that no medication cart should have a loose unlabeled glucometer and was unaware there had been one on the lower 100-hall medication cart. The DON also stated she was not aware the visual cue cards were no longer present on the medication carts. She stated all staff including agency staff had been educated on glucometer use back in March 2025 and could not speak to why Nurse #1 had used a loose glucometer and not disinfected it. The DON stated Nurse #1 should have used Resident #8's designated glucometer and thrown away the loose unlabeled glucometer. The DON explained the loose unlabeled glucometer could be thrown away because if a staff member needed a new one, there were new ones located in the medication room. During an interview with the Administrator on 5/15/25 at 2:00pm, the Administrator explained during the facility's last annual survey in February 2025 there had been an issue with staff not disinfecting shared glucometers before and after use between residents. He explained right after the February survey, the facility purchased plastic containers and more glucometers so each resident could have their own designated glucometer, the facility began monitoring/auditing, and education was provided. The Administrator discussed the on-going monitoring and audits related to glucometer use. He also discussed the education that was completed and included agency staff. The Administrator stated this was an unforeseeable action and could not comment on what he thought caused Nurse #1 to not disinfect a glucometer. The facility's Administrator was informed of the immediate jeopardy (IJ) on 5/15/25 at 2:30pm. The facility provided the following plan for IJ removal: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On May 15, 2025, it was observed that a facility staff member (an agency nurse) used an unlabeled glucometer (blood glucose meter) on Resident #8 without disinfecting the glucometer before or after use. The Director of Nursing (DON) promptly called and left a voicemail with the Responsible Party (RP) for Resident #8 regarding this incident. Upon interview, the nurse stated she did not use that particular unlabeled glucometer for any other residents. The glucometer used was not a shared facility glucometer designated for multiple residents; rather, it was an unlabeled glucometer discovered in the medication cart. The nurse acknowledged her awareness that Resident #8 had an individually assigned, labeled, and properly stored glucometer present in the medication cart. She indicated she used the unlabeled glucometer because she was nervous about being observed by the surveyor. This agency nurse had received training on February 5, 2025, as part of a previous Directed Plan of Correction (DPOC). She stated she failed to disinfect the glucometer involved in the May 15, 2025, incident due to being nervous while under observation by the surveyor. The nurse's failure to use the individually assigned glucometer for Resident #8 and her failure to disinfect the unassigned glucometer before and after use are significant deviations from established infection control procedures. The facility's system mandates individually assigned glucometers for each resident requiring blood glucose monitoring. These glucometers are labeled with the resident's name, and each resident's glucometer is stored in an individual plastic container on the medication cart. The system failed in this instance because the unlabeled glucometer should not have been present in the medication cart, making it available for potential use, and the trained staff member failed to adhere to established procedures regarding use of resident-specific glucometer and proper disinfection. A review of resident records who were receiving blood glucose monitoring through the use of glucometers was conducted by the Minimum Data Set (MDS) Nurse on the morning of May 15, 2025. The review identified there were at least four residents currently residing in the facility, and having their blood glucose monitored with a glucometer, who had been diagnosed with one or more bloodborne pathogens. Failure to clean and disinfect shared or improperly maintained medical equipment, such as glucometers, according to manufacturer's instructions and with a disinfectant registered with the national environmental protection agency (EPA), created a significant risk of cross-contamination and exposure to bloodborne pathogens. Shared or improperly cleaned blood glucose meters can become contaminated with blood and bodily fluids. This practice potentially exposes any resident undergoing blood glucose monitoring with a shared, improperly disinfected device to the spread of bloodborne pathogens. Resident #8, and any other resident who the facility might have determined (though none were identified) to have had their blood glucose tested using an unassigned and improperly disinfected glucometer, are considered likely to suffer a serious adverse outcome (e.g., transmission of bloodborne pathogens) as a result of this noncompliance. An immediate audit was initiated on May 15, 2025, by the Director of Nursing (DON) to identify all residents requiring blood glucose monitoring and to ensure each had an individually assigned and properly labeled glucometer. This audit confirmed all residents requiring blood glucose monitoring had an individually assigned and properly labeled glucometer, and no other issues were identified. Immediate Actions Taken for Affected and At-Risk Residents (Completed: May 15, 2025): A series of immediate actions were completed on May 15, 2025, for affected and at-risk residents. Firstly, the medical provider for Resident #8 was notified of the potential exposure on May 15, 2025, by the DON. Secondly, the one unlabeled glucometer identified was immediately removed from the medication cart and discarded on May 15, 2025, by the DON, ensuring no further use was possible. Thirdly, an immediate inventory check was completed on May 15, 2025, by the DON and nursing leadership (Assistant Director of Nursing (ADON), Quality Assurance (QA) Nurse, Unit Managers), which confirmed that sufficient individually assigned, and resident-labeled, glucometers, and appropriate EPA-registered disinfectant wipes were available for all residents requiring blood glucose monitoring. Reporting (Completed: May 15, 2025): This infection control breach and the potential for exposure to bloodborne pathogens were reported to the local health department on May 15, 2025, by the Director of Nursing (DON). The health department recommendations included testing for Human Immunodeficiency Virus (HIV), Hepatitis B, and Hepatitis C for any potentially exposed residents. Action Taken on Health Department Recommendations (Completed: May 15, 2025): In response to health department recommendations, several actions were completed on May 15, 2025. Orders for baseline testing for HIV, Hepatitis B, and Hepatitis C were obtained from the medical provider for Resident #8. Subsequently, specimens for these ordered tests for Resident #8 were ordered on May 15, 2025, and collected on May 16, 2025, as per facility policy and state regulations. Any follow-up on results and further medical intervention for Resident #8 will be managed by their attending physician and documented in their medical record. The facility acknowledges this is a repeat Immediate Jeopardy (IJ) citation. A previous Directed Plan of Correction (DPOC) had been implemented. This DPOC included comprehensive training for all nursing staff, including the involved agency nurse on February 5, 2025, covering infection control practices for glucometer use. This training emphasized principles from established guidelines (e.g., statewide infection control and epidemiology guidelines (SPICE)), such as the use of single-use, auto-disabling disposable lancets; proper hand hygiene; individual assignment of glucometers; and correct disinfection of devices using EPA-registered wipes with appropriate contact time (noting alcohol pads are for skin preparation only and unsuitable for device disinfection). A thorough root cause analysis was conducted by the Administrator, Director of Nursing (DON), Regional Director of Operations, and Regional Nurse Consultant following the May 15, 2025, incident. The recurrence of the deficient practice was determined to be due to a combination of factors. Firstly, a System Failure in Glucometer Control occurred, as an unauthorized, unlabeled glucometer was present on a medication cart, indicating a weakness in previous inventory control processes. Secondly, Individual Staff Performance under Stress was a factor, wherein the individual agency staff member, despite prior training and knowledge of correct procedure (and the availability of the resident's assigned glucometer), failed to adhere to established and previously trained procedures when under the perceived pressure of surveyor observation. Thirdly, there was a lapse in Environmental Reinforcement, as visual aids related to glucometer procedures were not replaced by pharmacy staff after a medication cart upgrade, potentially weakening environmental reinforcement of correct procedures (though the nurse involved did not state this as a factor for her specific actions). The employment of the agency nurse involved in the incident was terminated by the Director of Nursing (DON) on May 15, 2025. No other staff members have been identified as committing the same deficient practice. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The following systemic changes were implemented to immediately alter the deficient practice, prevent recurrence, and ensure ongoing compliance, thereby removing the immediate jeopardy. All actions listed below were completed by the end of day on May 15, 2025, unless otherwise specified. System for Glucometer Control, Assignment, and Policy To strengthen the system for glucometer control, assignment, and policy, several actions were completed by May 15, 2025. Firstly, the facility's Glucometer Procedure: Use, Cleaning, and Infection Control was reviewed and updated. This procedure now reflects all current corrective actions, emphasizing the critical importance of using only individually assigned, labeled glucometers and adherence to new surveillance. Following this, all licensed nursing personnel acknowledged receipt and understanding of this updated policy and its implications for daily practice. This was presented by the DON and nursing leadership (ADON, QA Nurse, Unit Managers). Secondly, an initial system-wide glucometer audit was performed. A comprehensive audit was conducted by the DON and nursing leadership (ADON, QA Nurse, Unit Managers), ensuring every resident requiring blood glucose monitoring had an individually assigned, correctly labeled glucometer, stored in its designated clean, individual, hard container within the medication cart. As noted, this audit found no deficiencies. All unauthorized/unlabeled glucometers (the single one identified) were removed from circulation and discarded by the DON and nursing leadership. Thirdly, a strict protocol for the introduction of new or replacement glucometers became effective May 15, 2025. The Director of Nursing (DON), or Nursing Leadership (ADON, QA Nurse, Unit Manager) in the DON's absence, is responsible for obtaining new glucometers for the facility. The Administrator notified and trained the DON on this new process on May 15, 2025. All new glucometers will be delivered directly to DON's office. The glucometers will then be labeled for a specific resident and distributed by the DON or Nursing Leadership (ADON, QA Nurse, Unit Manager) in her absence, before being placed into service on any medication cart. New glucometers not yet in use (unassigned) will be stored exclusively in the DON's office. No unassigned or unlabeled stock glucometers will be permitted to be stored on medication carts or in general nursing units outside of the DON office's control. For new admissions requiring a glucometer after hours or on weekends, the assigned nurse will notify the Unit Manager or other member of the nursing leadership team (ADON, QA Nurse), who will obtain the glucometer from the DON's office. In an emergency after hours, if a current resident suddenly requires a glucometer, the DON's office has an access code (communicated to nursing leadership: ADON, QA Nurse, Unit Managers, and Administrator); the nurse would notify the nursing manager on duty, who will obtain the glucometer from the DON office. Unused glucometers for discharged residents will be removed from the medication cart by the Unit Manager within 24 hours during routine audits and discarded. On May 15, 2025, the Administrator in-serviced the Central Supply Clerk regarding the new protocol, specifically that all glucometers were to be delivered to the DON office upon receipt at the facility. The DON and the nursing leadership team (ADON, QA Nurse, Unit Managers) were also included in this in-service and communication regarding the new glucometer control protocol. System for Maintaining Visual Aids and Equipment Management Effective May 15, 2025, laminated visual reminders outlining critical steps from the Glucometer Procedure: Use, Cleaning, and Infection Control policy, including disinfection steps, were reviewed and confirmed to be accurately placed on all medication carts and in medication rooms by the DON and nursing leadership. Furthermore, the facility's equipment management protocol has been updated. Following any medication cart modification, replacement, or significant repair that may impact visual aids, the Director of Nursing (DON) or Nursing Leadership (ADON, QA Nurse, Unit Manager) in her absence, is responsible for ensuring all necessary signage and visual aids, including the 'Glucometer Procedure: Use, Cleaning, and Infection Control' reminder cards, are promptly verified as present and correctly reinstalled before the medication cart is returned to service. The Administrator trained the Director of Nursing on this updated process. This ensures direct oversight by nursing leadership for this critical component. Education and Competency Validation All actions regarding education and competency validation were completed on May 15, 2025. Medication aides do not perform blood sugar checks and therefore are not included in this specific glucometer competency training. Immediate In-service Training was conducted for all licensed nursing staff (including agency nurses) on May 15, 2025. This training was conducted by the Director of Nursing (DON) and Administrative Nurses (DON, ADON, Unit Managers). The training covered the facility's comprehensive Glucometer Procedure: Use, Cleaning, and Infection Control policy, which includes the new protocol detailed in this plan of correction, covering several key areas. Emphasis was placed on the critical importance of adhering