Every finding on record at Hendricks Community Hospital

Based on interview and document review, the facility failed to ensure the medical director (MD-A) attended QAPI meetings for 4 of 4 quarters. Findings include: Review of the QAPI meeting minutes submitted for the months of June, August, Sept and [DATE], and Jan and April 2026, identified the facilities quarters were Quarter 1: July-Sept, Quarter 2: Oct-Dec, Quarter 3: Jan-March, and Quarter 4: April-June. Of the months submitted, in:June 2025: MD-A is listed on the attendance sheet, but he had not signed off as having attended the meeting.The remaining months of August, September and October 2025, and January and April 2026, MD-A's name was not on sign in sheet and there was no evidence to support he attended at least quarterly as required. Interview on 6/25/26 at 1:11 p.m., with the director of nursing (DON) identified she had overseen QAPI since January 2026. In review and discussion of the above meeting minutes/agendas, she agreed MD-A was not in attendance at any of their QAPI meetings. The DON agreed the facility needed to ensure the medical director was attending as required. Review of the February 2026, QAPI policy identified the QAPI committee was to include the medical director and other appropriate staff. QAPI was to meet at least 4 times per year to oversee and direct facility activities. There was no mention in the policy of how to ensure the medical director (or his or her appropriate designee) attended meetings as required.

Based on interview and document review, the facility failed to ensure the Resident Council's concerns during 3 of 3 months of minutes reviewed (March, April, and May 2026) were addressed with potential or actual resolution and/or responses brought back to the resident council for discussion and documented in the Resident Council minutes. Findings include: Resident council meeting was held on 6/24/26 at 2:35 p.m., with R4, R10, R22, and R34. During the meeting the residents identified they had concerns regarding the menu options and the tenderness of the meat served, especially the roast beef. They expressed having difficulty chewing the meat that was served and said they had requested other items be added to the menu, such as chili. They have requested the dietary manager (DM) attend resident council so they could express their concerns directly, however, she had not attended. They stated they have no way to know if the DM knew what their concerns were. They identified no staff had communicated with them what was going to be done to address their concerns. These requests had been vocalized in resident council to the Activity Director (AD) on multiple occasions over the past several months. They had voted for the AD to be the staff person that would represent the resident council at the facility; however, they were not certain if their concerns had been relayed to the DM. Review of resident council minutes identified in:March 2026, Resident Council minutes under the dietary old business identified residents discussed their love of meals and snacks and some of their favorite food items. Dietary new business noted resident's favorite dishes for traditional Easter meals with requests for grilled lunches through summer months and incorporating more fruits into snacks. The Resident Council minutes made no mention of the concerns with the menu plan, or tough difficult to chew meat, or that the Resident Council would like the DM to attend a council meeting. April 2026, Resident Council minutes under dietary old business identified residents discussed their favorite dishes for traditional Easter meals. They requested grilled lunches through summer months and incorporating more fruits into snacks. New business identified they discussed Muffins and Moms event and that residents had no feedback regarding their meals or snacks for the month. The Resident Council Minutes made no mention that residents wanted the DM to attend a meeting or that they had concerns with the menu plan or tough difficult to chew meat. May 2026 Resident Council minutes under dietary old business identified they discussed Muffins and Moms event and that residents had no feedback on their meals or snacks for the month. Under new business the minutes noted residents enjoyed taco in a bag in May and would like to have it again in June. They discussed having fresh fruits, breakfast sandwiches, and requested less carrots as a side. The council minutes again made no mention the residents had expressed concerns regarding the tenderness of the meat, the menu plan, or that they had requested the presence of the DM at the Resident Council meeting. Interview on 6/24/26 at 3:21 p.m., with the DM identified she was aware of some concerns that came from resident council. The AD communicated the concerns through email and the DM said she does what she can to address those concerns. She Identified she was aware the council had some concerns and wanted her to attend the meeting, but she had not been able to because she is only at the facility 3 days a week and has had staffing shortages in the kitchen that she had been covering. Review of the 3/30/26, email sent from the AD to the DM identified resident council was requesting grilled foods, breakfast for dinner, fresh fruits, baked potatoes, a waffle bar, and ice cream sundae bar. The DM replied saying they could possibly grill food once weekly, fresh fruits will be coming on the spring/summer menu soon, potato choices will be changing, waffle bar could be an activity and snack, and they could do a sundae bar. The email made no mention that the Resident Council had concerns regarding the meat or that they wanted the DM to attend the meeting. Interview on 6/25/26 at 9:00 a.m., with the Activity Director, identified when the Resident Council brings concerns to the meeting, she would reach out to the appropriate department manager by email. If she had not received a response within a week, she would follow up with them again. Once she received a response she would follow up with the council at the next meeting. She identified she did not get all the council's concerns or the DM's response documented in the resident council meeting minutes. She reviewed the Resident Council process policy and identified that there was a form she was not aware of that was to be used, and stated she would be using that for documentation going forward. Interview on 6/25/26 at 11:18 a.m., with the director of nursing (DON) identified it is her expectation that the AD document any concerns and the resolution in the Resident Council meeting minutes and bring the information back to the Resident Council to be reviewed at the next meeting. Review of February 2026, Resident Council policy identified a designated staff will facilitate and record meeting minutes per council approval. Previous meetings minutes, including department responses, will be read at the beginning of the resident council meeting for resident approval. Designated staff will follow the Resident Council Agenda to record resident concerns, comments, questions, and suggestions. Resident council minutes will be shared with the department leaders once per month and concerns will be addressed in writing.

