Every finding on record at Cherith Care Center at Willow Brook

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure residents had appropriate indications for use of antipsychotic medications. This affected one (Resident #21) of two residents reviewed for psychotropic medication use. The census was 32.Findings Include: Review of the medical record revealed Resident #21 was admitted to the facility on [DATE]. Diagnoses included vascular dementia, restlessness and agitation, osteoarthritis, hypertension, hyperlipidemia, hypothyroidism, dysphagia, edema, vitamin D deficiency, and unspecified protein calorie malnutrition. Review of Resident #21's Minimum Data Set (MDS) assessment, dated 03/04/26, revealed he had severe cognitive impairment.Review of Resident #21's physician orders revealed he was admitted to the facility with an order for the antipsychotic medication quetiapine 150 milligrams (mg) twice daily for dementia, behaviors related to vascular dementia with severe agitation. The order was started on 11/24/25.Review of Resident #21's current care plan revealed a focus area of Resident #21's use of psychotropic medications related to vascular dementia with agitation resulting in risk of injury to self or others. Interventions for the care plan included discussing with a medical doctor and family regarding the ongoing need for the use of the medication and review behaviors/interventions and alternate therapies attempted and their effectiveness per facility policy.Review of Resident #21's progress notes, dated 11/24/25 to 04/24/26, revealed no progress notes to provide further justification or clarity for the order of quetiapine 150 mg twice daily. There were no psychiatry notes and/or physician notes to monitor, discuss, or justify the use of quetiapine other than dementia and behaviors. Review of Resident #21's psychotropic medication informed consent form, dated 12/03/25, revealed he was prescribed quetiapine for the diagnosis of vascular dementia, severe with agitation and restlessness and agitation. A handwritten note was added to the form that read, admitted with medications in place.Interview with the Director of Nursing (DON) on 04/23/26 at 11:03 A.M. confirmed the facility did not have any other diagnoses other than dementia with agitation and restlessness for the justification of using quetiapine for Resident #21. The DON confirmed the facility did not us psychiatry services for Resident #21 due to being on hospice services and his primary care physician was the person who ordered and monitored the medication. The DON confirmed Resident #21 was admitted to the facility from the facility's assisted living facility with the medication order in place, so they were maintaining it. The DON confirmed the facility would contact Resident #21's primary care provider to discuss the diagnosis and use of quetiapine to determine if it remained justified.Review of the facility medication monitoring policy, dated 06/21/17, revealed a resident's medication regimen shall promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, as identified by the resident and/or representative(s) in collaboration with the attending physician and facility staff. If drug therapy with a psychotropic drug was indicated, then the agent selected should be the most effective, have the fewest potential side effects and be used in the lowest possible dose for that resident.

Based on medical record review and staff interview, the facility failed to ensure hospice provider documentation, including plans of care, assessments, and care notes, were provided to the facility in a timely manner to ensure the continuity of resident care. This affected one (Resident #3) of one residents reviewed for hospice services. The facility census was 32.Findings include: Review of the medical record for Resident #3 revealed an admission date of 09/29/25 with diagnoses including Alzheimer's disease, pulmonary hypertension, history of transient ischemic attack, traumatic fracture, chronic diastolic heart failure and sepsis.Review of the hospice admission consent dated 01/12/26, signed by Resident #3's representative, revealed consent was provided to initiate for hospice services.Review of a physician order dated 01/12/26 revealed an order to admit Resident #3 to hospice with a diagnosis of hypertensive heart disease with heart failure.Review of Resident #3's medical record revealed hospice documentation available for review consisted of only four home health/hospice nurse visit notes dated 03/09/26, 03/20/26, 03/31/26, and 04/06/26.On 04/23/26 at 12:58 P.M. and interview was conducted with the Director of Nursing (DON) requesting Resident #3's hospice records. A follow up interview on 04/23/26 at 2:38 P.M. with the DON confirmed hospice records had not yet been obtained.Interview on 04/23/26 at 3:10 P.M. with the Director of Assisted Living (DAL) #230 revealed they were still attempting to obtain hospice notes and expressed frustration regarding difficulty reaching the hospice provider. DAL #230 confirmed that without the documentation readily available, staff could not determine whether the resident had a change in condition, a change in plan of care, abnormal assessment findings, or new physician orders. DAL #230 confirmed hospice records should be readily available onsite for all residents receiving hospice services.Interview on 04/23/26 at 3:19 P.M. with the Administrator and the DON revealed it required multiple calls with multiple staff with the hospice provider to obtain the resident's hospice documentation. The records were received approximately two and a half hours after the initial request and included the plan of care, level of care, assessments, evaluations, narratives, vital signs, and interventions.

Based on review of the payroll based journal (PBJ), staff interviews and record review, the facility failed to ensure a Registered Nurse (RN) worked at least eight consecutive hours, seven days a week. This had the potential to affect all facility residents. Facility census 30. Findings include Review of the PBJ report from the review period of 10/01/24 to 12/31/24 revealed the facility triggered for no RN for at least eight hours a day, seven days per week. Review of the registered nurse schedule for October 2024 revealed on 10/05/24, 10/06/24, 10/19/24, and 10/20/24 the facility had no RN working in the nursing home. Review of the registered nurse schedule for November 2024 revealed on 11/02/24, 11/03/24, 11/16/24, 11/17/24 and 11/30/24 had no RN working in the nursing home. Review of the registered nurse schedule for December 2024 revealed on 12/01/24, 12/14/24, 12/15/24, and 12/29/24 the facility had no RN working in the nursing home. Interviews on 05/22/25 from 1:00 P.M. to 3:30 P.M. with the Administrator and Minimum Data Set (MDS) Nurse #389 confirmed the information provided for the PBJ report identified the facility did not always have an RN scheduled to provide care in the facility. They also confirmed the schedules had several days without RN coverage including four days in October and December and five days in November. The Administrator stated the facility had been using the RN that was working in the assisted living as the RN coverage.

