Every finding on record at Annandale Care Center Inc

Based on observation and interview the facility failed to label and properly dispose of expired medications reviewed in 1 of 2 medications carts. This had the potential to 17 out of 34 residents in the facility whose medications were stored in the cart.Findings include:On 8/12/25 at 11:59 during review of the medication cart following a medication pass licensed practical nurse (LPN)-A discovered six bottles of medication with no open dates noted, and two of those six bottles were expired.Photocopies taken on 8/12/2025 at 12:00 p.m. showed the following medications:1. Tylenol 500 milligram (mg) tablets, expired in July of 2025 and lacked an open date.2. Tylenol 500 milligram (mg) tablets, expired in July of 2025 and lacked an open date.3. Tylenol 325mg tablets, lacked an open date.4. Tylenol 500mg tablets, lacked an open date.5. Docusate Sodium 100mg tablets, lacked an open date.6. Senna Time 8.6mg-50mg tablets, lacked an open date.On 8/12/25 at 12:00p.m, LPN-A confirmed all six bottles were not labeled appropriately, and the two Tylenol bottles listed above were expired. LPN-A stated the medication should not be used as the staff had no way to know when the bottle was opened, and some were expired. During the interview, the director of nursing (DON) came into the room and confirmed the two bottles of Tylenol were expired and all six bottles, listed above, were undated and would be destroyed. The DON's expectation was when a resident was admitted to the facility the nurse on duty should check the orders to make sure it was the appropriate medication, check all expiration dates, and put an open date on the bottle. The DON stated the importance of labeling each bottle with open dates for the staff to know how long the medication was ok to be used for, and the importance of not using expired medications as they lose their efficacy once that expiration date has passed.The facility policy Medication storage last revised 7/2025, indicated drug containers with missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing, and the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals.

Based on observation, interview and record review, the facility failed to comprehensively assess environmental hazards and/or ensure the environment was free from accident hazards for 1 of 3 residents (R1) reviewed for falls. The facility's failures caused actual harm when R1 tripped and fell on a mechanical lift which resulted R1 suffering multiple rib fractures with hemothorax, unstable T11 fracture, and a large laceration to her elbow. Findings include: R1's admission Record dated 4/17/24, identified R1's diagnoses included dementia with other behavioral disturbance, Hospice care, muscle weakness, unsteady gait, impaired safety awareness, and history of falls. R1's admission Minimum Data Set (MDS) dated [DATE], R1 required limited assistance for activities of daily living (ADLs), and mobility and had severe cognitive impairment. R1's care plan initiated 4/1/25, indicated R1 had a history of falls, impaired safety awareness, and unsteady gait. Staff interventions included providing assistance with mobility/ADLs. R1's fall risk assessment completed 4/1/25, indicated R1 is a high risk for falls related to muscle weakness, cognitive impairment, unsteady gait, and impaired safety awareness. R1's progress note dated 5/20/25 at 10:50 p.m. indicated R1 appeared to trip on a mechanical lift parked against a wall outside of her room as she turned the corner out of her room with her walker, attempting to ambulate independently. The note indicated R1 fell on her left side sustaining a large skin tear to her elbow, upper arm, and part of forearm with left side. R1 complained about ribs pain. R1's emergency department (ED) note dated 5/20/25 at 11:47 p.m. indicated R1 presented to ED for ground level fall with trauma, multiple or serious injuries. The note stated exam revealed laceration of left elbow, which was not amenable to repair, chest wall tenderness and left sided rib fractures. R1's progress note dated 5/21/25 at 2:21 a.m., indicated R1 was admitted at the hospital with multiple ribs fracture to her left side, hemothorax ( a condition where blood accumulates in the space between the lung and the chest wall) to her right side and an unstable spinal fracture to T11. During an interview on 6/17/25 at 10:51 a.m., a family member (FM)-A stated she turned and saw R1 when she was falling down just outside her room. FM-A stated R1 had a walker, and her back hit part of the mechanical lift parked a foot or two from her doorway against the wall. During an interview on 6/17/25 at 11:09 a.m., FM-B stated R1 walked right outside of her room and her walker got caught by the mechanical lift parked right outside her room against the wall a foot from her doorway when she fell on the lift. During an interview on 6/17/25 at 12:52 p.m., nursing assistant (NA)-D stated she witnessed R1's fall and stated R1 landed with her left side on the mechanical lift which was one or two feet from her doorway. NA-D stated nursing staff did not have a designated spot to park the lifts and she did not recall receiving any education about environmental safety hazards. During an interview on 6/17/25 at 2:54 p.m., licensed practical nurse (LPN)-A stated on 5/20/25 R1 fell on the legs of the mechanical lift with her left side and started bleeding heavily. LPN-A stated R1 was one person assist with mobility and supervision. LPN-A did not recall receiving any education about environmental safety hazards after the incident. During an observation on 6/16/2025 11:37 a.m., a mechanical lift was observed parked against the wall less than a foot just outside of R5's doorway. During continuous observation, another mechanical lift was parked against the wall of R4's room with two wheels visible in R4's doorway. At 11:45 a.m., an unknown nursing staff member was noted to be in the hallway moving back and forth from the nursing station walking by the lifts. During an interview on 6/16/25 at 1:32 p.m., NA-A stated nursing staff have been trained on how to use the mechanical lift during their orientation. NA-A stated she was educated to put the mechanical lift on the right side of the hallway, against the wall between residents' rooms during her orientation. NA-A stated she did not receive any education about a designated spot to park the mechanical lifts. NA-A stated nursing staff had to use their own judgment to put the lift in the middle against the wall to prevent any accident. NA-A did not identify the lift parked against the walls in the hallway as a safety and/or tripping hazard. During an interview on 6/16/25 at 2:17 p.m., NA-B indicated sometime between new employee orientation but before R1's accident, she was trained only to park the mechanical lift on the right side of the hallway against the wall facing one way. That training did not address any specific spot the lifts should parked other than the right side of the hallway. NA-B explained after R1's fall nursing staff did not receive any education pertaining to the storage of lifts and/or where in the hallway they should be parked and did not identify the lifts in the hallway a safety hazard for residents. During an interview on 6/17/25 at 10:23 a.m., NA-C stated she was directed to put the mechanical lift locked against the wall on the right side, using common sense not to put it on the resident's doorway. NA-C stated she did not receive any environmental safety hazard education recently. During an interview on 6/16/25 at 4:10 p.m., LPN-A stated nursing staff were supposed to park the mechanical lift on the right side of the hallway against the wall without blocking or inside the egress of the resident's doorway. LPN-A stated night shift should put them in the tub room if they were not using them, but nurses have to use their own judgment about putting the lift on the hallway. During an interview on 6/17/25 at 10:43 a.m., LPN-B stated they did not have a specific spot to put the mechanical lift as long as it was not blocking the doorway. LPN-B stated she did not recall receiving any environmental safety hazard education recently. During an interview on 6/17/25 at 9:46 a.m., a registered nurse (RN)-A stated after using the lifts, nursing staff have to put it at a safe location not blocking the hallway. RN-A stated he did not receive any direction about parking the lift at a designated location. During an interview on 6/17/25 at 1:25 p.m., RN-B stated she was responsible for training nursing assistants upon hire and she was part of the safety committee. RN-B stated she did provide training at the facility skills fair last week including how to use the mechanical lift, however she did not provide environmental safety hazard education to the nursing staff recently. Nursing staff were directed to park the mechanical lift on the right side of the hallway against the wall. No specific education pertaining to R1's incident had been provided, and no audits regarding how lifts have been parked properly in the hallway was conducted. During an interview on 6/17/25 at 3:19 p.m., the director of nursing (DON) stated R1 was a high risk for falls and was having increased confusion due to her dementia condition. The interdisciplinary team (IDT) did root cause analysis after the incident but did not consider the placement of the mechanical lift as a contributing factor in the incident. DON stated she did not do anything to address the mechanical lift parked in the hallway as a potential fall hazards or try to figure out a different safe location to store them after its used. DON explained she had not provided any environmental safety hazards education to the staff or audits regarding the residents' ability to safely maneuver around the mechanical lift in the environment for ambulatory residents who independently used assistive devices. During an interview on 6/17/25 at 3:52 p.m., the administrator stated during the IDT meeting they discussed R1's fall incident and determined it was related to R1 increased weakness and confusion but did not consider the lift as contributing factor to her injuries. The administrator stated R1 sustained injuries when she fell on the lift. The administrator stated the facility procedure was to park the mechanical lift on the right side of hallway against the wall because of a lack of storage. The administrator stated they met every morning with IDT and discussed many items including falls and their Quality Assurance and Performance Improvement (QAPI) meeting was scheduled for 6/20/25. The facility Environmental Hazards Policy dated January 2012 and revised in November 2020, indicated the facility shall maintain a safe, clean and orderly interior and directed staff to survey their assigned work area routinely to ensure a properly maintained, safe clean and orderly environment.

Based on interview and document review, the facility failed to ensure residents were free from falls for 2 of 3 residents (R1, R2) reviewed for falls. Findings include: R1's care plan dated 6/12/22, directed R1 required extensive assist of two staff for bed mobility. R1's readmission Minimum Data Set (MDS) dated [DATE] indicated R1 had diagnoses of pneumonia and anxiety. The MDS indicated R1 required a mechanical lift for transfers, and two staff for bed mobility. In addition, the MDS indicated R1 had no history of falls. The undated Nursing Assistant Assignment sheet (nursing assistant care guide) directed R1's bed mobility to be provided with assistance of two staff, and transfers to be completed with one staff and the mechanical stand assist lift. On 10/18/24 a progress note indicated R1 had a witnessed fall at 6:30 a.m. R1 stiffened his body and slipped out of bed landing on his left side. R1 had no injuries. On 10/22/24 at 1:32 p.m., R1 stated nursing assistant (NA)-A provided cares by herself on 10/18/24. When she attempted to sit him up at the edge of the bed, he fell to the floor. There were supposed to be two staff get him out of bed in the morning. On 10/22/24 at 2:30 p.m., NA-A stated she provided cares independently to R1 on the morning of 10/18/24. He slid to the floor when she attempted to sit him up on the edge of the bed. The Nursing Assistant Assignment sheet directed R1 was supposed to have two staff assist for bed mobility, and one staff for transfers. On 10/22/24 at 3:02 p.m., licensed practical nurse (LPN)-A stated she was working on 10/18/24 when R1 fell . NA-A was trying to get him out of bed by herself, and R1 required assistance of two staff to get out of bed. On 10/23/24 at 9:04 a.m., registered nurse (RN)-A stated Nursing Assistant Assignment sheets were updated daily. The NAs were expected to carry them, and reference the sheets as they reflected each residents' current care plan. Two staff should have been present for R1's morning cares on 10/18/24. On 10/23/24 at 10:03 a.m., the director of nursing (DON) stated the Nursing Assistant Assignment sheets were updated when the care plans were updated. NA-A did not follow the care plan when she attempted to get him up by herself. On 10/23/24 at 12:06 p.m., physical therapist (PT)-A stated R1 had been assessed and discharged from physical therapy on 10/9/24. At that time, the recommendation was made to provide assistance of two staff for bed mobility, due to his stiff tone. The assistance of two staff included getting him up and out of bed. Once he was out of bed, R1 could transfer with the mechanical stand assist lift and one staff. R2's care plan dated 4/3/24 indicated she required assist of one staff and the mechanical standing lift for transfers. R2's quarterly MDS dated [DATE] indicated R1 had diagnoses of debility, heart failure and dementia. The MDS indicated R2 was dependent for transfers, and required substantial assistant with bed mobility. R2's MDS indicated she had no history of falls. The undated Nursing Assistant Assignment sheet directed R2's transfers to be completed with one staff using the mechanical stand assist lift. On 10/5/24 a progress note indicated R2 had a witnessed fall in the morning after becoming weak, and was lowered to the floor. R2 had no injuries. On 10/23/24 at 8:48 a.m., LPN-B stated she was working on 10/5/24 when R2 fell . It appeared NA-B had transferred R2 without the mechanical lift. NA-B did not have the Nursing Assistant Assignment sheet with her at the time of the incident. On 10/23/24 at 9:30 a.m., NA-B stated she was caring for R2 on 10/5/24. She was transferring R2 with a gait belt when R2 was lowered to the floor. She did not read the Nursing Assistant Assignment sheet to determine how she should transfer R2. On 10/23/24 at 12:16 p.m., PT-A stated R2 was not strong enough to transfer without a lift. The facility policy Routine Resident Care dated 3/23, directed following each resident's care plan for activities of daily living (ADL)s, including bathing, dressing, eating, toileting, and encouraging participation in recreational activities.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information at least quarterly or more often, including information for agency and contract staff, based on payroll and other verifiable and auditable data during (2023) 1 of 2 quarters reviewed (Quarter four) in Federal Fiscal Year (2023), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This has the potential to affect all 34 residents residing in the facility. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705 D identified the following dates triggered for review: (October 1, 2023 to December 31,2023 - quarter one) for one star staffing rating. Review of staffing schedules identified the facility had met the requirement for staffing to meet resident needs including twenty-four-hour licensed nurse and eight hours continuous registered nurse coverage for quarter one. When interviewed on 5/15/24 at 1:42 p.m., the administrator stated there was an error in reporting for quarter four (July 1, 2023 to September 30, 2023) and when the facility missed reporting nursing staff hours for the last week in September and continued to show on the quarter one PBJ report therefore the data submitted in the PBJ to CMS was inaccurate. The administrator stated for the next reporting quarter (October 1, 2023 to December 3, 2023) the the PBJ system was frozen so was unable to submit a new report resulting in the inaccurate nursing staffing data carrying over to the next reporting quarter. There was no policy related to PBJ entries provided by the end of the survey.