to infection control principles. The facility's policy on blood glucose monitoring was reviewed, stressing the use of individually assigned glucometers for each resident, stored in an individually labeled, hard storage container, and the strict prohibition of using unlabeled or shared glucometers. The process for gathering equipment and supplies was detailed, ensuring gloves, glucometer, alcohol pads, gauze pads, single-use, auto-disabling, disposable lancet, blood glucose testing strips, approved disinfecting wipes, and paper towels/tissues are available. Hand hygiene procedures were reinforced: performing hand hygiene before entering the resident's room, before handling supplies, after removing gloves, and after cleaning is complete. The resident-interaction portion of the training on May 15, 2025, conducted by the Director of Nursing (DON) and Administrative Nurses (ADON, Unit Managers) for all licensed nursing staff (including agency nurses), covered protocols for explaining the blood glucose monitoring procedure to the residents and ensuring their privacy was maintained throughout the process. The procedure for obtaining the capillary blood sample according to facility policy and manufacturer guidelines, including donning gloves, was reviewed. The critical steps for cleaning and disinfection of the glucometer were explicitly detailed: retrieving two approved disinfecting wipes (noting alcohol pads are for skin preparation only and not suitable for device disinfection, per SPICE guidelines and manufacturer instructions for EPA-registered disinfectant wipes); using the first wipe to clean the glucometer, removing any visible blood, dirt, or contaminants; using the second wipe to disinfect, ensuring the surface remains wet for at least 3 minutes (or per the disinfectant's contact time instructions); and allowing the glucometer to air dry completely. Regarding storage and labeling, the training reiterated the prohibition of using unlabeled or extra glucometers found in medication carts. As part of the comprehensive Glucometer Procedure: Use, Cleaning, and Infection Control in-service training on May 15, 2025, conducted by the Director of Nursing (DON) and Administrative Nurses (ADON, Unit Managers) for all licensed nursing staff (including agency nurses), staff were explicitly educated on this prohibition. The training included the updated procedure to follow if a resident does not have a labeled glucometer: nursing staff are to immediately notify nursing leadership (DON, ADON, QA Nurse, Unit Manager) to retrieve a new, properly labeled glucometer and approved storage container from DON's office before any use. Instructions were provided for placing glucometers on a clean, dry paper towel or tissue if set on a bedside table or medication cart, and proper storage and handling of all associated supplies were reviewed. Finally, the risks associated with noncompliance, including the potential for transmission of bloodborne pathogens, were thoroughly discussed. All staff were required to sign an acknowledgement form confirming receipt and understanding of this training. Competency Validation was completed for all licensed nursing staff (including agency nurses) through direct observational competency validation for blood glucose monitoring on May 15, 2025. This validation, conducted by the DON or other qualified nursing leadership (ADON, Unit Managers), ensured adherence to all steps outlined in the Glucometer Procedure: Use, Cleaning, and Infection Control training. This included correct identification and use of the resident's individually assigned glucometer and labeled hard storage container; correct procedure for cleaning and disinfecting the glucometer (two-wipe method, 3-minute contact time, air dry); proper hand hygiene at all required steps; and correct disposal of used lancets, test strips, and wipes. Ongoing Training requirements were established on May 15, 2025. This comprehensive education and competency validation will be incorporated into the orientation program for all new nursing hires and agency staff prior to them performing any resident care assignments independently. Annual competency refreshers will also be conducted. This training will be conducted by the DON or Nursing Leadership (ADON, QA Nurse, Unit Manager) in her absence, or the Staff Development Coordinator. A Tracking System was implemented. As of May 15, 2025, the DON, ADON, and scheduler were assigned responsibility for maintaining records of all completed training, signed acknowledgement forms, and competency validations. They are responsible for ensuring all nursing staff have completed the required training and demonstrated competency before they are assigned to resident care duties involving blood glucose monitoring. Ongoing Supervisory Support and Procedural Adherence Commencing May 15, 2025, and on an ongoing basis, the facility is committed to a comprehensive plan of direct supervisory support and surveillance of licensed nurses, including agency nurses, to ensure continued adherence to the correct blood glucose monitoring procedures. This will involve active engagement with all nursing staff performing this procedure, across all shifts (day, evening, night, and weekends). These supportive surveillance activities will be conducted by Nursing Leadership (DON, ADON, Unit Managers, Regional Nurse Consultant), ensuring a visible l[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews with staff, Physician Assistant, and responsible party (RP), the facility failed to protect 2 cognitively impaired residents' right to be free from sexual abuse. On 4/4/25 at approximately10:00 PM, a Medication Aide observed a female resident (Resident #1) in a male resident's (Resident #2) room sitting upright on Resident #2's bed. Resident #2 was standing in front of Resident #1 with his pants down and his penis inside of her mouth. When the Medication Aide asked what was going on, Resident #2 backed away from Resident #1 removing his penis from her (Resident #1) mouth. The residents did not have the capacity to consent to sexual relations. Resident #1's RP stated due to Resident #1's advanced dementia she was not aware of her behaviors and had no insight into what happened. A reasonable person expects to be protected from abuse in their home environment and would have experienced trauma with feelings such as fear, humiliation, anger, anxiety, and depressed mood as a result of the intimate sexual relations enacted without the capacity to consent. This deficient practice affected 2 of 3 residents (Resident #1 and Resident #2) reviewed for abuse. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, communication deficit and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had unclear speech, had difficulty making herself-understood and was severely cognitively impaired. Resident #1 had no behavioral symptoms and she wandered 1 to 3 days during the 7-day MDS look back period. Resident #1 required 1-person assistance from staff for activities of daily living and supervision or touching assistance with ambulation. Resident #1's revised care plan dated 1/7/25 included a focus area for impaired cognitive function and impaired thought process related to dementia/Alzheimer's disease. Resident #1's care plan did not identify any sexually inappropriate behaviors. Resident #2 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included dementia, mood disturbance, anxiety and depression. Resident #2's revised care plan dated 2/17/25 included a focus area for behaviors of disrobing in common areas, wandering in other resident rooms, and inappropriate behaviors toward others. Resident #2 had potential sexual behaviors exhibited by attempting to invite other residents into his room. Resident #2 had a behavior problem as evidence by wandering and threatening behavior towards other residents. He had the potential to become aggressive when his space was invaded without warning. Resident #2 was historically territorial over his room and personal space. The goal included Resident #2 would not demonstrate inappropriate sexual behaviors. The approaches included notifying physicians of behavior; staff to monitor behaviors, offer redirection and provide structured activities; and staff to provide one to one (1:1) monitoring for inappropriate behaviors. The quarterly MDS assessment dated [DATE] revealed Resident #2 was severely cognitively impaired and had no behavioral symptoms or wandering during the 7-day MDS look back period. Resident #2 was independent with dressing, transfers, and ambulation. A physician order for Resident #2 dated 3/31/25 revealed Depakote (a mood stabilizer that can be used to decrease sexual urges) 125 milligrams one tablet daily and estradiol (synthetic form of estrogen) transdermal patch 0.1 milligrams to be applied on the right shoulder weekly for sexual behavior. The incident report completed by Nurse #1 on 4/4/25 at 9:45 PM revealed Resident #1 was found in Resident #2's room performing oral sex on Resident #2. Both residents were separated immediately. Skin assessments were done for both residents and there were no injuries noted. The physician, responsible parties for both residents and Director of Nursing were notified of the incident. The initial allegation report dated 4/4/25 completed by the Administrator indicated Resident #1 and Resident #2 resided on the memory care unit. Resident #1 was noted in Resident #2's room with Resident #2's penis exposed. Both residents were placed on 1:1 observation. The physician, state agency, local law enforcement and responsible person(s) for both residents were notified. No injury or harm or change of condition noted for either resident and they were each at baseline mental and physical status. The Medication Aide's statement dated 4/4/25 revealed the Medication Aide was looking for another resident to administer medications when he walked into Resident #2's room and saw Resident #1 sitting on the bed. Resident #2 was standing in front of Resident #1 with his pants down and his penis in Resident #1's mouth. He asked what they were doing and Resident #2 backed up and pulled his pants up. Resident #1 was removed from the room and he (the Medication Aide) got the nurse. A telephone interview was conducted on 4/10/25 at 9:45 AM with the Medication Aide who stated Resident #2's room was at the end of a hall and he did not have a roommate. On 4/4/25 around 10:00 PM he walked to Resident#2's room and the door to the room was open. Resident #1 was observed to have her mouth around the penis of Resident #2. The Medication Aide stated Resident #2 was standing on the floor at the head of the bed with his pants down and Resident #1 was seated on the edge of the bed with her right knee down on the floor. She was actively performing oral sex on Resident #2. The Medication Aide stated when he asked what was going on Resident #2 backed away and pulled up his pants. Both residents were separated immediately. There were no visible signs that Resident #2 forced Resident #1 to perform oral sex. The Medication Aide stated Resident #2's penis was flaccid after he removed his penis from Resident #1's mouth and Resident #1 was removed from the room with the assistance of Nurse Aide #1. He stated he asked Resident #1 what happened, and she was unable to state what happened. Resident #1 left the room with Nurse Aide #1 in no apparent distress. The nurse was immediately notified of the incident. He further stated within 15 minutes sitters were sent to each of the residents' rooms for 1:1 monitoring. The Medication Aide stated Resident #2 had been moved to another unit about two years ago before coming back to the memory care unit on 3/7/25 due to a history of inappropriate sexual behaviors and comments. Resident #2 previously made the statement can an old man get some before he dies. An interview was conducted on 4/9/25 at 3:29 PM with Nurse Aide #1 who assisted Resident #1 back to her room following the incident on 4/4/25. The Nurse Aide stated when she entered the room, both residents had already been separated and Resident #2 was already dressed. Resident #1 was unable to state what happened when asked and she willingly left the room. Nurse Aide #1 stated Resident #1 did not show any visible distress, voiced no complaints, and expressed no discomfort. Nurse Aide #1 stated she sat with Resident #1 until Nurse #1 did a full assessment. The assigned sitter arrived after completion of the assessment. A telephone interview was conducted on 4/9/25 at 2:26 PM with Nurse #1 who stated on 4/4/25 the Medication Aide reported that Resident #2 was in his room standing in front of Resident #1 with his pants down. Resident #1 was sitting on the bed. Resident #1 was observed in Resident #2's room actively performing oral sex on Resident #2. She indicated she last saw Resident #2 in the dayroom a little after 9:00 PM and could not recall the location of Resident #1. She further stated she went to Resident #2's room and both residents had already been separated and Resident #1 had been taken to her room by Nurse Aide #1. She stated she did a head-to-to-toe assessment of Resident #2 who had no complaints or injuries. Nurse #1 stated she asked Resident #2 what happened and Resident #2 put his head down. Nurse #1 reported she did Resident #1's head-to-toe assessment and no injuries were noted. Following the assessments, she notified Nurse #2 who immediately came to the unit and provided 1:1 sitters to monitor both residents. Attempts were made to contact Nurse #2 on 4/10/25 at 1:43 PM and 4/11/25 at 9:00 AM. She was unable to be reached for interview. Resident #2's RP was contacted on 4/9/25 at 2:37 PM and 4/10/25 at 1:15 PM and was unavailable for interview. A telephone interview was conducted on 4/10/25 at 1:08 PM with Resident #1's RP who stated he received a call from the Director of Nursing who informed him of the 4/4/25 incident. He stated due to Resident #1's advanced dementia she was not aware of her behavior and had no insight into what happened. A full body assessment dated [DATE] at 10:35 PM completed by the Director of Nursing revealed Resident #1 was assessed due to resident-to-resident sexual abuse. No negative findings were observed. A full body assessment dated [DATE] at 10:38 PM completed by the Director of Nursing revealed Resident #2 was assessed due to resident-to-resident sexual abuse. No negative findings. An interview was conducted on 4/9/25 at 3:30 PM, with the Director of Nursing (DON) who stated she received a call on 4/4/25 around 10:00 PM about the incident. She notified the Administrator who came into the facility with her to initiate a full investigation. She reported when they arrived at the facility, both residents had been separated and placed on 1:1 monitoring with sitters. The DON stated Nurse #1 completed skin assessments