Based on interview and document review, the facility failed to ensure a timely review with a rationale for a as needed (PRN) psychoactive medication was completed for 1 of 7 sampled residents (R10). Additionally, the facility failed to ensure target symptoms/behaviors were identified for an antidepressant medication to ensure monitoring for effectiveness for 1 of 7 sampled residents (R3). Findings include: R10's 5/13/26, accepted quarterly Minimum Data Set (MDS) assessment identified R10's cognition was intact. R10 had diagnoses of heart failure, high blood pressure, renal insufficiency (kidney disfunction), and seizure disorder. There were no identified diagnoses of anxiety. R10's 3/27/26, physician's Comfort Kit order identified lorazepam (antianxiety medication) 0.5 milligrams (mg) orally every 4 hours PRN for anxiety. If anxiety not improved in 1/2 hour, staff may repeat one time. R10's 6/24/26, printed Medication Administration Record (MAR) identified an order for lorazepam 0.5 mg every 4 hours PRN, comfort measures only with no end date identified. Interview on 6/24/26 at 10:18 a.m., with registered nurse (RN)-C identified that R10 had an order for lorazepam with no end date, because she was currently on comfort cares (end of life treatment). The pharmacist continued to make recommendations to establish an end date or review date and that was done every 30 days for R10's lorazepam. She confirmed the pharmacist had made a recommendation on 5/22/26,to identify a rationale to continue R10's lorazepam PRN order or discontinue. RN-C stated she noted the recommendation on 5/27/26 and took the recommendation physically to the physician's office connected to the facility. RN-C said with the transition to the new electronic record system, she had forgotten to check on the status of the pharmacy recommendation. Typically, she would have followed up with the physician regarding pharmacy recommendations that had not been addressed. She reported she had walked over to the physician's office today (6/24/26) and found that the pharmacy recommendation was laying in a pile of papers on a desk and had not been reviewed yet by the physician. The physician did review and documented for staff to continue for 3 more months. She confirmed that the last review had been done on 4/9/26 for 60 days and that the lorazepam PRN order should have been addressed no later than 6/8/26, 17 days ago. She revealed that R10's lorazepam 0.5 mg PRN order had come from the order for a comfort kit due to R10's declining health and wanting to be kept comfortable. The facility had obtained the order for the comfort kit to ensure they had medications available if needed. Interview on 6/25/26 at 11:10 a.m., with the director of nursing (DON) identified the facility has had some concerns with providers acting timely on pharmacy recommendation and that had addressed at the provider meetings. The facility has had to keep on the providers to get pharmacy recommendations addressed timely. The DON reported that with the recent mitigation to the new electronic record system, the facility must not have followed up with the provider to ensure the pharmacy recommendation was acted upon timely for R10. A policy on PRN psychoactive medications was requested but not provided. R3's admission record identified she admitted to the facility in February of 2024. R3's 5/13/26, accepted comprehensive Minimum Data Set (MDS) assessment identified R3 cognition was intact. R3 had diagnoses of anemia, atrial fibrillation, coronary artery disease, renal insufficiency, arthritis, thyroid disorder, and depression. R3's current physician order identified Celexa 20 milligrams (mg) every day with no associated diagnosis. Review of R3's medical record identified that the Celexa was last increased on 1/8/26 from 10 mg to 20 mg. There was no indication of target symptoms/behaviors for the Celexa. R3's undated, care plan identified although there was a section on R3's psychosocial well-being with a goal to demonstrate her ability to cope with her hospitalization/illness, there was no mention of R3 having existing depression or taking an antidepressant medication with any identified target symptoms/behaviors that may increase with end of life, or for monitoring for the effectiveness of the antidepressant. Interview on 6/25/26 at 11:34 a.m. with registered nurse (RN)-B confirmed that R3 had nothing on her care plan that identified R3 had depression or that she was taking an antidepressant medication and no mention of target symptoms/behaviors that the antidepressant medication was treating for monitoring purposes. The target symptoms/behaviors were typically identified on the care plan. Interview on 6/25/26 at 4:17 p.m., with the director of nursing (DON) identified that each resident receiving a psychoactive medication should have target symptoms/behaviors identified for monitoring for effectiveness of the medication. A policy was requested for psychoactive medication was requested but not received.

Based on observation, interview and document review, the facility failed to ensure staff followed the facility policy to appropriately verify gastrostomy (G) tube placement prior to feedings and medication administration for 1 of 1 resident (R6) reviewed with a feeding tube.Findings include: R6's 5/24/26 accepted quarterly Minimum Data Set (MDS) assessment identified she had moderate cognitive impairment, required staff assistance for all activities of daily living (ADLS), had impairment of upper and lower extremities, and used a wheelchair for mobility. She had a feeding tube in place and received 51% or more of her total calories through the feeding tube. Average fluid intake was 501cc or more per day via the feeding tube. R6 received crushed medication via the feeding tube including an antidepressant, diuretic, opioid, blood pressure, medication for acid reflux, nausea and antiplatelet medications. R6 was admitted in February 2026, with diagnoses of oropharyngeal dysphagia (difficulty initiating a swallow from the mouth into the throat, feeding by G-tube, severe physical deconditioning, and cognitive impairment. She was admitted with a (gastric tube-PEG -a surgically placed tube through the abdominal wall directly into the stomach), and orders for Isosource (lactose-reduced food) with fiber 0.07 grams/1.5 kilo (k) calorie (Cal)/milter (ml) 900 ml/day. Free water was to be administered five times daily at 300 ml via PEG tube. Free water flush 300 ml via G-tube bolus four times daily (QID). Give 150 ml before feeding/medication and 300 ml all other times. R6's current, undated care plan identified she was at risk for impaired nutritional status, evidenced by the need for G-tube feedings. The identified goal was maintaining nutritional status and avoiding weight loss. R6 was to be weighed weekly. Feeding was identified as 900 ml of Iso-source 1.5 formula with a note to refer to orders for further details. Positioning: keep patient upright (30-45 -degree angle) during feeding and for 30-60 minutes afterward to prevent aspiration. Flushing: flush the tube with 150ml of warm water before and after each feeding or medication administration. May have risk for dehydration related to being on tube feedings. Follow registered dietitian recommendations for free water flushed. Notify the provider for tube dislodgement or concerns with patency. Observation on 6/25/26 at 8:23 a.m., with licensed practical nurse (LPN)-A as he prepared to administer R6's physician ordered medications. LPN-A checked the orders for medications, set-up and crushed each medication, placing them into a medication cup. He then took the medications to R6's room applied personal protective equipment (PPE), washed his hands and applied gloves. He explained to R6 he had her medications to administer through her G-tube. LPN-A retrieved a graduated container and filled it with 300 ml of tap water. He then mixed 90 ml of water into the crushed medication. He elevated the head of the bed to 45 degrees. LPN-A exposed R6's feeding tube, opened a 30 ml syringe, removed the plunger and inserted the syringe into the G-tube port. He opened the stop cock and reported he did that to let any air escape. LPN-A poured 90 cc of water in 30 ML intervals and allowed it to flow via gravity. When LPN-A opened the stop cock to allow air to escape a small amount of liquid was noted where the tube entered the abdomen. LPN-A continued to administer the water, then poured the medications into the G-tube and flushed with the remaining water. He then re-clamped the G-tube and told R6 he had also given her medication for nausea with her other medications LPN-A reported this was the normal procedure he followed for administering R6's medications and water. When finished LPN-A took the graduated container and syringe into the bathroom and rinsed and then placed on a paper towel to air dry. Interview on 6/25/26 at 8:43 a.m. with LPN-A identified he did not routinely check G-tube placement before administering medications or water, as he did not believe he needed to. He further stated when the tube had been changed the placement had been verified by x-ray. When asked about any fluid in the G-tube he reported he thought there was some liquid from the last feeding that came out when the air went out the tube, but he was not certain. Interview on 6/25/26 at 10:02 a.m., with registered nurse (RN)-A reported she did not think they were still supposed to check for G-tube placement prior to administration of medications or fluids, but she would need to check the policy to see what it directed. Interview on 6/25/26 at 3:55 p.m., with the director of nursing (DON) reported she thought there was a provider order for R6 that they did not need to check placement for her G-tube. She stated she thought this was because R6 had the G-tube for a long time. Review of the current physician orders with the DON failed to identify an order regarding checking placement of R6's G-tube. Review of the August 2025, policy Gastrostomy tube, PEG (Percutaneous Endoscopic Gastrostomy) tube care identified the Procedure:Place equipment and supplies at bedside where they will be easily accessed.Perform hand hygiene, [NAME] clean gloves.Observe and document external bumper length, verifying the bumper has not migrated. There should be approximately 1 centimeter (cm) between the skin and external bumper. Administering a feeding/checking placement Remove the tube cap or plug by closing the tube. Use a syringe to inject 5-10 ml of air into the tube to clear it.Aspirate gastric contents with the syringeConnect the syringe and infuse water, feeding and or medicationsOnce administration is completed flush with water according to MD order.Document time, feeding if administered, water, and amount administered, tolerance to administration, appearance of skin surrounding the tube, tube patency, and verification of tube placement. Medication Administration:Medications as ordered by providerThe amount of flush to be ordered by the MD.Liquid dosage forms are preferred if possible, and pharmacy will determine if ordered medications can be crushed. Liquefy medications in 15-30 ml of water. Check proper placement of the G-tube prior to administration.Flush the tube with water prior to and following administration of the medicationDocument medication administration

