Every finding on record at Highlands Lake Center

Based on observations, interviews, and record review, the facility failed to ensure the narcotics policy was followed by nursing to ensure narcotic audits were accurate for three residents (#1, #8 and #9) out of three residents sampled for pain management.Findings included:On 11/04/2025 at 8:33 a.m., an interview was conducted with Staff G, Licensed Practical Nurse (LPN). Staff G, LPN stated when narcotics are delivered, Staff G, LPN would sign a yellow sheet of paper and a hand-held device where an electronic signature would be required by the pharmacy. A copy would be provided to the nurse. Staff G, LPN stated he would take the prescription along with the actual narcotic card and place the prescription in the narcotic book located on the medication cart and place the narcotic card inside the locked area of the medication cart for narcotics. The copy of the yellow sheet will go to the unit manager's box. Staff G, LPN stated if a narcotic and/or a resident has been discontinued, the process would be to remove the narcotic card and take the Unit Manager, and both will sign off. The Unit Manager will bring the discontinued narcotic cards to the Director of Nursing (DON). Staff G, LPN stated he has two discontinued narcotic cards in the assigned cart. On 11/04/2025 at 8:40 a.m., an interview was conducted with Staff A. Staff A, LPN stated when pharmacy delivers a narcotic medication, a yellow copy is signed, and a copy would be provided to the nurse. Staff A, LPN stated a signature would be required as well on the pharmacist's phone. Staff A, LPN stated she would get another nurse to witness the narcotic card going into the cart to ensure the count is correct. Staff A, LPN stated pharmacy delivers at different times. Staff A, LPN stated the card count (Controlled Substance Audit Record) requires two nurses' signature at the change of shift but again she may or may not get a second witness during the day if she places a new narcotic card in the locked narcotic box in the medication cart. Staff A, LPN stated discontinued narcotics are brought to the unit manager or DON along with the white prescription sheet, the count would be verified, and the card count sheet would be updated.On 11/04/2025 at 8:58 a.m., an interview was conducted with Staff H, Registered Nurse (RN). Staff H, RN stated pharmacy delivers around 5-6:00 p.m., and 4-5:30 a.m. Staff H, RN stated the nurse will sign the yellow copy, pharmacy will give a copy to the nurse, and the nurse would sign in their phone. Staff H, RN stated she would get a second nurse to witness the narcotic card placed inside the medication cart. Staff H, RN stated if the narcotic is discontinued, she would take the medication out , adjust the log and bring the narcotic to the Unit Manager or the DON.On 11/04/2025 at 2:30 p.m., an interview was conducted with the DON. The DON stated on 10/21/2025 (Tuesday) she was walking the hallways prior to their 9:00 a.m. morning clinical meeting. The DON stated there were no staff present at the nurses' station, including the Unit Manager assigned to the unit and stated she was probably making her morning rounds. The DON stated she saw in the nurses' station a medication monitoring sheet on top of the nurses' work area. The DON stated the medication monitoring sheet was for Resident #1 and the prescription was for his Hydrocodone 10 mg (milligrams)/325 mg with the date of 10/18/2025 signed by Staff I, LPN. The DON stated the medication monitoring sheet showed the documented total number of tablets received at the top but no further tallies were noted on the sheet. The DON stated she went to cart HP1 to see if the actual medication was in the narcotic drawer. The DON stated there was no narcotic card within the locked narcotic box within the medication cart. The DON stated she looked through the entire medication cart just in case it was misplaced. The DON stated she contacted her Assistant Director of Nursing for assistance. The DON stated they looked in other care areas, checked the med rooms, and shred boxes. The DON stated she checked the shred box in front of the Unit Manager's office and found a blister pack with Resident #1's name still on the pack. The DON stated she immediately notified the Nursing Home Administrator (NHA). The DON stated we notified our regionals and started an immediate investigation. The DON stated upon review of Resident #1 Medication Administration Record (MAR) the resident received his as needed pain medication upon request. The DON stated this particular medication is also available in their [electronic medication dispensary] to ensure the resident had the requested medication for pain available. The DON stated the primary physician was notified and the Advanced Registered Nurse Practitioner (ARNP) prescribed another prescription at no cost to the resident. The DON stated all residents in the unit with a Brief Interview for Mental Status (BIMS) of 12 (mildly impaired) or higher were interviewed. The DON stated all the residents denied any issues with receiving their medications. The DON stated she did not ask specifically about narcotics. The DON stated Staff I, LPN, works per diem and sometimes assigned to other areas in the facility. The DON stated she interviewed the two nurses who had worked with Staff I, LPN and both stated they did not see any medications lying around, nor notice odd behavior from Staff I, LPN. The DON stated she interviewed three certified nursing assistants, but all stated they did not see loose medication or odd behavior from Staff I, LPN. The DON stated she called Staff I, LPN on 10/22/2025 for an interview. The DON stated Staff I, LPN admitted to signing in the narcotic on 10/18/2025 but could not account for the blister pack. She was informed she was suspended pending the investigation. The DON stated we reviewed the sign-in and sign-out log sheet for the narcotic cards (Controlled Substance Audit Record) and we did not see any discrepancies. The DON stated a 30-day audit for narcotics was initiated on 10/23/2025 where the Unit Manager would review the Controlled Substance Audit Record) and then sent to Medical Records. The DON stated we did not notice any abnormalities for the counts (Controlled Substance Audit Record). The DON stated after a review of the audits, no changes to their policy was needed. The DON stated Staff I, LPN resigned over the phone.On 11/05/2025 at 8:28 a.m., a telephone interview was conducted with Staff F, account manager for the contracted pharmacy services. Staff F stated the delivery driver will bring the sealed package directly to the nurse(s). The delivery driver will stand there until the nurse accepts the delivery. A yellow copy would be signed by the nurse, as well as an electronic signature. The delivery driver would give a copy of the yellow copy to the nurse as well as the sealed tote bag. Staff F stated the tote bag will contain medications to be delivered but the narcotic medication would be separated from the other medication. The narcotic card and prescription are in the sealed tote bag. Staff F stated it is the responsibility of the nursing staff to verify all information is accurate before receiving the medications. Staff F denied any knowledge or contact from the facility of a potential diversion scenario recently at the facility. Staff F provided information under an inquiry from the pharmacy's electronic tracking device for deliveries. A review showed the following: 10/18/2025 at 4:41 p.m., the pharmacy approved a one-time dose of Resident #1's Hydrocodone-Acetaminophen 10 milligrams/325 milligrams (mg) to be pulled from the facility's [electronic medication dispensary] -10/18/2025 at 5:32 p.m., Staff I, LPN pulled one tablet of Hydrocodone-Acetaminophen 10mg/325 mg for Resident #1. -10/18/2025 at 5:34 p.m., a delivery for Resident #1's prescribed Hydrocodone-Acetaminophen 10 milligrams/325 milligrams (mg) was delivered, 12 tablets, signed by Staff I, LPN -10/18/2025 at 22:24 p.m. Staff I, LPN pulled another tablet approved by pharmacy for Resident #1. Staff F stated no further episodes of medication pulled from the [electronic medication dispensary]. Staff F stated the most likely reason Staff I; LPN was able to pull another tablet of Hydrocodone-Acetaminophen 10 mg/325 mg despite a delivery of 12 tablets at 5:34 p.m. was that the delivery driver may have still been delivering to other facilities and had not arrived back to home base for the pharmacist to document delivery.On 11/05/2025 at 10:09 a.m., a telephone interview was conducted with Staff I, LPN. Staff I, LPN stated she had worked Saturday (10/18/2025) 7 a.m. to 7 p.m. Staff I, LPN, stated she had received a delivery from the pharmacy between 4-5 in the afternoon. Staff I, LPN stated at the end of the shift she and the oncoming nurse counted the narcotic cards in the narcotic box when I noticed the medication itself was missing. Staff I, LPN stated she immediately called the administrator on call, Staff J, ADON, and she told me to search everywhere for the medication. Staff I, LPN, stated she searched everywhere, the residents' rooms, soiled utility room, dumpster, garbage pails, and when we got the keys, we searched the shred box. Staff K, LPN/Unit Manager and Staff L, RN/weekend supervisor opened up the shred box and together we searched for any signs of the missing medication. Staff I, LPN stated she had already contacted the ARNP to get a new script for Resident #1. When the ARNP called me back, I was told not to say anything to the ARNP. Staff I, LPN stated she allowed the administration to look through her personal bag. Staff I stated she did not leave the facility until 11:00 p.m. but before she left the facility had me sign a piece of paper related to education for safekeeping of medication. Staff I, LPN stated during the delivery of the medication, Resident #1 was the only resident to receive a narcotic medication delivery. Staff I, LPN, stated she dispensed the medications to the other carts. Staff I, LPN stated, I can only think I may have thrown it away accidently. Staff I, LPN stated the DON and the NHA were present as well and were actively trying to find the missing medication. Staff I, LPN stated the DON and the NHA also searched in the shred box as well. Staff I, LPN, stated she recalls earlier in the morning she gave Resident #1 his last Hydrocodone-Acetaminophen 10 mg/325 mg and placed a request to pharmacy to dispense more for the resident. Staff I, LPN stated she later in the day was able to pull the medication for Resident #1 while waiting for a delivery. Staff I, LPN, stated she had made a joke with the pharmacy delivery driver because she had just administered the medication to Resident #1 minutes before the driver arrived with the medication. Staff I, LPN, stated she pulled another Hydrocodone-Acetaminophen 10 mg/325 mg from the [electronic medication dispensary] later in the night because the oncoming nurse asked for my assistance, but I did not document in the MAR, she did. Staff I, LPN, stated she was working with Staff M, LPN and another nurse but could not recall her name (Staff later identified as Staff N, RN). Staff I, LPN, stated Staff M, LPN helped her look as well during the initial search for the missing medication. Staff I, LPN, stated she attempted numerous times on Sunday to work on her up and coming schedule with the staffing coordinator, but her voicemails were never returned. Finally, on Tuesday I received a call from the DON to inform me I was suspended. Staff I, LPN, stated at some point she was requested to go downtown to the DCF (Department of Children and Families) for a statement. The DCF agent informed me the facility found an empty narcotic card in the shred box on Tuesday (October 21st). Staff I, LPN, stated she provided an email to the facility with her statement. Staff I, LPN, stated she could not figure out how the card eventually was found in the shred box when on Saturday, the shred box was opened and search not only by Staff L and Staff K but also the DON, ADON and the NHA on separate searches. Staff I, LPN, stated her normal routine does not have her throw away empty medicine cards in the shred box. Staff I, LPN, stated, she felt two people are supposed to check narcotics in, but it has been only one person and added we are so busy.On 11/05/2025 at 11:08 a.m., an interview was conducted with Staff M, LPN. Staff M stated on 10/18/2025 she saw Staff I, LPN receive the narcotic/medications but did not continue to watch Staff I, LPN, once the medications were delivered. Staff M, LPN stated at the end of her shift, Staff I, LPN, came to her asking if she had seen a loose narcotic medication card. Staff M, LPN, stated Staff I was very nervous. Staff M, LPN, stated she helped Staff I, LPN, search the unit. Staff M, LPN, stated they searched the soiled utility rooms, all three carts, and residents' rooms. Staff M, LPN stated she witnessed Staff I, LPN, Staff L, RN/weekend supervisor and Staff K, LPN/Unit Manager, search the shred box in [NAME] Point. Staff