Based on record review, interview and policy review the facility failed to include all required information on the skilled nursing advanced beneficiary notice (ABN). This deficient practice affected two (Resident #14 and Resident #238) of three residents reviewed for cut letters. The facility census was 40. Finding include: 1. Review of the medical record for Resident #238 revealed an admission date of 02/16/2025. Diagnoses included dementia, difficulty walking, chronic kidney disease, adult failure to thrive, dementia, pressure ulcer of the sacral region, abnormal weight loss, encephalopathy, cognitive communication deficit, and Parkinson's disease. Review of the Skilled Nursing Facility ABN for Resident #238 revealed Beginning on (no date written), you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. Interview on 05/22/2025 at 2:25 P.M. with Social Worker (SW) #360 confirmed the missing date on the ABN form for Resident #238. SW#360 confirmed that the ABN form should be filled out completely when providing them to residents or their representatives. 2. Review of medical record for Resident #14 revealed an admission date of 03/14/25. Diagnosis included hypertension, chronic obstructive pulmonary disease, chronic pain syndrome, muscle weakness, vascular dementia, difficulty walking, cognitive communication deficit, and dysphagia. Review of the Skilled Nursing Facility ABN for Resident #14 revealed Beginning on (no date written), you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. The cares you have been receiving during the inpatient skilled nursing facility include: physical and occupational therapy. Further review of Resident #14's ABN revealed We estimate that these services will cost you $ (left blank) per day/item or service. Interview on 05/22/2025 at 2:26 P.M. with Social Worker (SW) #360 confirmed the beginning on date and estimated service cost were not filled out on the ABN form for Resident #14. SW#360 confirmed that the ABN form should be filled out completely when providing them to residents or their representatives. Review of facility policy, Advance Beneficiary Notices dated 2025 revealed, The facility shall inform Medicare beneficiaries of his or her potential liability for payment. A liability notice shall be issued to Medicare beneficiaries and For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice Form.

Based on record review, interview, observation and policy review the facility failed to ensure physician ordered wound treatments were in place to promote wound healing This affected one (Resident #9) of one residents reviewed for pressure ulcers. The facility census was 40. Finding include: Review of the medical record for Resident #9 revealed an admission date of 02/10/2018. Diagnoses included dementia, chronic kidney disease stage 2, cirrhosis of the liver, malignant neoplasm of the breast, urinary incontinence, Alzheimer's disease, anorexia, pressure ulcer of the sacral region, protein calorie malnutrition, and abnormal weight loss. Review of wound- weekly observation tool for Resident #9 dated 04/16/2025 revealed a suspected deep tissue injury (SDTI) (a localized area of discolored, intact skin or a blood-filled blister caused by damage to the underlying soft tissue, typically from pressure or sheer) on the resident's sacrum. Review of wound- weekly observation tool for Resident #9 dated 05/19/2025 revealed the continued presence of SDTI on the resident's sacrum. Review of orders for Resident #9 dated 05/05/2025 revealed to cleanse the sacrum with soap and water, pat dry apply zinc barrier cream and cover with foam dressing every three days and as needed. Review of the care plan dated 05/13/2025 revealed Resident #9 was at risk for skin break down with interventions including to cleanse the sacrum with soap and water, pat dry, apply zinc barrier cream and cover with foam dressing every three days and as needed. Review of the treatment administration record (TAR) revealed the treatment was last completed to the resident's sacrum on 05/15/25. There were no as needed treatments documented on the TAR. Observation on 05/21/2025 at 10:44 A.M. of incontinence care revealed the resident did not have a foam dressing to the sacrum as ordered. The dressing was not observed in bed with the resident and it was not observed to be removed during incontinence care. Interview with Certified Nursing Assistant (CNA) #367 on 05/21/2025 at 10:47 A.M. verified the foam dressing was not observed to the resident's sacrum or in the resident's bed and the dressing was not removed during incontinence care. Interview on 05/21/2025 at 2:53 P.M. with the Director of Nursing confirmed that the expectation is for staff to follow orders as written for wound treatments. Review of the facility, Wound Treatment Management dated 12/2025 revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.