Based on observation, interview, and document review the facility failed to ensure 1 of 1 resident (R48) discontinued controlled narcotic medication was not stored with in-use medications in 1 of 2 medication carts.Findings include: Observation and physician order review on 6/24/26 at 2:30 p.m. with licensed practical nurse (LPN)-B and trained medication aide (TMA)-A as they performed the shift change narcotic count in 1 of 2 medication carts identified there was 1 blister pack card containing 30 Lorazepam 0.5milligram (mg) tablets with the printed pharmacy label identifying it had been dispensed on 6/2/26 for R48. The physician order recorded in the electronic medical record identified the order for Lorazepam 0.5mg by mouth (PO) every (Q) 6 hours (H) as needed (PRN) with a start date of 6/2/26 and the medication was discontinued on 6/16/26. Interview on 6/24/26 at 2:40 p.m. with LPN-B and TMA-A identified the card containing R48's Lorazepam had remained in the in-use narcotic box located on the medication cart co-mingled with other in-use medications and noted it should have been removed and destroyed when the order was discontinued. Interview on 6/24/26 at 2:49 p.m. with registered nurse (RN)-A identified the procedure when a controlled medication was discontinued was the nurse on duty should have pulled the discontinued medication from the active medications and destroyed with two nursing staff in attendance. Interview on 6/24/26 at 3:12 p.m. with the director of nursing (DON) identified when a controlled medication was discontinued it should be removed from the active medication and destroyed with two nursing staff in attendance. A policy for storage and disposal of controlled medications was requested but not received by the end of the survey period.

Based on interview and record review, the facility failed to determine whether a resident was safe to self-administer 2 nebulized medications for 1 of 1 resident (R6) who received 2 medications administered by nebulizer. Findings include: Observation on 6/25/26 at 8:41 a.m. as licensed practical nurse (LPN)-A administered R6's two ordered nebulized medications identified LPN-A assembled the nebulizer mask, tubing, and medication cup, emptied the single dose vial of Arformoterol Tartrate (a long-acting bronchodilator prescribed for the long-term twice daily maintenance treatment of airflow blockage), 15micrograms (mcg)/2mililiters (ml) into the nebulizer medication cup, attached the medication to the mask and positioned the mask on R6's face. He turned on the nebulizer and left the room while R6 received her medication dose. Prior to leaving the room, LPN-A informed R6 he would return in 10 minutes to give the 2nd medication. R6 was on her back in bed with the head of her bed elevated and did not reply as LPN-A left the room Observation on 6/25/26 at 8:53 a.m., identified LPN-A returned to R6's room, turned off the nebulizer, added the single dose vial of Budesonide (a liquid corticosteroid used to decrease airway inflammation) 0.5miligram(mg)/2ml to R6's nebulizer medication cup, and reapplied the mask, after turning on the nebulizer machine. He then verbalized he would return in 10 minutes to discontinue the treatment. LPN-A then left the room as R6 was receiving her treatment. Interview on 6/25/26 at 8:55a.m. with LPN-A reported he did not believe R6 had an order on file to self-administer her nebulized medications, but he felt it was acceptable to leave her unattended during administration of her nebulizer medications. Subsequent interview at 9:57 a.m. with LPN-A identified he had checked the medical record and R6 did not have an order to self-administer her nebulized medications, and as a result he should have remained in attendance during the administration. Interview on 6/25/26 at 10:02 a.m. with registered nurse (RN)-A identified case managers were responsible for completing assessments for residents for residents to self-administer medications, including nebulized medications. Upon review of R6's medical record two previous assessments for self-administration of medication had been completed since her admission on [DATE], and neither identified she was competent to self-administer her medications. Interview on 6/25/26 at 3:55 p.m., with the director of nursing (DON) identified her expectation for self-administration assessments to be completed for all residents prior to allowing them to remain unattended during administration of any medications. Review of the June 2026, Self-Administration of Medications policy identified an assessment was to be completed and reviewed by the interdisciplinary team (IDT). An assessment was to be completed quarterly, if there was a change in medical condition, mental status, or as needed. The results were to be documented in the resident's medical record and care plan. Documentation of a physician order for self-administration was to be obtained and include which medications the resident was able to self-administer.