and contacted the physician assistant who gave instructions to contact the families and inform them of the incident and offer each of them the option to have the resident transferred to the hospital for evaluation to rule out a sexually transmitted disease. The DON further stated she also did a complete head-to-toe assessment of both residents and did not have any negative findings mentally or physically. Following the completion of the physical assessments, she contacted the RPs for both residents and informed them of the incident and offered them a transfer to the hospital for further evaluation and both families declined transfer. Neither family reported any concern with the information provided or the investigation process. The DON stated Resident #1 did not have any known sexual behaviors prior to the incident. The DON asked Resident #1 what happened, and she was unable to state what happened due to her severe cognitive impairment and dementia. Resident #1 did not have the capacity to consent to any sexual activity. Resident #2 was also diagnosed with dementia and had limited insight into what happened or the significance of the inappropriate behavior. The DON reported Resident #2 had a documented history of inappropriate sexual behaviors of touching others without consent and making sexual comments. She reported the behaviors were addressed on the care plan with 1:1 supervision, redirection to activities of interest, psychiatric evaluations, transfer to another unit and medication adjustment. The family requested Resident #2 be returned to the memory care unit for safety reasons due to a recent fall. She further stated she was aware all residents must be protected from any form of abuse and the interdisciplinary team would review the current behavior plans for all residents. Resident #2's current medications at the time of the incident included the estradiol transdermal patch and Depakote to address the inappropriate sexual behaviors. The Depakote was increased after the 4/4/25 incident. An interview was conducted on 4/10/24 at 9:45 AM with the Social Worker who stated Resident #2 had a history of inappropriate sexual advances toward others. The Social Worker reported Resident #2 would attempt to inappropriately touch others or make sexual comments or advances. Resident #2's RP was aware of the inappropriate sexual behaviors and the use of medication to address the behaviors. Resident #2 had been on the memory care unit in the past but had been transferred to another unit for inappropriate sexual advances and comments about a year and half ago. He had 1:1 supervision on the unit. Resident #2 recently returned from the hospital and the family requested the resident return to the memory care unit for safety reasons due to recent falls. The Social Worker stated there had been no previous incident of Resident #1 exhibiting any sexual behaviors toward others. An interview was conducted on 4/10/25 at 10:00AM with the Physician Assistant who stated he received a call on 4/4/25 about inappropriate sexual activity between Resident #1 and Resident #2. He stated he gave the nurse instructions to offer the residents family the option for hospital transfer for evaluation for sexually transmitted diseases. He was informed both residents had been separated and placed on 1:1 monitoring. He further stated he had a discussion with the Director of Nursing who informed him both resident's family declined the hospital evaluation, therefore he ordered a psychiatric evaluation. Review of the skin assessments done by nursing and the Director of Nursing revealed there was no evidence of any sexual penetration other than the visible observation made by the medication aide. The Physician Assistant indicated Resident #1 and Resident #2 did not have the capacity to consent due to their diagnosis of dementia. Resident #1 did not exhibit any inappropriate sexual behavior prior to the 4/4/25 incident. Resident #2 had been on estradiol transdermal patch weekly and Depakote 125 milligram daily to address inappropriate sexual behaviors for more than a year along with intermittent 1:1 supervision on different units. An interview was conducted on 4/10/25 at 5:30 PM with the Administrator who stated when he received the call on 4/4/25 about the incident between Resident #1 and Resident #2, he came to the facility along with the Director of Nursing to investigate the incident. He reported the nursing team handled the residents' care and assessments and he completed the documents and reporting process to the local authorities and state agencies in accordance to facility policies and procedures and federal regulations. The Administrator acknowledged that all residents must be protected from any form of abuse. He stated the interdisciplinary team would evaluate the current behavior plans for all residents. The Administrator was notified of the Immediate Jeopardy on 4/10/25 at 4:36 PM. The facility provided the following Corrective Action Plan: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility identified an incident where residents' rights to be free from sexual abuse were not adequately protected. On 04/04/2025 at 10:00 PM, a Medication Aide observed an incident between Resident #1, a female resident with severe cognitive impairment related to dementia/Alzheimer's Disease (last seen between 8:45 PM and 9:00 PM by a CNA), and Resident #2, a male resident with severe cognitive impairment (last seen by a nurse at 9:03 PM). Resident #2 had a care plan for behaviors including wandering and disrobing due to personal preference to sleep without clothing and brief. The incident occurred in Resident #2's room where the Medication Aide observed Resident #1 sitting upright on the bed with Resident #2 standing in front of her. Resident #2's penis was in Resident #1's mouth; the penis was observed to be flaccid. When the Medication Aide asked what was going on, Resident #2 backed away, removing his penis from Resident #1's mouth. Neither resident possessed the cognitive capacity to consent to sexual activity. Upon discovering the incident on 04/04/2025 at 10:00 PM, the Medication Aide immediately separated the residents and notified the Charge Nurse. The Charge Nurse promptly conducted initial physical assessments of both residents, with no immediate concerns identified. No evidence of ejaculation was noted in Resident #1's mouth. Both residents were immediately placed on 1:1 supervision by nursing staff following the incident to ensure their safety and prevent recurrence. As of 04/11/2025, both Resident #1 and Resident #2 are still residents at the facility and currently remain on 1:1 supervision. On 04/04/2025 at 11:00 PM, Residents #1 and #2 were assessed by the Director of Nursing (DON), including complete skin assessments, with no injuries noted. The DON notified the primary care physician for both residents at 10:30 PM on 04/04/2025. The physician did not provide any new orders at that time. At 11:30 PM on 04/04/2025, the DON completed further assessments for Residents #1 and #2, including behavior assessments and updated sexual behavior assessments, covering areas such as trauma, psychosocial status, behavior monitoring, sexual history/activity, and change in condition evaluation. Also at 11:30 PM on 04/04/2025, the Director of Nursing notified the responsible parties for Residents #1 and #2 of the incident, with detailed documentation of these conversations obtained and filed. The DON notified the psychiatric services provider on 04/05/2025 at 1:44 AM. A medication review was conducted for both residents by the Psychiatric Provider on 04/05/2025 at 1:44 AM, resulting in new orders for Resident #2 that were implemented immediately upon receipt. For Resident #2, the psychiatric provider increased the dosage of his prescribed mood stabilizer (Divalproex Sodium) to address the inappropriate sexual behaviors. Resident #1 did not require medication changes as her assessment did not indicate a need for pharmacological intervention. The Director of Nursing updated care plans for both residents on 04/04/2025 at 11:45 PM to reflect current status, behavioral interventions, and increased monitoring requirements. For Resident #1, care plan updates included: 1) documentation of the incident, 2) implementation of 1:1 supervision, 3) specific approaches for redirection during periods of increased confusion, 4) activity participation guidelines to promote appropriate social interaction, and the addition of a trauma-informed care approach. For Resident #2, care plan updates included: 1) documentation of the incident, 2) implementation of 1:1 supervision, 3) behavior monitoring with specific triggers and warning signs identified, 4) incorporation of the psychiatric provider's medication recommendations including monitoring parameters for the increased mood stabilizer dosage, 5) specific interventions for staff to redirect inappropriate sexual behaviors, 6) activity programming to channel energy appropriately. Both care plans include detailed guidance for all shifts and disciplines on prevention strategies, early intervention techniques, and response protocols. The Administrator notified the local police department at 11:30 PM on 04/04/2025 of the incident/potential abuse, and a formal police report was taken. Adult Protective Services was also notified on 04/04/2025 at 11:35 PM. A long-term plan for Residents #1 and #2 has been developed. Initially, both residents will remain on 1:1 supervision for 10 days. Both Resident #1 and Resident #2 are still residents at the facility and currently remain on 1:1 supervision (as of 04/11/2025). Following this period, the interdisciplinary team will conduct a comprehensive reassessment to determine appropriate ongoing monitoring levels based on individual needs. This may include continued 1:1 supervision, 15-minute checks, or 30-minute checks as determined necessary. Resident #2 will receive ongoing behavioral health services with weekly assessments for the first month. Room placement and activity participation will be carefully monitored to ensure appropriate separation while maintaining quality of life for both residents. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents are at risk for this deficient practice, particularly those with cognitive impairments. On 04/05/2025, the Director of Nursing individually interviewed all residents with a Brief Interview for Mental Status (BIMS) score of 10 or greater to determine if they had experienced any inappropriate/unwanted sexual contact and if they felt safe in the facility. These interviews were conducted using a standardized interview protocol. Results of these interviews revealed no additional concerns or reports of inappropriate or unwanted sexual contact, and all interviewed residents reported feeling safe in the facility. On 04/05/2025, licensed nurses, specifically the Unit Managers on each unit, assessed all residents on the secured memory care unit for behaviors using the Behavior Assessment tool (Point of Care User-Defined Assessment). All residents on the secured memory care unit have severe cognitive impairment. This assessment revealed no resident who had additional concerns for sexual behaviors or resident abuse. Documentation was completed in each resident's electronic health record. On 04/05/2025, the Director of Nursing completed comprehensive skin assessments on all residents with a BIMS score of 9 or less to determine if there were any signs or symptoms of abuse, with no additional concerns noted. These assessments included full-body skin checks with documentation of findings in each resident's record. On 04/05/2025, licensed nursing staff, including Unit Managers and Charge Nurses, updated sexual history/behavior assessment User-Defined Assessment for all residents to ensure complete and current documentation of potential risk factors or concerns. This comprehensive assessment identified residents' normal sexual behaviors, history of inappropriate sexual behaviors, and risk factors that may contribute to sexual behaviors. On 04/05/2025, the Director of Nursing created a comprehensive list of all residents with behaviors, including those with histories of being sexually inappropriate or care planned for being sexually inappropriate, to ensure appropriate monitoring. This identification process included review of admission assessments, behavior tracking records, care plans, progress notes, and consultation with direct care staff who regularly interact with residents. No additional residents were found to have these behaviors. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 04/05/2025, the Administrator, Director of Nursing, and Quality Assurance (QA) Nurse educated all facility staff on the abuse prohibition and reporting policy, with emphasis on the requirement to document and report any behaviors affecting other residents at the time of occurrence. This education was conducted in person during all shifts through mandatory in-service meetings. The education covered: 1) identification of all forms of abuse including sexual abuse, 2) immediate intervention protocols to ensure resident safety, 3) proper reporting procedures including timeframes and notification chain, 4) documentation requirements, 5) resident rights, and 6) staff responsibilities for prevention and reporting. Following the education session, each staff member's understanding was verified through discussion and response to scenario-based questions. Staff acknowledged their understanding of the material and responsibilities by signing an attestation form, which is maintained in their personnel file. All education is documented in individual personnel files with employee signatures acknowledging understanding. Staff who were not present will not be permitted to work until they receive this education. The Director of Nursing maintains a tracking log to ensure 100% staff completion. On 04/05/2025, the facility established a comprehensive behavioral monitoring program for residents identified with behaviors such as physical/verbal aggression, wandering, disruptive vocalizations, inappropriate sexual advances, etc., to be placed on 15-minute checks, 30-minute checks by designated nursing staff, or 1:1 supervision for 72 hours or until determination can be made for continuation of monitoring. On 04/05/2025, all staff members (including agency personnel) received comprehensive education about the behavioral monitoring program. This education was provided by the Director of Nursing and Unit Managers. Any staff member not educated by 04/05/2025 will be educated prior to their next scheduled shift. The Administrator is responsible for ensuring this education is completed and documented in personnel files. Education includes dementia-specific training components. On 04/05/2025, the facility implemented clear staff