M, LPN, stated she was never asked for a statementOn 11/05/2025 at 11:22 a.m., an interview was conducted with Staff N, RN. Staff N, RN stated she was not aware of missing narcotic card until she returned to work the following morning (Sunday). Staff N, RN stated she did not notice anything, nor did anyone approach her on Saturday evening. Staff N, RN, stated none of her residents had a delivery of narcotics. Staff N, RN, stated she was not asked to give a formal statement.A record review of the Controlled Substance Audit Record for Cart #1 (Rm 301-305) (right side) with starting ledger date 10/29/2025 was reviewed as part of the auditing process the DON stated was initiated after the missing narcotic card. This Controlled Substance Audit Record was obtained by Staff B, LPN/UM, who had obtained the documentation from medical records. The DON stated the ledger had some missing items, blank spaces where a narcotic name should have been written and numbers were not added up. The DON stated the ledger was reviewed without any concern because it was in medical record. (photographic evidence obtained) 1. A review of Resident #1's admission Record showed an admission date of 8/30/2025 with the following diagnoses: Metabolic Encephalopathy Sepsis Type 2 diabetes mellitus w/ hyperglycemia Chronic diastolic (congestive) heart failure Cellulitis of unspecified part of limb Acute kidney failure with tubular necrosis Cardiomyopathy Difficulty in walking not elsewhere classified Chronic venous hypertension with ulcer of bilateral lower extremities Depression (unspecified_ Varicose veins of bilateral extremities with other complications Lymphedema not elsewhere classified A record review of Resident #1's admission Minimal Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13 out of total of 15, indicating the resident was cognitively intact.A record review of Resident #1's Care Plan showed the following: -Focus of opiate medications related to: pain not managed by alternative interventions, initiated on 9/09/2025 with a goal statement: resident risk for adverse effects related to use of opioids will be minimized through next review date, initiated on 9/09/2025. Interventions include but are not limited to: administer medication as prescribed by the physician (see current MA Rand physician orders for current dosage) initiated on 9/09/2025.-Focus area of pain and/or is at risk for pain related to decreased mobility, PVD (peripheral vascular disease), and neuropathy initiated on 9/02/2025 with a goal statement: the resident will have reduced complaints of pain and/or state that pain is at a tolerable level through next review date initiated 9/02/2025 and will not have an interruption in normal activities due to pain through the review date, initiated on 9/02/2025.A record review of Resident #1's current physician orders showed the following: -Monitor the resident for pain every shift ordered on 10/02/2025 -Gabapentin oral capsule 100 milligrams (mg) to give one capsule by mouth every 8 hours for neuropathy ordered on 10/22/2025 -Hydrocodone- Acetaminophen oral tablet 10mg - 325mg, to give one tablet by mouth every six hours as needed for non-acute pain ordered on 10/24/2025 -Hydrocodone-Acetaminophen oral tablet 10mg- 325mg, to give one tablet by mouth one time a day for non-acute pain ordered on 10/27/2025 -Oxycontin oral tablet ER (12 hours abuse deterrent) 15 mg, to give one tablet by mouth two times a day for non-acute pain ordered on 10/27/2025 - -Ondansetron HCL tablet 4 mg, give one tablet by mouth every 6 hours as needed for nausea and vomiting ordered on 10/02/2025 -Oxycontin oral tablet ER 12-hour abuse-deterrent 15 mg, give one tablet by mouth every 12 hours for non-acute pain, ordered on 10/24/2025 and discontinued on 10/27/2025A comparison record review between Resident #1's MAR and his Medication Monitoring Control Record for the month of October 2025 was compared for the prescribed order of Hydrocodone-Acetaminophen 10mg-325 mg and showed the following: -October 4th- two tablets documented as given and three tablets documented as pulled from the narcotic cart-October 7th- one tablet documented as given and three tablets documented as pulled from the narcotic cart-October 8th- two tablets documented as given and four tablets documented as pulled from the narcotic cart -October 9th- one tablet documented as given and three tablets documented as pulled from the narcotic cart-October 10th -zero documented as given and four c -October 11th- one tablet documented as given and three documented as pulled from the narcotic cart-October 12th- one tablet documented as given and three documented as pulled from the narcotic cart-October 13th- zero documented as given and four one tablet documented as given and three documented as pulled from the narcotic cart-October 15th- one tablet documented as given and three documented as pulled from the narcotic cart-October 16th- two tablets documented as given and four documented as pulled from the narcotic cart October 17th- one tablet documented as given and four documented as pulled from the narcotic cart October 18th - one tablet documented as given and two documented as pulled from the narcotic cart October 19th- two tablets documented as given and one documented as pulled from the narcotic cart October 20th- four tablets documented as given and five documented as pulled from the narcotic cart October 21st- zero documented as given and three documented as pulled from the narcotic cart October 23rd- zero documented as given and four documented as pulled from the narcotic cart October 24th - zero documented as given and three documented as pulled from the narcotic cart October 25th- one tablet documented as given and three documented as pulled from the narcotic cart October 26th - two tablets documented as given and three documented as pulled from the narcotic cart October 29th- two tablets documented as given and three documented as pulled from the narcotic [NAME] comparison record review between Resident #1's MAR and his Medication Monitoring Control Record for the month of November 2025 was compared for the prescribed order of Hydrocodone-Acetaminophen 10mg-325 mg revealed the following: November 2nd- two tablets documented as given and four documented as pulled from the narcotic cart2.On 11/5/2024 at 1:15 p.m. an interview was conducted with Resident #9. She revealed she is currently on a pain management program and she receives routine and as needed pain medications for her lower back pain. Resident #4 revealed she has at times refused her medications but felt mostly when she calls out for pain medication, the nurses will provide her with the medication. Resident #8 could not remember a time when she believed she did not receive her pain medications. Resident #8 felt after the medication was provided, she felt relief.Review of Resident #9's medical record to include 9/2025, 10/2025, and 11/2025 Medication Administration Record (MAR), as well as the Medication Monitoring/Control records for 9/2025, 10/2025 and 11/2025 revealed medications subtracted and signed off in the Medication Monitoring/Control records were not documented in the MAR for the medication Oxycodone/APAP Tab 5 mg-325 mg 1 PO (by mouth) TID (three times a day) PRN (as needed) for non-acute pain as follows: 9/28/25 2130 - (medication was not documented as offered/provided in the Medication Administration Record (MAR).9/29/25 0600 - (medication was not documented as offered/provided in the Medication Administration Record (MAR).9/30/25 0600- (medication was not documented as offered/provided in the Medication Administration Record (MAR).10/2/25 0900- (medication was not documented as offered/provided in the Medication Administration Record (MAR).10/2/25 1200- (medication was not documented as offered/provided in the Medication Administration Record (MAR).10/3/25 0845- (medication was not documented as offered/provided in the Medication Administration Record (MAR).10/3/25 2057- (medication was not documented as offered/provided in the Medication Administration Record (MAR).10/5/25 2024- (medication was not documented as offered/provided in the Medication Administration Record (MAR).10/6/25 1500- (medication was not documented as offered/provided in the Medication Administration Record (MAR).10/6/25 2004- (medication was not documented as offered/provided in the Medication Administration Record (MAR).10/8/25 1900- (medication was not documented as offered/provided in the Medication Administration Record (MAR).10/11/25 1542-(medication was not documented as offered/provided in the Medication Administration Record (MAR).10/12/25 0800-(medication was not documented as offered/provided in the Medication Administration Record (MAR).10/12/25 2000-(medication was not documented as offered/provided in the Medication Administration Record (MAR).10/13/25 2139- (medication was not documented as offered/provided in the Medication Administration Record (MAR).10/15/25 2000- (medication was not documented as offered/provided in the Medication Administration Record (MAR).Review of Resident #9's medical record revealed she was admitted to the facility on [DATE] with diagnoses including: Intervertebral Disc displacement, Morbid Obesity, Neuropathy, Noncompliance with medication regimen. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 of 15, indicating intact cognition. Review of the Physician's Order Sheet (POS) for months 10/2025 and 11/2025 revealed Resident #9 was on a pain management program for mild pain and lower back pain.Review of the 10/2025 and 11/2025 Physician's Order Sheet revealed Resident #9 was ordered and received the following but not limited to medications: -Oxycodone/APAP (Percocet) tab 5-325 mg 1 tab by mouth three times a day as need (PRN) for non-acute pain. This order originated on 6/4/2024.3. Review of Resident #8's medical record to include 10/2025, and 11/2025 Medication Administration Record (MAR), as well as the Medication Monitoring/Control records for 10/2025 and 11/2025 revealed medications subtracted and signed off in the Medication Monitoring/Control records were not documented in the MAR for the medication Oxycodone/APAP Tab 5-325 1 tablet by mouth every six hours as needed for pain for five days as follows: -10/02/25 1730 - (medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/08/2025 1952 - (medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/10/2025 2100- (medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/11/25 2032- (medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/12/25 1600- (medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/13/25 2015- (medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/14/25 2030- (medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/18/25 0715- (medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/18/25 1230- (medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/22/25 0800- (medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/22/25 2100- (medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/25/25 1700-(medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/26/25 1800-(medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/27/25 0700-(medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/27/25 1300- (medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/27/25 1800- (medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/28/25 0900- (medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/28/25 1500- (medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/31/25 0925- (medication was not documented as offered/provided in the Medication Administration Record (MAR).-10/31/25 2100- (medication was not documented as offered/provided in the Medication Administration Record (MAR).