Based on interview and document review, the facility failed to follow up with the dental provider after a dental evaluation was completed, and a need for a treatment had been identified for 1 of 1 residents (R25) reviewed for dental concerns. Findings include: R25's Face Sheet identified multiple diagnoses, which included diabetes mellitus (a disease which affects how the body uses blood sugar (glucose), nausea with vomiting, gastroparesis (a condition where the stomach muscles can't move food normally through the digestive tract), and gastro-esophageal reflux disease (a condition that causes acid reflux and heartburn) with esophagitis (inflammation of the esophagus). R25's care plan, edited 7/10/23, identified R25 was on a regular diet with thin liquids and regular textures, with foods cut for resident. The care plan also identified R25 was independent with hygiene and grooming, with staff assistance provided as needed. During interview on 7/24/23 at 6:16 p.m., R25 stated she had a partial denture in place, as well as broken teeth present. R25 stated she had seen a dentist for evaluation since admission, and although she was unaware of the specific work needed, stated there was a recommendation for further dental work. A review of the Consult section in R25's electronic medical record lacked indication of any dental visits completed. On 7/26/23 at 1:06 p.m. registered nurse (RN)-B was consulted regarding any history of dental consults for R25. At 1:39 p.m. RN-B provided documentation of a dental consult which had been completed on 12/8/22. The document identified R25 had active dental disease and a treatment plan was to be developed once radiographs (x-rays) were reviewed. RN-B stated she was unsure of the time frame when the reports should have been received, however, stated the recommendations should have been received prior to this. RN-B stated follow through on dental recommendations was important for prevention of other dental issues. On 7/26/23 at 2:45 p.m. the director of nursing (DON) stated follow up should have been in place to track consultation visit notes of those consultations completed to ensure the appropriate follow up was received. The facility policy, reviewed 9/17, titled Consultation Tracking Records, identified nursing was to track all appointments each resident had and were to record them in the progress notes in the Automated record. The policy lacked indication as to the process of obtaining the progress notes following consultation, and the process of coordination of recommended treatment.

Based on interview and document review, the facility failed to ensure 2 of 5 residents (R26 and R35) were offered, or received, the pneumococcal vaccine (PCV20) in accordance with the Centers for Disease Control (CDC) recommendations. Findings include: The CDC's PneumoRecs VaxAdvisor identified: Based on shared clinical decision-making, decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose and patients age 19-64 with the risk factor of diabetes mellitus are recommended to have one dose of PCV15 or PCV20 at least 1 year after their last dose of PPSV23. The CDC's Pneumococcal Vaccine Timing for Adults, dated 3/15/23, identified: Together with the patient, vaccine providers may choose to administer PCV20 to adults [AGE] years and older who have already received PCV13 (but not PCV15 or PCV20) at any age and PPSV23 at or after the age of [AGE] years old. R26's Resident Face Sheet, identified she was [AGE] years old, and had multiple diagnoses, which included Type 2 diabetes mellitus, pulmonary nodule (a growth which may be cancerous or non-cancerous), and malignant pleural effusion (a condition where fluid with cancer cells accumulates in the space between lungs and the chest wall). R26 had no allergies to vaccines or contraindications to the PCV20 vaccine listed. R26's immunization report identified she had previously received the PPSV23 on 3/25/13, and the PCV13 on 9/23/15. R26's medical record lacked evidence the recommended PCV20 vaccination was offered or received. R35's Resident Face Sheet, identified she was [AGE] years old. R35's diagnoses included chronic respiratory failure with hypoxia, other forms of dyspnea, chronic obstructive pulmonary disease, and obstructive sleep apnea. R35 had no allergies or contraindications to the PCV20 vaccine listed. R35's immunization report identified she had previously received the PCV13 on 3/30/17 and the PPSV23 on 11/1/02 and 3/5/10. R35's medical record lacked evidence the recommended PCV20 vaccine was offered or received. When interviewed on 7/26/23 at 10:02 a.m. the infection preventionist, registered nurse (RN)-A, stated although she was aware of the requirement to offer the PCV-20 to residents upon their admission to the facility, she was unaware of the need to develop a plan to audit the records of those currently residing in the facility. RN-B stated she was using the recommendations as outlined by CDC from 4/1/22. RN-A stated it was important to be aware of current recommendations for residents in long term care as They are at such high risk of severe illness or death. The facility policy, Vaccinations and Immunizations, last reviewed on 10/2022, directed upon admission a nurse reviewed the residents vaccination history to determine the need for vaccinations. Under the title Procedure, the policy went on to identify for the pneumococcal vaccine the facility staff was to follow the recommendations from MDH (Minnesota Department of Health)/CDC r/t (related to) timing of PCV13, PCV15, PCV20, and/or PPSV23. The policy went on to direct the staff if additional pneumococcal vaccine was indicated after admission, the RN was to proceed with providing the resident the risk versus benefits using the most current vaccination information. The policy lacked identification as to how vaccination recommendation were to be determined or what processes were to be used.

Based on observation, interview and document review, the facility failed to ensure fall interventions were implemented as care planned to prevent falls for 1 of 2 residents (R1) reviewed for accidents. This resulted in actual harm when R1 fell from a toileting sling and was diagnosed with a left shoulder fracture. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had hemiplegia and anxiety. The MDS indicated R1 was cognitively impaired, did not reject care, transferred with extensive assist of two, was always incontinent of bladder and frequently incontinent of bowel. The MDS further indicated R1 had occasional pain and had one fall with major injury since admission. R1's Care Plan dated 10/3/22 , indicated R1 was at moderate risk for falls related to weakness, needed assistance with mobility, diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side. The care plan indicated R1 used a bed pan for toileting until toileting sling use was re-assessed for proper fit. A Resident Abuse/Neglect Investigation Report Form completed by the facility on 10/03/22, indicated on 10/03/22, at 3:30 p.m. R1 was being transferred from commode to wheelchair using Hoyer lift and toileting sling when R1 started to slide out of sling and fell to the floor. The report indicated R1 had left shoulder pain with movement and denied other pain. The report indicated no neglect or abuse was found and care plan, policies and procedures were followed and facility was re-evaluating type of sling used, but sling in place was correct for lift and toileting. A Fax Form from the facility dated 10/03/22, at 4:23 p.m. to R1's physician indicated, at 3:50 p.m. R1 was being lifted with the hoyer lift using the toileting sling. When they were getting ready to lower her back to her wheelchair the NARs noticed R1 was slipping and before they could get the chair under her, she fell to the ground. R1 was assessed and stated her back, shoulder and head hit the ground. After being assessed, R1 was lifted to her bed using a hoyer lift and full body sling with compliants of pain in left shoulder with movement. She also complained of level 4 pain in left lateral thigh/lower flank area. There was a L shaped bruise in that area. Review of physician response fax was to monitor and update. An Office Visit note dated 10/06/22, indicated R1 was seen, had x-rays and was found to have a fracture of the left humeral neck (shoulder fracture). The note indicated an order for an arm splint and follow up in a week. Increased Tylenol to 1,000 milligrams (mg) TID (three times a day) for the next week and resume current dose. A CentraCare Clinic fax dated 10/07/22, indicated R1 continued to have increased left shoulder pain and Tramadol (used to treat pain) 50 mg one tablet every 6 hours as need. Review of Occupational Therapy (OT) and Certified Occupational Therapy Assistant (COTA)-A notes dated 8/19/22 through 10/04/22, indicated the following: On 8/19/22, OT indicated patient was educated on benefit of trial with toilet sling for toileting. On 8/22/22, staff CNA (certified nursing assistant) training to continue use hoyer transfers with toilet sling during use of commode. Patient completes transfers with assist of two. Occupational therapy (OT) updates toilet sling transfers, criss crossing leg straps for improved bilateral lower extremity stability. On 9/07/22, OT indicated concerns from staff over the weekend with patient use of toileting sling. Consulted with licensed practical nurse (LPN)-A and NA-K regarding incident, [FM]-A present reporting staff were not using the toileting sling. The note indicated social services was informed of FM-A concern. In addition the note indicated the director of nursing (DON) was looking into larger slings for R1. On 9/12/22, COTA-A indicated writer collaborates with nursing regarding toilet transfers. Writer provided staff training to use toilet sling crossing leg straps for improved security. On 9/21/22, COTA -A indicated writer consulted with NA-K and night staff concerns of poor safety using toileting sling. NA-K reported concerned with R1's posture in toilet sling during the night with increased fatigue. The note then indicated R1 was able to maintain posture in toilet sling during the night and OT will upgrade Functional Maintenance Plan (FMP) and RN education and collaboration regarding toileting task using the bed pan. R1's Rehab Visions Occupational Therapy report also known as Functional Maintenance Plan (FMP) dated 9/26/22, indicated R1 toileted with assist of two, toileting sling, and bedside commode. Use of bed pan as need (PRN). During observation and interview on 1/03/23, at 9:35 a.m. R1 was lying in bed and stated she had no pain. R1 stated she preferred to use the bedpan instead of the toileting sling. R1 then wanted to have her family member involved in the conversation so R1 used her [NAME] device (virtual assistant technology) and called (FM)-A. FM-A stated he was informed the facility felt the cause of the fall on 10/03/22, was due to R1's left arm slipped through the toileting sling and then fell to the floor. FM-A stated he was upset because after the fall R1 no longer received therapy and she became private pay. FM-A stated he wanted R1 to use the commode and hoped she would eventually be able to come home. FM-A stated he was not informed R1 was experiencing fatigue in the evening, but some of the staff would not want to use the sling. He encouraged them to use it since he felt it was painful for R1 to use the bed pain. During interview on 1/03/23, at 12:20 p.m. COTA-A stated she assessed R1 during the day and had no concerns with transfers using the toileting sling, but did not look at R1 later in the day or evening when staff expressed concerns with fatigue. COTA-A stated she was aware R1 had weakness later in the day and added to R1's functional maintenance plan (FMP) to use the bed pan as needed (PRN) instead of toileting sling and commode for safety. In addition, COTA-A stated she trained the staff on the floor on how to use the toileting sling on R1 if they communicated they had concerns. When asked if there was any training documentation, COTA-A stated she did not record the individual training's. During interview on 1/03/23, at 2:00 p.m. nursing assistant (NA)-A stated she had been working at the facility for over two years and always used the bed pan for R1's toileting needs and was never aware R1 used the toileting sling. During interview on 1/03/23, at 2:06 p.m. registered nurse manager (RN)-A stated she was aware the staff were reporting they were uncomfortable with using the toileting sling with R1 so she referred the concerns to the therapy department and felt if they assessed R1 to be safe using the toileting sling, then she felt it was safe. RN-A stated after R1 fell on [DATE], they were no longer using the toileting sling. RN-A confirmed, previous to the fall, she was not aware of PRN order to use bed pan if R1 was fatigued. During interview on 1/03/23, at 8:13 p.m. NA-B stated prior to R1's fall they used the toileting sling and felt it was small and R1's arms would go into the air. In addition, NA-B stated R1 would get tired in the evening and this had been reported to the nurses working. NA-B added, even though he voiced concerns of safety with the sling, he had not received any training on using the toileting sling with R1 and so would try to avoid the sling at any cost and just use the bed pan. NA-B stated he was not aware of the order to use the bed pan PRN if R1 was fatigued. During interview on 1/03/23, at 8:44 p.m. NA-C stated I would not transfer [R1] using the toileting sling, it would pinch at the wrong angles and was not a big fan of the sling. During interview on 1/03/23, at 8:45 a.m. NA-D stated she was the NA working when R1 slipped out of the sling. NA-D stated the sling was too small and R1's legs started to slide out, even though the straps around the legs were criss-crossed, her bottom was sliding down. NA-D stated she thought they used the biggest toileting sling they had and was never told it was too small until after the incident. NA-D stated when the incident occurred she was new to working at the facility and was trained on the B-wing not the A-wing where R1 was on. During interview on 1/04/23, at 9:40 a.m. DON stated, they checked the sling and R1's weight and according to the chart the toileting sling was appropriate for R1. The DON stated she felt the incident occurred because R1 pulled her arm in and out of the sling, slid out, and fell . Since the incident they have been using the bed pan. During interview on 1/04/23, 12:32 p.m. NA-F stated to be honest I was never aware [R1] used a toileting sling and was never trained. NA-F stated she worked evenings and they had a lot of new staff and there had been no formal training on how to use the sling on R1. During interview on 1/04/23, at 1:24 p.m. NA-G indicated she worked evening shifts and had been at the facility for over two years and never used the toileting sling on R1. NA-G stated she had heard staff state they were uncomfortable using the toileting sling. During interview on 1/04/23, at 1:33 p.m. NA-H stated she worked the evening shift and when she would use the toileting sling R1's arms and body would sink into the sling. It didn't look right and was too small. NA-H stated she reported to the nurses, but therapy wanted us to use the toileting sling and it was on our Nursing Assistant Care Sheet to use the toileting sling. NA-H stated she was not surprised after a short leave and then returning to find out that R1 had slid out of her sling. In addition RA-H stated even though she reported her concerns to the nurses she never received any training or direction on transfers for R1 when she became fatigued and felt the new staff should all be trained on the proper way to complete transfers so the residents were safe. During interview on 1/04/23, at 5:00 p.m. NA-I stated she worked the evening shift. When she transferred R1, the sling around her back did not fit her and she would just leave the leg straps un-crossed because she did not want to pinch her legs. NA-H further stated they communicated concerns to FM-A and nursing staff, but FM-A insisted they use the toileting sling for R1 and not the bed pan. During interview on 1/04/23, at 6:08 p.m. NA-D stated when she was transferring R1 she was not aware she could have used the commode (PRN when fatigued) and R1 probably slid through her toileting sling because she was tired and weak. During interview on 1/04/23, at 6:18 p.m. NA-J stated her and NA-D were the ones that transferred R1 when she slid out of her toileting sling adding, they knew her left arm had weakness and that when her arm slid through the sling, R1 could not hang on and fell to the floor. NA-J stated R1's weakness could have been the cause of her fall. NA-J added that they no longer used the toileting sling and used the bed pan for safety. During interview on 1/05/23, at 9:38 a.m. DON stated the COTA-A would train the staff working on the shift when she was there but not all 79 staff. In addition, DON stated she did not understand why the two staff working with R1 did not know they could have used the bedpan the day of her incident since it was listed on her resident care sheet and they should be looking at that every day. In addition she was unaware who the COTA-A discussed the use of the bed pan with when R1 was weak according to the therapy note on 9/21/22, since she spoke to her nurse manager and the nurse manager was never informed of the collaboration that was listed in the COTA's documentation. In addition, the DON stated the FMP and care plan should have addressed the reason for using the bed pan for weakness and not just stating it was used PRN. The facility was unable to provide documentation of communication or education provided to staff regarding changes to R1 care plan. Although therapy had recommend using the bed pan when R1 was weak or tired and revised care plan treatment on 10/03/22, the facility staff were unaware of the intervention and transferred R1 using the toileting sling which resulted in a left humorous fracture. A facility policy Fall Protocol dated 9/2022, indicated Realizing that not all falls can be prevented that the elderly population have multiple predispositions to falling and will fall, preventive measures shall be initiated when deemed appropriate to decrease the number of falls whenever possible. The policy further indicated if an assessment finds the resident at risk the RN case manager will implement appropriate interventions and/or precautions on the care plan as an attempt to reduce the risk of falls or the risk of injury due to falls.