responsibilities when a behavior is identified, with emphasis on prevention and immediate intervention when abuse is observed or reported. These responsibilities are detailed as follows: Nurses are responsible for immediately assessing residents involved in reported behavioral incidents for both physical and psychological impacts. They must document comprehensive assessment findings in progress notes including physical and mental status. Nurses implement interventions according to facility protocols and individualized care plans, which include specific approaches for each resident based on their unique needs and triggers. They notify the Unit Manager, Director of Nursing, and Administrator of significant behavioral incidents immediately upon discovery. Nurses contact the appropriate provider for consultation regarding new or modified orders when residents exhibit behavioral changes. They follow the provider's orders and document implementation and resident response. Following incidents, nurses monitor residents closely for changes in condition, complete incident reports for all behavioral events per facility policy, conduct thorough shift-to-shift handoff regarding residents with behavioral concerns, ensure appropriate supervision levels are maintained based on resident needs, and report changes in resident condition to primary physician and psychiatric services. Nurses report directly to their Unit Managers for guidance and support when managing resident behaviors. Nurse Aides immediately report any observed behaviors to the charge nurse/unit manager verbally and document observed behaviors in the Point of Care system at time of occurrence. They implement immediate interventions as directed by care plan (redirection, one-to-one supervision, etc.), monitor residents for escalation or changes in behavior and report changes promptly, and follow specific behavioral care plan approaches for each individual resident. Nurse Aides also follow directives from nurses and/or management regarding interventions for behaviors and use techniques learned in dementia-specific training to de-escalate situations before they progress. Unit Managers assess residents when behavior is reported, conducting comprehensive evaluations that include physical, cognitive, and psychosocial components. They document assessment findings in progress notes, notify the Director of Nursing/Administrator of behavior incidents, contact primary physician and responsible party as appropriate, update care plans to reflect new or increased behaviors, communicate behavior and interventions to all staff during shift report, conduct follow-up assessments to monitor effectiveness of interventions, ensure all documentation is complete and accurate, and coordinate interdisciplinary team response to behavior incidents. Social Workers conduct psychosocial assessment following behavior incidents, facilitate communication with families regarding behaviors and interventions, coordinate referrals to mental health services when indicated, assist with development of behavior management strategies, provide staff education on behavior management techniques specific to individual residents, participate in care plan meetings to address behavioral concerns, document all interventions and resident response in the medical record, follow up with residents to assess ongoing psychosocial needs, and provide resources and support to residents and families. On 04/05/2025, the Director of Nursing implemented daily reviews of progress notes, electronic Medication Administration Record, and Plan of Care for behavior documentation. These reviews occur 7 days a week; the DON or designee reviews the previous day's documentation during the morning clinical meeting held Monday-Friday at 9:30 AM, and the weekend Charge Nurse performs these reviews on Saturdays, Sundays, and holidays. This process identifies any new or increased behaviors and ensures appropriate follow-up. The appropriate follow-up includes immediate notification to providers, family, updating care plans, and implementing appropriate interventions. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Beginning 04/05/2025, the Administrator and Director of Nursing will interview at least 5 staff members per week for 4 weeks to identify any new or increased resident behaviors (including sexual behaviors) using an incident-specific monitoring tool and ensure appropriate reporting. This will be followed by interviewing 3 staff members per week for an additional 8 weeks (total monitoring period of 12 weeks). If the Administrator or Director of Nursing is unavailable, this responsibility will be delegated to the Social Worker to ensure continuity. Beginning 04/05/2025, the Director of Nursing will conduct daily reviews of all behavior documentation, including progress notes, electronic Medication Administration Record, and Point of Care during morning clinical meetings, seven days a week including weekends and holidays. On days when the Director of Nursing is not available, the Assistant Director of Nursing or designated Unit Manager will conduct these reviews to ensure continuous monitoring. Beginning 04/05/2025, the Administrator determined all findings shall be formally reported to the Quality Assurance Performance Improvement committee with detailed documentation. Audits will continue at the discretion of the Quality Assurance Performance Improvement committee based on findings, with potential for increased frequency or extended duration if any concerns are identified. The monitoring process will include verification that all staff have received the required education, documentation review, and continued assessment of all residents with specific attention to those residents identified as being at higher risk. All corrective actions were implemented by 04/05/2025. The facility's alleged date of compliance is 04/06/2025. Allegation of immediate jeopardy removal and compliance date: 4/6/25. The corrective action plan was validated onsite on 4/9/25 and 4/10/25. It was verified through staff interviews that Residents #1 and #2 were immediately separated and assessed for injury. There were no negative findings for either resident. Resident #1 and Resident #2 were placed on 1:1 supervision and documentation of supervision was verified. Observations of the 1:1 for both residents were conducted on 4/9/25 and 4/10/25. Review of skin assessments and body audit forms verified they were completed on all residents on the memory care unit as well as residents on the other 4 units on 4/5/25. In addition to skin assessments, resident interviews were conducted for individuals with a BIMS score of 10 or greater to determine if they had experienced any type of inappropriate/unwanted sexual contact. All residents were assessed with the use of the behavior assessment tool, sexual activity assessment, and post-traumatic stress disorder assessment. Care plans for Resident #1 and Resident #2 and other residents with identified behavioral concerns were reviewed and revised if needed. Staff interviews verified employees were educated with post-education knowledge checks completed as indicated in the corrective action plan that included sexual abuse, dementia, reporting/ documentation of abuse, 1:1 supervision, increased unit rounds for wandering residents and review of the updated care plans for residents with behaviors. The facility implemented monitoring systems that

Based on record reviews, observations, and interviews with staff and Medical Director, the facility failed to provide an agency nurse (Nurse #1) with orientation and training to meet residents' care needs, including education and verification of the nurse's competency on glucometer (blood glucose meter) disinfection. Nurse #1 used a shared glucometer without disinfecting the meter between residents for 1 of 3 residents (Resident #107) who was observed to have her blood glucose checked. This occurred while there were 18 residents identified with a known bloodborne pathogen in the facility. There was a high likelihood that a resident without an existing blood borne pathogen could be exposed to a bloodborne pathogen as a result of staff not using the resident's dedicated glucometer, not knowing how to effectively clean and disinfect a glucometer, and staff not handling and storing the glucometer in a method to protect against cross-contamination via contact with other meters or equipment. Also, Nurse #2 (an agency nurse) failed to demonstrate competency with the disinfection of individually assigned glucometers stored outside of the residents' rooms in accordance with the instructions provided by the manufacturer of the disinfectant wipes for 2 of 3 residents (Residents #66 and #93) observed to have their blood glucose levels checked. This occurred for 2 of 2 nurses reviewed for training and competency (Nurse #1 and Nurse #2). Immediate jeopardy began on 2/4/25 when Nurse #1 failed to demonstrate competency as he used a glucometer dedicated to Resident #134 to check Resident #107's blood glucose without disinfecting the shared glucometer between residents. Immediate jeopardy was removed on 2/6/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) for finding #2 and for the facility to complete agency and employee staff training with monitoring to ensure appropriate interventions are put into place. The findings included: This tag is cross referred to: F880 Based on record reviews, observations, and interviews with staff and Medical Director, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents for 1 of 3 residents (Resident #107) observed to have her blood glucose (sugar) level checked. This occurred while there were 18 residents identified with a known bloodborne pathogen in the facility. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer of the glucometer potentially exposes residents to the spread of bloodborne infections. Care must also be taken by personnel handling and storing glucometers to protect the glucometers against cross-contamination via contact with other meters or equipment. Also, the facility failed to disinfect individually assigned glucometers stored outside of the residents' rooms in accordance with the instructions provided by the manufacturer of the disinfectant wipes for 2 of 3 residents (Residents #66 and #93) observed to have their blood glucose levels checked. 1. An interview was conducted on 2/4/25 at 6:17 AM with Nurse #1. When Nurse #1 was asked how long he had worked at the facility, he stated this was his first week. Upon further inquiry, the nurse reported he received a short orientation from facility for agency nurses. On 2/4/25, the facility provided a copy of the orientation packet given to agency nurses when they first began working at the facility. A review of the Information Packet for Registry Nurses revealed it contained information on the following topics: Welcome to [Name of Facility]; Important Guidelines (including dress code, personal devices, medication protocol, supplies, and identification); admission Assessment (indicating the admission documentation required); Nurse Responsibilities in Admission; Daily Responsibilities; and Documentation Expectations. The orientation packet did not include any information about either the disinfection or storage of glucometers. During an interview conducted with the facility's Director of Nursing (DON) on 2/5/25 at 8:40 AM, the DON stated the only orientation material the facility provided for agency nurses was the Information Packet for Registry Nurses. She acknowledged the facility did not provide education on glucometer disinfection to agency nurses prior to the nurse working at the facility. The DON stated it was assumed that agency nurses had received training to ensure their overall competency to care for residents prior to being hired and assigned to work in their facility. A follow-up interview was conducted on 2/7/25 at 8:19 AM with the DON to inquire about the training / orientation provided to newly hired staff nurses. When asked, the DON reported that staff nurses went through an orientation program led by the facility's Staffing Coordinator and Human Resources Manager. She also noted new staff nurses were assigned a mentor to supplement their orientation. A telephone interview was conducted with the facility's Medical Director on 2/6/25 at 2:27 PM to discuss the concerns related to glucometer disinfection identified during observations conducted at the facility. When asked, the Medical Director reported she had been informed of these concerns. She reported this sounded like a training issue and stated, This is the first time I have heard of this happening. The Medical Director reported she thought glucometer disinfection required better learning or training for all staff throughout. The facility's Administrator and DON were informed of the immediate jeopardy (IJ) on 2/5/25 at 2:00 PM. The facility provided the following plan for IJ removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance On 02/04/2025, an agency nurse (Nurse #1) provided care without receiving proper orientation and competency validation regarding glucometer disinfection procedures. The nurse used a glucometer dedicated to Resident #134 for Resident #107 without proper disinfection between residents. When interviewed, the nurse stated they were unaware of facility policies and procedures for glucometer disinfection and did not know which products were approved for disinfection. All residents requiring blood glucose checks were identified as being at risk. An audit conducted by the Director of Nursing and nursing unit coordinators on 02/04/2025 identified all facility residents requiring blood glucose checks and confirmed the presence of residents with blood borne pathogens, creating risk for cross-contamination. The following immediate actions were taken: - At approximately 7:00 AM on 02/04/2025, upon discovery of the incident, Nurse #1 was immediately removed from resident care duties - The Director of Nursing contacted Nurse #1 by telephone regarding the requirement to complete comprehensive glucometer competency validation before accepting any future assignments at the facility Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete The following systemic changes have been implemented as of 02/05/2025: 1. Comprehensive Glucometer Training and Competency Program: All licensed nurses (including facility staff and agency staff) must complete the following training and demonstrate competency before performing blood glucose monitoring: a. Required Equipment and Supplies: - Gloves - Glucometer - Alcohol pads - Single-use lancet - Blood glucose testing strips - Disinfecting wipes - Paper towels or tissues b. Complete Glucometer Procedure and Cleaning Steps: - Obtain needed equipment and supplies - Perform hand hygiene - Explain the