-11/01/25 0900- (medication was not documented as offered/provided in the Medication Administration Record (MAR). Review of Resident #8's medical record revealed she was admitted to the facility on [DATE] with diagnoses including: Pyogenic arthritis, chronic obstructive pulmonary disease, type 2 diabetes malignancies with hyperglycemia, bilateral primary osteoarthritis of knee, and muscle weakness.Review of Resident #8's admission Minimum Data Set (MDS) assessment, dated 9/30/2025 revealed, Section C. Cognition/Brief Interview Mental Status score or BIMS 15 of 15 showing intact cognition. Review of Section J. Heal Conditions revealed Resident #8 received pain medication.Review of the 10/2025 and 11/2025 Physician's Order Sheet revealed Resident #8 was ordered and received the following but not limited to medications:-Oxycodone-Acetaminophen Oral Tablet 5-325 mg give one tablet by mouth every six hours as needed for non-acute pain. This order originated on 09/30/2025.On 11/05/2025 at 11:34 a.m., an interview was conducted with the DON and the Regional Nurse Consultant regarding the discrepancies upon record review for Resident #1. The DON stated she reviewed the Controlled Substance Audit Record sheets ledgers but did not go into detail. The Regional Nurse Consultant stated she thinks the nurses do not understand which could be looked at as misappropriation of the medications. The nursing staff need to have a better understanding of the severity of documenting in the medical record.On 11/05/2025 at 11:50 a.m., an interview was conducted with the DON and Regional Nurse Consultant present. The DON stated on 10/18/2025 she received a call in the evening from the ADON, who was the Administrator on call. The ADON informed the DON, Staff I, LPN, telephoned her (ADON) of a missing narcotic card. The DON stated she (ADON) informed the NHA and both arrived at the facility. The DON stated she arrived at the facility along with the NHA and the ADON. At the time the DON arrived she stated, Staff K, LPN/UM and Staff L, RN/ weekend supervisor were searching for the missing narcotic card. The DON stated we looked in all the carts, trach cans, the residents' rooms on [NAME] Point, shred boxes. Staff K, LPN/UM looked in the unlocked locker rooms. The DON stated Staff I, LPN, does not have a locker but allowed us to look into her personal bag and pockets. The DON stated Staff I, LPN appeared calm, she did not look like she was hiding anything and stated, Staff I, LPN was baffled. The DON stated Staff I, LPN, wanted to go dumpster diving in the trash compacter but we stopped her. The DON stated we kept looking throughout the weekend but could not find the missing narcotic card. The DON stated Resident #1 did get a new prescription for his medication. The DON stated she went again to look on Tuesday the 21st to look for the yellow copy packing slips stating, I wanted to make sure I did not miss it. The DON stated she looked in the shred box and found the missing narcotic card with all the 12 tablets punched out and missing. The DON stated the shred box was searched twice on Saturday by two different parties of staff, herself and the NHA, included unsuccessfully. The DON stated the investigation started at this point because the narcotic medication card was located. The DON stated Sunday and Monday, she did her morning rounds as usual with nothing out of the ordinary. The DON stated Staff I, LPN, was suspended pending investigation but she verbally resigned while talking with her on the phone.On 11/05/2025 at 12:29 p.m., an interview was conducted with the NHA. The NHA stated he could not recall who notified him nor the time, but he stated he arrived to the facility after dinner time. The NHA stated he participated in searching for the missing medication. The NHA stated he searched in the residents' rooms, outside by the three storage sheds and trash cans outside but stated he does not recall looking in the shred box. The NHA stated Staff I, LPN, provided an e-mail statement 10/21/2025 at 11:06 a.m. In the email, Staff I, LPN, wrote on 10/18, Saturday, multiple medications were delivered. She stated she accepted the Hydrocodone 12 tablets, she placed the paper in the narc book after punching holes in the sheet. Staff I, LPN stated during shift narcotic count was when she discovered the missing narcotic medication card. Staff I, LPN, wrote there was a mass search for the missing card, but she assumed the card was thrown away accidentally. The NHA denied an Ad-Hoc meeting was held to discuss the missing narcotic medication card. At the conclusion of the interview, the DON stated no change in their policy of handling, receiving or storing of narcotics . The DON stated education was started on 10/21/2025 with the topic titled: Misappropriation for the entire facility.Review of the facility policy titled Narcotic Count Sheet, dated 6/2024, revealed the following: Policy: The facility will reconcile schedule II narcotics each shift. Procedure: .3. schedule II controlled medications are received upon arrival, counted and entered on a count sheet. 4. When it's scheduled to medication is administered, the licensed nurse will complete the count sheet indicating the date and time of administration, amount administered, amount remaining and signature.6. Not just experience at the end of each shift, the oncoming nurse and the off going nurse will count the medication and reconcile them with the count sheets.7. If the account is incorrect, an investigation will be started immediately. 8. The [NAME] will be notified of the discrepancy and will make every attempt to reconcile the discrepancy. Reconcilable discrepancies are documented by the [NAME] and a report. If there is a major discrepancy, or a pattern of discrepancies, the Don, administrator and the consultant pharmacist will make a determination to notify police or other enforcement agencies and any other actions to be taken.9. Disposition of schedule 2 medications will be conducted by the Don/designee.Review of the facility policy titled medication administration, with a date of 1/2024, revealed the following: Standard: Medications are ordered and administered safely as prescribed. Guideline: medications will be administered safely and as prescribed by only licensed personnel. Procedure:. 17. As required are indicated for a medication, the individual administering the medication records and the residence medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration;.

Based on observations, interviews, and record review, the facility failed to ensure scheduled pain medication was provided as ordered for one resident (#1) out of three residents sampled for pain. Findings included:On 11/04/2025 at 9:06 a.m., an interview was conducted with Resident #1 in his room. Resident #1 was observed adjusting the level of the bed in a more down position and stated he is in a lot of pain. Resident #1 stated, I haven't gotten my pain medication in three days. Resident #1 stated the pain medication he was missing was Oxycontin extended release. Resident #1 stated last night it took over six and a half hours to get his pain medication and then he threw it up. Resident #1 stated his pain is a 10 no, an 11 right now. On 11/04/2025 at 9:15 a.m., an interview was conducted with Staff A, Licensed Practical Nurse (LPN) assigned to Resident #1. Staff A, LPN stated she had recently administered Resident #1's Hydrocodone as scheduled but did not realize the resident was missing his Oxycontin for three days. She stated she will contact the ordering provider for a new prescription. On 11/04/2025 at 9:20 a.m., an interview was conducted with Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM). Staff B, LPN/UM stated if a resident was out of a medication, especially a narcotic, the nurse can call the pharmacy to obtain a code to obtain a missing dose in our [electronic medication dispensary] but only if the prescription was still good. If not, the nurse would have to call the ordering doctor to obtain a new order. Staff B, LPN/UM reviewed the order and stated Resident #1 has an order for Oxycontin 15 mg (milligram) extended release (ER) twice a day (bid) and Hydrocodone 10 mg/325 mg as needed (prn). Staff B, LPN/UM reviewed the Medication Administration Record (MAR) for October and November 2025 and stated the resident did not get the Oxycontin medication as ordered and will text the doctor to get a new prescription. Staff B, LPN/UM stated the resident did not get his medication as ordered for the Oxycontin 15 mg ER on 10/31, 11/02, or 11/03. Staff B, LPN/UM was able to explain why the resident received his Oxycontin 15 mg ER medication on 11/01. She stated the pharmacy had dispensed originally 12 tablets out of a possible 14 tablets. The two tablets could be dispensed for the future if needed and the nurse requested the medication on 10/31 in the evening and the two tablets were delivered by the pharmacy to have available for 11/01. A review of Resident #1's admission Record showed an admission date of 8/30/2025 with the following diagnoses: Metabolic Encephalopathy Sepsis Type 2 diabetes mellitus w/ hyperglycemia Chronic diastolic (congestive) heart failure Cellulitis of unspecified part of limb Acute kidney failure with tubular necrosis Cardiomyopathy Difficulty in walking not elsewhere classified Chronic venous hypertension with ulcer of bilateral lower extremities Depression (unspecified_ Varicose veins of bilateral extremities with other complications Lymphedema not elsewhere classifiedA record review of Resident #1's admission Minimal Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13 out of total of 15, indicating the resident was cognitively intact. In Section J-Health Conditions, Pain Management- complete for all residents, regardless of current pain level, Question A. -Received scheduled pain medication regimen? -No, Question B. - Received PRN pain medications or was offered and declined? Yes, Question C.- Received non-medication interventions for pain? No, Section J0200 Should pain assessment interview be conducted? Yes, Section J0300 Pain Presence: Ask resident: Have you had pain or hurting at any time in the last 5 days?' Yes, Section J0410 Pain Frequency: Ask resident: How much of the time have you experienced pain or hurting over the last 5 days? Almost constantly, Section J0150 Pain Effect on Sleep: Ask resident: Over the past 5 days, how much of the time has pain made it hard for you to sleep at night? Almost constantly, Section J0520 Pain Interference with Therapy Activities: Ask resident: Over the past five days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain? rarely or not at all, Section J0600 Pain Intensity- admission on LY ONE of the following pain intensity questions (A or B), A. Ask resident: Please rate your worst pain over the last five days on a zero to 10 scale, with 0 being no pain and 10 as the worst pain you can imagine (show resident 00-10 pain scale) enter 2- digit response enter 99 if unable to answer. 9.A record review of Resident #1's Care Plan showed the following: -Focus of opiate medications related to: pain not managed by alternative interventions, initiated on 9/09/2025 with a goal statement: resident risk for adverse effects related to use of opioids will be minimized through next review date, initiated on 9/09/2025. Interventions include but are not limited to: administer medication as prescribed by the physician (see current MA Rand physician orders for current dosage) initiated on 9/09/2025.-Focus area of pain and/or is at risk for pain related to decreased mobility, PVD (peripheral vascular disease), and neuropathy initiated on 9/02/2025 with a goal statement: the resident will have reduced complaints of pain and/or state that pain is at a tolerable level through next review date initiated 9/02/2025 and will not have an interruption in normal activities due to pain through the review date, initiated on 9/02/2025.A record review of Resident #1's current physician orders showed the following: -Monitor the resident for pain every shift ordered on 10/02/2025 -Gabapentin oral capsule 100 milligrams (mg) to give one capsule by mouth every 8 hours for neuropathy ordered on 10/22/2025 -Hydrocodone- Acetaminophen oral tablet 10mg - 325mg, to give one tablet by mouth every six hours as needed for non-acute pain ordered on 10/24/2025 -Hydrocodone-Acetaminophen oral tablet 10mg- 325mg, to give one tablet by mouth one time a day for non-acute pain ordered on 10/27/2025 -Oxycontin oral tablet ER (12 hours abuse deterrent) 15 mg, to give one tablet by mouth two times a day for non-acute pain ordered on 10/27/2025 - -Ondansetron HCL tablet 4 mg, give one tablet by mouth every 6 hours as needed for nausea and vomiting ordered on 10/02/2025 -Oxycontin oral tablet ER 12-hour abuse-deterrent 15 mg, give one tablet by mouth every 12 hours for non-acute pain, ordered on 10/24/2025 and discontinued on 10/27/2025A review of Resident #1's Medication Administration Record (MAR) for October 2025 revealed one missed dose of Oxycontin ER 15 mg bid on 10/31/2025. A review of Resident #1's MAR for November 2025 revealed five missed doses of Oxycontin ER 15 mg bid on 11/02/2025, 11/03/2025 and 11/04/2025. On 11/04/2025 at 10:28 a.m., an interview was conducted with Staff C, Advanced Nurse Practitioner (ARNP) for Physical Medicine and Rehabilitation/Pain. Staff C, ARNP stated Resident #1 was identified upon admission as a pain management resident who had received prior pain management care at home. Staff C, ARNP, stated the resident was complaining of left hip pain, normally experienced in the past at home, but exacerbated after he fell at home. Staff C, ARNP stated Resident #1 wanted to continue with the pain regimen he had received prior to his admission but, she was trying to make him more functional and to require less pain medication gradually as he participated more in therapy. Staff C stated they went from scheduled pain medication to as needed to work with therapy. Staff C, ARNP stated, therapy stated he was better which then tells me he is tolerating at his dose regimen. Staff C, ARNP stated the primary ARNP for Resident #1 ordered Oxycontin 15 mg ER bid and this morning she (Staff C) stated she went and approved and prescribed this morning to be administered twice a day. Staff C, ARNP stated she spoke with the resident and the resident was updated on the order to continue