Based on record review, interview, policy and facility assessment review the facility failed to prevent Resident #88 from exiting the facility unsupervised and failed to complete a comprehensive assessment and thorough investigation following the incident. This affected one resident (Resident #88) of three residents reviewed for accidents. Findings include: Review of the medical record revealed Resident #88 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included Parkinson's disease, type 2 diabetes, atherosclerotic heart disease, hyperlipidemia, mood disorder, benign prostatic hyperplasia, history of transient ischemic accident, and traumatic subdural hemorrhage. Review of hospital records (prior to admission) dated 04/21/25 revealed the resident had Parkinson's Disease with increased forgetfulness which was concerning with dementia. The resident had been placed on delirium precautions in the hospital. The wandering risk assessment dated [DATE] revealed Resident #88 was at low risk for wandering. The fall risk assessment dated [DATE] revealed Resident #88 was at moderate risk for falls. Review of the plan of care for falls dated 04/25/25 revealed Resident #88 was at risk for falls with interventions to anticipate and meet the resident's needs, ensure call light was in place, and personal alarm to bed and chair. The resident did not have an elopement or wandering care plan. A communication note dated 04/27/25 at 9:20 P.M. authored by Registered Nurse (RN) #392 revealed Resident #88's wife was informed that staff could not get Resident #88 to stay in bed or in his room (due to it being bedtime). Resident #88 was wandering in the halls and into other resident rooms. Resident #88's wife talked to Resident #88 on the phone and then stated she would come to the facility and stay with Resident #88 until he fell asleep. Record review revealed no new wandering/elopement risk assessment was completed at this time and no elopement or wandering care plan was implemented . Review of the facility incident log dated 04/28/25 at 1:00 A.M. revealed Resident #88 had wandered off the unit and was found sitting in a grassy area outside of the main entrance. Resident #88 had a scraped right knee and an abrasion to the left lateral knee. Resident #88 was unable to make any meaningful statements regarding the event. One-on-one (supervision) was provided due to Resident #88 having confusion with behaviors. The resident was subsequently moved to the secured unit after the incident. An elopement investigation dated 04/28/25 at 1:00 A.M. authored by RN #392 revealed predisposing environmental factors included a fall alarm, poor lighting, confusion, impaired memory, and recent illness. There was no additional information regarding the resident's unsupervised exit of the facility including employee statements or a root cause analysis of the incident. A behavior note dated 04/28/25 at 1:05 A.M. authored by RN #392 revealed a Certified Nursing Assistant (CNA) notified RN #392 that Resident #88 was not in his room. Each room, bathroom, utility room, and medication room were searched. The hallways and units on the assisted living facility were also searched. A CNA went outside and circled the building and found Resident #88 sitting in the grass near the main entrance. Resident #88 was assisted back to his room and his pajama bottoms were changed. Resident #88 was put in a wheelchair at the nurse's station for one-on-one and then moved to the facility secured unit. An interview on 05/21/25 at 10:26 A.M. with the Licensed Nursing Home Administrator (LNHA) revealed Resident #88 did not go out main entrance but went straight down the hall and out the assisted living entrance. The LNHA stated staff had seen Resident #88 right before he left the building. When staff discovered Resident #88 was not in the building, a CNA went outside to look for Resident #88 and found him in the grass near the building. The LNHA verified there were no statements from the staff, but the nurse stated Resident #88 was only gone a few minutes. The LNHA was unsure if the resident's bed alarm was sounding at the time of the incident to alert staff that Resident #88 had gotten out of bed. The LNHA revealed the exit door did not have an alarm at that time but one had been installed since Resident #88 eloped from the building. An interview on 05/22/25 at 11:15 A.M. with RN #392 revealed Resident #88 had wandered from the day he was admitted , but staff kept an eye on him (the RN did not clarify what she meant by wandering). RN #392 then stated five-minute checks were done to monitor Resident #88. RN #392 stated at the time of the elopement incident, the resident's bed alarm was not sounding. RN #392 stated as a result of the incident, Resident #88 sustained a wound to one knee. RN #392 stated she cleaned the wound and applied antibiotic ointment. RN #392 stated she did not measure the wound because it was the least of her worries. An interview on 05/21/25 at 12:05 P.M. with the LNHA revealed any investigation pertaining to the elopement and fall were not included as part of the resident's medical record. An interview on 05/21/25 at 12:10 P.M. with Resident #88's wife revealed Resident #88 wandered at home and had left their home several times. Resident #88's wife believed the facility was aware Resident #88 was at risk for wandering and elopement when he was admitted . Resident #88's wife revealed at the time of the incident on 04/28/25, she was told Resident #88 was found within minutes of leaving the facility. An interview on 05/22/25 at 1:17 P.M. with Certified Nursing Assistant (CNA) #376 revealed Resident #88 had been walking around and staff stayed near him unless they had to provide care for other residents. On 04/28/25 the CNA indicated staff had laid the resident down in bed right before he left as they then went to provide care to other residents. CNA #376 stated at the time of the elopement, Resident #88's bed alarm was not sounding. The CNA was aware the resident sustained a little scratch on his leg after falling outside. The facility Elopements and Wandering Residents policy revised 2025 defined wandering as a random or repetitive locomotion that may be goal-directed or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. The facility was equipped with door locks/alarms to help avoid elopements. Alarms were not a replacement for necessary supervision. Staff were to be vigilant in responding to alarms in a timely manner. The policy included the facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation, and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The facility assessment dated [DATE] revealed the facility provides care and services based on the needs of residents which included behavioral health issues, pain and pain management.

Based on record review, review of standing orders, and interview, the facility failed to ensure the facility bowel protocol for constipation was followed for Resident #14 and Resident #24. This affected two (Resident #14 and #24) three reviewed for bowel and bladder. Facility census was 30. Findings include: 1. Review of the medical record revealed Resident #14 was admitted on [DATE] with diagnosis that included osteoarthritis, spinal stenosis, anxiety, major depressive disorder, type 2 diabetes, and chronic pain. A plan of care dated 03/18/25 revealed Resident #14 was a risk for constipation due to decreased mobility and medication use. Interventions included to follow facility bowel protocol for bowel management, milk of magnesia (laxative) as needed if no bowel movement in three days, monitor bowel movements every shift, and record bowel movement pattern each day. A significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #14 had cognitive impairment and was frequently incontinent of bowel and bladder. Resident #14 was dependent on staff for toileting. Review of the treatment administration record (TAR) revealed Resident #14 did not have a bowel movement from 05/07/25 through 05/11/25. The TAR did not reveal any as needed laxative medication being administered from 05/07/25 through 05/11/25. Review of the electronic documentation by Certified Nursing Assistants (CNA) revealed no documentation of a bowel movement from 05/07/25 through 05/11/25. Interview on 05/22/25 at 9:26 A.M. Registered Nurse (RN) #389 verified the documentation revealed Resident #14 did not have a bowel movement for five days and there was no documentation of the facility bowel protocol being followed. RN #389 stated bowel movements were documented on paper, in point of care by CNA's, and on the TAR by nurses. RN #389 verified there was not a system in place to make sure the bowel protocol was followed. Review of standing order set revealed Miralax (laxative) 17 grams to be administered daily for constipation persisting three days or more and bisacodyl (laxative) suppository twice a day until the resident had a bowel movement. 2. Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses that included major depressive disorder, chronic kidney disease, urinary retention, and anxiety disorder. A plan of care dated 06/30/23 revealed Resident #24 was at risk for constipation. Interventions included fleet enema rectally as needed for constipation, follow facility bowel protocol, glycolax powder every 12 hours as needed for constipation, milk of magnesia as needed for constipation, and Psyllium Husk (fiber) every 24 hours as needed. A significant change MDS dated [DATE] revealed Resident #24 was cognitively intact. The MDS also revealed Resident #24 was always incontinent of bowel and bladder and was dependent on staff for toileting. Review of the TAR revealed Resident #24 did not have a bowel movement from 04/30/25 through the evening of 05/04/25. The TAR did not reveal any as needed laxative medication being administered from 04/30/25 through 05/04/25. Review of the electronic documentation by the CNA's revealed no documentation of a bowel movement from 04/30/25 through the evening of 05/04/25. Interview on 05/22/25 at 9:26 A.M. RN #389 verified the documentation revealed Resident #24 did not have a bowel movement for four days and there was no documentation of bowel protocol being followed. RN #389 stated bowel movements were documented on paper, in point of care by CNA's, and on the TAR by nurses. RN #389 verified there was not a system in place to make sure the bowel protocol was followed. Review of standing order set revealed Miralax (laxative) 17 grams to be administered daily for constipation persisting three days or more and bisacodyl (laxative) suppository twice a day until the resident had a bowel movement.