procedure to the resident - Provide privacy - [NAME] gloves - Obtain capillary blood glucose sampling - Remove and discard gloves, perform hand hygiene prior to exiting the room - Retrieve (2) disinfectant wipes from container - Using the first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer - After cleaning, disinfect with second wipe, maintaining 3-minute wet contact time. Allow the glucometer to air dry - Discard disinfectant wipes in waste receptacle - Perform hand hygiene - Ensure glucometer is stored in individual plastic bag for each resident to prevent cross contamination - Place clean dry paper towel or tissue under glucometer before placing on resident table or on top of medication cart to prevent contamination 2. Competency Validation Process: Direct observation by nurse management of: - Complete blood glucose monitoring procedure as outlined above - Proper hand hygiene and glove use at specified steps - Correct glucometer cleaning and disinfection technique - Appropriate wet contact time monitoring - Proper barrier use and storage procedures - Return demonstration required for all steps - Documentation of competency verification in employee file - No blood glucose monitoring permitted until competency validated 3. Ongoing Monitoring: - The Director of Nursing maintains documentation of all completed competency validations - The staffing coordinator verifies completion of glucometer competency before scheduling Immediate Jeopardy Removal Date: 2/6/2025 The facility's credible allegation of immediate jeopardy removal was validated on 2/7/25. The validation was evidenced by nurse observations and/or interviews conducted on each hallway with regards to the required infection control practices for the disinfection of glucometers. All nurses who were interviewed reported they had received the required in-service training prior to beginning their shift. The education provided stressed the importance of using individually assigned glucometers for each resident requiring blood glucose monitoring and storing these glucometers in individual, re-sealable plastic bags. The in-service training also included a review of the manufacturer's instructions for the facility's glucometer and disinfectant wipes related to glucometer disinfection, as well as completing a return demonstration of the proper procedures for effective glucometer disinfection. Nurses observed to conduct blood glucose checks and subsequent glucometer disinfection completed the task without difficulty. The nursing practices observed included the proper handling and storage of glucometers to protect the meters from potential cross-contamination via contact with other meters or surfaces. There were no concerns identified during either the interviews or observations. The credible allegation was validated, and the immediate jeopardy was removed on 2/6/25. 2. An interview was conducted on 2/4/25 at 12:14 PM with Nurse #2. During the interview, the nurse estimated that she had worked at the facility four times in the last three months. On 2/4/25 at 12:35 PM, a follow-up interview was conducted with the nurse. At that time, Nurse #2 was asked if she received orientation upon starting to work at the facility. She stated, No, I did not. When asked, Nurse #2 reported she did not know how long a glucometer should remain wet (wet contact time) after using a disinfectant wipe to ensure the meter was adequately disinfected. On 2/4/25, the facility provided a copy of the orientation packet given to agency nurses when they first began working at the facility. A review of the Information Packet for Registry Nurses revealed it contained the following topics: Welcome to [Name of Facility]; Important Guidelines (including dress code, personal devices, medication protocol, supplies, and identification); admission Assessment (indicating the admission documentation required); Nurse Responsibilities in Admission; Daily Responsibilities; and Documentation Expectations. During an interview conducted with the facility's Director of Nursing (DON) on 2/5/25 at 8:40 AM, the DON stated the only orientation material the facility provided for agency nurses was the Information Packet for Registry Nurses. She acknowledged the facility did not provide education on glucometer disinfection to agency nurses prior to the nurse working at the facility. The DON stated it was assumed that agency nurses had received training to ensure their overall competency to care for residents prior to being hired and assigned to work in their facility. A follow-up interview was conducted on 2/7/25 at 8:19 AM with the DON to inquire about the training / orientation provided to newly hired staff nurses. When asked, the DON reported that staff nurses went through an orientation program led by the facility's Staffing Coordinator and Human Resources Manager. She also noted new staff nurses were assigned a mentor to supplement their orientation. A telephone interview was conducted with the facility's Medical Director on 2/6/25 at 2:27 PM to discuss the concerns related to glucometer disinfection identified during observations conducted at the facility. When asked, the Medical Director reported she had been informed of these concerns. She reported this sounded like a training issue and stated, This is the first time I have heard of this happening. The Medical Director reported she thought glucometer disinfection required better learning or training for all staff throughout.

Based on record reviews, observations, and interviews with staff and Medical Director, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents for 1 of 3 residents (Resident #107) observed to have her blood glucose (sugar) level checked. This occurred while there were 18 residents identified with a known bloodborne pathogen in the facility. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer of the glucometer potentially exposes residents to the spread of bloodborne infections. Care must also be taken by personnel handling and storing glucometers to protect the glucometers against cross-contamination via contact with other meters or equipment. Also, the facility failed to disinfect individually assigned glucometers stored outside of the residents' rooms in accordance with the instructions provided by the manufacturer of the disinfectant wipes for 2 of 3 residents (Residents #66 and #93) observed to have their blood glucose levels checked. Immediate jeopardy began on 2/4/25 when Nurse #1 was observed to perform blood glucose testing for Resident #107 using a glucometer dedicated to Resident #134 without disinfecting the shared glucometer between residents. Immediate jeopardy was removed on 2/6/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) for finding #2 and for the facility to complete agency and employee staff training with monitoring to ensure appropriate interventions are put into place. The findings included: The manufacturer instructions for cleaning and disinfecting the (Brand Name) glucometer used at the facility were summarized in a Technical Brief (Revised 9/24). The Technical Brief read in part, To minimize the risk of transmitting bloodborne pathogens, the cleaning and disinfecting procedures should be performed as recommended in the instructions below. The (Brand Name) meter may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed. The meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of bloodborne pathogens .Clean and disinfect the meter following step-by-step instructions in the Quality Assurance (QA) / Quality Control (QC) Reference Manual. Cleaning and Disinfecting Procedures specified in the glucometer's QA/QC Reference Manual (Revised 10/24) included, in part: --Cleaning: Step 1 (of 7): Wear appropriate protective gear such as disposable gloves. Step 3 (of 7): Wipe surface of the meter to clean blood and other body fluids . Step 4 (of 7): If blood is visible on the meter, it should be cleaned prior to each disinfection step. --Disinfecting: Step 5 (of 7): Pull out 1 new towelette and wipe the entire surface of the meter horizontally and vertically to remove bloodborne pathogens. Carefully wipe around the test strip port by inverting the meter so that the test strip port is facing down. Step 6 (of 7): Treated surface must remain wet for recommended contact time. Please refer to wipe manufacturer's instructions. The manufacturer's Technical Brief for the glucometer listed the disinfectant wipes used at the facility as one of the EPA-registered wipes recommended to clean and disinfect the (Brand Name) glucometer. The instructions on the label of the disinfectant wipes read in part: To clean and disinfect and deodorize hard, nonporous surfaces: Wipe surface to be disinfected. Use enough wipes to treated surface to remain visibly wet to the contact time listed. Let Dry. Special instructions for cleaning and decontamination against human immunodeficiency virus (HIV), hepatitis B and hepatitis C indicated, Allow surfaces to remain wet for one minute, let air dry. For all other organisms, see directions for contact time. Mycobacterium bovis (an organism that can cause tuberculosis) was killed in 2 minutes. The instructions indicated enough wipes should be used for the treated surface to remain visibly wet for 3 minutes to kill Clostridium difficile spores. 1. A medication administration observation was initiated on 2/4/25 at 5:39 AM with Nurse #1. Nurse #1 identified himself as an agency (temporary staff) nurse. Upon approaching the medication (med) cart, a glucometer was observed to be placed directly on top of the med cart. Nurse #1 reported he needed to do a blood glucose check for Resident #107. Nurse #1 was observed as he collected supplies (a test strip, lancet and alcohol wipe), donned gloves, picked up the glucometer stored on top of the medication cart, and entered Resident #107's room to conduct the blood glucose check. Nurse #1 inserted a strip into the glucometer and used a lancet to puncture the resident's finger. As he held the glucometer (with the strip inserted) at an angle and applied a drop of blood to the strip, the glucometer was observed to have lettering on the side of the meter. After the blood glucose check was completed, Nurse #1 returned to the med cart and placed the glucometer back on top of the medication cart. The side of the glucometer was observed to be labeled with the name of Resident #134. Nurse #1 removed his gloves, opened a drawer of the med cart, and placed this glucometer in the drawer directly in contact with other glucometers which were each stored inside an individual, resealable bag. As the nurse did so, an individually assigned and labeled glucometer for Resident #107's (in a clear, plastic resealable bag) was observed to be stored in the same drawer. At that time, Resident #107's glucometer was pointed out to the nurse. When asked why Resident #107's assigned glucometer was not used for her blood glucose check, Nurse #1 stated, [I] grabbed the wrong one by mistake. The interview with Nurse #1 continued on 2/4/25 at 5:46 AM. During the interview, the nurse was informed that the glucometer (labeled for Resident #134) used to check Resident #107's blood glucose was not observed to be disinfected either before or after it was used for her. When asked if this was correct, the nurse stated, Correct. When asked if it would be correct to say he did not disinfect this glucometer at any point in time, he responded, yes. The nurse was then asked when glucometers should be disinfected. Nurse #1 stated, I don't know the routine here. The nurse further explained, I don't know the protocol [at the facility]. Nurse #1 reported he thought that most places where he worked would have the glucometers cleaned only once at the start of the first nursing shift. Upon further inquiry, the nurse confirmed he didn't disinfect any glucometers on his current night shift while working from 7:00 PM - 7:00 AM. He reported Resident #107 was the only resident whose blood glucose was checked during his shift. On 2/4/25 at 6:17 AM, a follow-up observation and interview were conducted with Nurse #1. When asked if there were disinfectant wipes stored on the medication cart, Nurse #1 was observed as he pulled each drawer of the med cart open to look. There were no disinfectant wipes stored on the med cart. Nurse #1 stated there should be sanitation wipes in a container on the med cart. However, he added that if these wipes were not available on his med cart, he could always use alcohol wipes kept in individual packets on the med cart. The nurse held up two packets of alcohol wipes (taken from the medication cart drawer) to show what he could alternatively use for cleaning/disinfection of the glucometers (alcohol is not an EPA-registered disinfectant approved for glucometer disinfection). When asked to confirm whether he had conducted any other blood glucose checks during his shift, he stated, That was the only blood glucose I had to do. An interview was conducted on 2/4/25 at 6:28 AM with the facility's Director of Nursing (DON) as she was standing nearby in the hallway assigned to Nurse #1. When the DON was informed there were no disinfectant wipes on Nurse #1's medication cart, she provided a container of the facility's EPA-registered disinfectant wipes to enable a review of the manufacturer labeling. The DON reported she would expect these wipes to be used for glucometer disinfection with a wet contact time of three (3) minutes, as the product labeling indicated. On 2/4/25 at 1:30 PM, the facility's DON provided a copy of the facility's (Brand Name) glucometer instructions printed on page 47 of its User Instruction Manual. At that time, an interview conducted with the DON revealed the facility did not have a policy/procedure specifically related to glucometer disinfection. The DON reported the facility used the glucometer instructions which read: Cleaning and Disinfecting Guidelines: Healthcare professionals should wear gloves when cleaning the [Brand Name] meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. --Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. --To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. --Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. An interview was conducted on 2/7/25 at 8:08 AM with the facility's Infection Preventionist. During the interview, the Infection Preventionist was asked what her thoughts were with regards to the concerns identified with the glucometer's disinfection observed on 2/4/25. She stated, It's unfortunate. A telephone interview was conducted with the facility's Medical Director on 2/6/25 at 2:27 PM to discuss the concerns related to glucometer disinfection identified during observations conducted at the facility. When asked, the Medical Director reported she had been informed of these concerns. She stated, This is the first time I have heard