the Oxycontin 15 mg ER bid. On 11/04/2025 at 11:39 a.m., an interview was conducted with Staff D, ARNP. Staff D, ARNP, stated as of this morning, she had ordered a one-time order for Zofran 4 mg to be administered intramuscularly for his nausea because of his episode of vomiting earlier this morning. Staff D, ARNP, stated some time a few weeks ago, Resident #1 stated to me his pain was not controlled and had not received pain medication scheduled pain medication in a timely manner. Currently, the resident has a scheduled Hydrocodone-Acetaminophen 10 mg/325 mg daily prior to physical therapy. Plus, he can get the same medication as needed every six to eight hours. In addition, the resident has scheduled Gabapentin as well as Tylenol as needed. Staff D, ARNP, stated the resident in addition to the pain regimen described, the resident has an additional order for Oxycontin 15 mg ER twice a day scheduled. Staff D, ARNP stated the resident has always stated he has uncontrolled pain, since he's been here. Staff D, ARNP stated she checked on the [web-based electronic narcotics national registry] for Resident #1 and saw the resident was prescribed Oxycontin 15 mg ER and Hydrocodone-Acetaminophen 10mg-325mg in the past. Staff D, ARNP stated Resident #1 has chronic pain and never states his pain level never gets below a 4. Staff D, ARNP, stated as a nurse practitioner, she can only order a 7-day supply prescription but I am always available by phone if needed. Staff D, ARNP stated she was on call last weekend and denied she received a call/text for a renewal/order of the resident's prescription for Oxycontin 15 mg ER. A review of the progress notes provided by the facility did not show any entries from 10/30/2025 to 11/03/2025 of the nursing staff contacting the physician for a missed scheduled dose of Oxycontin 15 mg ER or a request to refill the prescription. On 11/04/2025 at 10:00 a.m., a brief interview was conducted with the Director of Nursing (DON). The DON stated Resident #1 received his Hydrocodone-Acetaminophen 10 mg/325 mg for pain but will have to research his Oxycontin order and why Resident #1 had missed scheduled doses. On 11/05/2025 at 8:30 a.m., an interview was conducted with Staff E, Pharmacist. Staff E, Pharmacist, was able to provide an inquiry search for Resident #1's Oxycontin 15 mg ER order. On 10/24/2025, an order was placed for Oxycontin 15 mg ER to be administered twice daily to dispense 14 tablets. On 10/25/2025 at 4:54 a.m., the pharmacy delivered 12 tablets. Staff E stated, the pharmacy will typically not dispense the full prescribed order in case the medication runs out and the nursing staff could technically pull from their [electronic medication dispensary] for emergency situations. Staff E stated the reason the pharmacy does not dispense all medications would be to offset contacting the physician in a timely manner or requesting more to be dispensed by the nursing staff if the prescription were to still be active. Staff E stated on 10/31/2025 at 5:27 a.m., a request was made by the facility to dispense the final two tablets of Resident #1's Oxycontin 15 mg ER. On 10/31/2025 at 5:50 p.m., the pharmacy delivered the last of the two tablets to complete the prescription to the facility. Staff E, pharmacist, stated on 11/04/2025 at 10:44 a.m., a new prescription was placed for Oxycontin 15 mg ER on e tablet twice daily for Resident #1, to dispense 14 tablets. Staff E, pharmacist, stated on 11/04/2025 at 2:13 p.m. a delivery of Resident #1's Oxycontin was delivered to the facility. A review of the facility's policy titled: Standards and Guidelines: Medication Administration issued 10/2020 and revised on 01/2024 showed:Procedure:.3. Medications are administered in accordance with prescriber orders, including any required time limit.4. Medication administration times are determined by resident need, preference, and benefit, not staff convenience. Factors that are considered include:a. Enhancing optimal therapeutic effect of the medication;b. Preventing potential medication or food interactions: andc. Honoring resident choices and preferences, consistent with his or her care plan.5. Medication errors are documented, reported, and reviewed by the QAPI (Quality Assurance and Performance Improvement) committee to inform process changes and or the need for additional staff training.(Photographic evidence obtained)

Based on record review and interviews the facility failed to implement an effective grievance program related to ensuring voiced concerns are acknowledged, documented, and resolved for the attending resident council members during six months (November, December, January, February, March and April) of six months reviewed. Findings included: Review of Grievance Logs for a six-month period from November 2024 to April 2025 revealed each month there were on-going call light concerns. Review of the Grievance Log for November 2024 revealed a grievance for Resident #1 dated 11/22/24 for Activities of Daily Living (ADL) care not provided, medications left at the bedside, and pain meds not provided in a timely manner. Follow up to grievance revealed: pain medication scheduled for as needed (prn), staff educated on ensuring that the residents receive their medications in a timely manner and as needed, and staff educated on providing ADL care in a timely manner, date resolved 11/22/24. Staff education in-service roster for medications should be administered timely dated 11/15/24. Review of the Grievance Log for December 2024 revealed a grievance for Resident #1 dated 12/9/24 for call light response time for care needed. Follow up to grievance revealed: unable to clarify response date due to system being down for repairs and staff educated. Date resolved 12/17/24. Review of the Resident Council Minutes dated 11/14/24 revealed a section titled Old Business no issues/concerns were listed and a check mark in the box stating all items from previous meeting were resolved. Under the section New Business revealed a list of upcoming activities, no mention of issues/concerns. Review of the Grievance Log dated November 2024 revealed six entries titled Resident Council all dated 11/14/24 with the following concerns: 1. Grievance Form dated 11/14/24 from Resident Council revealed complaint/grievance: staff loud in hallways on 3-11 & 11-7. The form is marked resolved dated 11/25/24, with education to the staff. 2. Grievance Form dated 11/14/24 from Resident Council revealed complaint/grievance: customer service in dining room. The form is marked resolved dated 11/20/24, with education to the staff. 3. Grievance Form dated 11/14/24 from Resident Council revealed complaint/grievance: use of phone in residents' room. The form is marked resolved dated 11/17/24, with education to the staff. 4. Grievance Form dated 11/14/24 from Resident Council revealed complaint/grievance: takes a long time for clean clothes personable to be returned (weeks). The form is marked resolved dated 11/25/24, with education to the staff. 5. Grievance Form dated 11/14/24 from Resident Council revealed complaint/grievance: staff dragging soiled linen bags on floor. The form is marked resolved dated 11/25/24 with education to the staff. Review of the Resident Council Minutes dated 1/9/25 revealed a section titled Old Business, revealed old business reviewed - accepted - and no check mark in the box stating all items from previous meeting were resolved. Under the section New Business revealed a list of upcoming activities, and response times of call lights grievance wrote. Review of the Resident Council Minutes dated 1/23/25 revealed a section titled Old Business, revealed old business reviewed and no check mark in the box stating all items from previous meeting were resolved. Under the section New Business revealed a list of upcoming activities, and no concerns/issues were noted. Review of the Grievance Log dated January 2025 revealed two entries titled Resident Council dated for 1/9/25. 1. Grievance Form dated 1/9/25 from Resident Council revealed complaint/grievance: call light response times, staff not responding to call lights in a timely manner on 3-11& 11-7 shifts. The form is marked resolved dated 1/14/25, with education to the staff. 2. Grievance Form dated 1/6/25 from Resident Council revealed complaint/grievance: staff wearing ear pods in resident areas on all shifts. The form is marked resolved dated 1/14/25, with education to the staff. Review of the Resident Council Minutes dated 2/9/25 revealed a section titled Old Business, revealed We discussed call light response times. Also talked about things in facility getting fixed in all departments so that residents have what they need at all times and a check mark in the box stating all items from previous meeting were resolved. Under the section New Business revealed not answering call lights/turning off call lights without doing what residents need. Morning shift not working right away, items not repaired in facility. Residents not happy about their laundry not being returned/lost. Wheelchairs not being able to go over door that leads to gazebo. Review of the Resident Council Minutes dated 2/20/25 revealed a section titled Old Business, revealed clothes not getting returned, call lights not getting answered at timely manner. Not getting meals at feeding and a check mark in the box stating all items from previous meeting were resolved. Under the section New Business revealed cannot get food when they want, does not get offered after snacks. Can't get food that we needs to fit our diet. Review of the Grievance Log dated February 2025 revealed one entry titled Resident Council dated for 2/6/25 revealing : 1. Grievance Form dated 2/6/25 from Resident Council revealed complaint/grievance: not getting offered snacks. The form is marked resolved dated 2/10/25, with education to the staff. No mention of call lights. Review of the Resident Council Minutes dated 3/6/25 revealed a section titled Old Business, revealed cannot get food when they want, does not get offered afternoon snacks. Can't get food that we needs to fit our diet. Food is not always good. Staff taking too long to respond to call lights and a check mark in the box stating all items from previous meeting were resolved. Under the section New Business revealed coffee cold, never get what is on the food ticket, nobody gets given snacks! Not knocking on door/not introducing themselves. I don't know who CNA [Certified Nursing Assistant] is/are on weekends . Review of the Resident Council Minutes dated 3/20/25 revealed a section titled Old Business, revealed cannot get food when they want, does not get offered afternoon snacks. Can't get food that we needs to fit our diet. Staff taking too long to respond to call lights and a check mark in the box stating all items from previous meeting were resolved. Under the section New Business revealed Not enough CNAs during the night shift. Not getting changed throughout the night time. Staff needs more teamwork! (Getting back to luncheon for new hires) Needs longer head with reach showers are too cold nobody wants to shower. (Trees)(Roaches) getting washers and dryers fixed ASAP. List of snacks. Smokers don't need to smoke in outside area. Review of the Grievance Log dated March 2025 revealed two entries titled Resident Council dated for 3/26/25. 1. Grievance Form dated 3/26/25 from Resident Council revealed complaint/grievance: residents not getting changed timely on overnight shift. The form is marked resolved dated 3/31/25, with education to the staff. 2. Grievance Form dated 3/26/25 from Resident Council revealed complaint/grievance: laundry is taking too long to come back to the residents. The form is marked resolved dated 3/29/25. 3. Grievance Form dated 3/26/25 from Resident Council revealed complaint/grievance: not getting changed throughout the night. The form is marked resolved dated 3/29/25. Review of the Resident Council Minutes dated 4/3/25 revealed a section titled Old Business, revealed Not enough CNAs during the night shift. Needs longer shower heads in shower. It is always cold in shower room. not getting offered snacks. Roaches in rooms/bathrooms. Getting washers and dryers worked on and a check mark in the box stating all items from previous meeting were resolved. Under the section New Business revealed Still not getting offered snacks . CNAs are acting lazy . not taking time to properly clean residents. CNAs on phones or at nurse station talking and laughing not checking on residents. Review of the Grievance Log dated April 2025 revealed five entries titled Resident Council dated for 4/10/25. 1. Grievance Form dated 4/10/25 from Resident Council revealed complaint/grievance: CNAs on phones or at nurse station talking loud. The form is marked resolved dated 4/10/25, with education to the staff. 2. Grievance Form dated 4/10/25 from Resident Council revealed complaint/grievance: not making up beds right away after striping them. The form is marked resolved dated 4/10/25, with education to the staff. 