Based on record review, interview, and policy review, the facility failed to ensure a rationale was provided when a gradual dose reduction for psychotropic medications was contraindicated for Resident #24. This affected one (Resident #24) of five residents reviewed for unnecessary medications. Facility census was 30. Findings include: Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses that included major depressive disorder, chronic kidney disease, urinary retention, and anxiety disorder. Pharmacy recommendations dated 09/23/24 revealed Resident #24 had been receiving Zoloft (antidepressant) 100 milligram (mg) daily, mirtazapine (antidepressant) 7.5 mg daily, and hydroxyzine (antihistamine also used for anxiety) 25 mg daily without a gradual dose reduction (GDR). Pharmacy asked if a GDR could be attempted in order to be sure Resident #24 was using the minimum effective dose. If a GDR was not warranted, a statement needed to be included explaining why a GDR would be detrimental. The physician signed the recommendations on 09/30/24 and checked the box that a GDR was contraindicated but did not provide a statement why the GDR for Zoloft, mirtazapine, and hydroxyzine would be detrimental. An interview on 05/22/25 at 9:06 A.M. with the Director of Nursing (DON) verified the physician did not provide a rationale why a GDR was contraindicated for Resident #24's Zoloft, mirtazapine, and hydroxyzine. Review of the Medication Monitoring policy dated 10/01/18 revealed if the physician declines or otherwise rejects the consultant pharmacists recommendation, an explanation as to the rationale for the rejection shall be documented in the resident's medical record. If the physician fails to address a recommendation or document a rationale for rejecting a recommendation, the director of nursing will be notified and a summary shall be provided to the quality assurance and performance improvement (QAPI) committee on a periodic basis. The incomplete recommendation should be reviewed with the physician.

Based on record review, review of the incident and accident log, interview and policy review the facility failed to maintain complete and accurate medical records related to resident incidents. This affected one resident (Resident #14) of three residents reviewed for accidents. The facility census was 30. Findings include: Review of the medical revealed Resident #14 was admitted on [DATE] with diagnosis that included osteoarthritis, spinal stenosis, anxiety, major depressive disorder, type 2 diabetes, and chronic pain. Review of the incident and accident log revealed on 04/02/25 at 12:00 A.M. a Certified Nursing Assistant (CNA) reported Resident #14 was on the floor. Resident #14 was found sitting on the floor in front of her recliner. The CNA stated Resident #14 was sliding out of the recliner when the CNA attempted to reposition Resident #14 but Resident #14 slid out of the chair onto the floor. A new intervention for a non-slip material was to be placed in the recliner. The Committee Review of Incidents dated 04/02/25 revealed Resident #14 had a fall on 04/02/25 at 12:00 A.M. A Witnessed Fall form dated 04/02/25 that was privileged and confidential and not part of the medical record-do not copy revealed Resident #14 was confused, had gait imbalance, incontinent, and weakness/fainted. The box during transfer was marked. A nurse's note dated 04/04/25 at 3:11 A.M. revealed Resident #14 was status post fall without injury. Resident #14 had no pain at this time. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #14 had cognitive impairment. An interview on 05/22/25 at 12:24 P.M. with the Director of Nursing (DON) verified accidents/falls were documented in incidents which was not part of the medical record. The DON verified there was not a nurse's note, vitals, assessment, investigation, or any follow up documentation about the fall Resident #14 had on 04/02/25. Review of the Fall Prevention Program policy revised April 2025 revealed when a resident experienced a fall, the facility will assess the resident, complete an incident report, notify the physician and family, review the resident's care plan and update as indicated, documented all assessments and actions, and obtain witness statements if applicable.