Based on interview and document review, the facility failed to ensure incident of potential neglect was reported immediately, within two hours, to the State Agency (SA) for 1 of 2 residents (R1) reviewed for accidents who slid from a lift and had a left shoulder fracture during provisions of care. Findings include: R1's significant change minimum data set (MDS) dated [DATE], indicated R1 required transfer with extensive assist of two, always incontinent of bladder and frequently incontinent of bowel. R1's Care Plan dated 10/3/22, indicated R1 was at moderate risk for falls related to weakness, needing assistance with mobility, diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side. The care plan indicated R1 used a bed pan for toileting until toileting sling use was re-accessed for proper fit. A Resident Abuse/Neglect Investigation Report Form completed by the facility on 10/03/22, indicated on 10/03/22, at 3:30 p.m. R1 was being transferred from commode to wheelchair using Hoyer lift and toileting sling when R1 started to slide out of sling and fell to the floor. The report indicated R1 had left shoulder pain with movement and denied other pain. The report indicated no neglect or abuse was found and care plan, policies and procedures were followed and re-evaluating type of sling used-but sling in place was correct for lift and toileting. The report failed to indicate the SA was informed of the incident. A Office Visit note dated 10/06/22, indicated R1 was seen and had x-rays and was found to have a fracture of the left humeral neck (shoulder fracture). The note indicated an order for a arm splint and follow up in a week and increased Tylenol to 1,000 milligrams (mg) TID (three times a day) for the next week and resume current dose. During interview on 1/05/23, at 9:38 a.m. DON stated she should have reported the incident since the staff did not understand the use of the bed pan. The facility Abuse Prevention Plan Policy and Procedure dated 9/2021, indicated The Administrator is notified immediately of any suspected abuse. Immediately is defined as 'as soon as possible but no later than 24 hours after an incident'. Immediately means as soon as possible after discovery of the incident but no later than 2 hours after allegation is made. Social Services or other designated staff will immediately report to appropriate agencies. In addition the policy indicated neglect as a categories of abuse Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. This presumes that instances of abuse/neglect of all residents, even those in a coma, cause physical harm or pain or mental anguish. (Active Neglect: conscious, intentional, willful deprivation. Passive Neglect: unintentional deprivation, unwilful.).

Based on interview and document review the facility failed to thoroughly investigate an allegation of neglect for 1 of 2 residents (R1) reviewed for accidents who had fell from a toileting sling which resulted in a left shoulder fracture. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had hemiplegia and anxiety. The MDS indicated R1 was cognitively impaired, did not reject care, transferred with extensive assist of two, was always incontinent of bladder and frequently incontinent of bowel. The MDS further indicated R1 had occasional pain and had one fall with major injury. R1's Care Plan dated 10/3/22 , indicated R1 was at moderate risk for falls related to weakness, needing assistance with mobility, diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side. The care plan indicated R1 used a bed pan for toileting until toileting sling use was re-assessed for proper fit. A Resident Abuse/Neglect Investigation Report Form completed by the facility on 10/03/22, indicated on 10/03/22, at 3:30 p.m. R1 was being transferred from commode to wheelchair using Hoyer lift and toileting sling when R1 started to slide out of sling and fell to the floor. The report indicated R1 had left shoulder pain with movement and denied other pain. The report indicated no neglect or abuse was found and care plan, policies and procedures were followed and re-evaluating type of sling used but sling in place was correct for lift and toileting. A Office Visit note dated 10/06/22, indicated R1 was seen and had x-rays and was found to have a fracture of the left humeral neck (shoulder fracture). The note indicated an order for an arm splint, follow up in a week and increase Tylenol to 1,000 milligrams (mg) TID (three times a day) for the next week and resume current dose. During interview on 1/03/23, at 12:20 p.m. COTA-A stated she assessed R1 during the day and had no concerns with transfers using the toileting sling, but did not look at her later in the day or evening when staff expressed concerns with fatigue. COTA-A stated she was aware R1 was having weakness later in the day and added to R1's functional maintenance plan (FMP) to use the bed pan as needed (PRN) instead of toileting sling and commode for safety. During interview on 1/03/23, at 8:45 a.m. NA-D stated she was the NA working when R1 slipped out of the sling. NA-D stated the sling was too small and R1's legs started to slide out, even though the straps around her legs were criss-crossed, her bottom was sliding down. NA-D stated she thought they used the biggest toileting sling they had and was never told it was too small until after the incident. NA-D stated when the incident occurred she was new to working at the facility and was trained on the B-wing not the A-wing where R1 was on. During interview on 1/04/23, at 9:40 a.m. director of nursing (DON) stated, they checked the sling and R1's weight and according to the chart, the toileting sling was appropriate for R1. The DON stated she felt the incident occurred because R1 pulled her arm in and out of the sling and slid out and which resulted in the fall, adding, since the incident they have been using the bed pan. During interview on 1/04/23, at 1:24 p.m. NA-G stated he worked the evening shift and had been at the facility for over two years and never used the toileting sling on R1. NA-G stated he had heard staff state they were uncomfortable using the toileting sling. During interview on 1/04/23, at 1:33 p.m. NA-H stated she worked the evening shift and when she would use the toileting sling R1's arms and body would sink into the sling and it didn't look right and too small. NA-H stated she reported to the nurses, but therapy wanted us to use the toileting sling and it was on our Nursing Assistant Care Sheet to use the toileting sling. NA-H stated she was not surprised after a short leave and then returning to find out that R1 had slid out of her sling. In addition RA-H stated even though she reported her concerns to the nurses she never received any training or direction on transfers for R1 when she became fatigued and felt the new staff should all be trained on the proper way to complete transfers so the residents are safe. During interview 1/04/23, at 5:00 p.m. NA-I stated she worked the evening shift and when she transferred R1 the sling around her back did not fit her and she would just leave the leg straps un-crossed because she did not want to pinch her legs. NA-H further stated they communicated concerns to FM-A and nursing staff, but FM-A insisted they use the toileting sling for R1 and not the bed pan. During interview on 1/04/23, at 6:08 p.m. with NA-D who stated when she was transferring R1 she was not aware she could have used the bed pan and R1 probably slid through her toileting sling because she was tired and weak. During interview on 1/04/23, at 6:18 p.m. NA-J stated her and NA-D were the ones that transferred R1 when she slid out of her toileting sling adding, they knew her left arm had weakness and that when her arm slid through the sling, R1 could not hang on and fell to the floor. NA-J stated R1's weakness could have been the cause of her fall. NA-J added that they no longer use the toileting sling and use the bed pan for safety. During interview on 1/05/23, at 9:38 a.m. DON stated the COTA-A would train the staff working on the shift when she was there and not all 79 staff they had working. In addition, DON stated she did not understand why the two staff working with R1 did not know they could have used the bedpan the day of her incident since it was listed on her resident care sheet and they should be looking at that every day. In addition she was unaware who the COTA-A discussed the use of the bed pan with when R1 was weak according to the therapy note on 9/21/22, since she spoke to her nurse manager and the nurse manager was never informed of the collaboration that was listed in the COTA's documentation. In addition, the DON stated the FMA and care plan should have addressed the reason for using the bed pan for weakness and not just stating it was used PRN. An additional interview on 1/05/23, at 10:00 a.m. DON stated the facility investigation should have been more thorough and included if R1 was fatigued during her fall from the toileting sling and why the bedpan was not being used that day. In addition, DON stated she can see the investigation focused on if the correct sling was used during the transfer and not if R1 might have been fatigued and the bedpan should have been used. The facility Investigation report lacked evidence the care plan and therapy notes were reviewed to ensure provisions of care were in place, staff were implementing appropriate care and treatment, all necessary staff were interviewed, and staff were determined to be competent. The facility Abuse Prevention Plan Policy and Procedure dated 9/2021, indicated Resident and tenant incident reports are reviewed by staff to determine whether there is reasonable evidence to suspect abuse and/or neglect of a vulnerable adult. This includes identifying events such as suspicious bruising, injuries of an unknown source, of resident's occurrences, patterns and trends that may constitute abuse.