3. Grievance Form dated 4/10/25 from Resident Council revealed complaint/grievance: Still not getting offered snacks. The form is marked resolved dated 4/10/25, with education to the staff. During an interview on 4/16/2025 at 10:56 AM with a resident who participates in resident council stated the council has not had resolution on the call light response time especially on the evening and weekend shifts. During an interview on 4/17/2025 at 11:51 AM with the Activities Director (AD). The AD stated being responsible for planning and overseeing the recreational needs of the building. Part of the duties include assisting resident council if requested and is usually requested to take the minutes. The AD explained the resident council form includes attendees, old business and new business. Explaining the check boxes on the form are for the activity staff to ensure they review the items from prior meeting, not necessarily the item was resolved completely. The residents do have concerns that are continuing, especially call lights. During an interview on 4/17/25 at 2:56 PM with the Social Service Director SSD and the NHA. The SSD explained the grievance process. Anyone can complete a grievance for a resident, the concern/grievance form is turned into the SSD. The SSD logs the grievance and takes the grievance to the management meeting, that is held every morning for review. The grievance is given to the respective department for follow-up. The department manager completes the follow up and turns the completed grievance form back into the SSD for completion. The NHA stated the facility had noted an increase in grievances and put a performance improvement plan in place on 3/10/25. Review of the audit and plan revealed a plan for audits on day shift. The plan did not include any audits for evening, night and weekend shifts confirming concerns related to unresolved resident grievances. Review of the facility's policies and procedures titled Standards and Guidelines: Grievances - Resident Rights, with a revision date of 7/2024 revealed Guideline: The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Proceduere: . 10. The Grievance Officer, Administrator and Staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. 11. The Administrator will review the findings with the Grievance Officer to determine what corrective actions, if any, need to be taken.

Based on interview and record review the facility failed to obtain physician ordered cultures in a timely manner for two (#1 and #4) of three sampled residents. Findings Included: 1. Review of Resident #1's admission record revealed an admitted [DATE] for short term rehabilitation with diagnoses to include myoneural disorder, acute respiratory failure with hypercapnia, sepsis, chronic obstructive pulmonary disease and other co-morbidities. Review of Resident #1's medical nurse practitioner progress note dated 12/12/24 revealed: Resident #1 has been having increased episodes of diarrhea, with recommendations to obtain a stool sample. Review of Resident #1's order summary report revealed a physician order dated 12/12/24 and 12/13/24 - obtain stool sample. Review of Resident #1's nursing note dated 12/13/24 revealed collected stool sample for lab. Review of Resident #1's order summary report revealed a physician order dated 12/15/24 obtain urinalysis (UA) for burning during urination. The laboratory results for the UA revealed the lab received the UA on 12/16/24 at 10:26 a.m. and reported on 12/16/24 at 2:25 p.m. The lab results revealed: cloudy appearance, blood level 250, protein 15-30, nitrite positive, leukocytes 500; the microscopic UA revealed WBCs (White Blood Cells) TNTC (Too Many To Count), RBCS 26-50, bacteria 1+ (few), epithelial cells 3-5, mucus few. Review of Resident #1's nurses progress notes dated 12/16/24 at 7:29 p.m. revealed notification to provider of UA results and provider wants to wait on the culture and sensitivity prior to ordering a treatment. Review of Resident #1's rehabilitation nurse practitioner progress note dated 12/16/24 revealed the resident was having diarrhea and stomach cramping earlier. Review of Resident #1's order summary report revealed an order for UA C/S (culture/sensitivity) for dysuria (painful and uncomfortable) dated 12/19/24 and 12/20/24. The laboratory results for the UA revealed the lab received the UA on 12/23/24 at 9:00 and reported 12/26/24 at 12:19. Review of Resident #1's rehabilitation nurse practitioner progress note dated 12/26/24 at 7:46 p.m. revealed: Resident concern is wanting to get the results of her stool sample and urine sample. The resident was told the results were in but has not been informed. Medical NP (nurse practitioner) was notified and asked to order medication to treat her UTI (Urinary Tract Infection). Review of Resident #1's order summary revealed an order for Ciprofloxacin HCl tablet 500 MG for UTI for 7 days dated 12/26/24. Review of Resident #1's medical nurse practitioner progress noted note dated 12/23/24 revealed no stool results available in chart, will have staff contact lab. Recent UA done without culture, therefore repeat UA with culture was ordered and awaiting the culture report. Review of Resident #1's record on 4/16/25 revealed there was no record of stool sample results for Resident #1. 2. Review of Resident #4's admission record revealed an admitted [DATE] for short term rehabilitation with the diagnoses including: lymphedema, morbid (severe) obesity, cervical disc degeneration, and other co-morbidities. Review of Resident #4's rehabilitation nurse practitioner progress note dated 12/5/24 revealed: Resident is unable to turn herself. Resident reports pain upon the slightest touch or turn. Resident is morbidly obese and definitely needs to improve her therapy progress. I noted a large hematoma to her R (right) thigh, and I ordered an US (ultrasound) for that .Resident had fallen OOB (out of bed) when being turned for cleaning the previous day. Review of Resident #4's order summary report did not reveal an order for an ultrasound. During an interview on 4/17/25 at 12:22 p.m. with the rehabilitation nurse practitioner. The rehabilitation nurse practitioner stated if documentation in the note reveals an ultrasound was ordered, then the order needed to be completed. During an interview on 4/17/25 at 9:14 a.m. the Director of Nursing (DON) confirmed Resident #1's record did not contain information regarding the stool sample results, nor notification to the physician. The DON stated not knowing what happened with the UA. The DON stated the expectation would be for the orders to be followed, and the physician to be notified of results when they were received from the laboratory. Review of the facility's policy and procedures revised 6/2023, titled Standards and Guidelines showed - Change in Resident Condition or Status - Resident Rights - Standard: Facility shall notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Guideline: To ensure the facility provides timely notification in accordance with State and Federal Regulations as it pertains to residents' rights. Procedure: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a. accident or incident involving the resident. b. discovery of injuries of an unknown source. c. adverse reaction to medication. d. significant change in the resident's physical/emotional/mental condition. e. need to alter the resident's medical treatment significantly. f. refusal of treatments or medications of 3 or more consecutive times g. need to transfer the resident to a hospital/treatment center. h. discharge without proper medical authority; and/or i. specific instruction to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). b. Impacts more than one area of the resident's health status. c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source. b. There is a significant change in the resident's physical, mental, or psychosocial status. c. There is a need to change the resident's room assignment. d. A decision has been made to discharge the resident from the facility; and/or e. It is necessary to transfer the resident to a hospital/treatment center. 4. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. 5. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observations, interviews, and record review, the facility failed to ensure therapy gym equipment was maintained in a safe and operative manner for one of one sampled therapy rooms. Findings included: An interview was conducted on 8/6/24 at 1:25 p.m. with Resident #6. She said she received physical therapy three times a week to help with standing and walking. She said the parallel bars in the therapy gym were not secure. She said one side of the parallel bars moved and the therapist told her the screw was stripped. She said she used the parallel bars, and she asked the therapy staff to have her stand on the side of the parallel bars where the screw was not stripped because she did not want to fall. She also said one of machines in the therapy room was missing a handle. She said she did not use the machine, but she saw other residents using the machine. An observation and interview were conducted 8/6/24 at 2:39 p.m. of the therapy gym equipment. There was one set of parallel bars located in the middle of the room on an elevated surface. The left side of the parallel bar was able to freely move in and away from the right-side parallel bar. The nu-step machine had a missing handle. An interview was conducted with Staff B, Physical Therapy Assistant (PTA) he said he had worked at the facility for two months. He confirmed the left side of the parallel bars was not secure and moved in and out because the screw to secure the bar did not tighten. He said when residents used the parallel bars and he would push his body against the left bar while the residents were standing or walking to ensure the bar did not slide. He also confirmed the nu-step handle was missing from the machine and he confirmed residents still used the machine but they only utilized the feet function of the machine. He said the handle on the nu-step machine had been broken for many months, since before he started at the facility, and the parallel bars had been broken for a couple months. An interview was conducted on 8/6/24 at 2:41 p.m. with the Rehabilitation Director. She said the left side of the parallel bars were not secure and the maintence director fixed it. She observed the parallel bars and confirmed the left bar was still not secure and slid freely in and out towards the right side of the parallel bars. The Rehabilitation Director said the screw that was in the parallel bars was the fix the maintence director did prior. She did not know when the last time the Maintence Director fixed the parallel bars but she said she would put in a work order. She observed the Nu-Step machine and confirmed it was missing a handle. She said residents did not use the machine. She said the Maintence Director knew about the missing handle and had the part to fix it. She said she did not know how long it had been broken and she did not know why maintence had not fixed the machine. An interview was conducted on 8/6/24 at 4:42 p.m. with the Maintence Director and the Nursing Home Administrator (NHA). The Maintence Director said he started working at the facility in 2010 and became the Maintence Director in July of 2024. He said he knew there was a problem with the parallel bars in the therapy gym. He said he knew the parallel bars was not secure because the knob on the screw was broken. He said when he fixed it on an unknown date, he just took off the knob and left the screw in place. He confirmed there was not a work order for the parallel bars. He said the staff would just come up to him or another maintence employee and tell them what was wrong but now he wanted them to put everything in the work order tracking system so it could be tracked. The NHA confirmed the residents who were at the facility for rehabilitation used the parallel bars to stand and walk. He said the expectation would have been for the therapy staff to take the broken equipment out of service and put a work order into the tracking system every day until it got fixed. The Maintence Director said the locking screws were used to expand the parallel bars and secure the bar in place. He said the Nu-Step machine had been broken for a couple months. The locking mechanism on the arm of the handle of the machine was broken. He stated, I'm having a hard time finding the part to fix it, so I have glued it back together and I put tape around the broken parts and the arm of the machine and now I am just waiting for the glue to ferment. The Maintenance Director said he did not know how long it took for the glue to set. He said there was not a work order in the tracking system related to the Nu-Step machine. The NHA reviewed the work orders in work order tracking system going back as far as January of 2024 and confirmed there was not a work order related to the Nu-Step Machine. An interview was conducted with the NHA on 8/6/24 at 5:50 p.m. he said the facility did not have a policy related to maintaining equipment in a safe and working order.