Based on interview and document review the facility failed to notify the ombudsman of a discharge for 1 of 2 sampled residents (R52). Findings include: R52's 4/22/26, accepted discharge Minimum Data Set (MDS) assessment identified R52 had been discharged to home/community with return not anticipated. R52's 4/16/26, discharge summary identified that R52 had discharge with home health services following completing therapy services. Interview on 6/25/26 at 3:30 p.m., with registered nurse (RN)-A and social service designee (SSD) both identified the facility only notified the ombudsman when there was an emergency discharge to the hospital or a resident leaves the facility against medical advice. The SSD reported the facility did not notify the ombudsman of any planned discharges and confirmed the ombudsman was not notified for R52's discharge back to the community. Interview on 6/25/26 at 4:17 p.m., with director of nursing (DON) identified she was unaware that the facility had not been notifying the ombudsman about all discharges. She confirmed the facility had a policy and it identified to notify the ombudsman of all discharges. Review of December 2025, Transfer or Discharge Notice policy identified a copy of a transfer or discharge would be sent to the ombudsman.

Based on interview and document review, the facility failed to revise the care plan for 1 of 13 sampled residents (R10) with a diagnosis of end stage kidney disease. Findings include: R10's 5/13/26, accepted quarterly Minimum Data Set (MDS) assessment identified R10's cognition was intact. R10 had diagnoses of heart failure, high blood pressure, renal insufficiency (kidney dysfunction), chronic kidney disease, and end stage renal disease. R10's 5/20/26, physician visit note identified consideration for palliative/hospice care had been previously discussed. R10 was interested in this when the time comes for her kidneys. She anticipated that her nephrologist would inform her of that. R10's 6/11/26, nephrology visit note identified chronic kidney disease, stage 4 with bilateral hydronephrosis (enlarged kidney affecting the body's ability to excrete urine), pyuria (pus in urine), and hematuria (blood in urine). Different forms of renal replacement therapy were discussed, and it was noted R10 had declined dialysis. R10's current, undated care plan identified staff were to watch for signs and symptoms of bladder infection, however; there was no mention R10 had end stage kidney disease or that R10 had declined dialysis treatment and chose to remain comfortable at the facility or what staff should watch for if her kidneys failed to operate and function. Interview on 6/25/26 at 11:10 a.m., with the director of nursing (DON) identified each resident should have a person-centered care plan. The care plan should be reviewed and revised as needed as care needs change. She agreed that when R10 had declined the dialysis treatment and requested to be kept comfortable at the facility that the facility should have updated R10's care plan to reflect that change. Review of July 2025, Care Plan policy identified a resident's care plan would be developed by the interdisciplinary team including participation by the resident. The residents' care plan would be updated as needed and reviewed at minimum quarterly.

Based on interview and document review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 5 sampled residents (R3) with a diagnosis of depression.Findings include: R3's admission record identified she admitted to the facility in February of 2024. R3's 5/13/26, accepted comprehensive Minimum Data Set (MDS) assessment identified R3 cognition was intact. R3 had diagnoses of anemia, atrial fibrillation, coronary artery disease, renal insufficiency, arthritis, thyroid disorder, and depression. R3's current physician order identified Celexa 20 milligrams (mg) every day. Review of R3's medical record identified that the Celexa was last increased on 1/8/26 from 10 mg to 20 mg. R3's undated, care plan identified although there was a section on R3's psychosocial well-being with a goal to demonstrate her ability to cope with her hospitalization/illness, there was no mention of R3 having existing depression or taking an antidepressant medication with any identified target symptoms/behaviors that may increase with end of life, or for monitoring for the effectiveness of the antidepressant. Interview on 6/25/26 at 11:34 a.m. with registered nurse (RN)-B identified the facility care plans were still a work in progress as the facility had just switched to a new electronic medical record system. She confirmed that R3 had nothing on her care plan that identified R3 had depression or that she was taking an antidepressant medication. There were no target symptoms/behaviors that the antidepressant medication was treating for monitoring purposes. The care plan lacked what staff are to do as interventions if R3 displayed symptoms of depression and normally all that information would be addressed on the resident's care plan. RN-B identified R3 had started the antidepressant prior to admission to the facility. Interview on 6/25/26 at 4:17 p.m., with the director of nursing (DON) identified that each resident should have a person-centered care plan developed. R3's care plan should have addressed her depression and what her target symptoms/behaviors were and what staff were to do if she displayed those behaviors. She agreed target symptoms/behaviors should be identified in order to monitor for effectiveness of the medication. Review of July 2025, Care Plan policy identified a resident's care plan would be developed by the interdisciplinary team including participation by the resident. The resident's care plan would include medications used as an intervention for the residents' medical needs. The residents' care plan would be updated as needed and reviewed at minimum quarterly.

The facility's request for a waiver was accepted and approved by the State Agency following the survey dated 7/17/23. The tag was re-issued however, NO plan of correction was required. This will remain in effect until such time as the registered nurse (RN) coverage can be filled and the facility achieves compliance. F727: CFR 483.35 (b)(1), RN coverage 8 consecutive hours a day, 7 days a week. Findings include: Review of the facility nursing staff schedules for February 2025, March 2025 and April 2025 identified in: 1) March 2025, No 8-hour consecutive RN coverage for 2 of 31 days: 3/8 and 3/9/2025. 2) April 2025, No 8-hour consecutive RN coverage for 1 of 30 days: for 4/12/2025. Interview on 4/30/25, 2:30 p.m. with the director of nursing (DON) reported the scheduler attempted to fill open shifts and notified management of call-ins or unfilled shifts. The DON reported there was a registered nurse on call, and she could be assigned to cover the open shift also if needed, or the nurse managers could pick up and work the open hours. The facility continues to struggle with hiring to ensure there was a registered nurse (RN) 8 hour/24-hour on duty, but the facility was attempting to find more staff. Interview on 4/30/25 at 3;30 p.m., with the administrator reported the facility has reached out to many resources to fill RN positions, in addition to utilizing online web-sites to obtain licensed employees. They struggle with hiring and filling that position all days. Interview and source verification review on 4/30/25 at 3:42 p.m. with human resources officer (HR) identified she had posted staff openings on Indeed, both local and neighboring city newspapers, Facebook, and other county specific web-sites. Review of the July 2023, Scheduling and Absenteeism Policy -HCHA Long Term Care identified the facility policy was to maintain staff staffing levels and provide the necessary care and safety to the residents in the facility, Staffing was identified according to need with the number of residents residing in the facility. The policy identified the goal of RN coverage a minimum of 8 hours/24 hours, 7 days/week.