Based on interview and document review, the facility failed to thoroughly investigate and implement corrective action to keep residents safe following an allegation of staff (alleged perpetrator) to resident abuse for 2 of 2 residents (R1, R2) reviewed for abuse. This resulted in an immediate jeopardy. Additionally, 4 residents (R3, R4, R5, R6) alleged abuse against the same staff during the facility's removal plan implementation. The immediate jeopardy (IJ) began on 9/15/21 when, following an allegation of staff to resident physical abuse, the facility failed to interview other residents who worked with the alleged perpetrator (AP) who fit the description and worked during the alleged scheduled hours (overnights), failed to follow up with picture identification of AP and interview additional staff on the overnight shift. These failures were identified on 9/23/21. The administrator and director of nursing were notified of the IJ for R1 and R2 on 9/23/21, at 11:15 a.m. The IJ was removed on 9/30/21, at 12:00 p.m. but noncompliance remained at a scope and severity level of a D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's admission minimum data set (MDS) dated [DATE], indicated severely impaired cognition, and required extensive assistance of one with bed mobility, transfers and toileting. An allegation of abuse was reported to the State Agency on 9/15/21, indicating R1 alleged .dark hair heavy set aid shoved her into the wall while doing cares in the bathroom on overnights. [R1] stated because the aid was mad, she wet the bed . Review of the facility's internal investigation confirmed the facility interviewed the resident who remained consistent with the description of alleged perpetrator (AP). The facility showed R1 pictures of different overnight staff who fit the description, R1 was able to point out two possible staff, but indicated she was unsure. The report lacked evidence of any other steps the facility took as part of an internal investigation such as interviewing staff (only 3 were interviewed), residents, or alternative strategies to determine who the alleged perpetrator was. The report did indicate action to prevent reoccurrence was to place R1 on a two-person buddy system. During interview on 9/22/21, with social services designee (SS), stated although the two-person buddy system was placed on the report for a corrective action it was not started until 9/22/21. The SS stated they had planned to start this but had not updated the group sheets to reflect this yet. During the state agency investigation on 9/21/21, R1 possibly identified AP through pictures shown to her with SS present but R1 was not positive, the staff member in question was going to be working that night so a plan was made to follow up with R1 the next morning. The next day 9/22/21, R1 confirmed, with SS present, the staff who worked last night was the AP in question and reported that the AP shoved her into bed last night. R1 stated AP worked the night shift and worked until the morning shift. In addition, R1 stated, It's like I am too slow for her and she shoves me to be quicker, I tell her don't be so mean to me, and she says I am not mean to you! She does this every time she works with me, she is just rough and pushy she has pushed me into the bathroom wall. During interview on 9/22/21, at 9:23 p.m. nursing assistant (NA)-B stated she worked with the night shift on 9/22/21, and confirmed AP toileted R1 alone (no 2-person buddy system implemented) a couple of times during the night and was unaware of any rough treatment. During interview on 9/23/21, at 10:00 a.m. with AP stated she had never been rough with the residents and in fact treats them like her own grandparents and would never hurt them. The AP did state sometimes she might use her own strength a little hard since she used to work at a facility with patients that required heavy lifting and sometimes she might not know her own strength but would never mean to hurt the residents. R2's significant change MDS dated [DATE], indicated intact cognition, required extensive assist of one with bed mobility and extensive assist of two with transfers. During interview on 9/22/21, at 12:40 p.m. R2 stated, when [AP] works she is rough when putting me to bed, I feel like a sack of potatoes and afraid I might fall out of the other side of the bed! R2 added that she asks the evening shift if AP is working and if she finds out AP is, she will ask the evening staff to just put her to bed early to avoid AP putting her to bed. R2 went on to state it hurts her when AP puts her to bed. During interview on 9/22/21, at 1:00 p.m. NA-C stated R2 has told her AP has been rough with cares and will request to be put to bed early when the AP is working the overnight. NA-A stated she reported this to the evening nurses when R2 reported the rough treatment but does not remember which nurses she reported to. During interview on 9/28/21, at 9:35 a.m. SS designee stated he interviewed R2 on 9/23/21, and R2 stated she was treated roughly by the AP when getting her into bed and while positioning her and had told her family but not the facility. R2 stated she was afraid of retaliation from the staff member. Following immediate jeopardy findings, the facility completed an investigation which concluded 4 additional residents who alleged abusive behavior against the AP. R3's significant change MDS dated [DATE], indicated he was cognitively intact, needed assist of two with bed mobility occasionally incontinent of bladder and had medically complex conditions. During interview on 9/28/21, at 9:45 a.m. SS designee stated he interviewed R3 on 9/23/21, R3 reported about two months ago he was in bed and while his pad was being changed, he was pushed against the wall. R3 felt he was being abused and felt AP was pushy and hot tempered. R4's admission MDS dated [DATE], indicated she was cognitively intact, needed extensive assistance of two with transfers and bed mobility and assist of one with dressing. During interview on 9/28/21, at 9:50 a.m. SS designee stated R4 felt rushed and handled roughly while being cared for by the AP during the night shift. In addition, R4 stated she placed her transfer belts on her too tight and takes her socks off to quickly and everything she does is rough and feels like the AP is mad at her. R5's quarterly MDS, dated [DATE], indicated she was moderately cognitively intact required assist of one with bed mobility and transfers and had [CONDITION(S)]. During interview on 9/28/21, at 10:00 a.m. SS designee stated when he interviewed R5 she stated she was pushed into the wall while transferred and she is mean and not a nice person and she is always grumpy. R5 stated she reported this to her family but not to the facility. R6's significant change MDS dated [DATE], indicated he was cognitively intact, had arthritis required extensive assist with transfers, bed mobility and toileting. During interview on 9/28/21, at 10:15 a.m. SS designee stated during interview with R6 he stated several nights ago the night staff pulled his pants down roughly and he was afraid his catheter would get pulled out and felt the AP was being kind of rough. The facility's abuse policy Annandale Health & Community Services Facility Abuse Prevention Plan Policy and Procedure revised 3/21, indicated all staff are to report suspected maltreatment immediately, but no less than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. In addition, the policy indicated Annandale Health Care Services has a vulnerable adult investigation committee to review all complaints/concerns involving a resident who is suspected of abuse or has been abused or neglected or has sustained a physical injury which is not reasonably explained. The committee will do a thorough investigation of the possible neglect or abuse cases, taking the appropriate action providing protective and/or counseling services as needed (prevention mechanism). The immediate jeopardy that began on 9/15/21, was removed on 9/30/21, when the facility took immediate corrective action by removing AP, conducted a thorough investigation, reviewed policies related to abuse and provided training to staff on abuse and reporting policies and procedures.

Based on observation, interview and document review, the facility failed to report timely to the state agency (SA) and administrator allegations of abuse of care for 1 of 1 residents ( R2 ) who reported allegations of abuse. Findings Include: R2's significant change MDS dated [DATE], indicated intact cognition, required extensive assist of one with bed mobility and extensive assist of two with transfers. During interview on 9/22/21, at 12:40 p.m. R2 stated, when [AP] works she is rough when putting me to bed, I feel like a sack of potatoes and afraid I might fall out of the other side of the bed! R2 added that she asks the evening shift if AP is working and if she finds out AP is, she will ask the evening staff to just put her to bed early to avoid the AP putting her to bed. R2 went on to state it hurts her when AP puts her to bed. During interview on 9/22/21, at 1:00 p.m. NA-C stated R2 has told her AP has been rough with cares and will request to be put to be early when the AP is working the overnight. NA-A stated she reported this to the evening nurses when R2 reported the rough treatment but does not remember which nurses she reported to. During interview with the facility administrator on 9/25/21, at 4:45 p.m. stated they were unaware of the incident that occurred with R2, and neither of the evening nurses recall the incident being reported to them. The administrator stated the incident should have definitely been reported to her and the nurses and would have been reported to the SA immediately according to policy. The facilities abuse policy Annandale Health & Community Services Facility Abuse Prevention Plan Policy and Procedure revised 3/21, indicated all staff are to report suspected maltreatment immediately, but no less than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. In addition the policy indicated Annandale Health Care Services has an vulnerable adult investigation committee to review all complaints/concerns involving a resident who is suspected of abuse or has been abused or neglected or has sustained a physical injury which is not reasonably explained. The committee will do a thorough investigation of the possible neglect or abuse cases, taking the appropriate action providing protective and/or counseling services as needed (prevention mechanism).

Based on observation, interview and document review the facility failed thoroughly investigate an allegations of abuse for 1 of 1 residents (R1) who alleged physical abuse and rough care by a staff member. Findings include: R1's admission minimum data set (MDS) dated [DATE], indicated severely impaired cognition, and required extensive assistance of one with bed mobility, transfers and toileting. An allegation of abuse was reported to the State Agency on 9/15/21, indicating R1 alleged .dark hair heavy set aid shoved her into the wall while doing cares in the bathroom on overnights. [R1] stated because the aid was mad, she wet the bed . Review of the facility's internal investigation and interview confirmed the facility interviewed the resident who remained consistent with the description of alleged perpetrator (AP). The facility showed R1 pictures of different overnight staff who fit the description, R1 was able to point out two possible staff, but indicated she was unsure. The report lacked evidence of any other steps the facility took as part of an internal investigation such as interviewing staff (only 3 were interviewed), residents, or alternatives strategies to determine who the alleged perpetrator was. The report did indicate action to prevent reoccurrence was to place R1 on a two-person buddy system. During interview on 9/22/21, with social services designee (SS), stated although the two-person buddy system was placed on the report for a corrective action it was not started until 9/22/21. The SS stated they had planned to start this but had not updated the group sheets to reflect this yet. During the state agency investigation on 9/21/21, R1 possibly identified AP through pictures shown to her with Social Services representative (SS) present but R1 was not positive, the staff member in question was going to be working that night so a plan was made to follow up with R1 the next morning. The next day 9/22/21, R1 confirmed, with SS present, the staff who worked last night was the AP in question and reported that the AP shoved her into bed last night. R1 stated AP worked the night shift and worked until the morning shift. In addition, R1 stated It's like I am too slow for her and she shoves me to be quicker, I tell her don't be so mean to me, and she says I am not mean to you! She does this every time she works with me, she is just rough and pushy she has pushed me into the bathroom wall. R2's significant change MDS dated [DATE], indicated intact cognition, required extensive assist of one with bed mobility and extensive assist of two with transfers. During interview on 9/22/21, at 12:40 p.m. R2 stated, when [AP] works she is rough when putting me to bed, I feel like a sack of potatoes and afraid I might fall out of the other side of the bed! R2 added that she asks the evening shift if AP is working and if she finds out AP is, she will ask the evening staff to just put her to bed early to avoid the AP putting her to bed. R2 went on to state it hurts her when she puts her to bed. During interview on 9/28/21, at 9:35 a.m. SS designee stated he interviewed R2, and R2 stated she was treated roughly by the AP when getting her into bed and also while positioning her and had told her family but not the facility. R2 stated she was afraid of retaliation from the staff member. SS designee stated when he did his initial investigation with R1 she had a difficult time figuring out thru pictures who the AP was so he initial felt through his investigation the incident was inconclusive and did not interview any of the other residents and should have and informed surveyor he found four additional incidents of abuse allegations involving the AP. The facilities abuse policy Annandale Health & Community Services Facility Abuse Prevention Plan Policy and Procedure revised 3/21, indicated all staff are to report suspected maltreatment immediately, but no less than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. In addition the policy indicated Annandale Health Care Services has an vulnerable adult investigation committee to review all complaints/concerns involving a resident who is suspected of abuse or has been abused or neglected or has sustained a physical injury which is not reasonably explained. The committee will do a thorough investigation of the possible neglect or abuse cases, taking the appropriate action providing protective and/or counseling services as needed (prevention mechanism).