Based on observation, interview, and record review, the facility failed to ensure medications were secured for three (#6, #7, and #8) out of 11 sampled residents. Findings included: 1. A review of Resident #6's Admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with medical diagnoses not limited to, pulmonary embolism, type 2 diabetes, polyneuropathy, osteoarthritis, chronic pain, right knee effusion, anxiety disorder, and muscle wasting and atrophy. An observation and interview were conducted on 8/6/24 at 1:25 p.m. with Resident #6. The resident was observed to be sitting in her wheelchair next to her bed in front of her over bed table with a multi shelf cart next to her. On the top shelf of the cart there was a box with a tube in it of triamcinolone Acetonide External Cream 0.1% The resident said the cream was hers and she liked to keep it there. A review of Resident #6's quarterly, Minimum Data Set (MDS), dated [DATE], section C, Cognitive Patterns revealed a brief interview of mental status (BIMS) score of 9 out of 15 which indicated moderate cognitive impairment. A review of Resident #6's physician orders revealed an inactive order with a start date of 7/12/24 and an end date of 7/26/24 for Triamcinolone Acetonide External Cream 0.1 % (Triamcinolone Acetonide (Topical)) apply to face topically two times a day for seb [seborrheic] dermatitis for 14 days. A review of Resident #6's July medication administration record (MAR) showed, Triamcinolone Acetonide External Cream 0.1 % (Triamcinolone Acetonide (Topical)) Apply to face topically two times a day for seb dermatitis for 14 Days with a start Date of 7/12/2024 at 9:00 a.m. and showed the medication was administered twice a day from 7/13/24 through 7/24/24. On 7/25/24 the documentation revealed the resident was out on pass. A review of Resident #6's medical record did not show Resident #6 was assessed to self-administer Triamcinolone Acetonide External Cream 0.1 %. 2. A review of Resident #7's Admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included but were not limited to cellulitis of right lower limb, other specified disorders of bone density and structure, gout, prosthetic heart valve, muscle wasting and atrophy, and muscle weakness. An observation and interview were conducted on 8/6/24 at 1:27 p.m. with Resident #7. The resident was observed walking with a walker throughout her room. Her family member was present in the room at the time of the interview and observation. On Resident #7's over bed tray table located next to her bed was a bottle of Arthritis Pain Reliever-Acetaminophen 650 mg tablets as well as a bottle of vapor rub. The resident said, I only take two tablets of the pain medicine at night to help me sleep. The family member picked up the bottle of arthritis pain medication and said where did you get this from? Resident #7's roommate said in the basket and pointed to the closet. Resident #7 confirmed what the roommate said. Resident #7 said she used to ask for the medication at night but it would take 30 minutes to get it. During the interview Staff A, Certified Nursing Assistant (CNA) came into the room and removed Resident #7's meal tray located next to the bottles of acetaminophen and vapor rub and exited the room leaving the medications bottles on the bedside tray table. A review of Resident #7's Medicare-5 day MDS, Section C, dated 6/3/24 revealed a BIMS score of 15 out of 15 which indicated no cognitive impairments. A review of Resident #7's physician orders revealed an order with a start date of 5/15/24 for Acetaminophen Tablet 325 MG [milligram] Give 2 tablet by mouth every 4 hours as needed for General Discomfort Notify physician/midlevel provider if discomfort persists. Do not exceed 3 g [grams]/day. There was no physician order for vapor rub. A review of Resident #7's August MAR revealed the resident was not administered her ordered Acetaminophen. A review of Resident #7's July MAR revealed she was administered her ordered Acetaminophen three out of 31 days. A review of Resident #7's medical record did not show a self-administration of medication assessment related to Acetaminophen. 3. A review of Resident #8's Admission Record revealed she was admitted to the facility on [DATE] from and acute care hospital. Her medical diagnoses included but are not limited to chronic obstructive pulmonary disease (COPD) with acute exacerbation, mild persistent asthma with status asthmaticus, chronic respiratory failure with hypoxia, need for assistance with personal care, and muscle wasting and atrophy. An observation and interview were conducted on 8/6/24 at 12:48 p.m. with Resident #8 revealed she was sitting in a wheelchair in the hall, outside of her room, with the bedside tray table in front of her. Resident #8 stated she chose to sit outside her room in the hall. An observation of the bedside table revealed three medications. Further observation of the medications revealed they were next to her lunch meal tray. Resident #8 stated two of the medications were inhalers and one was a nasal spray. She stated she self-administered the medications. An observation and interview were conducted on 8/6/24 at 2:00 p.m. with Resident #8. She was observed to be sitting outside of her room, in the hallway, in her wheelchair with her bedside tray table in front of her. She had 3 medications on her bedside tray table, Combivent inhaler, fluticasone nasal spray, and a Advair inhaler. Resident #8 said she took the Combivent when the staff gave her, her medications in the morning. She said she took the fluticasone nasal spray when the inside of her nose burned from the oxygen she wore at night, and she took the Advair when she was wheezing. A review of Resident #8's quarterly MDS, section C, cognitive patterns, dated 6/16/24 showed she was assessed to have a BIMS score of 14 out of 15 which indicated no cognitive impairments. A review of Resident #8's physician orders revealed an order with a start date of 10/25/23 and no end date for Combivent Respimat Inhalation Aerosol Solution 20-100 MCG [microgram]/ACT [active] (Ipratropium-Albuterol). 1 puff inhale orally four times a day for Shortness of Breath Rinse mouth with water after use, spit out, do not swallow. A physician order with a start date of 10/25/23 and no end date for Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/DOSE (Fluticasone-Salmeterol), 1 inhalation inhale orally every 12 hours for Shortness of Breath rinse mouth after use, spit out do not swallow. A physician's order with a start date of 6/12/24 and an end date of 6/20/24 for Fluticasone Propionate Suspension 50 MCG/ACT. 1 spray in each nostril one time a day for Allergic rhinitis for 7 Days. A review of Resident #8's August MAR revealed her ordered Advair was administered twice a day from August 1st through 5th. Her ordered Combivent was administered four times a day August first through fifth. There was no documentation in the month of August related to the Fluticasone Propionate nasal spray. Review of Resident #8's medical record did not reveal a self-administration of medication assessment for Advair, Fluticasone, or Combivent. An interview was conducted on 8/6/24 at 3:00 p.m. with the Director of Nursing (DON). She said medications should not be at the resident's bedside. But if medications were at the bedside the resident should be assessed for self-administration for medications and the physician's order would say may self-administer. Review of the facility's Standards and Guidelines: Medication Administration policy revised on 1/2024 revealed Standard: Medications are ordered and administered safely and as prescribed. Guideline: Medications will be administered safely and as prescribed by only licensed personnel. Procedure: 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. .21. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely .

Based on interview and record review, the facility failed to ensure the grievance process was followed for one (#5) of eleven sampled residents. Findings included: A review of Resident #5's clinical record, the face sheet, documented an admission of 03/02/2022, readmission of 01/08/2024. A review of Resident #5's medical diagnosis list included: Parkinson's disease, Diffuse traumatic Brain injury, epilepsy, unspecified convulsions and muscle wasting. A review of the Minimum Data Set Annual Assessment, dated 03/27/2024, showed a Brief Interview for Mental Status score of 6, which indicated severe cognitive impairment. A phone interview was conducted on 08/06/2024 at approximately 4:15 p.m. with Resident #5's family member. The family member stated the resident was transferred to the hospital on 06/24/2024. The resident had a fever and was shaking on 06/23/2024 but the family member had not been notified of this. A review of the Grievance form, dated 06/27/2024, documented Resident #5's family member submitted a complaint: was not notified of resident having a fever. The form was blank in the area that would indicate the date of the occurrence, the form documented the 3-11 shift; the form did not document who completed the form; the form did not document the person investigating the complaint. The form follow-up: Staff interviewed. Nurses and CNAs educated on reporting changes to MD (medical doctor) and family. 1-1 education provided to nurse. Further review of the form showed the section for the NHA (Nursing Home Administrator) to review and approve the resolution had an illegible signature with no date. An interview was conducted on 08/06/2024 at 2:30 p.m. with the Director of Nursing (DON). She stated, [the Unit Manager, Staff D, Licensed Practical Nurse (LPN)] told me the [family member's] concerns about the temperature. That was when I filled out the grievance. The DON said she had not spoken to the family member regarding the resolution of the grievance. She stated, [the family member] came in to pack the resident's belongings, we were still working on the grievance. I do not remember what day it was she came in. We should have called. A review of the facility's Standards and Guidelines: Grievances-Resident Rights, issued 04/2017, revised 07/2024, documented the Guideline: The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Procedure: 1. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning the care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances may also be voiced or filed regarding care that has not been furnished. 2. Residents, family and resident representatives have the right to voice or file grievances . 3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to verbally and / or in writing upon request including a rationale for the response. . 8. Upon receipt of a grievance and/ or complaint, the Grievance Officer will review and investigate the allegations and submit a report of such findings to the Administrator within five (5 ) working days of receiving the grievance and/ or complaint. In the event the facilities investigation exceeds five (5 ) working days, the resident / responsible party will be notified. . 10. The Grievance Officer, Administrator and Staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. 11. The Administrator will review the findings with the Grievance officer to determine what corrective actions, if any, need to be taken. 12. The resident, or person filing the grievance and / or complaint on behalf of the resident, will be informed (verbally and/ or in writing as per request) of the findings of the investigation and the actions that will be taken to correct any identified problems. a. The Administrator, or his or her designee, will make such reports orally within ten (10) working days of the filings of the grievance or complaint with the facility. b. A written summary of the investigation will also be provided to the resident upon request, and a copy will be filed in the business office . Class III

Based on interviews and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level I upon admission for three residents (#43, #128, and # 98) of seven residents sampled for PASRR Level 1. Findings Included: Review of the Admission Record, dated 03/06/2024, showed Resident #43 was admitted on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to major depressive disorder, recurrent, moderate, dementia in other disease classified elsewhere, moderate, with mood disturbance. Review of Resident #43's PASARR, dated 09/14/2022, revealed no qualifying mental health diagnosis and no PASARR Level II was required. Review of an Admission Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. An interview was conducted on 03/07/2024 at 2:00 PM., with the Director of Nursing (DON). She said their process is when a resident is admitted to the facility, she reviews the PASRR Level I to make sure they are accurate. She stated if she reviews an inaccurate PASARR they reach out to the hospital to have them correct it. She stated Resident #43's PASRR Level I should have been redone to reflect the resident had major depressive disorder and dementia. She stated, Resident # 43's PASRR is not accurate. 49497 Review of the medical record showed Resident #128 was admitted on [DATE] with diagnoses that included dementia in other disease classified elsewhere, unspecified severity with mood disturbance, Bipolar disorder, major depressive disorder, and Schizophrenia. The medical record revealed Resident #128 was not assessed for a Level I Preadmission Screening and Resident Review (PASRR) at, or prior to admission on 12/5/2022. Review Of Resident #128 medical record revealed a Level I PASRR completed on 2/24/2023 Part A. showed a Schizophrenia diagnosis checked and in Section IV PASRR Screen Completion a Level II PASRR evaluation not required. Review of medical record for Resident #128 revealed a new diagnosis of Bipolar disorder on 2/27/2023, major depressive disorder on 6/29/2023, generalize anxiety disorder on 6/29/2023, and a PASRR Level II was not completed. Review of the PASRR Level I completed on 8/18/2023 Part A showed Depressive Disorder and Schizophrenia box checked. Anxiety and Bipolar diagnoses boxes were unchecked. On 3/7/2024 at 12:50 PM an interview was conducted with the Director of Nursing (DON). She stated the PASRR's are received upon admission and reviewed to ensure clinical accuracy. She said, if the PASRR is inaccurate, they reach back out to hospital to correct the information. She said, if the hospital does not correct the screening then she (DON) will correct it by completing a new Level I PASRR. She stated when a new diagnosis is added to the medical record the expectation is to complete a new PASRR with the new diagnosis. She stated she will complete an updated PASRR when informed by doctor or staff that a resident acquires a new diagnosis. The DON stated Resident #128 should have had a Level I PASRR completed prior to, or at admission and an updated Level I PASRR should have been completed when new diagnoses were added to his medical record. Review of the medical record showed Resident #98 was admitted on [DATE] with primary diagnosis of unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Other diagnoses included schizoaffective disorder, major depressive disorder, pseudobulbar affect, and generalized anxiety disorder. Review of Resident #98's Level I PASRR completed on 3/22/2021 showed Section I: PASRR Screen Decision Making Part A with all listed diagnosis boxes unchecked. Section II: Other indications for PASRR Screen Decision-Making, Continued showed A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of an Serious Mental Illness, Intellectual Disability, or both. A Level II PASRR may only be terminated by the Level II PASRR evaluator in accordance with 42 CFR S483.128(m)(2)(i) or 42 CFR S483.128(m)(2)(ii). No Level II PASRR was completed. Section IV: PASRR Screen Completion showed box was checked marked for No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Review of Resident #98 Level I PASRR completed on 1/23/2024 shows Section I: PASRR Screen Decision Making part A has diagnosis Anxiety Disorder and Depressive Disorder box marked with check mark. Schizophrenia box is unchecked. Other box is unchecked and line to right to specify other is left blank. Section II: Other indications for PASRR Screen Decision-Making, Continued showed A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of an Serious Mental Illness, Intellectual Disability, or both. A Level II PASRR may only be terminated by the Level II PASRR evaluator in accordance with 42 CFR S483.128(m)(2)(i) or 42 CFR S483.128(m)(2)(ii). No Level II was completed. Section IV: PASRR Screen Completion showed box was checked marked No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. On 3/7/2024 at 12:50 the DON stated Resident #98 should have had a Level II PASRR completed on admission due to her primary diagnosis of dementia and should have had schizoaffective affective disorder and dementia diagnoses listed on the Level I PASRR completed on 1/24/2024. Review of the facility policy titled, Admission Criteria, revised December 2016, showed the following: Policy: Our facility will admit only those residents who's medical and nursing care needs can be met. Policy Interpretation and Implementation: 7. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre- Admission Screening and Resident Review program (PASRR) to the extent practicable.

Based on interviews and record review, the facility 1) failed to provide appropriate notification when changes occur with the resident's coverage for two (#137 and #159) of 3 residents sampled for beneficiary notices, and 2) failed to provide one resident (#368) out of three residents sampled with a refund within 30 days after discharging from the facility. Findings included: Review of Resident #137's record revealed he was admitted to the facility on [DATE]. The resident's last covered day for Part A services was 12/2/23. The resident elected to remain in the facility for Long Term Care (LTC). Review of the Beneficiary Protection Notification Review form and the notice given revealed the resident only received the Notice of Medicare Non-Coverage (NOMNC CMS-10123), but did not receive the Advance Beneficiary Notice of Non-coverage (ABN CMS-10055). Review of Resident #159's record revealed he was admitted to the facility on [DATE]. The resident's last covered day for Part A service was 2/3/24. The resident elected to remain in the facility for Long Term Care (LTC). Review of the Beneficiary Protection Notification Review form and the notice given revealed the resident only received the Notice of Medicare Non-Coverage (NOMNC CMS-10123), but did not receive the Advance Beneficiary Notice of Non-coverage (ABN CMS-10055). An interview with the Social Service Director on 03/07/24 at 3:21 PM revealed she was not aware she was supposed to give both notices and she stated she uses the current process based on how she was trained. Review of the undated facility policy titled Requirements revealed the following: You must issue an ABN: When a Medicare item or service isn't reasonable and necessary under Program standards, including care that's: -Not indicated for the diagnosis, treatment of illness, injury, or to improve the functioning of a malformed body member 46498 Review of the Admission Minimum Data Set (MDS) Section A showed Resident # 368 was admitted on [DATE] with diagnoses, to include but not limited to, nontraumatic intracerebral hemorrhage, intraventricular, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder, single episode, Review of the Care Plan, revised on 06/21/2023 and canceled on 06/21/2023, showed Resident # 368 was admitted to short-term placement with plans to transition to long term care. Review of the care plan interventions, revised on 06/21/2023, and canceled on 06/21/0223, showed the discharge plan was discussed with resident/ responsible party and Resident # 368 planned to discharge back to the community. Review of a Heath Status Note, dated 06/19/2022, showed the family requested Resident #368 be discharged to [Facility Name] on 06/20/2023. The note revealed the resident was accepted for admission. Review of a Nursing Home Transfer and Discharge Notice, dated 06/20/2023, showed Resident #368 was discharged to the facility per family request. Review of a Discharge Planning Summary, dated 06/20/2023, showed Resident #368 was transferred to the facility with all her belongings on 6/20/2023. During an interview on 03/06/2024 at 12:17 PM., with Resident #368's representative, she said the resident discharged from the facility in June and was owed a refund from the facility. She stated she spoke with the last Business Office Manager in November 2023 and was told the refund would be sent, but she had not received the money. She stated she tried to reach back out to the Business Office Manager to follow-up with her about the refund, but she had not received a response from her or anyone at the facility regarding the matter. An interview was conducted on 03/06/2024 at 9:34 AM., with the Business Office Manager. She said Resident #368 was admitted to the facility on [DATE] and discharged on [DATE]. She was skilled under Medicare from 7/27/22 to 7/31/22 and then she was skilled under Managed Care from 81/22 to 8/14/22. She stated Resident #368 had another payor change on 8/15/2022 to Medicaid long term care until she discharged from the facility on 6/20/2023. She stated Resident #368 was not private pay at any time during her stay and she had a financial responsibility of $745 dollars according to her Medicaid; part was covered by her Social Security. She said the resident's family was responsible for handing her finances. She stated there was a refund on her account for $301.40 which goes to the family, and $458.00 goes back to Medicaid for a total refund on her account of $ 759.43. She stated, I have only been here for three months since I started at the facility, I have been working on all the refunds. There are over 20 refunds that I have been working on since I started in this position. I have a back log that I am working on, and my goal was to make sure the request for refunds were all completed by the 21st of February and sent to corporate so that the refunds can get sent out. She stated the facility process was the resident or their representative should have their refund within thirty days of discharging from the facility. She stated the back log goes from 2022, to 2023. She stated, I identified this problem when I first started at the facility three months ago. Review of the Facility policy titled, Resident Rights Attachment 3, undated, showed the following: A) Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and service inside and outside the facility, including those specified in this section. (18) The facility must inform each resident before, ort at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. ( iv) the facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.

Based on interviews and record reviews, the facility failed to ensure accuracy of comprehensive assessments for three (#135 and #83) of fifty two sampled residents. Findings included: A review of Resident #83's medical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses of cerebral atherosclerosis, dysphagia following cerebral infarction, and dementia. A review of Resident #83's physician's orders revealed an order, dated 10/3/2023, for hospice services for end of life care related to a diagnosis of cerebral atherosclerosis. A review of Resident #83's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/28/2024, revealed under Section O - Special Treatments, Procedures, and Programs, Resident #83 was not receiving hospice services during her time as a resident of the facility. An interview was conducted on 3/7/2024 at 10:34 AM with Staff A, MDS Registered Nurse (RN). Staff A, MDS RN stated Resident #83 was receiving hospice services, which should be reflected on the resident's MDS assessment. Staff A, MDS RN reviewed Resident #83 quarterly MDS assessment with an ARD of 2/28/2024 and stated the assessment did not reflect Resident #83 was receiving hospice services. 39866 Review of Resident #135's Admission Record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. Her admission medical diagnoses include post-traumatic stress disorder (PTSD), major depressive disorder, and generalized anxiety disorder. Review of Resident #135's 5-day Minimum Data Set (MDS), dated , 2/16/24, Section I, Active Diagnoses revealed Psychiatric/Mood Disorder Post Traumatic Stress Disorder (PTSD): No An interview was conducted on 03/07/24 at 10:35 AM with Staff A, MDS Registered Nurse (RN). She said, I put in the medical diagnoses when they [residents] are admitted or when residents are given a new diagnosis, and they pull over automatically in the MDS. The nurse who completes the MDS checks to ensure the diagnoses are correct. They will also look on the physician notes and add new diagnoses as well. Staff A, MDS, RN reviewed Resident #135's PTSD diagnoses and confirmed Resident #135 had the diagnoses since her admission. She reviewed the Medicare 5-day MDS, dated [DATE], Section I, and confirmed the resident was not identified on the MDS to have PTSD and she should have been.