Based on interview and document review, the facility failed to ensure data submitted to 1 of 1 Quality Assurance Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 47 residents. Findings include: Review of QAPI meeting minutes provided from 4/16/2024 through March 31, 2025 identified in: 1.) April 16, 2024- agenda items identified problem with falls, but no identified goal, action plan, data collection or analysis of the information identified. 2.) June 25, 2024- agenda items identified some areas of concern, but failed to include goals, action plan, method for data collection or analysis 3.) July 30, 2024- Identified working on family notification for therapy, completion of 72 H forms, resident toileting, or repositioning. No goals, action plan, data or analysis identified. 4.) [DATE]- no review of any projects in place [DATE]. 2025-no review of any projects, or associated data. 5.) January 28. 2025-no review of any projects or associated data. 6.) February 25, 2025-no review of any projects or associated data 7.) March 31, 2025-no review of any projects, however notation of team review of quality indicators and identified two areas, behaviors/antipsychotic medication use and falls. No goals, action plan, data collection or analysis included. Interview on 4/30/25 at 4:01 p.m., with the Director of Aging Services (QAPI director on the phone), and the facility administrator and the director of nursing (DON) in attendance reported the facility had not completed a thorough analysis of data to include measurable goals, plans, or outcomes. Review of the February 2024 Quality Assurance and Performance Improvement (QAPI) policy identified the facility was to have a QAPI plan to address resident's Quality of Life, and resident choices. The plan was to be developed according to details included in the Facility Assessment. The policy identified the QAPI program was to identify areas of high risk, high volume, and/or problem areas for improvement by identifying and correcting the areas of deficiency. The components to be included: 1.) Tracking and measure of performance 2.) Establish goals with thresholds for performance improvement. 3.) Identify and prioritize areas of quality deficiencies. 4.) Analyze causes of deficiencies. 5.) Develop and implement corrective action plans. 6.) Monitor and evaluate the action plan with revisions, as necessary.

Based on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas were identified with appropriate data collection, analysis, and evaluation of the identified concern(s) during Quality Assurance Program Improvement (QAPI). This had the potential to affect all 47 residents residing in the facility. Findings include: Review of QAPI meeting minutes provided from 4/16/2024 through 3/31/25, identified no PIP projects identified with Goals, Action Plans, Data collection, and Analysis for identified areas/issues of concern for improvement within the facility. Interview on 4/30/25 at 4:01 p.m., with the Director of Aging Services (QAPI director on the phone), and the facility administrator and the director of nursing (DON) in attendance reported the facility had some previous PIP projects but had not developed formal PIP plans for the past year. Review of the February 2024 Quality Assurance and Performance Improvement (QAPI) policy identified the facility was to have a QAPI plan to address resident's Quality of Life, and resident choices. The plan was to be developed according to details included in the Facility Assessment. The policy identified the QAPI program was to identify areas of high risk, high volume, and/or problem areas for improvement by identifying and correcting the areas of deficiency.

Based on interview, and document review the Quality Assurance and Performance Improvement (QAPI) committee failed to document attendance, ensure they received regular reports from the infection preventionist (IP) on the infection control program, and review State Agency (SA) and incident reports for 4 of 4 quarters reviewed. Findings include: Review of provided QAPI meeting minutes of March 31, 2024, April 16, 2024, June 25, 2024, July 30, 2024, October 23, 2024, January 28, 2025, February 25, 2025, and March 31, 2025, identified no data was correlated and presented by the IP on facility process, outcome surveillance, outbreaks, and implementation of any control measures, staff illness,and the Antibiotic Stewardship Program (ASP) related to antibiotic use and resistance data. There was no mention of any review of submitted SA or incident reports provided for review by the QAPI committee. The minutes contained a typed list of members of the QAPI committee, but there was no identification of who was absent and/or who was in attendance to confirm required attendance of the committee members at the quarterly meetings. Interview on 4/30/25 at 4:01 p.m. with the QAPI/ Director of Aging Services (via phone) and the administrator and director of nursing (DON) in attendance identified the facility did not have sign in sheets to document attendance at meetings. The QAPI director reported she recalled the IP was not present at the March 2025 meeting, but did not recall other meetings. She reported the IP gave a verbal update on what she is working on, any training provided, any concerns but did not document any areas of discussion, goals, or plan for improvement. The administrator and QAPI director reported a short version of SA and incident reports were discussed at the monthly meeting, but she was uncertain if it was discussed with the medical director quarterly. She confirmed there was no documentation of review of incident or SA reports. Review of the February 2024 Quality Assurance and Performance Improvement (QAPI) policy identified the facility was to maintain documentation to confirm the implementation of QAPI program compliance with Centers for Medicare and Medicaid Services (CMS) requirements. The QAPI committee was to consist of at a minimum, the DON, the medical director or designee, the IP, and at least three other staff, one of whom must be the facility administrator, owner, board member, or other individual with knowledge and ability to make changes in facility systems. The facility was to develop, implement and maintain a QAPI program that was effective, data driven, comprehensive and focused on provision of care regarding resident Quality of Life.

Based on interview and document review the facility failed to ensure timely submission of a Death in facility Minimum Data Set (MDS) for 1 of 14 residents (R9) who was reviewed for an MDS record over 120 days old. Findings include: R9's medical record identified her last scheduled Minimum Data Set (MDS) assessment that had been submitted and validated was 11/26/24. R9's death in facility MDS was signed by the responsible party on 1/7/25 and locked on 1/7/25. The death in facility MDS had not been successfully submitted and/or transmitted; as R9's electronic health record identified it had been completed rather than accepted under the status section, indicating it had not been submitted. Observation, and interview and validation report review on 4/29/25 at 8:49 a.m., with registered nurse (RN)-A identified she had taken over as the MDS coordinator the second or third week of January 2025. Before that, multiple persons had completed MDS assessments. RN-A identified the person who had completed R9's final assessment completed and locked the assessment on 1/7/25, but failed to validate the assessment which would have sent the assessment to the submission file in the Meditech electronic medical record program. She kept a list of MDS due dates, and her process was to submit completed MDS's each week and review the Validation report to ensure all MDS assessments had been submitted successfully. RN-A reported she had not reviewed MDS submissions prior to her taking over the position and had not been aware of the outstanding assessment. RN-A was unsure why R9's death in facility MDS had not been validated and submitted, but she identified she would now validate and submit the assessment. Interview on 4/30/25 at 2:30 p.m. with the director of nursing (DON), identified her expectation for the MDS coordinator to keep track of Assessment Reference Date (ARD), with completion, validation, and submission of MDS assessments within the required time frames. Review of the September 2023, Completion of Assessments policy identified assessments were to be completed according to the MDS ARD with submission according to required time frames. All MDS assessments were to be completed by responsible departments prior to the last identified date of the observation period. The RN MDS coordinator completed and signed the assessment on the Assessment Reference Date.