of this happening. The Medical Director reported she thought glucometer disinfection required better learning or training for all staff throughout. Upon request, the facility provided a Diagnosis Report for its current residents (dated 2/4/25 at 3:39 PM). The Diagnosis Report indicated 18 residents were identified as having at least one bloodborne pathogen, which included hepatitis B, hepatitis C, and HIV. The facility's Administrator and DON were informed of the immediate jeopardy (IJ) on 2/4/25 at 3:00 PM. The facility provided the following plan for IJ removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance On 02/04/2025, an agency nurse used a glucometer (blood glucose meter) dedicated to Resident #134 for Resident #107 without disinfecting the shared glucometer between residents. This occurred for 1 of 3 residents who were observed to have their blood glucose checked (Resident #107). At the time of the incident, Resident #107 had an assigned glucometer that was properly labeled with a label maker and stored in the medication cart, but the agency nurse incorrectly used another resident's glucometer instead. All residents requiring blood glucose checks are at risk of being affected by this practice. An audit conducted by the Director of Nursing and nursing unit coordinators on 02/04/2025 identified all facility residents requiring blood glucose checks. All residents were confirmed to have an individual glucometer assigned. Each glucometer is labeled with the resident's name using a label maker and stored in individual re-sealable plastic bags in the medication cart. The following immediate actions were taken for affected residents: - At approximately 7:00 AM on 02/04/2025, upon discovery of the incident, the Director of Nursing and the Unit Coordinator cleaned and disinfected the glucometer per manufacturer guidelines and professional standards - On 02/04/2025, Resident #107 was assigned a new individual glucometer by the Unit Coordinator, labeled with the resident's name using a label maker and stored in an individual re-sealable plastic bag in the medication cart - Resident #107's medical provider was notified of this occurrence by the Director of Nursing with no additional instructions provided Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete The following systemic changes have been implemented as of 02/04/2025: 1. Staff Education and Competency Validation: - The agency nurse involved was contacted by telephone by the Director of Nursing to provide education regarding proper glucometer disinfection protocols. The Director left a voicemail, and the nurse will not be allowed to accept a resident care assignment at facility prior to education and blood glucose competency being validated in person - All licensed nurses were educated by the Director of Nursing and nursing unit coordinators regarding: - The importance of using appropriate EPA-registered disinfectant wipes - Following manufacturer's instructions for cleaning and disinfection - Requirements for stocking medication carts with EPA-registered disinfectant wipes - Blood glucose monitoring is performed only by licensed nurses at the facility - All licensed nurses' competency to check blood glucose, including proper disinfection, was validated through direct observation by nurse management. This validation included observation of: - Proper glucometer disinfection technique - Correct storage of glucometers in labeled individual re-sealable plastic bags - Complete blood glucose monitoring procedure - Newly hired, contract, agency, as-needed staff, and staff returning from leave will be educated and have their competency validated through direct observation prior to accepting any resident assignment - The Director of Nursing is responsible for tracking education completion and competency validation 2. Process Changes: - Visual reminders have been placed on all medication carts outlining the complete glucometer procedure: 1. Obtain needed equipment and supplies: - Gloves - Glucometer - Alcohol pads - Single-use lancet - Blood glucose testing strips - Disinfecting wipes 2. Perform hand hygiene 3. Explain procedure to resident 4. Provide privacy 5. [NAME] gloves 6. Obtain blood glucose sampling 7. Remove and discard gloves, perform hand hygiene 8. Retrieve (2) disinfectant wipes 9. Clean with first wipe to remove soil/blood 10. Disinfect with second wipe, maintaining 3-minute wet contact time 11. Allow to air dry 12. Discard wipes 13. Perform hand hygiene This infection control breach was reported to the local health department on 2/5/2025, and they provided no further recommendations. Immediate Jeopardy Removal Date: 2/6/2025 The facility's credible allegation of immediate jeopardy removal was validated on 2/7/25. The validation was evidenced by nurse observations and/or interviews conducted on each hallway with regards to the required infection control practices for the disinfection of glucometers. All nurses who were interviewed reported they had received the required in-service training prior to beginning their shift. The education provided stressed the importance of using individually assigned glucometers for each resident requiring blood glucose monitoring and storing these glucometers in individual, re-sealable plastic bags. The in-service training also included a review of the manufacturer's instructions for the facility's glucometer and disinfectant wipes related to glucometer disinfection, as well as completing a return demonstration of the proper procedures for effective glucometer disinfection. Nurses observed to conduct blood glucose checks and subsequent glucometer disinfection completed the task without difficulty. The nursing practices observed included the proper handling and storage of glucometers to protect the meters from potential cross-contamination via contact with other meters or surfaces. There were no concerns identified during either the interviews or observations. The credible allegation was validated, and the immediate jeopardy was removed on 2/6/25. 2. An observation of blood glucose checks and medication administration was initiated on 2/4/25 at 12:04 PM with Nurse #2. Nurse #2 identified herself as an agency (temporary staff) nurse. As the nurse prepared to conduct a blood glucose check for Resident #66, she removed his individually assigned (and labeled) glucometer from the medication (med) cart drawer. The glucometer labeled for Resident #66 was observed to have been stored in the med cart drawer directly in contact with six (6) other glucometers which were stored in individual, resealable bags. The glucometer for Resident #66 was not stored in an individual, resealable bag. Nurse #2 was observed as she placed the glucometer directly on top of the med cart and collected supplies for the blood glucose check (a test strip, lancet and alcohol wipe) and placed these supplies in a clean plastic cup. The nurse removed a container containing (Brand Name) disinfectant wipes from the bottom drawer of the medication cart and placed it on top of the cart. She did not use any of the disinfectant wipes at that time. Nurse #2 was observed as she picked up the cup (containing the supplies) and glucometer and entered Resident #66's room to conduct a blood glucose check. Upon entering the resident's room, Nurse #2 placed the cup and glucometer on Resident #66's dresser while she used hand sanitizer and donned gloves. The nurse checked Resident #66's blood glucose. On 2/4/25 as 12:12 PM, Nurse #2 returned to the med cart. At that time, she disposed of the used supplies, placed the glucometer directly on the pullout tray of the med cart, and removed her gloves. The nurse performed hand hygiene with hand sanitizer and donned clean gloves. Nurse #2 then picked up the glucometer and used one disinfectant wipe to wipe the meter for 15 seconds. Afterwards, she placed the glucometer back on top of the pullout tray of the med cart, then into the drawer of the medication cart with the other glucometers. She did not place Resident #66's meter in an individual, resealable bag. The observation of Nurse #2 continued on 2/4/25 at 12:15 PM as the nurse prepared to check Resident #93's blood glucose. The nurse was observed as she pulled Resident #93's individually assigned (and labeled) glucometer from the medication (med) cart drawer. His glucometer was observed to be stored in an individual, resealable bag while in the drawer. Nurse #2 placed the glucometer (in the bag) on top of the med cart and began to collect the supplies needed for Resident #93's blood glucose check. The nurse reported this resident also needed to receive 3 units of Novolin R (regular) insulin. However, she was unable to find an insulin syringe on the med cart. On 2/4/25 at 12:18 PM, the nurse picked up the glucometer (still in the bag) and supplies and left the med cart to retrieve an insulin syringe. She returned to the med cart on 2/4/25 as 12:23 PM. Upon her return, Nurse #2 placed the glucometer (stored in the bag) and supplies on the top of the med cart. After all of the supplies were collected, Nurse #2 performed hand hygiene and donned a gown and gloves prior to entering the resident's room. Resident #93's room was currently on Enhanced Barrier Precautions (EBP). EBP is an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. On 2/4/25 at 12:27 PM, Nurse #2 entered Resident #93's room, removed his glucometer from its bag and placed the meter on a bedside tray table. After checking the resident's blood glucose level, the glucometer was again placed on the tray table while the nurse administered the resident's insulin. On 2/4/25 at 12:32 PM, Nurse #2 picked up the glucometer and used supplies and returned to the medication cart. She discarded the used supplies and placed the meter directly on the pullout tray of the med cart. The nurse removed her gloves, performed hand hygiene, and donned clean gloves. She then picked up the glucometer and used one disinfectant wipe to wipe the surface of the glucometer for 20 seconds. The meter was placed directly on top of the med cart as Nurse #2 removed her gloves, put the glucometer back into its individual resealable bag, and returned it to the med cart drawer. An interview was conducted on 2/4/25 at 12:35 PM with Nurse #2. During the interview, the nurse was asked what the required wet contact time was for the disinfectant wipe to be effective in disinfecting the glucometer. Nurse #2 responded by stating she did not know. When asked, the nurse acknowledged Resident #93's glucometer was not visibly wet when it was put away. Additionally, concern related to the potential for the cross-contamination of both Resident #66's and Resident #93's glucometers was discussed. During an interview conducted on 2/4/25 at 6:28 AM, the facility's Director of Nursing (DON) reported she would expect the facility's EPA-registered wipes to be used for glucometer disinfection with a wet contact time of three (3) minutes, as the product labeling indicated. On 2/4/25 at 1:30 PM, the facility's DON provided a copy of the facility's (Brand Name) glucometer instructions printed on page 47 of its User Instruction Manual. At that time, an interview conducted with the DON revealed the facility did not have a policy/procedure specifically related to glucometer disinfection. The DON reported the facility used the glucometer instructions which read: Cleaning and Disinfecting Guidelines: Healthcare professionals should wear gloves when cleaning the [Brand Name] meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. --Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. --To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. --Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. Upon request, the facility provided a Diagnosis Report for its current residents (dated 2/4/25 at 3:39 PM). The Diagnosis Report indicated 18 residents were identified as having at least one bloodborne pathogen, which included hepatitis B, hepatitis C, and human immunodeficiency virus (HIV). A follow-up interview was conducted on 2/5/25 at 8:40 AM with the facility's DON. During this interview, the DON reported it was assumed that agency nurses had received training to ensure their overall competency to care for residents prior to being hired and assigned to work in their facility. An interview was conducted on 2/7/25 at 8:08 AM with the facility's Infection Preventionist (IP). During the interview, the IP was asked what her thoughts were with regards to the concerns identified with the glucometers' disinfection observed on 2/4/25. She stated, It's unfortunate. She added that the facility initiated education and training then and there immediately after the concerns were brought to the facility's attention on 2/4/25. A telephone interview was conducted with the facility's Medical Director on 2/6/25 at 2:27 PM to discuss the concerns related to glucometer disinfection identified during observations conducted at the facility. When asked, the Medical Director reported she had been informed of these concerns. She stated, This is the first time I have heard of this happening. The Medical Director reported she thought glucometer disinfection required better learning or training for all staff throughout.