Based on interview and record review, the facility failed to ensure a physician prescribed mechanically altered diet was provided to 1 of 7 residents (R2) reviewed for theraputics diets. Findings include: R2's significant change Minimum Data Set (MDS), dated [DATE], identified R2 had intact cognition; however had a [DIAGNOSES REDACTED]. The MDS indicated R2 had further [DIAGNOSES REDACTED]. In addition, R5 had been edentulous (no natural teeth), had not shown any possible swallowing issues with current interventions, and ate independently. An RN (registered nurse) Nursing Assessment-Version 3, dated 11/14/20, identified R2 had difficulty swallowing liquids and had impaired swallowing. The assessment indicated R2's Current diet is nectar thick liquids and pureed textures and crushed medications. A section labeled ORAL identified R2 utilized upper and lower dentures. No referrals had been indicated. R2's care plan section labeled Nutritional Status, edited on 11/10/20, identified R2 received a pureed texture diet with nectar thick liquids related to dysphagia with an approach that he received this altered diet. R2's abuse prevention care plan, edited on 11/23/20, identified he was vulnerable related to dysphagia with an approach to refer to individual care plan problems, goals, and approaches to minimize the risk of abuse. In addition, the care plan section labeled ADL (activity of daily living) eating indicated R2 had been independent with eating, had a history of [REDACTED]. A Physician order [REDACTED]. A progress note on 1/22/21, at 1:45 p.m. indicated R2 had been given lunch food that had not been pureed. The progress note identified R2 had been fine when the incorrect diet had been discovered; however, R2 had spit out phlegm and experienced pain near his diaphragm 30 minutes after the event. A progress note, recorded on 1/22/21, at 3:10 p.m. indicated R2 had expelled a chunk of chicken. A progress note on 1/23/21, at 12:20 a.m. indicated R2 had reported discomfort in his chest due to him having consumed the wrong textured food. A completed State agency (SA) submitted follow up investigation, dated 1/27/21, identified the facility's completed investigation into the incident. The report outlined nursing assistant (NA)-C had obtained R2's and another resident's ready to deliver lunch trays from the kitchen and brought them to R2 and the other resident. The process had been for the kitchen staff to label a plate and match it to a tray; however, the diet cards for the plates were not matched to the diet cards on the trays. The facility had discovered a kitchen staff had placed the wrong plate on R2's and the other resident's trays. R2 had received a regular meal which resulted in him having experienced some pain/discomfort in his diaphragm and coughing up phlegm. The report indicated the facility had developed a new tray passing policy after the incident had occurred in which the dietary manager (DM) had reviewed with the employees. In addition, the report indicated no alleged perpetrator (AP) had been identified. The report lacked actions or evidence of a systemic response by the facility to educate all facility staff in regards to food delivery processes that ensured residents were given the correct physician ordered food items at all times of the day. During interview on 1/29/21, at 11:07 a.m. NA-A stated dietary staff brought the meal trays down on the carts. NA-A explained she checked the meal cards at times to ensure the residents received the correct food; however, she voiced she had become so used to the routine that (she) will not always check them. NA-A denied she had received any recent education on ensuring residents received the correct food items as ordered by their physicians. When interviewed on 1/29/21, at 11:32 a.m. NA-B stated she tries to look at the tray cards before she passes out meal trays; however, she explained dietary staff passes the trays now. NA-B denied she had received any recent education on ensuring residents received the correct food items as ordered by their physicians. During interview on 1/29/21, at approximately 12:15 p.m. cook (C)-A stated the kitchen's process for prepped meal trays relied on a dietary aide listing off a residents name and their associated diet to the staff member. That staff member would then place the correct food items on the plates. C-A explained she had remembered the incident; however, could not remember any real details other than it was a plate swap in which the trays were completely normal just a different plate. C-A stated nursing staff had delivered R2's and the other resident's meal trays that day after the kitchen had prepared them and further explained that in response to the incident dietary staff were now the only staff members who delivered the meal trays as is is something we should have caught. When interviewed on 1/29/21, at 12:49 p.m. assistant dietary director (ADD) stated when dietary staff prepped meal trays the dietary assistants would tell the cooks the resident's name, diet, and any other information required. Once the cook finished preparing the plate, they would hand it back to the dietary assistant and the resident's name would again be stated. The dietary assistant finished the process by wrapping the plate and placing it on the tray with the associated diet card. The ADD explained R2 and the other resident's trays had been the last two trays prepped for lunch in which a dietary assistant had wrapped them right away; however, had not placed them on the trays. The ADD had not known who had placed the plates on the trays prior to NA-C taking the trays and delivering them. The ADD stated after the incident a new policy and procedure had been developed that required only dietary staff to pass resident meal trays. In addition, the ADD stated she had only provided education to dietary staff regarding the new policy and procedure processes. The ADD denied having completed audits to ensure the new policy and procedure had been followed or that residents' meal trays had been prepared per physician orders. During interview on 1/29/21, at 1:09 p.m. dietary aide (DA)-A stated she had taken the last two lunch meal trays which had belonged to R2 and another resident after the cooks had wrapped the plates so that they could keep up. DA-A explained about half way down the hall NA-C had approached her and she had agreed to NA-C's offered assistance for NA-C to deliver the trays the rest of the way. DA-A explained dietary staff now passed out the meal trays and set the residents up with the trays so that they could perform a visual check of the trays before they left the resident's room. DA-A voiced, It (the incident) could have been a lot worse, and, Accidents happen but this (residents getting the wrong diet order) cannot happen. When interviewed on 1/29/21, at 1:34 p.m. NA-C stated she had visualized R2's tray card long enough to ensure the tray had been his and that the dessert had been pureed. NA-C explained she did not think anything of it (the chicken having been the wrong texture) and when she had went back after the meal to check on R2 he had stated, I almost choked to death. NA-C offered R2 alternative meal options after he had voiced he did not wish to eat any more on his meal. When NA-C had visualized R2's plate, she stated R2 had cut up chicken and a vegetable blend. NA-C explained after she had brought R2 his tray she brought the other tray to that associated resident and assisted her to eat; however, NA-C stated diet orders can change and thus at that time it (the other resident was being fed pureed food) did not click with me. NA-C explained the two resident tray cards and other items on the meal trays had been correct; however, the meal plates had been switched. NA-C confirmed she is supposed to make sure that the tray card, the resident, and the meal is correct before the resident received food items. NA-C reported, We no longer pass the trays now. Further, NA-C denied having received disciplinary action related to the incident or education to ensure residents received the correct diet and food items as ordered by their physician. During interview on 1/29/21, at 4:07 p.m. the director of nursing (DON) stated education had only been provided to dietary staff after the incident as the meal tray had came out of the kitchen. The DON confirmed NA-C and other nursing staff had not received education about providing residents with appropriate diet textured foods despite nursing staff providing residents with food items at times other than meals. The DON explained her expectation was for staff to look at the resident diet orders and to make sure the residents received food items based on their physician diet orders. When interviewed on 2/1/21, at 10:46 a.m. R2 stated the incident had been terrible. R2 explained his plate had bigger pieces and when he had tried to chew them, I could not swallow them. Further, R2 explained, I was choking like crazy. R2 stated he normally gets mashed up foods which he had no concerns with and thus R2 explained he had not paid any attention to what had been on his plate that meal and just started eating. After the incident, R2 stated, It had hurt like hell for awhile, and it stuck in the middle of my chest, in which he had experienced pain for about half the day after choking. R2 explained, I now look before I eat. During a subsequent interview on 2/1/21, at 11:05 a.m. the DON stated the facility had gone back and forth regarding which department would be best to deliver meal trays in which due to R2's choking the facility had went back to only dietary delivering meal trays. The DON explained nursing staff, which included NA-C, should have been educated/retrained right away after the incident. The DON stated, We overlooked a big piece. The DON stated her expectation was that if staff questioned food items being delivered to residents they should not deliver the tray and should discuss their concerns with the nurse or dietary staff. The DON denied the facility had performed audits to ensure food being delivered from the kitchen had been prepared per physician orders. When interviewed on 2/1/21, at 12:00 p.m. the administrator stated the facility had determined the two trays being taken from the kitchen had their plates switched. The administrator explained they encourage the facility departments to work together; however, when NA-C asked if she could help DA-A deliver the last two remaining meal trays we lost our second check. The administrator stated she expected staff to know what they were giving a resident before they gave it to them. Further, the administrator stated she also expected staff to follow physician orders [REDACTED]. A policy Diet Policy/Enhanced Foods, dated 8/2/16, identified the following diet types in the following order: regular, reduced sodium, reduced calorie, small/large portions, and mechanically soft or enhanced pureed. The section labeled mechanically soft or enhanced pureed indicated Any of the above diets may be altered in texture to meet a resident's needs and that a registered nurse (RN) or a certified dietary manager (CDM) can downgrade mechanically soft or enhanced pureed diets and a speech language pathologist (SLP) can upgrade this type of diet. The policy failed to indicate preparation directions or descriptions that identified what a mechanically soft or enhanced pureed diet consisted of.

Based on interview and document review the facility failed to ensure all staff entering the facility were completing COVID screening prior to entering resident care area for the prevention and potential transmission of COVID-19. This had the potential to affect all 29 residents currently residing in the facility at the time of the COVID-19 focused survey. Findings include: On 1/04/21, at 11:00 a.m. the survey team entered the facility via the building's locked main entrance. Surveyors completed a COVID-19 symptom and screening questionnaire, reviewed by a facility' employee after. A facility employee took temperatures, assured eye protection and masks were in place, and hand hygiene was performed before allowing surveyors entrance to the facility. During the entrance conference on 1/04/21, at 11:20 a.m. the director of nursing (DON) stated the facility had 7 confirmed cases (1 currently in the hospital) of COVID-19. During interview on 1/04/21, at 11:52 a.m. licensed practical nurse (LPN)-A stated all employees enter through the back door employee entrance. LPN-A stated staff are to perform hand hygiene, put on their mask and face shield and fill out the questionnaire before entering the facility. LPN-A then stated that another staff person is to verify the information is correction and the form is completed. On 1/04/21, at 12:00 p.m. the employee entrance was observed. There were designated area for staff to complete hand hygiene along with an area to store individualized face shields and masks and complete questionnaires on a clipboard A review of the facilities Annandale Health and Community Services Employee COVID-19 Screening sheets, indicated NA-B worked on 11/26/20. The screening documented NA-A had a temperature (temp) of 96.0 Fahrenheit (F). Even though there was a documented staff screener signature to verify NA-B completed the form, the section of whether NA-B has signs/symptoms (S/S), this column was blank. A review of the facilities Annandale Health and Community Services Employee COVID-19 Screening sheets, from 11/26/20 - 11/29/20, for NA-B the following was documented: > 11/26/20 - temp 96.0 F, s/s area was blank > 11/27/20 - temp 96.9 F, s/s area was blank > 11/29/20 - temp 97.1 F, s/s area was blank > 11/29/20 - there was no evidence of NA-B being screened. In a further review of the facilities Annandale Health and Community Services Employee COVID-19 Screening sheets, from 11/26/20 - 11/30/20, indicated that there was a total of eight (8) employees who had their screening process verified, lacking documention of whether they had s/s of COVID-19. During an interview on 1/04/21, at 3:48 p.m. the director of nursing (DON) after review of the facility's COVID staff screening sheets, the DON stated it appears we have an issue with staff completing them. DON stated that the facility had a informal process, having the nurses checking the screening sheets as a third check for staff documentation. Don stated that the nurses had been educated to review the screening sheets for completion each shift. However, this appears this is not being done. An interview 1/04/21, at 4:46 p.m. LPN-B also stated that staff need to screen themselves with a witness of another staff member. However, LPN-B was unaware that nurses were to check the screening sheets for completion by staff. LPN-B stated maybe the registered nurses do that. A review of the CDC's guidance, entitled: Criteria for Return to Work for Healthcare Personnel with Suspected for Confirmed COVID-19 (Interim Guidance) indicated the following: Time-Based Strategy. Exclude from work until: 10 days have passed since the date of their first positive (COVID-19 diagnostic test assuming they have not subsequently developed symptoms since their positive test. A review of the facility's policy, entitled: Annandale Care Center COVID-19: Infection Prevention & Control (last reviewed 12/2020) indicated that All residents and staff will be tested if symptomatic and went on to list the signs and symptoms the facility will screen their employees for.