Based on record review, interview, and policy review the facility failed to obtain resident or resident representative consent and provide education prior to administration of the influenza vaccination. This affected three resident residents (Resident #9, #10 and #20) of five residents reviewed for vaccinations. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 02/10/2018. Diagnoses included dementia, atherosclerotic hear disease of native coronary artery, chronic kidney disease stage 2, cirrhosis of the liver, malignant neoplasm of the breast, Alzheimer's disease, anorexia, dysphagia, pressure ulcer of the sacral region, protein calorie malnutrition, and abnormal weight loss. Review of Resident #9's influenza vaccination 2024 records revealed an inoculation date of 09/17/2024. Further review of the medical record revealed no influenza consent or vaccine information/education was provided Interview on 05/22/2025 at 11:50 A.M. with Minimum Data Set (MDS) Coordinator #389 confirmed the facility gave Resident #9 an influenza vaccination on 09/17/2024. MDS Coordinator #389 confirmed the facility failed to obtain a 2024 consent form for influenza vaccination and failed to document that Resident #9 received education regarding the influenza vaccination. 2. Review of the medical record for Resident #10 revealed an admission date of 11/26/2021. Diagnoses included chronic pain syndrome, orthostatic hypotension, hypothyroidism, hyperlipidemia, repeated falls, major depressive disorder, protein calorie malnutrition, pneumonia, abnormal weight loss, weakness, acute respiratory failure with hypoxia, unspecified dementia, hypotension, cognitive communication deficit, and chronic obstructive pulmonary disease. Review of Resident #10's influenza vaccination 2024 records revealed an inoculation date of 09/25/2024. Further review of the medical record revealed no influenza consent or vaccine information/education was provided Interview on 05/22/2025 at 11:50 A.M. with Minimum Data Set (MDS) Coordinator #389 confirmed the facility gave Resident #10 an influenza vaccination on 09/25/2024. MDS Coordinator #389 confirmed the facility failed to obtain a 2024 consent form for influenza vaccination and failed to document that Resident #10 received education regarding the influenza vaccination. 3. Review of the medical record for Resident #20 revealed an admission date of 08/17/2022. Diagnosis include unspecified dementia, type 2 diabetes, atherosclerosis of aorta, thrombocytopenia, hypertension, glaucoma, hypothyroidism, chronic obstructive pulmonary disease, repeated falls, seizures, adult failure to thrive, abnormal weight loss, hemiplegia and hemiparesis following cerebral infarction, contracture of right hand, contracture of left hand, atrial fibrillation, metabolic encephalopathy, pneumonitis due to inhalation of food, chronic kidney disease, chronic obstructive pulmonary disease, muscle weakness, and nontraumatic intracerebral hemorrhage. Review of Resident #20 influenza vaccination 2024 records revealed an inoculation date of 09/17/2024. Further review of the medical record revealed no influenza consent or vaccine information/education was provided Interview on 05/22/2025 at 11:50 A.M. with Minimum Data Set (MDS) Coordinator #389 confirmed the facility gave Resident #20 an influenza vaccination on 09/17/2024. MDS Coordinator #389 confirmed the facility failed to obtain a 2024 consent form for influenza vaccination and failed to document that Resident #20 received education regarding the influenza vaccination. Review of facility, Influenza Vaccination policy dated 05/19/24 revealed, Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be provided a copy of CDC's current vaccine information statement relative to the influenza vaccination. Individuals receiving the influenza vaccine, or their legal representative, will be required to sign a consent form prior to the administration of the vaccine. The completed, signed, and dated record will be filed in the individuals medical record.

Based on observations, staff interview and review of the facility policy, the facility failed to ensure safe and sanitary food storage in the refrigerator and freezer in the main kitchen area. This had the potential to affect all 31 residents residing in the facility who received food from the kitchen. Findings include: Observations on 05/01/23 at 9:56 A.M. of the kitchen revealed a cup of creamer or milk left uncovered and had spilled on a tray in the refrigerator; a pre-made plate of sausage with peppers and onions was left undated in the refrigerator; coconut shrimp was in an individually sized portioned zip lock bag and was left open to air in the freezer; a pack of veggie burgers were left open to air in the freezer; a bag of rice was on top of a container with rice bags inside of it. The individual bag was undated; a metal container of hot dogs were left uncovered and open to air in the freezer; a bag of fries was undated and had a hole with food coming out of the hole in the freezer; two pies were left on a rack in the walkway of the kitchen undated and uncovered open to air; a tray of cookies were left on a rack in the hallway of the kitchen undated and uncovered open to air; and a cart of desserts were in left in a cart on shelves and were left uncovered and open to air. Interview on 05/01/23 at 10:15 A.M. with Corporate Coordinator of Culinary Services (CCCS) #605 confirmed the findings and revealed the milk was just left and staff should have removed it and revealed the display plate was not planned to be eaten but was a display for residents in independent living for the meal. CCCS #605 revealed it was unknown if the bag of rice was extra and did not fit in the container below it or it was from the previous container. CCCS #605 confirmed the pies and cookies were not covered and revealed they were recently made and would be cut and put on plates and placed in the cart until time for service. Review of the facility policy titled Food Safety Requirements, dated 2023, revealed the facility policy stated food would be stored in accordance with professional standards for food safety. Food should be stored in a manner that prevents deterioration or contamination of the food. Refrigerator and freezer areas shall maintain safe storage including labeling, dating and monitoring food so it was used by the use-by date and keeping food covered or in tight containers.

Based on staff interviews, review of the facility policy, and record review, the facility failed to ensure pharmacy recommendations were followed up and implemented timely. This affected three (Residents #14, #20 and #25) of five residents reviewed for unnecessary medications. The facility census was 31. Findings include 1. Review of the medical record for Resident #20 revealed an admitted [DATE]. Diagnoses included gastroesophageal reflux disease (GERD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had moderate cognitive impairment. Review of the physician orders for Famotidine (treats GERD) revealed from 01/14/222 to 04/28/23, Famotidine was to be administered at 40 milligrams (mg) tablet daily. On 04/28/23, the order for Famotidine was changed to 20 mg tablet daily. Review of the monthly pharmacy recommendation dated 03/21/22 revealed it was reviewed by the physician on 03/24/22. The recommendation was for Famotidine 40 mg once daily to be decreased to 20 mg daily. The physician marked agree. However, the physician order was not completed until 04/28/23. Review of the monthly pharmacy recommendation dated 04/27/23 revealed it was reviewed by the physician on 04/28/23. The recommendation was for Famotidine 40 mg daily to be decreased to 20 mg daily. The physician marked agree. Interview on 05/03/23 at 2:10 P.M. with the Director of Nursing (DON) confirmed the decrease in Famotidine was not done timely after the pharmacy recommendation was made and the physician agreed to pharmacy recommendation. 2. Review of the medical record for Resident #25 revealed an admitted [DATE]. Diagnoses included polyneuropathy, osteoarthritis and pain in the joints. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact. Review of the monthly pharmacy recommendation dated 12/29/22 revealed it was reviewed by the physician on 12/30/22. The recommendation was for a complete blood count (CBC) at least every 12 months and a serum creatinine lab every six months due to Eliquis medication. The physician marked agree. Review of the physician orders dated 12/29/22 to 05/03/23 revealed there was no physician order for a serum creatinine lab to be drawn every six months or a CBC draw for every 12 months. Review of the laboratory value results for Resident #25 dated 05/31/22 revealed a serum Creatinine were completed on 05/31/22. From 06/01/22 to 05/03/23, there was no serum Creatinine or CBC completed during this time. Interview on 05/03/23 at 4:10 P.M. with the Director of Nursing (DON) confirmed the last creatine lab was done in 05/2022 and there was no CBC draw from 06/01/22 to 05/02/23. The DON confirmed there was no physician order for this to be completed. 3. Review of the medical record for the Resident #14 revealed an admitted [DATE]. Diagnoses included gastroesophageal reflux disease (GERD). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact. Review of the monthly pharmacy recommendation dated 01/31/23 revealed it was reviewed by the physician on 02/03/23. The recommendation was for Protonix to be reduced from 40 mg to 20 mg. The physician marked agree. Review of Resident #14's physician orders dated from 0/1/31/21 to 05/02/23 revealed an order for Protonix (treats GERD) 40 milligrams (mg) to administer one tablet daily. There was no physician order to administer Protonix 20 mg daily during this time period. Interview on 05/03/23 at 4:10 P.M. with the Director of Nursing (DON) revealed no evidence of the Protonix medication orders being changed or followed up on after the pharmacy recommendation. DON confirmed the pharmacy recommendations were provided to the physician and the physician signs off timely and two nurses should be updating the orders. The DON confirmed the facility had no system in place to ensure the recommendations were followed up on after physician signature. Interview on 05/04/23 at 9:47 A.M. with Medical Director (MD) #606 revealed he receives the pharmacy recommendation and completes within about a week. MD confirmed the signed forms were then provided to the DON for follow up. MD revealed the facility had no process in place to verify orders were implemented in the medical record orders. Review of the facility policy titled Pharmacy Services, dated 2023, revealed the policy stated a pharmacist would be involved with eliminating errors and addressing medication concerns.