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews with resident, family, staff, and Emergency Medical Services paramedic, Police Detective, Nurse Practitioner, psychiatry provider, and Medical Director, the facility failed to protect a resident's right to be free from physical abuse when a resident (Resident #1) assaulted another resident (Resident #2) for 1 of 3 residents reviewed for resident-to-resident abuse. On [DATE], Resident #1 approached his roommate (Resident #2) with a knife (described as a butter knife on a meal tray) to cut Resident #2's head. Resident #2 initially pushed Resident #1 away; however, Resident #1 returned to Resident #2's bedside multiple times and continued to cut his head with the knife. Resident #2 was a bedbound resident who was cognitively intact and, on an anticoagulant (apixaban). Resident #2 was unable to loudly shout out for help due to a history of a tracheostomy. While passing out lunch trays, a Nurse Aide (NA #1) observed Resident #1 standing beside Resident #2 and carving on his forehead. The attack ended and Emergency Medical Services (EMS) was called to transport Resident #2 to the hospital. Resident #2 sustained profuse bleeding with a 19-centimeter (cm) laceration on his forehead that exposed his skull, a 2-cm cut on the bridge of his nose, and multiple defensive wounds on his hands. He was taken to the hospital for treatment and required two units of fresh frozen plasm (used to help blood clot during active bleeding when a person is on a blood thinner), two units of packed red blood cells (used to replace blood when a person has had a large amount of bleeding with blood loss), sutures for the laceration, and pain management. Immediate Jeopardy began on [DATE] when Resident #1 assaulted Resident #2 with a knife. Immediate jeopardy was removed as of [DATE] when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education and ensure monitoring systems put into place are effective. The findings included: A review of Resident #1's hospital record dated [DATE] revealed the resident was initially found sleeping on the floor in a gas station. When he was told to leave, he got up, wandered around and failed to respond to anyone. The police were contacted, then EMS was called. EMS transported Resident #1 to the hospital Emergency Department (ED). Resident #1 was unable to provide much of his medical history and provided incorrect information of his place of residence. It was determined he had lived in at least 3 different group homes since [DATE]. Resident #1's Physical Examination in the ED Provider Notes was dated [DATE] at 12:37 AM. It reported the resident was initially cataleptic [a condition that disrupts a person's awareness of the world and their ability to move and communicate], waxy flexibility [a relatively rare symptom typically seen in catatonia where a person's limbs respond like a warm candlestick being moved and positioned], staring, mute. Then spontaneously converted to normal pleasant interactive behavior. The trigger for the resident's catatonia was unclear. A hospital ED Provider Note dated [DATE] at 8:40 AM read, Reached out to case management .case has been escalated to difficult placement. Another notation in the hospital record (dated [DATE] at 3:33 PM) reported the resident, Had an episode of leaving ED room and being found outside, now stable and back in room safely. Has had previous similar presentations in past. Resident #1 was discharged from the hospital and admitted to the locked Memory Care Unit (MCU) of the facility on [DATE]. His cumulative diagnoses included dementia with other behavioral disturbance and schizophrenia. The resident's admission orders included the following psychotropic medications: 20 mg citalopram (an antidepressant) to be given as one tablet by mouth one time a day; 1 mg lorazepam (an antianxiety medication) to be given as one tablet by mouth every 8 hours as needed for anxiety/agitation for 14 days; 80 mg lurasidone (an antipsychotic medication) to be given as one tablet by mouth one time a day for schizophrenia; and 10 mg asenapine (an antipsychotic medication) to be given as one sublingual tablet placed under the tongue each night at bedtime. Additional admission orders included the following: -- Monitor behaviors of anxiety/agitation. --Routine resident checks to help maintain resident safety and well-being at least every 2 hours, document exceptions in nurses notes every shift (documented by a check mark on the resident's monthly MAR with a Start Date of [DATE]). Resident #1's individualized care plan included the following areas of focus, in part: --[Resident's name] is not an elopement risk/wanderer r/t [related to] Dementia, Psychotic Disturbance and Mood Disorder. Date Initiated: [DATE]; Revision on [DATE]. --[Resident's name] has potential to have behaviors r/t Dementia, Mental / Emotional illness. Date Initiated: [DATE]; Revision on: [DATE]. --[Resident's name] uses psychotropic medications r/t Behavior management (Dx [Diagnosis] of schizophrenia). Date Initiated: [DATE]; Revision on: [DATE]. The resident's admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had severely impaired cognition. He was reported as having no behaviors nor rejection of care during the 7-day look back period. The resident required supervision for walking in the corridor, locomotion on the unit and for eating; limited assistance for walking in his room and personal hygiene; and extensive assistance from staff for bed mobility, transfers, dressing and toileting. Resident #1 was seen for a Psychiatry Initial Consult by a Psychiatric Mental Health Nurse Practitioner (PMHNP) on [DATE]. The consultation progress note included an Assessment and Plan as follows: 1. Dementia: Provide supportive care. He takes citalopram for depression associated with dementia. Continue med. 2. Schizophrenia: Continue lurasidone as prescribed. Please report any change in behavior or mood. No changes at this time. 3. Insomnia: Continue melatonin (a nutritional supplement). Supportive care. Orders: Orders for this visit: None A review of Resident #1's April Medication Administration Record (MAR) revealed the resident was documented as having anxiety/agitation one time in April (on [DATE] during the 7:00 PM to 7:00 AM shift). He was administered one dose of lorazepam on [DATE] with the medication reported as having been effective. No other documentation of anxiety/agitation, side effects of the psychotropic medications, nor exceptions related to the routine resident checks were identified. An Interdisciplinary Team (IDT) Progress Note dated [DATE] at 5:52 PM was authored by the facility's Social Worker (SW). This note documented Resident #1 was moved from his room in the locked MCU to a room on the 200 Hall outside of the Unit as he no longer met the criteria to be in the MCU. The notation read, Appropriate staff will continue to monitor roommate compatibility. Accompanied by the facility's Administrator, Resident #1's new room was observed on [DATE] at 11:45 AM. Resident #1 was assigned to Bed A (the bed closest to the door) while his new roommate (Resident #2) remained in Bed B (the bed next to the window). The room was observed to be located just before the entrance to the MCU and at the farthest end of the hallway from the Nursing Station. On [DATE] at 9:27 AM, the facility's Maintenance Director reported the distance from Resident #1 and Resident #2's door to the Nursing Station was 126 feet. Resident #2 was initially admitted to the facility on [DATE] with re-entry to the facility on [DATE] after a hospital stay. His cumulative diagnoses included glaucoma, atrial fibrillation (a type of irregular heartbeat), chronic obstructive pulmonary disease, muscle wasting / atrophy, and chronic pain syndrome. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. Resident #2 was assessed to have intact cognition. He was reported as having no behaviors nor rejection of care during the 7-day look back period. The resident was independent with eating, required supervision with dressing, extensive assistance for bed mobility and toileting, and he was totally dependent on staff for personal hygiene. Transfers, walking, and locomotion did not occur during the 7-day look back period. Resident #2's Care Plan included the following areas of focus, in part: --The resident has an Activities of Daily Living (ADL) self-care performance deficit and mobility deficit related to chronic health conditions. He needs staff assistance to complete daily ADL tasks (Date Initiated: [DATE]; Revision on: [DATE]). --The resident is on anticoagulant therapy related to atrial fibrillation (Date Initiated: [DATE]; Revision on: [DATE]). --The resident is at risk for pain .he has chronic pain and consults a pain clinic for treatment (Date Initiated: [DATE]; Revision on: [DATE]). A review of the resident's electronic medical record (EMR) indicated he was seen for a 60-day follow up visit on [DATE] from his Medical Doctor (MD) who also served as the facility's Medical Director. A progress note from this visit reported Resident #2 had no complaints of pain at that time. He described the resident's general appearance as comfortable, alert, no anxiety noted, no acute distress. Resident #2's EMR also included a physician's progress note for a palliative care follow-up visit dated [DATE]. The resident was being seen for help with advance care planning, symptom management, and ongoing psychosocial support. This note reported the resident had a history of prolonged respiratory failure resulting in a tracheostomy (which had since been removed). Resident #2's chronic pain was noted as stable and a report made to indicate he was now off of opioid therapy altogether and only taking gabapentin (a medication frequently used to treat nerve pain) and acetaminophen. A review of Resident #2's current medication orders as of [DATE] included the following, in part: --650 mg acetaminophen scheduled for administration by mouth every 6 hours for pain (Start Date [DATE]). --100 mg gabapentin to be given as two capsules by mouth at bedtime for neuropathy pain (Start Date [DATE]); --2.5 milligrams (mg) apixaban to be given as one tablet by mouth every 12 hours for clot prevention (Start date [DATE]). Resident #2's EMR included a Nursing Note dated [DATE] at 1:35 PM and authored by the facility's Weekend Supervisor (Nurse #1). This Nursing Note read: I was alerted by the CNA [Certified Nurse Aide] to come to the resident's room. Upon entering the resident's room, resident [Resident #2] was noted with a large gash across his forehead, an injury to his right eye and injuries to the left side of his face. Copious amount of blood noted on the resident and the resident's bedding. Staff present was trying to control the bleeding. I immediately called 911. I walked into the hall so 911 could hear me. Resident's roommate [Resident #1] was noted in the tv room, down the hall, in the presence of staff. I explained to 911 the situation at hand and they stated ems was on the way. After speaking to 911, I went back into the room to assist staff in the care of the injured resident until EMS and police arrived. EMS took over the situation, controlled the bleeding and dressed the resident wounds. Resident was then transported to [name of hospital]. Resident's RP [name of Responsible Party] was made aware of the situation. An interview was conducted on [DATE] at 2:40 PM with Nurse Aide #2 (NA #2). NA #2 reported she was assigned to care for both Resident #1 and Resident #2 on the first shift of [DATE] from 7:00 AM to 7:00 PM. The NA reported this was the first time she had cared for Resident #1, but she was familiar with Resident #2. Upon inquiry, the NA reported everything seemed to be fine with these two roommates at the beginning of her shift. NA #2 stated she last went into their room before lunch around 12:00 to 12:15 PM as she was doing her rounds. At that time, Resident #2 was asleep lying on his back with his left leg hanging off the bed. She asked the resident if she could help him put his leg back up on the bed, but he declined saying he always laid like that. As she walked out of the room, NA #2 recalled seeing Resident #1 laying on his bed with his hands placed behind his head. Resident #1 gave her a half-smile as she left the room to go assist another resident next door since the lunch meal trays had not yet come out to the hall. Approximately 10 minutes later, NA #2 reported, I heard the screaming. The NA stated she initially thought this screaming was coming from the memory care unit but later thought it may have been Resident #2 calling for help. As she opened the door of the room she was in, she saw NA #1 going into Resident #1 and Resident #2's room. The NA heard NA #1 scream and run out of the room hollering, He's trying to kill him, He's trying to kill him! NA #2 reported she went right behind NA #1 to get help and to find the Weekend Supervisor (Nurse #1). A telephone interview was conducted with NA #1 on [DATE] at 12:37 PM. During the interview, the NA reported on [DATE] around 1:30 PM, she and several other NAs were passing out lunch trays for the residents on the hall. She pulled the lunch tray for Resident #2 from the meal cart. As she was walking into the room, she could see Resident #2's leg had blood on it. She reported, I put the tray down and pulled the curtain back and saw [Resident #1] carving into [Resident #2's] skull. I yelled at [Resident #1], 'What are you doing?' and he moved away. When she asked Resident #1 what he was doing, the NA reported Resident #2 only said, Help! She stated Resident #1 stepped back from Resident #2 and started to walk in the direction of his own bed and the room's door. NA #1 continued by stating, At that point, I ran out of the room. When I came back another [NA] had [Resident #1] in a wheelchair. The NA explained she had run out of the room to get help. Meanwhile, Nurse #1 and 3 other NAs ran into the room to provide assistance. Upon inquiry, NA #1 reported after everyone was in the room, Resident #2 said he had been calling for help for a while. However, the NA stated she had not heard him from out in the hallway because his voice was quite soft. When asked what kind of knife had been used to cut Resident #2's forehead, she reported it was a butter knife, like off of the [meal] trays. An interview was conducted on [DATE] at 11:40 AM with NA #3. NA #3 recalled seeing Resident #1 self-propelling his wheelchair as he came out of the MCU around 12:10 to 12:15 PM. She was passing meal trays on the 100 Hall at that time. A while later, she was helping to pass meal trays on the 200 Hall when she saw her coworker coming out of Resident #1 and Resident #2's room saying something was done to the resident. NA #3 stated, I went in [to the room] within seconds. When asked what she saw, the NA reported, A lot of blood. [Resident #1] was going back to the bed .he was heading to his bed. He was about at the curtain dividing the two beds with his back to [Resident #2]. NA #3 reported she knew her Unit Manager (Nurse #2) was in the MCU, so she went to the door of the unit (next to the residents' room) and screamed for Nurse #2 to come, then returned directly back to help care for Resident #2. NA #3 reported Nurse #2 and a couple of others came to help. Resident #1 was removed from the room by a co-worker while Nurse #2 instructed the NAs to put pressure on Resident #2's wounds. NA #3 stated she stayed with Resident #2 until EMS came. When asked, the NA reported Resident #2 was just crying out in pain. She did not recall hearing the resident say much else. An interview was conducted on [DATE] at 11:14 AM with NA #4. NA #4 reported she had been sitting in the MCU hall monitoring when she heard a co-worker yell for help outside the Unit. She went into Resident #1 and Resident #2's room, looked to see how Resident #2 was, then put Resident #1 into a wheelchair and took him to the smoking area. The NA reported when she asked Resident #1 what had happened, he said he didn't know. She stated, He just acted like he hadn't done anything. She reported she was familiar with Resident #1 from working in the MCU when he resided there. NA #4 reported she was not aware of Resident #1 having any issues with his roommate or other residents while he was in the Unit. An interview was conducted on [DATE] at 2:15 PM with Nurse #2. Nurse #2 reported she worked as the Unit Manager over the 100 and 200 Halls, which included the