Based on interview and document review, the facility failed to ensure nursing staff followed acceptable standards of practice for the disposition of narcotic medication and/or controlled substances (medications regulated and classified by the Drug Enforcement Agency (DEA)) in a manner to prevent potential drug diversion for 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for controlled medication administration and destruction. In addition, the facility failed to have a systematized oversight process to identify discrepancies and unusually patterns related to narcotic and controlled medication administration, destruction, and documentation practices. Findings include: R1's annual Minimum Data Set ((MDS) dated [DATE], identified R1 had severe cognitive impairment with [DIAGNOSES REDACTED]. The MDS indicated R1 had received scheduled and as needed pain medication with opioid pain medication administered daily. R2's admission MDS dated [DATE], identified R2 had severe cognitive impairment with [DIAGNOSES REDACTED]. The MDS indicated R2 had received scheduled and as needed pain medication with opioid pain medication administered daily. R3's quarterly MDS dated [DATE], identified R3 had intact cognition with a [DIAGNOSES REDACTED]. R4's quarterly MDS dated [DATE], identified R4 had moderate cognitive impairment with [DIAGNOSES REDACTED]. The MDS indicated R4 had received scheduled and as needed pain medication with antianxiety and opioid pain medication administered daily. R5's admission MDS dated [DATE], identified R5 had intact cognition with [DIAGNOSES REDACTED]. The MDS indicated R5 had received scheduled and as needed pain medication with opioid pain medication administered daily. An initial report was submitted to the SA on 11/5/20, at 8:15 p.m. by the director of nursing (DON). The incident report identified an allegation that licensed practical nurse (LPN)-C had possibly documented forged signatures of other nursing staff members when she had destroyed narcotic medications belonging to R1 and R4 after the narcotic had been dropped or popped out of card. Subsequent incident reports were submitted to the SA on 11/6/20, at 2:14 p.m., 2:22 p.m., 2:29 p.m., and 2:37 p.m. respectively by the DON. The incident reports identified the SA had directed the facility to submit a separate report for each involved resident. In addition, the four incident reports identified an allegation of probable drug diversion of R1, R2, R3, and R5's narcotic medication by LPN-C. Follow up incident investigation reports submitted to the SA on 11/12/20, for R1, R2, R3, and R4 all indicated, On 11/3/20 it was brought to the DON's attention that some nurses felt (LPN-C) may be diverting narcotics by wasting the medication and saying it was dropped or taken from the wrong card. Further, the report identified, On the morning of 11/4/20, 3 nurses came to see the DON saying they had been looking at the narcotic log book, and felt signatures may have been forged as a cosigner for wasted medication. A few nurses adamantly said some of the signatures were not theirs and a couple of wastes had no cosigner at all. In addition, the report identified after the completed investigation process there had been a policy and procedure change which indicated the facility would perform routine audits of the narcotic log and electronic medical records for any irregularities or discrepancies, along with verifying nursing staff and trained medication aide signatures upon hire with annually witnessed leadership reverification thereafter. LPN-C's employee file indicated a hire date of 6/29/20 and an employment termination date of 11/6/20. LPN-C had been a full time employee with main hours scheduled 2:00 p.m. to 10:30 p.m. An undated facility provided summary of events indicated a history of alleged narcotic mishandling by LPN-C stated as, On August 27, 2020 a warning was issued to (LPN-C) as it was found that she was signing narcotics out of the narcotic ledger and not recording them as given to residents. A conference statement was done with (LPN-C) and we followed up with audits. The undated document additionally included a summary section, dated 11/5/20, identified a more recent audit had been completed which had found (LPN-C) had on multiple occasions signed that narcotics had been wasted due to the medication falling on the floor, having been removed from the wrong card, or in which the medication had popped out of the card. These instances had been identified to occur at higher levels than any other staff nurses. The facility provided summary audit indicated the narcotic books for wing A and wing B had been audited in which the following had been identified: - Wing A book indicated seven narcotic destruction entries that ranged from 8/20/20 through 10/24/20 having occurred between the hours of 1:20 p.m. and 10:05 p.m. The audit indicated the destruction of five [MEDICATION NAME] doses belonged to R2 and R3 and two [MEDICATION NAME] doses having had belonged to R5. The reasons for the medication destruction indicated one dose had fallen on the floor, one dose had popped out of the card, four doses were from the wrong card, and one dose indicated it had been wasted; however, lacked a documented reason. Cosigner information indicated one illegible nurse signature and four identified nurse signatures. Two nurses had been identified to indicate their documented cosign on two of the entries had not been theirs and one nurse had been unable to verify an additional entry co-signature as hers. - Wing B book indicated eight [MEDICATION NAME] destruction entries that ranged from 9/29/20 through 10/31/20 having occurred between the hours of 3:00 p.m. and 12:45 a.m. The [MEDICATION NAME] dosages belonged to R1 and R4. The reasons for the medication destruction indicated three of the doses had been found in the narcotic drawer out of the card, four doses were from the wrong card, and one dose had fallen on the floor. Cosigner information indicated three entries that lacked a cosigner signature and four identified nurse signatures. Two nurses had been identified to indicate their documented cosign on two of the entries had not been theirs and (registered nurse (RN)-A) had been identified to indicate the signature documented on 10/6/20, at 6:00 p.m. had not been her's as she had not worked on that date. Facility nursing schedule, dated 10/6/20, indicated RN-A had not worked on 10/6/20 at 6:00 p.m. Individual Narcotic Record sheets for R1, dated 9/26/20 through 11/2/20, indicated R1 had been administered 100 doses of combined scheduled and PRN [MEDICATION NAME]. Further, the sheets identified five entries that indicated LPN-C as the only nurse who had destroyed R1's [MEDICATION NAME] during the time frame. Medication administration history reports, dated 10/1/20 through 11/30/20, indicated R1 had a physician order [REDACTED]. The November report identified R1 had received zero doses of the PRN [MEDICATION NAME]. An Individual Narcotic Record sheet for R2, dated 9/29/20 through 10/29/20, indicated R2 had been administered 30 doses of PRN [MEDICATION NAME]. Further, the sheets identified one entry that indicated LPN-C as the only nurse who had destroyed R2's [MEDICATION NAME] during the time frame. Medication administration history reports, dated 10/1/20 through 11/30/20, indicated R2 had a (PO) for [MEDICATION NAME] 5mg every four hrs PRN for [DIAGNOSES REDACTED]. The November report identified R2 had received five doses of the PRN [MEDICATION NAME] from staff other then LPN-C. Individual Narcotic Record sheets for R3, dated 8/19/20 through 8/25/20 and 10/14/20 through 10/27/20, indicated R3 had been administered 90 doses of combined scheduled and PRN [MEDICATION NAME]. Further, the sheets identified four entries that indicated LPN-C as the only nurse who had destroyed R3's [MEDICATION NAME] during that time frame. Medication administration history reports, dated 10/1/20 through 11/30/20, indicated R3 had a (PO) for [MEDICATION NAME] 5mg every six hrs PRN and [MEDICATION NAME] 5mg four times a day for [DIAGNOSES REDACTED]. The October report identified R3 had received four doses of the PRN [MEDICATION NAME] in which all four doses had been administered by LPN-C. The November report identified R3 had received one dose of the PRN [MEDICATION NAME] from staff other then LPN-C. An Individual Narcotic Record sheet for R4, dated 8/27/20 through 11/4/20, indicated R4 had been administered 16 doses of PRN [MEDICATION NAME]. Further, the sheets identified three entries that indicated LPN-C as the only nurse who had destroyed R4's [MEDICATION NAME] during the time frame. Medication administration history reports, dated 10/1/20 through 11/30/20, indicated R4 had a (PO) for [MEDICATION NAME] 5mg every four hrs PRN for [DIAGNOSES REDACTED]. The report identified R4 had received four doses of the PRN [MEDICATION NAME] in which one dose had been administered by LPN-C on 11/4/20. Individual Narcotic Record sheets for R5, dated 8/18/20 through 9/5/20, indicated R5 had been administered 59 doses of PRN [MEDICATION NAME]. Further, the sheets identified the dosing of the [MEDICATION NAME] to be 4mg every 4 hrs as needed In addition, the sheets identified two entries that indicated LPN-C as the only nurse who had destroyed R5's [MEDICATION NAME] during the time frame. Medication administration history reports for October and November 2020 were not available for R5 due to R5's discharge from the facility on 9/23/20. During interview on 1/4/21, at 1:38 p.m. RN-A stated it was required that after she administered a controlled or narcotic medication she had to document the administration in both the resident's electronic medication administration record (eMAR) and in the medication cart narcotic book. RN-A explained it was required when she destroyed a controlled or narcotic medication she had to document the destruction in the medication cart narcotic book and on two additional designated forms located in the RN office's locked closet that housed the MedSafe medication destruction container. Further, RN-A explained it was required practice that two staff had to document and witness the controlled or narcotic medication destruction. RN-A stated she had verified to facility administration and the local police department that some of the documented cosign signatures identified as potentially her's in the narcotic book had not been signed by her. When interviewed on 1/4/21, at 1:50 p.m. LPN-A stated not too long after LPN-C had started working for the facility she had noticed during her own medication administration passes that it appeared as if LPN-C gave more narcotics to residents then they typically took when other nurses worked. Further, LPN-A explained she would often find LPN-C had signed narcotics out in the narcotic book but did not sign the same narcotic out in the eMAR. LPN-A explained at the time administration had been updated about her concerns. LPN-A stated it was required to have two staff involved in the destruction of any controlled medication. During interview on 1/4/21, at 4:20 p.m. the DON stated her expectation would be that any controlled medication was to be documented in both the eMAR and the medication cart narcotic book. Further, the DON explained her expectations regarding controlled medication destruction would be that the process should be documented in the narcotic book as to why the destruction was required and that the actual destruction process step was witnessed by two staff. The DON voiced that LPN-C had not performed these expectations consistently and back in August of 2020 when she had questioned LPN-C, she would give excuses. The DON stated audits at that time had been completed regarding LPN-C's narcotic administration and documentation practices in which the audits had shown improvements and no major concerns. No further audits had been completed that pertained to LPN-C's medication administration performance. The DON voiced she had not had knowledge of any further concerns regarding LPN-C's controlled medication documentation and destruction practices until LPN-D had updated her in November of 2020 on concerns she had regarding LPN-C. The DON explained during staff interviews staff had voiced confirmation that some of the cosigned signatures had not been theirs. In addition, the DON explained she had not felt any resident had missed any scheduled medication dose/s in relation to LPN-C's actions of potential controlled medication theft; however, the DON did voice the financial impact to the residents had been a concern. The DON stated facility practice had been for the night nurse to do audits that watched for discrepancies and further explained this had been the reason LPN-D brought the issues to light. During a telephone interview on 1/5/21, at 12:47 p.m. LPN-C confirmed she had access to resident controlled medications during her employment and she further confirmed she had knowledge of the facility's policy for narcotic medication documentation and destruction procedures. LPN-C explained after she had administered a controlled medication she documented the administration in the resident's eMAR and in the narcotic book and then when she destroyed a narcotic medication this process had required two staff. LPN-C voiced there had been occasions where documentation had been missed due to the computer system was bad or she had gotten busy and would forget to sign out the administered medications in the eMAR. LPN-C denied resident medication theft practices and stated that she has not used drugs recreationally. During a telephone interview on 1/5/21, at 1:42 p.m. LPN-D stated she had felt something was off when she and LPN-C had performed a shift change controlled medication count. LPN-D voiced she had been unable to remember the exact date of this count with LPN-C. LPN-D explained she noticed in the narcotic book that a pill had been destroyed the day before by LPN-C with an indicated reason that it had fell out of the card. LPN-D stated LPN-C had explained she had destroyed the medication with another staff member; however, LPN-D could not recall the nurse that LPN-C had indicated. In addition, LPN-D voiced she had again questioned another narcotic destruction entry completed by LPN-C during the following day's evening shift count in which LPN-C had again stated she had destroyed the medication due to something had been wrong with the card. LPN-D stated she had reported her suspicions to the DON the following morning after that second shift count with LPN-C. Formal night shift narcotic and controlled medication audits performed prior to the allegation were not provided. A policy Medication Destruction, revised 11/19, indicated medications were to be destroyed in a safe, efficient manner consistent with established facility procedures and DEA requirements in which two nurses were to perform and witness the destruction of controlled medications/narcotics and schedule II-V medications. The policy failed to identify steps and/or processes the facility took to decrease the risk of drug diversion above and beyond general shift to shift narcotic counting and the policy further failed to direct staff on potential signs of drug diversion and how to identify drug diversion indicators. A policy Controlled/Narcotic Medications, reviewed 3/20, indicated the procedure in the event a controlled drug dose had become broken, partially used, discarded or lost required the nurse to record the dose on the narcotic book page, the nurse and another nurse would co-sign the proof of use sheet (narcotic book page), and the medication would be placed in the MedSafe for destruction. The policy failed to identify steps and/or processes the facility took to decrease the risk of drug diversion above and beyond general shift to shift narcotic counting and the policy further failed to direct staff on potential signs of drug diversion and how to identify drug diversion indicators. A policy Administration of Medications, revised 3/5/19, indicated six rights of medication administration staff were to follow when medications were administered. The sixth right identified pertained to the right documentation in which staff were to, Promptly and accurately document the medication administration. The policy further indicated, After each medication is administered, document each medication in the correct box in the MAR (medication administration record), and to, Ensure accurate documentation of all medications. The policy failed to identify steps and/or processes the facility took to decrease the risk of drug diversion above and beyond general shift to shift narcotic counting and the policy further failed to direct staff on potential signs of drug diversion and how to identify drug diversion indicators.