Based on observation, record review, staff interview, and review of the facility policy, the facility failed to have a medication error rate less than five percent. There were two medication errors out of 26 opportunities resulting an a 7.69 percent (%) medication error rate. This affected two (Resident #14 and #19) of four residents observed for medication administration. The facility census was 31. Findings include: 1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included supraventricular tachycardia, age related osteoporosis, and dementia with severe agitation. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 was severely cognitively impaired, had no delusions, hallucinations, or behaviors documented. Review of Resident #19's physician orders revealed an order for Oyster Shell Calcium (supplement) 500 milligram (mg) - five micrograms (mcg) with Vitamin D twice daily. Observation of medications delivered to Resident #19 from Licensed Practical Nurse (LPN) #603 on 05/02/23 at 8:15 A.M. revealed the following medications were administered to Resident #19 orally: Eliquis (anticoagulant) five mg, Oyster Shell Calcium 500 mg to five mcg, Seroquel (antipsychotic) 25 mg, Seroquel (antipsychotic) 50 mg, Zoloft (antidepressant)100 mg, and Tylenol (antipyretic) 325 mg two tablets. Observation and interview with LPN #603 on 05/02/23 at 12:53 P.M. confirmed the Oyster Shell Calcium 500 mg-five mcg was in the medication cart and was administered to Resident #19. LPN #603 verified she administered Oyster Shell Calcium 500 mg - five mcg to Resident #19 and the medication had no Vitamin D included in the medication. 2. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression, atrial fibrillation, and diabetes mellitus (DM). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact, had a diagnosis of DM, and received insulin. Observation of Resident #14 receiving medications from Licensed Practical Nurse (LPN) #601 on 05/02/23 at 11:48 A.M. revealed the resident received Novolog insulin five units via a delivery pen, and Oxybutynin (anticholinergic) five milligrams (mg) orally. LPN #601 was observed to dial the Novolog pen to five units and administer the medication to Resident #14. Interview with LPN #601 on 05/02/23 at 11:53 A.M. confirmed she had primed the Novolog insulin pen with one unit of insulin prior to dialing the five units required for the dose that was administered to the resident. Review of the policy titled Insulin Pen Administration, dated 2022, revealed the facility is to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. The policy explanation and compliance guidelines included insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. The instructions state to prime the insulin pen; Dial two units by turning the dose selector clockwise; With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears; Set the insulin dose; Turn the dose selector to ordered dose. A click will be heard for each unit dialed. If an incorrect dose has been set, dial the dose selector forward or backward until the correct number of units has been set; then check dose a second time. Review of the undated policy titled Medication Administration revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The guidelines included to review Medication Administration Record (MAR) to identify medication to be administered. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.

Based on observation, record review, staff interview, and review of the facility policy, the facility failed to administer insulin correctly to a resident, resulting in a resulting in a significant medication error. This affected one (Resident #14) of four residents observed for medication administration. The facility census was 31. Findings include: Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression, atrial fibrillation, and diabetes mellitus (DM). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact, had a diagnosis of DM, and received insulin. Observation of Resident #14 receiving medications from Licensed Practical Nurse (LPN) #601 on 05/02/23 at 11:48 A.M. revealed the resident received Novolog insulin five units via a delivery pen, and Oxybutynin (anticholinergic) five milligrams (mg) orally. LPN #601 was observed to dial the Novolog pen to five units and administer the medication to Resident #14. Interview with LPN #601 on 05/02/23 at 11:53 A.M. confirmed she had primed the Novolog insulin pen with one unit of insulin prior to dialing the five units required for the dose that was administered to the resident. Review of the policy titled Insulin Pen Administration, dated 2022, revealed the facility is to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort, and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge. The policy explanation and compliance guidelines included insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. The instructions state to prime the insulin pen; Dial two units by turning the dose selector clockwise; With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears; Set the insulin dose; Turn the dose selector to ordered dose. A click will be heard for each unit dialed. If an incorrect dose has been set, dial the dose selector forward or backward until the correct number of units has been set; then check dose a second time.