MCU. The nurse recalled there were no behaviors or roommate issues for Resident #1 when he was initially admitted to the facility on the Unit. Nurse #2 stated that although she was not assigned to work on [DATE], she just came into the facility to check in and make sure everything was going smoothly. While she was there, she relieved the Hall monitor on the MCU so she could go to lunch. In a written statement provided by Nurse #2, the nurse reported being on the Unit around 1:20 PM on [DATE] when Resident #1 came into the Unit; she redirected him outside the Unit and back to his room (the first door to the right after exiting the MCU). During the interview, Nurse #2 stated that after just a few minutes she heard her name being screamed outside of the MCU. She jumped up, ran out of the Unit to see what was going on, then entered the residents' room. At that time, she saw Resident #1 lying on his bed relaxing with his legs crossed and hands placed behind his head. As she approached Resident #2, she saw the brown comforter on his bed had blood on it. She stated, There was a lot of blood. He had a white blanket on his head but after seeing all the blood, she called for someone to get towels and sheets to help stop the bleeding. She reported, Everyone was running and getting me stuff. The nurse stated she didn't realize how bad Resident #2's injuries were until they moved the blanket off his head, and she could see the forehead laceration was to the bone. She reported staff put wet towels on his wounds to try and stop the bleeding. Resident #2 was moving his hands and saying he couldn't see. Nurse #2 told him who she was and kept trying to reassure him she was there to help. She recalled Resident #2 was alert, he knew who she was, and he let her hold his hands. Meanwhile one of the NAs (NA #4) put Resident #1 into a wheelchair and took him out of the room. Three NAs (identified as NA #3, NA #5, and NA #6) assisted the nurse in getting linens and applying pressure to the wounds. Nurse #2 reported she stayed with Resident #2 until EMS arrived on the scene. After EMS came for Resident #2, the nurse reported she went out to the resident smoking area where staff had brought Resident #1. She recalled when she asked Resident #1 what happened he stated, I don't know. Afterwards, she accompanied a police officer back to the residents' room. She reported at that time she observed blood behind Resident #2's headboard, on pillows, his blanket, and comforter. She also observed a knife was on Resident #1's rolling bedside table. An interview was conducted on [DATE] at 2:56 PM with Nurse #3. Nurse #3 reported she was working on [DATE], the date of the incident involving Resident #1 and Resident #2. She recalled working in the front conference room on another task when she received a phone call from Nurse #2 requesting 911 be called and that she come to Resident #1 and Resident #2's room for assistance. She reported being unable to get through to 911 (although another staff member did). When she reached Resident #1 and Resident #2's room, she noted there was a lot going on as she tried to assist in providing first aid to Resident #2. Resident #2 was trying to touch his head and staff were encouraging him not to do so as they provided reassurance to the resident that they were there to help him. She reported the resident was low spoken .he was mumbling. Shortly after Nurse #3 got to the room, EMS arrived. An interview was conducted on [DATE] at 11:20 AM with Nurse #4. Nurse #4 identified herself as Resident #1 and Resident #2's usual hall nurse on first shift. The nurse reported she was working on the hall the day of the incident involving these two residents ([DATE]) and recalled she had last seen them around 11:30 AM on that day without any concerns noted. During the interview, the nurse reported on [DATE] she was in another room on the hall feeding a resident when she heard someone call out for 911 to be called because Resident #2 was stabbed. Nurse #4 reported she was able to get through to 911 on the second attempt. Nurse #4 then went to the room. She stated, All I could see was a towel on his head I stepped out of the room. She noted other staff members were in the room helping the resident. After stepping out of the room, she reported seeing Resident #1 on the patio. The nurse went to the nursing station to get Resident #2's paperwork together and ready for EMS to transfer him to the hospital. When asked if she was aware of any disagreements between the two residents since they became roommates, she stated she was not. The nurse added that she was certain Resident #2 would have told her if there was a problem with his roommate because they were close. But she stated, He never said a word to me. An interview was conducted on [DATE] at 3:09 PM with Nurse #1. Nurse #1 identified himself as the Weekend Supervisor assigned to work on [DATE] at the time of the incident. The nurse reported he was sitting outside in the smoking area when NA #1 banged on the glass yelling, He's trying to kill him. Nurse #1 went to Resident #1 and Resident #2's room and reported he saw blood all over the bed. Resident #2 had a huge wound on his forehead and a bloodied area on the right side of his face around his right ear and eye. However, the nurse reported it was hard to know the extent of the injuries due to all of the blood. He stated, It was shocking what I saw. Staff were already providing first aid while he stepped out of the room to focus on calling 911. He reported there was blood everywhere and he wanted to get help as quickly as possible. After he got through to 911, he went back into the room to assist with what was happening but there were already several staff members in there to help the resident. Nurse #1 stated that meanwhile, Resident #1 was being contained in the TV room. An interview was conducted on [DATE] at 1:00 PM with NA #8. NA #8 reported he was in another resident's room when he heard someone yelling his name. He went into Resident #1 and Resident #2's room. At that time, he observed Resident #1 in his bed. When he went to Resident #2's side of the room, he saw the resident was injured. He retrieved some towels for him while another staff member took Resident #1 outside. He saw Resident #1 run back inside (from the smoking area) so he re-directed him to the TV room, and he stayed with the resident. When asked if the resident said anything to him, he stated, No. However, when the police came to talk to him, they told him if he didn't stay still, he would be put in handcuffs. Resident #1 didn't want that. When the police asked him if he was hurt, he said only his mind was. A Police Report dated [DATE] at 1:35 PM included the following narrative, in part: .Upon arriving, I spoke with the nurse, [name of NA #1], who stated that she walked into Resident #1 and Resident #2's room and saw the suspect, [Resident #1] sitting on top of [Resident #2] in his bed carving into his head with a butter knife. She said that she yelled what are you doing but [Resident #1] did not say anything back. The nurse took [Resident #1] out of the room while the medic unit came into the room. [Resident #1] and [Resident #2] have been roommates in the living center for a week. [Resident #1] was transferred from [name of hospital] Psychiatric [NAME] a month ago. [Resident #1] has Schizophrenia and dementia. When I asked [Resident #1] what happened he stated that he does not remember. I asked him if they were in an argument, and he said no. [Resident #1] looks to be spaced out. And continued to try and walk away. [EMS] arrived on scene and transferred [Resident #2] to [name of hospital] with semi life threatening injuries. [Resident #2] has a large gash on his forehead from one temple to the other. He has severe face and head injuries and his ear was cut off . [Resident #1] was transported to [name of hospital] for emergency commitment. A telephone interview was conducted on [DATE] at 1:21 PM with the Police Detective who was the lead investigator on the case involving Resident #1 and Resident #2 on [DATE]. The Detective reported when he arrived at the facility on [DATE], the attacker was already in the police car. Resident #1 had told the patrol officer he was Woodrow [NAME]. The Detective requested Resident #1 be brought to the hospital where he spent one day being evaluated before being arrested. During the telephone interview conducted on [DATE] at 1:21 PM, the Detective stated he has talked with the victim 3 times since the incident occurred. Resident #2 reported to the Detective that he and his roommate had on-going conversations regarding Resident #2's television. Resident #2 told the Detective Resident #1 tried several times to cut him, perhaps as many as 5-6 times. Resident #1 tried to cut him, then left (not sure where he went), and then returned to cut him again. Resident #2 reported this occurred over a period of up to 20 minutes (reported on the 2nd interview), but this estimation of time was changed on the 3rd interview to the assault lasting 5-minutes. Resident #2 said he was yelling for help and thought his yelling would have been heard outside of the room. However, the Detective reported the resident was soft-spoken and may not have been heard. Upon inquiry, the Detective reported he has looked into the statement written in the initial police report which indicated Resident #1's ear had been severed. He stated he was not finding anything from the hospital to support that statement and it was likely that due to the massive amount of bleeding, the actual injuries could not be accurately determined. The Detective reported as of [DATE], Resident #1 was incarcerated at the County Jail. There were four felony charges against him: --Assault inflicting serious bodily injury; --Assault with a deadly weapon inflicting serious bodily injury; --Felony assault on an individual with a disability; --Maming without malice. A follow-up telephone interview was conducted on [DATE] at 8:50 AM with the Police Detective. At that time, the Detective was asked about the possibility of interviewing Resident #1 about the incident. The Detective returned the call on [DATE] at 8:58 AM after talking with his supervisor. The Detective reported the resident may have been transferred out of the County Jail, so he was not sure of his location at that time. Regardless, he stated it was a bad idea to try to interview Resident #1. A review of the EMS Report revealed a 911 call was received from the facility on [DATE] at 1:36 PM. EMS arrived at the scene at 1:39 PM. The EMS Report indicated the resident had a deep laceration across his forehead ear to ear with active bleeding and defensive abrasions on both hands. The resident's level of distress was reported to have been moderate. The EMS report read, in part: EMS immediately placed hemostatic dressing [a dressing with an adhesive-like action that seals the wound and controls the bleeding] on the pts [patient's] wounds and wrapped the wound to control bleeding. EMS then transitioned the pt onto the stretcher and rapidly transported pt to [name of hospital]/Trauma alert was made to [hospital]. A telephone interview was conducted on [DATE] at 12:05 PM with the Emergency Medical Technician-Paramedic (EMT-P) who was the first responder to the facility on [DATE]. The EMT-P recalled when she arrived at the scene, 4-5 staff members were in the room with Resident #2 as he was lying on the bed. He was actively bleeding from a very deep laceration extending from ear to ear and from what she could recall, she thought one ear may have been severed because there was so much blood. Bloody wet towels were wrapped around the resident's head; no other residents were in the room. A knife was observed to be sitting on a rolling table in the room. She reported the EMTs' main focus during the call was to stop the bleeding. The resident was on a blood thinner and had already lost a lot of blood. She described the resident as very alert but noted that while he could tell the EMT-P his name, he seemed disoriented. The EMT-P reported she thought the incident had gone on for several minutes, based on the amount of damage done to Resident #2 before someone noticed and called 911. The hospital ED Provider Notes dated [DATE] at 2:20 PM reported Resident #2 presented to the ED as an assault victim with a stab wound to his head. The note read, Per EMS, pt was reportedly stabbed across forehead using butter knife. The resident's physical examination documented he had a complex, irregular border, deep laceration extending across his forehead. Upon examination, he complained of right eye pain with extra-ocular eye movements intact (testing that examines the function of the eye muscles). The resident was reported to have bilateral eyelid bruising and mild swelling. Another laceration was noted over his nose and there were scattered lacerations (defensive wounds) over both of his hands. No trauma was reported to the resident's ears. Resident #2 was noted to be hypotensive (have low blood pressure) and treated with two units of fresh frozen plasm (used to help blood clot during active bleeding when a person is on a blood thinner) and two units of packed red blood cells (used to replace blood when a person has had a large amount of bleeding with blood loss). Resident #2's records reported the hospital's Ear, Nose and Throat (ENT) service was consulted for the large scalp laceration down to bone. An ENT consultation note dated [DATE] at 6:32 PM reported Resident #2 was status post right eye corneal transplant with baseline left eye blindness. The resident was moaning in pain when seen by ENT and stated the pain was along his forehead but particularly in the right eye. Resident #2 reported his vision in the right eye was not at baseline and he was very sensitive to moving his right eye laterally (to the side). The ENT service closed the 19-centimeter forehead laceration (described as down to bone) with sutures and two Penrose drains sutured on either side of the head. A Penrose drain is a soft, flexible latex drain that allows blood and other fluids to move out of an area to prevent fluid from collecting and causing an infection. The 2-centimeter laceration over the resident's right nasal bridge and extending toward the medial canthus (the corner of the eye where the upper and lower lids meet) was also closed. Resident #2's hospital records revealed he received multiple medications in the ED, including 50 micrograms (mcg) fentanyl injection (an opioid pain medication) given intravenously on [DATE] at 2:18 PM and 0.5 milligrams (mg) hydromorphone (an opioid pain medication) administered intravenously on [DATE] at 4:39 PM. Additional pain medications administered to the resident during his hospital stay included the following: --On [DATE] at 10:25 PM, one dose of 4 mg of [NAME][TRUNCATED]