Based on interview and document review, the facility failed to ensure a background check was obtained and verified prior to allowing unsupervised access to residents for 2 of 13 employees reviewed as part of a background check sample following an investigation of a narcotic medication theft involving a staff member (See F755). Findings include: On 1/4/21, licensed practical nurse (LPN)-C's employee file lacked evidence a background study had been obtained and verified upon hire or during her employment at the facility. In addition, LPN-C's file lacked evidence of an Annandale Care Center - Hiring Packet Checklist. LPN-C's employee file indicated she had been hired on 6/19/20, with a start date of 6/22/20, and had been terminated on 11/6/20. The facility was asked to provide documentation of LPN-C background study, but no additional documents were provided. A requested Employee Information report dated 1/5/21, at 3:33 p.m. identified DA-B had been hired on 9/1/20 and was an active dietary employee. Dietary aide (DA)-B's background check indicated it had been performed on 1/5/21, with no evidence a background check had been submitted previously. When interviewed via telephone on 1/5/21, at 1:56 p.m. the director of nursing (DON) stated facility staff were unable to find LPN-C's background study. The DON voiced the facility had contacted the Minnesota (MN) Department of Human Services (DHS); however, she explained MN DHS had been unable to provide them with proof that a background check had been initiated. The DON stated human resources (HR) had been responsible for completing LPN-C's background study upon LPN-C's hire. The DON explained this HR staff member was no longer employed at the facility; however, an HR staff member was in the process of being trained. The DON denied the facility had reviewed employee files to ensure each employee had a background study obtained and verified after the HR member left her employment. The DON stated LPN-C's lack of a background study had appeared to be an isolated incident. During a telephone interview on 1/5/21, at 3: 57 p.m. the administrator stated the facility performed a digital check list to ensure items were completed for new employees, which included a background check. When questioned on LPN-C's digital check list, the administrator stated, We found the form but did not actually do the check. When interviewed via telephone on 1/6/21, at 12:38 p.m. HR-A stated her typical practice had been to perform the background check with the employee present. HR-A stated she could not say with 100 percent accuracy that she had completed LPN-C's background check; however, she verbalized that she felt it had been done. HR-A explained for background check auditing the facility had used an electronic form; however, she stated she had relied a lot on the emails that came from DHS as once it was in the system it would generate what was going on. During a follow-up telephone interview on 1/6/21, at 1:46 p.m. the administrator stated DA-B's background study had been missed potentially due to, Dietary thought HR was doing it and HR thought dietary was doing it. The administrator explained she felt, It (DA-B's background study) slipped through the cracks and no one knew who was supposed to do it. The administrator stated employee background studies are very important and have to be done to keep residents safe. A policy Annandale Health & Community Services' Facility Abuse Prevention Plan, dated 8/1/05, indicated, All employees will have a background check initiated at hire. Potential employees will be screened for a history of abuse, neglect or mistreating residents. This includes checking with the appropriate licensing boards and registries. If a background study is pending, staff will follow the recommendations of the background study for needed supervision. A policy Background Study, reviewed 1/2020, indicated that newly hired employees completed a background study through MN DHS prior to their first day of work. The policy identified the employee met with the HR manager or delegate to complete the background study together and that the HR manager or delegate followed up with the employee prior to the first day of work to ensure the entire process had been completed.

Based on interview and document review, the facility failed to report allegations of medication theft to the State Agency (SA) within 24 hours for 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for misappropriation of property. Findings include: R1's annual Minimum Data Set ((MDS) dated [DATE], identified R1 had severe cognitive impairment, had the ability to usually understand others and others usually understood her, and she required extensive physical assist for cares. [DIAGNOSES REDACTED]. The MDS indicated R1 had received scheduled and as needed pain medication with opioid pain medication administered daily. R1's self reported occasional, moderate pain; however, had been unable to express if the pain had impacted her sleep or day to day activities. R2's admission MDS dated [DATE], identified R2 had severe cognitive impairment, had the ability to usually understand others and others usually understood her, and she required limited to extensive physical assist with cares. [DIAGNOSES REDACTED]. The MDS indicated R2 had received scheduled and as needed pain medication with opioid pain medication administered daily. R1 self reported occasional pain with a score of 9 based on a zero to ten pain scale. R3's quarterly MDS dated [DATE], identified R3 had intact cognition and communication skills and had been overall dependent on others for her cares. [DIAGNOSES REDACTED]. The MDS indicated R3 had received scheduled pain medication with opioid pain medication administered daily. The MDS identified R3's ability to participate in a pain interview; however, one had not been conducted at that time. R4's quarterly MDS dated [DATE], identified R4 had moderate cognitive impairment, had the ability to usually understand others and others usually understood her, and she required extensive physical assist for cares. [DIAGNOSES REDACTED]. The MDS indicated R4 had received scheduled and as needed pain medication with antianxiety and opioid pain medication administered daily. The MDS indicated R4 had been unable to verbalize pain status; however, staff indicated R4 verbalized pain and displayed nonverbal indicators of pain daily. R5's admission MDS dated [DATE], identified R5 had intact cognition and communication skills and had required extensive physical assist for cares. [DIAGNOSES REDACTED]. The MDS indicated R5 had received scheduled and as needed pain medication with opioid pain medication administered daily. The MDS identified R5's ability to participate in a pain interview: however, one had not been conducted at that time. An initial report was submitted to the SA on 11/5/20, at 8:15 p.m. by the director of nursing (DON). The incident report identified an allegation that a nursing staff member had possibly documented forged signatures of other nursing staff members when she had destroyed narcotic medications belonging to R1 and R4 after the narcotic had been dropped or popped out of card. The date and time of the incident was identified as 11/5/20, at 7:00 p.m. Subsequent incident reports were submitted to the SA on 11/6/20, at 2:14 p.m., 2:22 p.m., 2:29 p.m., and 2:37 p.m. respectively by the DON. The incident reports identified the SA had directed the facility to submit a separate report for each involved resident. In addition, the four incident reports identified an allegation of probable drug diversion of R1, R2, R3, and R5's narcotic medication by a nursing staff member. The date and time of the incidents was identified as 11/5/20, at 6:00 p.m. Follow up incident investigation reports submitted to the SA on 11/12/20, for R1, R2, R3, and R4 all indicated, On 11/3/20 it was brought to the DON's attention that some nurses felt (licensed practical nurse (LPN)-C) may be diverting narcotics by wasting the medication and saying it was dropped or taken from the wrong card. In addition, the summary identified, On the morning of 11/4/20, 3 nurses came to see the DON saying they had been looking at the narcotic log book, and felt signatures may have been forged as a cosigner for wasted medication. A few nurses adamantly said some of the signatures were not theirs and a couple of wastes had no cosigner at all. When interviewed on 1/4/21, at 4:20 p.m. the DON stated that on 11/3/20, later in the day, nursing staff brought allegations of narcotic medication concerns to her. The DON explained after she had started the investigation, I thought there was enough evidence that we were going to have to do something; however, the DON further explained it had taken her time to put everything together. The DON stated after nursing staff had confirmed their signatures (documented as cosigners for narcotic destruction) had not been theirs she knew that it (the allegation) was reportable. The DON stated she had reported the allegation to the SA after she had talked to the administrator; however, she explained, We had to wait for legal. In addition, the DON expressed there had been no physical danger to the residents and, We just felt no further financial abuse was going to happen while waiting for legal, as LPN-C had not been working during the time of the investigation. The DON confirmed if there is an allegation of abuse the allegation is to be reported (to the SA) within two hours and she confirmed the allegation should have been reported on 11/3/20. When interviewed via telephone on 1/5/21, at 3:57 p.m. the administrator stated she expected staff to report abuse right away; however, she explained, I think our thought process was skewed based on how the investigation had been initiated. In addition, the administrator stated she had initially thought it had been a peer issue until we actually looked into it and felt we needed to report. The administrator explained, In hindsight we should have just filled it (SA abuse report) out. A policy Annandale Health & Community Services' Facility Abuse Prevention Plan, dated 8/1/05, indicated, The Administrator is notified immediately of any suspected abuse. Immediately is defined as 'as soon as possible but no later than 24 hours after an incident'. Social Services or other designated staff will immediately report to appropriate agencies. In addition, the policy identified, All employees of AHCS (Annandale Health Care System) are mandated reporters of any suspected abuse or neglect of a Vulnerable Adult. The Social Services department or designee will file the report during normal business hours; after hours, on weekends or holidays, the RN (registered nurse)/LPN on duty or on-call are trained to make the submission, and, Any person with the knowledge or suspicion of suspected violations shall report immediately, without fear of reprisal if the report is made in good faith.

Based on interview and document review, the facility failed to develop and implement a comprehensive infection prevention and control program (IPCP) to include surveillance of all potential infections; ongoing, comprehensive analysis of all collected surveillance data; and demonstrated investigation(s) of developed infections to help prevent potential recurrence and/or spread within the facility. This had potential to affect all 43 residents residing in the facility at the time of the COVID-19 Focused Infection Control survey. Findings include: On 4/30/20, at 1:29 p.m. the director of nursing (DON) and administrator were interviewed. They voiced the facility had no active or presumptive COVID-19 cases. At this time, the surveillance and analysis of the facility' IPCP was requested. An Antibiotics per Month listing, dated 3/1/20 to 3/31/20, identified a total of three residents had been treated with four different antibiotics. The listing identified two different residents had been treated for [REDACTED]. Further, one resident was identified to have a [MEDICAL CONDITION] (infection of the skin) infection which required 5 days of antibiotic therapy. There were no listed infections or resident infection symptoms which were not treated with antibiotics (i.e. common cold symptoms, [MEDICAL CONDITION] infections). A series of Allina Health-Medical Laboratories results, dated 3/25/20 and 3/26/20, identified both residents whom were listed as having UTIs on the facility' surveillance (outlined above). These results both identified the organism for the UTI as Proteus Mirabilis. An Overview of Infection Tracking and Monitoring, dated 3/2020, identified there were no identified trends of infection within the facility. A section was listed which read, UTI Infections: 2 residents with UTIs acquired in house. One resident was treated with 2 different antibiotics. An additional section was listed which read, Skin Infection: One resident with [MEDICAL CONDITION] acquired in house. Further, the completed form listed a comparison from March 2019, which read, No trends in infections noted from March 2019 to March 2020. The completed analysis demonstrated no evidence if any urinary cultures had been obtained and/or reviewed to determine if the UTI' were related; nor did the analysis demonstrate any investigation which had been completed into any of the facility acquired infections to help reduce the risk of recurrence to the same and/or other resident(s). Further, the analysis lacked evidence the facility had reviewed and compared the identified staff illnesses with resident illnesses to determine if any could be related. There was no documented, provided evidence which demonstrated the facility had a system for tracking non-antibiotic treated infections (i.e. [MEDICAL CONDITION] infections); nor any evidence demonstrating a comprehensive analysis of the identified infections was completed despite have two UTI with the same causative organism. Further, there was no provided evidence the facility had reviewed or investigated the developed infections for potential causes and addressed any subsequent action needed to reduce the risk of recurrence to the same and/or other resident(s). On 4/30/20, at 2:13 p.m. registered nurse (RN)-A was interviewed and stated herself along with the director of nursing (DON) helped manage the entire IPCP for the facility. RN-A explained she collected data for the program by reviewing progress notes and getting reports from the unit case managers. An Antibiotic Medications Report was reviewed so they could exclude antibiotics used for [MEDICATION NAME] reasons; and any acquired or hospital admitted infections were then placed on the Antibiotics per Month listing. RN-A stated the program did not track non-antibiotic treated infections or symptoms, however, there was some tracking done for those more in house in the separate resident' medical records. RN-A stated the collected surveillance data was then reviewed for trends and patterns on a monthly basis; then compared to the same month' data from a year prior. RN-A stated she was unsure why the data was compared to a year prior, however, it had just been their process for several years so she continued it. RN-A acknowledged the lack of a comprehensive analysis, including review of applicable cultures as directed by their policy, and added they had done it the same way for several years as they had never been told it was incorrect. Further, RN-A voiced completing an analysis, including investigating infection sources and causes, was important as it helps to see if there's trends or a staff concern. When interviewed on 4/30/20, at 2:36 p.m. the DON stated she oversaw the entire IPCP. The IPCP and lack of analysis was reviewed and DON stated she felt the staff were doing all those things, however, they were not being documented to reflect that. Further, the DON expressed the facility did not have a process to ensure non-antibiotic treated infections were tracked; and they would develop one to include it in the program. The provided Infection Control Surveillance Report Forms policy, dated 4/2020, identified surveillance was a method the facility used to find, analyze and control, and prevent nosocomial infections. The policy read, This collection, collation, and analysis of data is done to pass on information to those who are able to take action. The policy outlined several components of surveillance which included, Analysis A. Cultures B. Changes in prevalent organisms C. Clusters of prevalent organisms D. Increase in rates. Further, the policy directed data would be reviewed monthly for residents and employees for patterns; and resident illnesses would be tracked in the medical record and reported to the Quality Assurance (QA) program every six months. The policy lacked any information on how the program would track non-antibiotic treated infections or if/when investigations into the infections would be done. An additional provided Infection Control Policy, dated 11/2019, identified the objective of the requirement was for the facility to develop a comprehensive policy which established a facility-wide system for the prevention, identification, investigation and control of infections of residents, staff and visitors. The policy outlined it would be based upon a Facility Assessment and follow national standards and guidelines. From those, written policies and procedures would be developed which included several items including surveillance, reporting and how/when transmission-based precautions would be used. However, the policy lacked any information or guidance on how non-antibiotic treated infections were to be tracked; nor any dictation regarding how identified infections would be investigated to reduce the risk of recurrence.