Based on interview and document review, the facility failed to ensure the care plan was updated for 1 of 1 resident (R34) reviewed for side effect monitoring of anticoagulant (blood thinner) therapy. Findings include: R34's annual Minimum Data Set (MDS) dated [DATE], indicated R34 had severe cognitive impairment, received antipsychotic, antianxiety, antidepressant, and anticoagulant medication. R34's diagnoses included history of stroke and deep venous thrombosis (DVT), depression, anxiety, dementia and Alzheimer's disease. R34's medication order form printed 4/30/25, indicated R34's active order dated 4/1/25, for Eliquis (anticoagulant) 2.5 mg orally twice a day for DVT of left lower extremity (LLE). The order did not include any label comments or special instructions. R34's care plan printed 4/30/25, identified R34 was at high risk for falls as evidenced by history of multiple falls and vision loss and was at risk for medication side effects related to the use of antipsychotic, antidepressant, and antianxiety medications. R34's care plan lacked evidence of anticoagulant use, increased risk for bleeding, or need for anticoagulant side effect monitoring. During interview on 4/30/25 at 9:21 a.m., licensed practical nurse (LPN)-A confirmed R34's EMAR listed Eliquis but lacked any special instructions for monitoring for potential side effects. LPN-A further stated such instructions could also be found in the resident's care plan and confirmed R34's care plan lacked any reference to anticoagulant use, side effect monitoring or increased risk for bleeding. During interview on 4/30/25 at 10:20 a.m., director of nursing (DON) stated side effect monitoring for medications should be care planned. DON stated R34's care plan should include anticoagulant use and instruct staff to monitor for potential side effects including increased bleeding risk. DON further stated EMAR could also include special instructions for medications. DON confirmed R34's care plan and EMAR lacked any reference to anticoagulant use, risks or side effect monitoring. DON stated the MDS nurse often updated the resident's care plans and may have additional information. During interview on 4/30/25 at 10:35 a.m., MDS nurse stated side effect monitoring should be on a resident's care plan when they were receiving an anticoagulant. MDS nurse stated staff should be instructed to watch for bleeding. During interview on 4/30/25 at 10:54 a.m., consultant pharmacist (CP) stated staff should be aware of potential side effects of medications and should actively monitor for them. CP further stated this facility's population often received additional medications that put them at risk for falls and therefore, side effect monitoring of anticoagulants was particularly important. Facility policy Anticoagulation-Clinical Protocol dated 2018, instructed staff to, Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. The policy instructed staff to monitor for possible complications such as excessive bruising, hematuria (blood in urine), hemoptysis (coughing up blood), or other bleeding and to contact provider before administering next dose of anticoagulant. Facility policy Care Plans/Care Conferences dated 12/2022, indicated, An individualized, comprehensive plan of care will be developed, maintained and followed for each resident. The policy further indicated resident care plans should include information regarding how medications were being used and evaluated and should be updated as needed.

Based on interview and document review, the facility failed to ensure side effect monitoring for 1 of 1 resident (R34) reviewed for anticoagulant (blood thinner) therapy. Findings include: R34's annual Minimum Data Set (MDS) dated [DATE], indicated R34 had severe cognitive impairment, received antipsychotic, antianxiety, antidepressant, and anticoagulant medication. R34's diagnoses included history of stroke and deep venous thrombosis (DVT), depression, anxiety, dementia and Alzheimer's disease. R34's medication order form printed 4/30/25, indicated R34's active order dated 4/1/25, for Eliquis (anticoagulant) 2.5 mg orally twice a day for DVT of left lower extremity (LLE). The order did not include any label comments or special instructions. R34's care plan printed 4/30/25, identified R34 was at high risk for falls as evidenced by history of multiple falls and vision loss and was at risk for medication side effects related to the use of antipsychotic, antidepressant, and antianxiety medications. R34's care plan lacked evidence of anticoagulant use, increased risk for bleeding, or need for anticoagulant side effect monitoring. During interview on 4/30/25 at 7:46 a.m., licensed practical nurse (LPN)-A stated instructions such as monitoring for side effects of medications should be listed in the electronic medication administration record (EMAR) under special instructions. LPN-A stated increased bleeding was a potential side effect of anticoagulant use. During follow up interview on 4/30/25 at 9:21 a.m., LPN-A confirmed R34's EMAR listed Eliquis but lacked any special instructions for monitoring for potential side effects. LPN-A further stated such instructions could also be found in the resident's care plan and confirmed R34's care plan lacked any reference to anticoagulant use, side effect monitoring or increased risk for bleeding. LPN-A further confirmed R34's Eliquis pill bubble pack contained a yellow label instructing staff to contact provider if bleeding concerns and stated does not reference that label since those label instructions were supposed to be included in the EMAR under special instructions. During interview on 4/30/25 at 10:20 a.m., director of nursing (DON) stated side effect monitoring for medications should be care planned. DON stated R34's care plan should include anticoagulant use and instruct staff to monitor for potential side effects including increased bleeding risk. DON further stated EMAR could also include special instructions for medications. DON confirmed R34's care plan and EMAR lacked any reference to anticoagulant use, risks or side effect monitoring. DON stated the MDS nurse often updated the resident's care plans and may have additional information. During interview on 4/30/25 at 10:35 a.m., MDS nurse stated side effect monitoring should be on a resident's care plan when they were receiving an anticoagulant. MDA nurse stated staff should be instructed to watch for bleeding. During interview on 4/30/25 at 10:54 a.m., consultant pharmacist (CP) stated staff should be aware of potential side effects of medications and should actively monitor for them. CP further stated this facility's population often received additional medications that put them at risk for falls and therefore, side effect monitoring of anticoagulants was particularly important. Facility policy Anticoagulation-Clinical Protocol dated 2018, instructed staff to, Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. The policy instructed staff to monitor for possible complications such as excessive bruising, hematuria (blood in urine), hemoptysis (coughing up blood), or other bleeding and to contact provider before administering next dose of anticoagulant.