Based on medical record review, staff interview and policy review, the facility failed to ensure code status's in the electronic medical record were accurate. This affected two (#2 and #14) of 16 residents reviewed during the survey. The census was 31. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the electronic medical record revealed a physician's orders [REDACTED]. Review of the medical record for Resident #2 revealed a signed DNR Form dated 03/19/19 for Resident #2's code status to be DNR comfort care. Interview with Director of Nursing on 10/16/19 at 3:05 P.M. verified Resident #2's code status in the electronic medical record did not match the signed DNR form dated 03/19/19. 2. Review of the medical record for Resident #14 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the electronic medical record revealed a physician's orders [REDACTED]. Review of the medical record for Resident #14 revealed a signed DNR Form dated 05/21/19 for Resident #14's code status to be DNR comfort care. Interview with Director of Nursing on 10/16/19 at 3:05 P.M. verified Resident #14's code status in the electronic medical record did not match the signed DNR form dated 05/21/19. Review of the undated policy titled Cardiopulmonary Resuscitation revealed code status will be updated when changed and indicated in each resident's chart.

Based on medical record review, staff interview and policy review, the facility failed to update care plan interventions following a resident fall. This affected two (#9 and #79) of two residents reviewed for accidents. Facility census was 31. Findings include 1. Review of medical record revealed Resident #79 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive assessment dated revealed 10/02/19 revealed the resident had moderate cognitive impairment. Resident #79 required partial to moderate assistance for sit to stand, toilet transfers, and bed to chair transfers. Review of the comprehensive assessment dated [DATE] revealed Resident #79 had a history of [REDACTED]. The resident had fallen since admission and received an injury (not a major injury). Review of progress notes revealed on 09/23/19 Resident #79 was washing his/her hands in the bathroom, reached to get a paper towel while holding onto the walker and lost balance, falling straight back and hitting his/her head on the wall. The state tested nurses assistant (STNA) was in the bathroom with the resident. The nurse, physician and family were notified. Resident #79 was transported to the emergency room (ER) for evaluation. Review of the fall investigation dated 09/23/19 revealed a hematoma was noted to the back of the resident's head. Resident #79 reported a pain level of six and was alert and oriented to person, place, time, and situation. The interdepartmental team (IDT) investigated the fall and identified the STNA was present with the resident in the bathroom but did not have hands on the resident as the resident was washing hands. Staff was reminded to have hands on the resident while ambulating, transferring, and during care. Review of Resident #79's care plan revealed the resident had a self-care performance deficit and required limited assistance of one staff member for toileting. Resident #79's care plan also included a risk area for falls with the following interventions: - Anticipate and meet the resident's needs - Ensure the resident's call light was within reach and encourage the resident to use the call light for assistance as needed. The resident needed prompt response to all requests for assistance - Educate the resident/family/caregivers about safety reminders and what to do if a fall occurred - Encourage the resident to participate in activities that promoted exercise, physical activity for strengthening and improved mobility - Ensure the resident was choosing and wearing appropriate footwear when ambulating or mobilizing in the wheelchair - Tab alarm to bed and chair at all times - The resident needed a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, handrails on walls, personal items within reach. The care plan did not include the new fall intervention identified by the IDT to have hands on the resident while ambulating, transferring, and during care. Interview on 10/17/19 at 10:48 [NAME]M. interview with the Director of Nursing (DON) verified the fall intervention identified by the IDT was not included in Resident #79's care plan. 2. Review of the medical record for Resident #9 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #9 fell out of her wheelchair on 08/07/19. Review of the fall investigation for the Resident #9's fall which occurred on 08/07/19 revealed the intervention taken to prevent the incident from reoccurring was to ensure Resident #9's wheelchair brakes were locked prior to transferring transferring the resident into it as well as to ensure the resident had proper and safe positioning when in her wheelchair. Review of the comprehensive care plan for Resident #9 revealed Resident #9 was at risk for falls. Further review of the comprehensive care plan for Resident #9 revealed the interventions to ensure Resident #9's wheelchair brakes were locked prior to transferring transferring the resident into it and to ensure the resident had proper and safe positioning when in her wheelchair were not included on the comprehensive care plan. Interview with Director of Nursing on 10/17/19 at 10:55 [NAME]M. verified Resident #9's comprehensive care plan was not revised to include the above fall interventions. Review of the facility's undated policy titled Policy & Procedure for Falls revealed the plan of care will be updated as needed between reviews to reflect new or modified interventions. Review of the facility's undated policy titled Care Plans - Comprehensive revealed care plans are revised as changes in the resident's condition dictates.