Based on observation, interview and document review, the facility failed to ensure assessed interventions to reduce the risk of pressure ulcer formation were implemented for 1 of 1 residents (R37) reviewed for pressure ulcer care. Findings include: R37's quarterly Minimum Data Set (MDS), dated [DATE], identified R37 was cognitively intact and required extensive assistance to completed their activities of daily living (ADLs). Further, R37 was at risk for pressure ulcers and had one (1) unhealed stage 2 pressure ulcer, and had been formally and clinically assessed. R37's care plan, dated 2/24/20, identified R37 had a stage III pressure ulcer on (right) lateral malleolus (a bony projection on either side of the ankle) and listed a goal which read, Pressure ulcer will be healed by 5/18/2020. A series of interventions were listed to help R37 meet this goal which included, Pillow placed under right foot to float while in bed. In addition, an undated, provided nursing assistant care sheet listed R37 with an intervention which read, Float Heels. On 3/4/20, at 9:34 a.m. R37 was observed laying in bed. R37's heels were not floated with any visible devices or pillows and R37 had shoes on. At 10:48 a.m. (over an hour later), R37 remained in bed without their heels float and their shoes remained on. During interview on 3/04/20, at 10:50 a.m. nursing assistant (NA)-A stated R37 had been in bed since returning from breakfast around 9:00 a.m. NA-A acknowledged the lack of a pillow under R37's heels and stated it appeared to have been forgotten. Further, R37 will often refuse to have his shoes removed when in bed. On 3/05/20, at 9:06 a.m. registered nurse (RN)-A was interviewed and stated R37 should not have his shoes on while in bed and his heels should have been floated. R37 was dependant on staff for repositioning, and floating his heels was done to help prevent the development of pressure ulcers on his heels. The facility policy for pressure ulcer assessment and prevention was requested, however not provided.

Based on observation, interview and document review, the facility failed to comprehensively reassess and implement a process to ensure consumed fluids were adequately tracked and monitored to help prevent fluid overload for 1 of 1 residents (R3) reviewed who had an ordered fluid restriction. Findings include: R3's quarterly Minimum Data Set (MDS), dated [DATE], identified R8 had moderate cognitive impairment and was independent with eating after set up. Further, R3 had several medical [DIAGNOSES REDACTED]. R3's Nutritional Assessment, dated 12/9/19, identified R3 consumed a reduced calorie, regular texture diet with small portions. R3's fluid intake was identified as 1500-2000 cc's (cubic centimenters) a day and R3 was labeled as being at high risk for nutrition. Further, R3's Hydration Assessment was completed on 12/3/19, and identified R3 was independent with fluid consumption. On 3/220, at 7:48 p.m. R3 was observed sitting in her wheelchair with her feet flat on the floor. R3's feet and legs had visible swelling and R3 expressed she should probably have them elevated. R3 explained she had kidney problems and should likely be on [MEDICAL TREATMENT] (a process which removes excess fluid and toxins from the blood for people with kidney failure). R3 expressed she consumed swelling pills to reduce her fluid build-up, however, then voiced frustration as they (staff) won't let me have what I want to drink and proceeded to pick up a water mug from her bedside table which was empty to accentuate the point. R3's Emergency Department (ED) report, dated 2/25/20, identified R3 had been seen in the ED with severe underlying [MEDICAL CONDITION] (low heart rate of less than normal adult heart rate of 60 beats per minute) with a heart rate in the 40's. R3 was listed as receiving a daily dose of [MEDICATION NAME] (a diuretic medication) and R3 was kept in the ED under observation with several [DIAGNOSES REDACTED]. R3 returned to the nursing home on 2/26/20, with orders for a fluid restriction not to exceed 2000 ml (milliliters) in a day. R3's care plan, last revised 3/2/20, indicated R3 received a reduced calorie diet, and made poor choices with excessive use of salt on foods. R3 was to receive 1440 cc's from dietary per day, and was allowed 560 cc's from nursing staff per day (to total 2000 cc's per day). R3 was listed as being at risk of dehydration and directed staff to encourage fluids at meals and in between and continued, Independent with meals and fluids between meals. R3's medical record was reviewed and lacked evidence R3 had been comprehensively reassessed for their nutritional and hydration needs, including R3's input, despite having to present at the ED and being ordered with a fluid restriction. Further, there was no evidence in the medical record R3's total fluid intake (consumed with meals and in-between meals) was consistently tracked and monitored to ensure the ordered fluid restriction was not breached increasing R3's risk for fluid overload. On 3/5/20, at 1:35 p.m. licensed practical nurse (LPN)-A stated she was unaware how the fluid intake was tracked for R3. LPN-A stated R3 was able to request water or fluids, if she wished, however, again reiterated she was unsure as to how all consumed fluids were tracked for R3. On 3/5/20, at 1:39 p.m registered nurse (RN)-C stated a plan was identified to let staff know the amount of fluids R3 could have between meals, however, staff did not track R3's actual intake of fluid outside of meals. RN-C stated R3's intake at meals was monitored by the dietary staff, however, this would not accurately reflect her total daily intake. On 3/5/20, at 1:47 p.m. NA-B stated R3 can have whatever fluids were allowed on the care plan. A review of the current NAR (Nursing Assistant-Registered) Daily Assignment Sheet B Wing dated 3/4/20, lacked any indication of a fluid restriction, and only identified No Orange juice d/t (due to )diarrhea. NA-B stated they thought R3's fluids from nursing staff were tracked in the Medication Administration Record [REDACTED] On 3/5/20, at 2:51 p.m. RN-D state intake monitoring was to reflect all fluids consumed for the day to be able to determine what was actually consumed for the day. A facility Intake and Output policy dated 12/19, identified intake and output may be recorded for residents who may be on fluid restrictions. The policy identified all fluids are to be recorded at the end of the shift. The policy indicated the provider, dietary staff, and care plan was to be updated as indicated.

Based on interview and record review the facility failed to ensure residents were free of significant medication errors for one of five residents (R1) reviewed when R1 was not administered [MEDICATION NAME] (an oral blood thinner) for 15 days and was subsequently hospitalized , and died . Findings include: R1's medical record was reviewed. R1 was admitted with a [DIAGNOSES REDACTED]. R1 received [MEDICATION NAME] (an oral blood thinning medication) to prevent further [MEDICAL CONDITION]. R1's care plan dated [DATE], indicated R1 required limited assistance of one staff for toileting. R1's physician's orders [REDACTED]. The therapeutic goal set by the physician for the INR value was between ,[DATE]. R1's physician's orders [REDACTED]. R1's physician's orders [REDACTED]. R1's physician's orders [REDACTED]. R1's physician's orders [REDACTED]. Medical records indicated there was no INR check completed on [DATE] as ordered by R1's physician. R1's Medication Administration Record [REDACTED]. A medication error report completed by RN-F dated [DATE], indicated R1 had not received [MEDICATION NAME] from [DATE] to [DATE], due to a transcription error in which the order to recheck the INR was not entered, so a new order for [MEDICATION NAME] was not received. R1's medical record indicated the physician consulted regarding the omission of [MEDICATION NAME] on [DATE]. R1's physician order [REDACTED].) R1's physician order [REDACTED]. R1's physician orders [REDACTED]. R1's physician orders [REDACTED]. R1's nursing progress note dated [DATE], at 12:46 p.m. indicated R1 reported severe pain and an order was received by the physician to send R1 to the emergency room . R1's emergency room provider progress note dated [DATE], at 3:45 p.m. indicated R1's INR value was 1.8 and diagnosed R1 with an abdominal wall hematoma (a collection of blood outside of a vessel). R1 was discharged back to the facility after approximately five hours. R1's physician's orders [REDACTED]. R1's nursing progress note dated [DATE], at 9:55 p.m. indicated R1 had been weak and required two staff to help R1 stand. R1's nursing progress note dated [DATE], at 3:45 a.m. indicated R1 complained of severe abdominal pain. R1 was given 650 mg of Tylenol for the pain. The medical record did not indicate if the Tylenol was effective. R1's nursing progress note dated [DATE] at 9:23 a.m. indicated R1 was slow to answer questions and had vomited a small amount of undigested food. R1's nursing progress note dated [DATE] at 9:49 a.m. indicated R1 had been confused and hallucinating all morning. R1's nursing progress note dated [DATE] at 11:02 a.m. indicated R1's blood sugar was 351 but R1 was not symptomatic. The provider's nurse was updated on the emergency room visit on [DATE] and that R1 was confused, hallucinating, and had vomited this morning. R1's nursing progress note dated [DATE] at 9:51 p.m. indicated when staff got R1 up for dinner at 4:45 p.m. they needed to use a transfer device to move R1 out of bed. However, during the transfer R1 looked as if R1 was going to pass out. The staff stopped the transfer and assisted R1 back to bed. R1 felt cool and clammy when touched. The nurse took R1's vital signs. R1's temperature was 97.1, pulse 68, respirations 28, and the blood pressure was ,[DATE]. The nurse rechecked the blood pressure 30 minutes later and R1's blood pressure was ,[DATE]. Fluid was encouraged and at 9:00 p.m. the nurse rechecked the blood pressure it was ,[DATE]. R1's nursing progress dated [DATE] at 1:49 a.m. indicated R1 had stomach pain that was terrible and R1 was given an icepack. R1's nursing progress note dated [DATE] at 7:52 a.m. indicated R1 was too weak to stand and could not transfer using a gait belt and one staff. R1 required three staff to bring R1 to the toilet. R1 indicated he had abdominal pain when straining on the toilet. R1 was assisted off the toilet to the wheelchair with three staff. The nurse took R1's vital signs. R1's temperature 96.1, pulse 84, respirations 32, and the blood pressure was ,[DATE]. R1 indicated s/he was very sleepy. R1's nursing progress noted dated [DATE] at 8:29 a.m. indicated the nurse contacted a nurse practitioner at R1's clinic and received orders to send R1 to the emergency room . R1's emergency room provider progress note dated [DATE], at 10:02 a.m. indicated R1's INR was 4.2 with internal bleeding due to [MEDICATION NAME] injections. The same day, R1 was transferred to another hospital better able to manage the care R1 required. R1's hospital discharge summary dated [DATE] at 5:09 p.m. indicated the hospital was unable to reverse the effects of R1's bleeding. R1 passed away [DATE] at 9:00 p.m. due to acute blood loss. R1's death certificate dated [DATE] indicated cause of death as acute blood loss from abdominal bleed. An interview was conducted on [DATE], at 9:09 a.m. with medical record coordinator (MRC)-M, who stated his/her job duties included transcribing orders. S/he stated s/he entered R1's [MEDICATION NAME] to be given from [DATE] through [DATE] and forgot to enter the order to recheck the INR. MRC-M stated without the INR recheck, the [MEDICATION NAME] order expired and dropped off the electronic Medication Administration Record [REDACTED] An interview was conducted on [DATE], at 11:41 a.m. with RN-F, who stated that s/he discovered the omission of R1's [MEDICATION NAME] when conducting a medication review on [DATE]. RN-F stated s/he notified the director of nursing (DON) and the physician. An interview was conducted on [DATE], at 2:18 p.m. with the doctor of pharmacy (Pharm.D.)-L, who stated s/he completed a monthly review of R1's medications on [DATE] and noted the [MEDICATION NAME] had expired on [DATE]. S/he further stated there had been no red flag in the nurse's notes or the physician's notes to check deeper as to why R1 was no longer receiving [MEDICATION NAME]. Pharm.D.-L stated there was no other place in the medical record that tracked a resident on [MEDICATION NAME]. A review of the facility's policy on order transcription dated ,[DATE], indicated medical records personnel or a nurse entered new [MEDICATION NAME] orders into the computer without a stop date, and a second verification of the order was completed by a nurse.