Based interview and document review the facility failed to have a thorough ongoing infection control surveillance program that included resolution of symptoms and/or if any precautions had been implemented for 3 of 3 residents (R8, R12, R34). The facility also failed to identify when employees would be able to return to work after illness, dependent upon their symptoms of illness for 2 of 3 staff reviewed (nursing assistant (NA)-A, and trained medication aide (TMA)-A). Additionally, the facility failed to complete a tuberculosis screening for 1 of 5 residents (R32) reviewed. Findings include: Resident Surveillance Review of February 2025, LTC Respiratory Surveillance Line List identified the form included areas to document; Name/age/gender, Resident/staff, Hall/room, Symptoms onset date, Fever, Cough, Myalgia (body ache), Additional symptoms, Chest X-ray, Type of specimen collected/date of collection, Type of test ordered, Pathogen and Symptom resolution date. What the form lacked was if any precaution were implemented, what type of precaution, and/or when precautions were ended. Review of the 3 residents listed on the form identified: 1) R8 was identified with symptoms on 2/6/25, of fever, cough, myalgia and shortness of breath and Influenza A was identified. There was no resolution date or identification if any precautions implemented. 2) R12 was identified with symptoms on 2/6/25, of fever, cough, myalgia, and Influenza B was identified. There was no resolution date or identification if any precautions implemented. 3) R34 was identified with symptoms on 2/6/25, of fever and Influenza B was identified. There was no resolution date or identification if any precautions implemented. R8's 2/6/25, progress notes identified an encounter form had been sent to clinic related to R8 complaining of chest pain with coughing. New medication orders were received for as needed DuoNeb's and cough medication. There was no indication of any precautions being implemented. R8's 2/7/25, progress note identified that R8 had worked with therapy and after breakfast had increased respirations, elevated blood pressure and oxygen saturation was at 89% on room air. An as needed nebulizer and Mucinex was given without much improvement. Resident continued with coughing, wheezing and had crackles auscultated throughout bilateral lungs. A Call was placed to the provider and the resident was sent to ER for evaluation. Resident returned with order for Tamiflu and to continue oxygen. There was no indication of any precautions implemented. Review of progress notes for 2/8/25, 2/10/25, 2/11/25 had no mention of any type of precautions that may have been implemented. On 2/12/25, the progress note identified R8 was on quarantine for influenza and continued with a harsh cough. There was no indication when R8 had been placed in quarantine. R12's 2/3/25, progress note identified R12 had been coughing and the daughter had requested cough medication. There was no indication of any precaution being implemented. On 2/5/25, daughter requested a COVID test which was completed and negative. There was no indication of any precautions being implemented. The 2/6/25, progress note identified the son had requested R12 be tested for influenza. Progress notes on 2/7/25, identified a fever of 100.6, on 2/8/25 a fever of 99.4, 2/9/25 coughing, all with no indication of any precautions implemented. On 2/11/25, the progress note identified she remained in her room per protocol. There was no indication when R12 had started to remain in her room. R34's 2/6/25, progress note identified R34 had a cough, vitals taken, COVID test completed and negative. There was no indication if any precautions had been implemented or not. The 2/7/25, progress note identified R34's family was updated on the influenza diagnosis and status. R34 had a temperature of 101.3 at 10:30 p.m., and at 1:20 a.m., was down to 99.9. The was no indication if any precautions had been implemented or not. Review of progress notes on 2/8/25, 2/10/25, 2/11/25 had no mention of any type of precautions that may have been implemented. On 2/12/25, the progress note identified R34 was on quarantine for influenza and continued to cough. There is no indication when R34 had been placed in quarantine. EMPLOYEE SURVEILLANCE Review of staff call in log for January 2025 through April 2025 identified the form included area to document; Date/time, shift to be worked, name of employee, reason for call in (describe symptoms), replacement found, illness form filled out and placed in schedule, doctor note, initials of person taking call. Review of 2 staff listed on the form identified: 1) TMA-A called in on 3/3/25, with symptoms of vomiting, diarrhea, and fever. The form identified that an illness form had been filled out. Review of the Employee Illness Report form identified diagnosis/symptoms as gastroenteritis (vomiting/diarrhea) with a temperature of 100.4, date of absence was 3/3/25 and date returned to work was 3/4/25. 2) NA-A called in on 4/14/25, with symptoms of vomiting and diarrhea. The form identified that an illness form had been filled out. The director of nursing (DON) reported she was unable to find an Employee Illness Report form for NA-A. She confirmed that NA-A had returned to work on 4/15/25. Interview on 4/30/25 at 2:08 p.m., with DON agreed that the resident surveillance had not been filled out completely with no resolution date. She agreed that there was no place to identified if precaution had been implemented or not. If a resident was placed on precaution that would have been identified in the resident's progress note. She agreed it would be difficult to complete a quick audit or oversight to ensure implementation of precautions timely if not identified on the surveillance form. She confirmed that staff should not be returning to work after 24 hours of having vomiting and diarrhea and the facility should have a better follow up prior to returning to work. Review of September 2024, Infection Prevention and Control Program identified surveillance would be maintained for evaluation of effectiveness in reducing the risk of infections. Infection control program was responsible for prevention of infections through precautions, employee health program, and surveillance. The policy identified employee health surveillance for absence, the staff must complete an Employee Illness Form and staff must be cleared by a licensed nurse before returning to work. Review of undated, [NAME] Community Hospital Association Return to Work Guidelines identified staff with diarrhea would be restricted from patient contact, environment, and food handling until symptoms resolve. Tuberculosis (TB) R32's medical record identified R32 did not have a TB baseline symptom screening completed. R32 had been administered a tuberculin skin test upon admission however, the results were never read. A second tuberculin skin test was administered on 12/25/23 and read on 12/27/23 with a negative result. Interview on 4/29/25 at 11:05 a.m., with director of nursing (DON) confirmed the TB skin test had been administered but never read. She further agreed that the TB symptom screening should have been completed prior to administering the TB skin test. She reported she already was working on re-training on TB screening and testing. Review of undated, Tuberculosis, Screening Residents for policy identified upon admission all residents would be screened for tuberculosis infection (TB). If a potential resident has been exposed or is at increased risk of TB according to the screening and TB skin test would be completed.

The facility's request for a waiver was accepted and approved by the State Agency following the survey dated 7/17/23. The tag was re-issued however, NO plan of correction is required. This will remain in effect until such time as the registered nurse (RN) coverage can be filled and the facility achieves compliance. F727: CFR 483.35 (b)(1), RN coverage 8 consecutive hours a day, 7 days a week. Findings include: Review of the facility nursing staff schedules for February 2024, March 2024 and April 2024 identified in: 1) February 2024, there no 8-hour consecutive RN coverage for 6 of 29 days: 2/3; 2/4; 2/10, 2/11; 2/18, and 2/25/24 2) March 2024, there was no 8-hour consecutive RN coverage for 2 of 31 days: 3/3 and 3/17/24. 3) April 2024, there was no 8-hour consecutive RN coverage for 2 of 30 days: 4/14 and 4/28/24. Interview on 5/28/24 at 12:41 p.m. with licensed practical nurse (LPN)- B (staff scheduler), reported she completed assignments and notified management of call-ins. She reported when there was a call-in, she communicated the open shift via text message and updated the administration team. Interview on 5/29/24 at 12:16 p.m. with the administrator reported he had reached out to many resources in addition to utilizing online websites to obtain licensed employees. Interview on 5/29/24 at 12:21 p.m. with human resources (HR) identified she had posted staff openings on Indeed, the facility website, Handshake (for college students), and Lake area tech. She reported she had not had much luck with responses. She reported the facility had attempted one local job fair in [NAME] and had been involved with job fairs held with South Dakota state university. She reported most to the applications had been a result of Indeed or the website and when she received an application, she immediately contacted the applicant to set up an interview with the facility. Interview on 5/30/24 at 10:30 a.m. with the director of nursing (DON) reported the facility continued to struggle with consecutive registered nurse (RN) 8 hour/24-hour coverage, but the facility was attempting to find more staff but at the present time needed to continue with the RN waiver. Review of the July 2023, Scheduling and Absenteeism Policy -HCHA Long Term Care identified the facility policy was to maintain staff staffing levels and provide the necessary care and safety to the residents in the facility, Staffing was identified according to need with the number of residents residing in the facility. The policy identified the goal of RN coverage a minimum of 8 hours/24 hours, 7 days/week.

Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify facility specific concerns, implement an action plan to correct the identified concerns or to ensure the committee participated in the development and oversight of implementation of systems, and to ensure quality of life and quality of care were maintained for 46 residents residing in the facility. Findings include: Review of undated, facility performance improvement plan (PIP) identified a goal for the facility to observe medication administrations in the facility's dining room. The action plan was for education to be provided for nurses and train medication aides (TMA's) on medication administration. The improvement plan had no mention of a target date nor observation dates or times of medication administrations observed. The plan lacked interventions that would analyze the underlying cause and opportunities for improvement. Interview on 5/29/24 at 3:52 p.m., with director of nursing (DON) stated the nursing home utilized an online quality scorecard for both the hospital and nursing home that would track PIP's in the facility. She stated the facility would implement quality improvements projects during the fiscal year for month of July 2023 to June 2024. She stated the facility had no PIP's from the month of July 2023 to March 2024. She stated she had encouraged the administration and department heads during the facility monthly meetings to identify areas of improvement that facility could work on and create a PIP on the online quality scorecard. She stated she was aware that a PIP plan had recently been added on the facility scorecard by a department head who identified an improvement for medication administration. She stated the had been posted on SharePoint in the month of April of this year, because the facility had no success in implementing a PIP the last few months. She stated the current PIP needed improvements and stated it lacked audits and consistent data for analyzing performance improvements. Review of the February 2024, QAPI policy identified the QAPI program was to develop and implement performance improvement activities.

The facility failed to ensure the development and implementation, and the maintainence of an effective compliance and ethics program for oversight when 1 of 1 employee registered nurse (RN)-D, advised licensed practical nurse (LPN)-E to sign-off on a narcotic documentation form as having witnessed the count, when in fact, they had not. Findings include: Review of the facility west wing Shift Verification of Controlled Substances Count form identified one entry of a nurse signature missed on 5/16/24 for the 6:00 a.m. shift and a second entry of a nurse signature missed on 5/28/24 for the 10:00 p.m. to 6:00 a.m. shift. The documentation lacked supporting evidence to verify if the narcotic counts were completed appropriately. Observation and interview on 5/28/24 at 6:37 p.m., with LPN-E stated he was unaware of who completed the narcotic count with him and was aware the narcotic count was completed before his shift on 5/16/24 and confirmed the form was not sign by the departing nurse. Observation and interview on 5/28/24 at 6:39 p.m., with RN-D stated she worked the morning of 5/28/24 and stated LPN-C and LPN-F had completed a narcotic count during the previous shift change and stated LPN-C forgot to sign her name on the form. RN-D stated she observed the two nurses count the narcotics that morning and was sure the narcotic count was completed and stated the missing signature needed to be signed. RN-D then directed LPN-E (who did not perform the count) to sign the form for the date of 5/28/24. LPN-E asked RN-D where his signature should be placed. RN-D pointed to the form for the date of 5/28/24 and advised LPN-E to sign his name. LPN-E placed his pen on the narcotic form and was stopped by the surveyor as LPN-E had not witnessed the count. Review of LPN-E timesheet identified he worked on 5/28/24 beginning at 1:52 p.m. Review of RN-D timesheet identified she worked on 5/28/24 beginning at 5:54 am to 12:45 p.m. and then again from 1:41 p.m. to 6:54 p.m Interview on 5/28/24 at 6:52 p.m., with director of nursing (DON) stated her expectations would be for the nurses and trained medication aide (TMA) to count narcotics every shift and sign the narcotic form accurately when the task was completed. Interview on 5/29/24 at 8:58 a.m., with administrator stated it is not an acceptable practice for staff to [NAME] documentation if it was not completed accurately. It was his expectation would be for all staff to complete documentation in a timely manner when the task or work had been completed. In addition, he stated his expectation would be for employees to not alter documentation, but provide a rationale for not completing documentation in a timely manner. Review of 2/16/24 Skilled Nursing Facilities Orientation Checklist for Direct Care Staff-Nursing assistants and Nurses identified QAPI, Compliance and Ethics training deadline was due upon hire. Interview and record review on 5/29/24 at 10:15 a.m., with DON stated RN-D had a hire date of 2/29/20. She stated the information sent by human resources (HR) noted RN-D lacked documentation of ethics training upon hire. Review of RN-D facility education identified a printed Scorecard: All Competencies dated November, 2023 that listed completion of Ethics training. Interview on 5/29/24 at 3:14 p.m., with administrator stated the facility had no active Ethics committee but had assigned people that would meet, if requested. The facility committee had no meetings scheduled and had no reasons or concerns to meet regularly. Interview on 5/29/24 at 3:23 p.m., with DON stated she unaware of a ethics committee at the facility and had no knowledge of an ethics committee meeting regularly. Review of February, 2024 Controlled Substance Storage and Disposal policy identified controlled substance count verification should be done every shift by two (2) nurses or medication aides; one from previous shift and one form oncoming shift. Nurse and/or TMA going off duty and a nurse and/or TMA coming on duty would provide their signature. The signature would indicate the medications had been checked and the count was verified to be correct. If the narcotic count was incorrect, staff would notify the DON. Review of June, 2023 Employee Code of Conduct and Confidentiality policy identified employees will be expected to adhere to the regulations. The policy identified employees would complete medical records accurately and are expected to conduct themselves in a moral, honest and courteous manner. Review of August 2023 Ethics Committee policy identified the committee is a advisory resource for end of life situations and available as an advisory group and did not meet regularly, but would be available upon request.