Based on closed record review, and self reported incidents (SRIs) and staff interview the facility failed to communication a resident change in condition in a timely manner. This affected one (Resident #15) of two residents reviewed for SRI's. The facility census was 27. Findings include: Closed medical record review for Resident #15 revealed an admission date of [DATE] and a discharge date of [DATE]. Resident #15 had [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #15 as cognitively intact and as an extensive assist one person transfer. Review of the progress notes from 06/03/16 until 06/22/16 for Resident #15 revealed that an x-ray of the right hip was obtained on 06/21/16 due to the husband of Resident #15 reporting a problem with Resident #15 not being able to ambulate. The x-ray obtained on 06/21/16 verified a dislocation of the right hip. Resident #15 was sent out the emergency room for an evaluation. Further review of the progress notes revealed no incidents involving the right hip of Resident #15. Review of the SRI # 3 dated 06/22/16 revealed that Resident #15 obtained an right hip dislocation as an injury of unknown origin. On 06/21/16, Resident #15 complained of pain all over and could only ambulate one to two steps. The right hip area and upper leg noted to be [MEDICAL CONDITION]. An order was received to obtain a right hip x-ray which revealed a right hip dislocation. Resident #15 was transferred to the emergency room for treatment. Review of documentation by the facility showed no specific event that could have lead to the injury. Further review of the SRI investigation revealed a staff member statement dated 06/24/16 at 10:15 A.M. from STNA #132 stated on 06/19/16 during first shift she was putting Resident #15's legs into bed when she heard a pop. STNA #132 stated she asked Resident #15 if she was ok and she denied pain. STNA #132 stated she told the nurse of the incident. Review of the statement dated 06/23/16 from Occupational Therapist (OT) #141 revealed that on 06/20/16 she noticed the right foot of Resident #15 was externally rotated which she confirmed with a Physical Therapy Aide (PTA) that this was not normal for Resident #15. Review of the statement dated 06/24/16 from Registered Nurse (RN) #11 revealed that she was nurse on 06/18/16 and 06/19/16 from 7:00 A.M. to 7:00 P.M. and staff did not verbalize any incident with Resident #15 to her. Review of the statement dated 06/24/16 from the Director of Nursing (DON) revealed that she was made aware of the incident on 06/24/16 from STNA #132 when she was transferring resident Resident #15 to bed she heard a noise sounding like a pop. STNA #132 stated she had told RN #11 of this incident, however upon speaking with RN #11, she reported no recollection of being told of this event. Interview on 09/07/16 at 12:58 P.M. with RN #11 verified that she does not remember being told of an incident of where STNA #132 was transferring Resident #15's legs and heard a pop. RN #11 stated no staff members had told her anything about Resident #15's hip or leg. RN #11 stated Resident #15 had no increase in pain on 06/19/16. Interview on 09/08/16 at 8:25 A.M. with OT #141 revealed that she had remembered the abnormal external rotation of Resident #15's right foot. OT #141 stated she reported this abnormality to either RN #11 or Licensed Practical Nurse (LPN) #69. OT #141 stated anytime a therapist notices an abnormality with a resident, it is immediately reported to the nurse. Interview on 09/08/16 at 8:52 A.M. with LPN #69 stated no staff had told her any abnormalities with Resident #15. LPN #69 believed she was on vacation during the incident with Resident #15. Interview on 09/08/16 at 9:44 A.M. with the DON verified that all nurses who cared for Resident #15 from 06/19/16 until discharge to the hospital on [DATE] were interviewed and denied being told about any incidents or issues with Resident #15's right hip. The DON confirmed that both STNA #132 and OT #141 were aware of the possible right hip abnormality however this did not get communicated to nursing. If a staff member sees a change in condition with a resident, the DON stated that her expectation was the staff member was to make sure the resident was safe, and to notify the nurse immediately. If the nurse was not hearing or following up with the concern, her expectation was that the staff member then notified herself, the DON.

Based on record review and staff interview, the facility failed to ensure nonpharmalogical interventions were attempted prior to drug administration. This affected one (Resident #9) of five residents reviewed for unnecessary medications. The census was 27. Findings include: Review of medical record for Resident #9 revealed an admission date of [DATE]. A comprehensive assessment dated [DATE] revealed she was severely cognitively impaired. She was assessed as extensive assistance for bed mobility, transfers, dressing and toilet use, she was assessed as total dependence on locomotion in and out of room and supervision for eating. Review of care plan for Resident #9 revealed she was to be encouraged to try different pain relieving methods for example positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, and ultrasound. Review of physician orders [REDACTED].#9 revealed an order for [REDACTED]. Review of Medication Administration Record [REDACTED]. Review of progress notes from 07/19/16 through 09/08/16 revealed no documented evidence of any non-pharmacological interventions attempted first before giving [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg. Further review of progress note dated 07/20/16 revealed resident was given a pain medication for anxiety. Interview with Director of Nursing (DON) on 09/07/16 at 1:58 P.M. verified there was no documented evidence of nonpharmalogical interventions for [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg in Resident #9's chart.

Based on surveyor observation of the kitchen and staff interview, it was determined the facility failed to ensure the air return vents that were located over the clean dish area and ice machine were free from dust and debris. This deficient practice could potentially affect 28 of 28 residents who receive meals from the facility kitchen. Findings include: During tour of the kitchen on 01/03/12 at 9:39 A.M., revealed three white air return vents that were covered with dust and debris on the ceiling area surrounding the air vents. In addition, there were two silver air return vents in the ceiling that were located above the ice machine and clean dish storage that were also covered with dust and debris. Interview with the Director of Culinary Services on 01/03/12 at approximately 10:15 A.M., verified the two silver air return vents were covered in dust and debris. Interview with the Director of Culinary Services on 01/04/12 at 2:00 P.M., confirmed the presence of dust and debris around the three white ceiling vents. She further stated these air return vents were not on a cleaning schedule.

Based on review of the facility's fire drill records, review of facility policy and staff interview, it was determined the facility failed to conduct fire drills at varied times during the second and third shifts. This deficient practice could potentially affect 28 of 28 residents who reside in the facility. Findings include: Review of fire drill records from January 1, 2011 through December 31, 2011, revealed fire drills conducted on the second and third shifts were not held at unexpected times throughout the entire eight hour shifts. Review of the second shift (3:00 P.M.-11:00 P.M.) fire drills revealed four of four drills were held during the first half of the shift between the hours of 3:02 P.M. and 6:43 P.M. The fire drills were held on 02/24/11 at 5:10 P.M., 05/26/11 at 4:40 P.M., 08/02/11 at 6:43 P.M. and 11/17/11 at 3:02 P.M. There were no fire drills conducted during the second half of the shift between 6:43 P.M. and 11:00 P.M. Review of the third shift (11:00 P.M.-7:00 A.M.) fire drills revealed there were no fire drills conducted between the hours of 12:30 A.M. and 5:07 A.M. Fire drills were held on 03/09/11 at 6:45 A.M., 6/10/11 at 11:43 P.M., 09/20/11 at 12:30 A.M. and 12/12/11 at 5:07 A.M. Review of the facility's undated policy entitled,"Drills", indicated fire drills will be conducted under varied conditions to simulate unusual conditions caused by such a disaster. Interview with the Administrator on 01/04/12 at 3:30 P.M., verified the fire drills on the second and third shifts were not conducted at varied times throughout the eight hour shifts.