Based on observations, interviews, and review of facility policy, the facility failed to maintain an effective infection control and prevention program by 1.) failing to ensure hand hygiene was performed during medication administration and 2.) failing to ensure medications were dispensed in a sanitary manner for one (#84) of three residents observed during medication administration. Findings included: An observation of medication administration was conducted on 3/6/2024 at 8:30 AM with Staff D, Registered Nurse (RN) on the 100 unit of the facility. Prior to the observation, Staff D, RN was observed at a treatment cart near the end of the hallway after assisting a resident. Staff D, RN was not observed performing hand hygiene after handling items in the treatment cart or prior to the observation of medication administration. Staff D, RN reached into her pocket, removed the medication cart keys, and opened the medication cart before preparing the following medications for administration to Resident #84: - Aspirin 325 mg PO, one tablet. - Citalopram Hydrobromide 20 mg PO, one tablet. - Divalproex sodium 125 mg PO, one tablet. - Cholecalciferol 1000 units PO, one tablet. - Insulin Glargine 100 units/ml pen-injector - Lisinopril 10 mg PO, one tablet. - Gemfibrozil 600 mg PO, one tablet. - Fish oil 1000 mg PO, one capsule. During the observation, Staff D, RN was observed removing Resident #84's Citalopram, Divalproex sodium, Lisinopril, and Gemfibrozil tablets from a blister pack and into her ungloved hand before placing the medication into a medication cup. Staff D, RN removed the remainder of Resident #84's medications from the manufacturer's container, into the lid of the container, and into the same medication cup. Staff D, RN removed Resident #84's Insulin Glargine pen injector and applied a needle to the tip of the pen. Staff D, RN dialed the pen's dosage selector to 26 units, gathered an alcohol preparation pad and PO medications for the resident, and entered the resident's room. Staff D, RN administered the PO medications to Resident #84 before performing hand hygiene and donning clean gloves. Staff D, RN administered Resident #84's insulin into the resident's lower left quadrant. Staff D, RN performed hand hygiene and exited Resident #84's room. An interview was conducted following the observation with Staff D, RN. Staff D, RN stated she normally removed the medications from the medication blister packs and into her hand due to having pain in her thumbs. Staff D, RN addressed she did not perform hand hygiene after handling items in the treatment cart and stated she did not touch anything dirty inside of the treatment cart. An interview was conducted on 3/7/2024 at 2:16 PM with the facility's Director of Nursing (DON). The DON stated she would expect nursing staff to perform hand hygiene before handling medications, after passing medications, and before and after donning gloves. The DON also stated she would not expect nursing staff to dispense medications by placing the medications into their hand and the medication should be dispensed directly into the medication cup from it's container. A review of the facility policy titled Standards and Guidelines: Medication Administration, last revised in January 2024, revealed under the section titled Procedure, staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolations precautions, etc.) for the administration of medications, as applicable. A review of the facility policy titled Standards and Guidelines: Hand Hygiene Infection Control, last revised in June 2023, revealed under the section titled Procedure the facility acknowledges the CDC (Centers for Disease Control and Prevention) guidelines to improve adherence to hand hygiene in health care settings. The hand hygiene guidelines are part of an overall CDC strategy to reduce infections in health care settings to promote resident safety. The policy gives examples of situations that require hand hygiene such as before and after medication administration and after handling soiled equipment or utensils.

Based on observation, interviews, and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being related to outside provider appointments for 2 residents (#87 and #135) out of 2 sampled residents. Findings included: 1. Review of Resident #87's Admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included chronic obstructive pulmonary disease and vascular dementia. An interview was conducted on 03/04/24 at 11:11 AM with Resident #87 (Resident Council President) she said she has concerns related to appointments. She said her throat is sore and she is supposed to go see an Ear Nose Throat (ENT) Physician. She said the doctor thought she might've had a small airway and when she was sick and got intubated it might've caused some damage so the doctor wanted me to see an ENT and it's been two months. She said she still does not have an ENT appointment. Review of Resident #87's Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, revealed a brief interview for mental status (BIMS) score of 15 out of 15 indicating no cognitive impairment. Review of Resident #87's Advanced Practical Nurse Practitioner (ARNP) note date 3/5/24 revealed the following: Subjective .1/11/24 The patient is seen today to follow up on long-term care. The patient is sitting up in [sic] the side of the bed. The patient reports that her appetite is good. She reports that since she was intubated she has noticed that her vocal cords weren't as good. She reports that they've been like this for a while but she wants her singing voice back. We discussed for her to see an ENT [Ear Nose and Throat Physician] to assess her vocal cords and she reports that she was told about a Lidocine [sic] spray for her throat. We discussed that lidocaine spray could mask an issue. She reports that she doesn't want to see ENT at this time and wants to try Lidocaine spray first . 2/5/24 Patient seen for follow up on LTC [long term care] and per pt [patient] request. Reports she continues to have raspy voice/laryngitis and thinks should [sic] would like to see ENT now Review of Resident #87's physician orders revealed an order with a start date of 2/5/24 and no end date for ENT Consult Dx [diagnosis] Laryngitis. Review of Resident #87's medical record did not reveal an ENT appointment was scheduled. An interview was conducted on 03/06/24 at 12:35 PM with Staff L, Licensed Practical Nurse (LPN) Unit Manager (UM). She said when the doctor first ordered the ENT consult, she personally gave it to the transporter to have the appointment scheduled. She said Resident #87's ARNP came yesterday (3/5/24) and asked about the consultation and the Transporter had not scheduled the appointment yet but she was working on it. She confirmed Resident #87 does not have an ENT appointment scheduled. An interview was conducted on 03/06/24 at 02:48 PM with Staff N, Transporter. She said last month the Unit Manager gave her the ENT consult and she faxed it over to the ENT office Maybe within four or five days after receiving the consult. She said Staff L, LPN, UM asked her about the ENT appointment yesterday (3/5/24), so she called the ENT doctor, and they did not receive the fax so I need to refax the consult. I have not done it yet because I do all the appointments and the transportation for the whole building. She said she tries to get appointments scheduled in between her transports. 2. Review of Resident #135's Admission Record revealed she was initially admitted to the facility on [DATE] and readmitted back to the facility on [DATE] from an acute care hospital. Her medical diagnoses included lymphedema, venous insufficiency, cellulitis of the left lower limb, chronic pain syndrome, and difficulty in walking. An interview was conducted on 03/04/24 at 11:23 AM with Resident #135. Upon entering the resident's room Resident #135 had her eyes closed and grimacing. She said she was in excruciating pain in her left leg. She pulled back the covers and her left leg was dark red and purple with dry flaky skin. She said she finally went to the hospital and they told her she had lymphedema in her legs. She said they recommended her to go to a lymphedema specialist, but she has not gone. She said she does not have an appointment that she knows of. She said the doctor told her, her legs Look angry so she ordered an antibiotic. Review of Resident #135's Minimum Data Set (MDS), Section C, Cognitive Patterns, dated 2/16/24 revealed a brief interview for mental status (BIMS) score of 13 out of 15 indicating the resident's cognition was intact. Review of Resident #135's hospital records dated 2/6/24 revealed the following: History of Present Illness [Resident #135] is admitted to the hospital with poss [possible] infection both lower legs. She is admitted from the nursing home where she resides currently. States that she has difficulty walking due to the pain in her legs and weakness . Assessment/Plan 1. Bilateral lower leg cellulitis Suspect that the erythema is a result of her lymphedema rather than infection. 2. She would benefit from a lymphedema clinic evaluation upon discharge . Review of Resident #135's medical record did not reveal a consultation to a lymphedema clinic or lymphedema specialist. Review of Resident #135's physician SOAP Note dated 2/14/24 revealed .follow up BLE [bilateral lower extremity] cellulitis, and other related chronic conditions .Patient seen at bedside sitting up in bed. Patient is alert and oriented and able to make her needs known. BLE swollen +3. Patient currently in bed with BLE elevated. No skin weeping noted. Ace bandage on BLE. Patient encouraged to keep her legs elevated while in bed. An interview was conducted on 03/06/24 at 12:40 PM with Staff L, LPN Unit Manager. She said, Resident #135 does not have an appointment to see a lymphedema specialist or an appointment to go to a lymphedema clinic. She was not aware she needed the services. She said they used to wrap her legs, but Resident #135 would refuse it and then she would get cellulitis, so we stopped doing the wraps. An interview was conducted on 03/06/24 at 02:48 PM with Staff N, Transporter she said Resident #135 came to her yesterday and told her she was supposed to see a lymphedema therapist so I need to look at her hospital records and her chart because that was the first time, I have been informed about her needing an appointment for her lymphedema. Staff N, Transporter confirmed Resident #135's legs were swollen. An interview was conducted with the Director of Nursing (DON) on 3/7/24 at 9:38 AM. She said, I know we don't have a lymphedema specialist at the facility. She said she does not know off the top of her head anything about Resident #135 needing to see a lymphedema specialist. She said when a resident comes from the hospital, Admissions uploads the discharge medication list and the nurses call the physical and ensure those medications are still appropriate to keep ordered. When the resident arrives, they come with hospital paperwork and the medications are reconciled again to ensure no changes were made and the next morning at morning meeting the clinical team reviews all hospital documents and orders to ensure appointments are made and orders are in place. An interview was conducted on 3/7/24 at 9:38 AM with the DON she said once a consult is ordered or recommended the scheduler should be working on it immediately. If there are concerns with getting the appointment that should be communicated to the Unit Manager, the DON, and the family. Review of the facility's Transportation Standard Procedure undated, revealed the following: .Community Resident Physician/Provider Visits .Ordered appointments related to the residents stay can be accommodated through the following methods: scheduled with specialty providers credentialed with the facility who make in-house visits, telehealth via video call, in-house driver to add to schedule, and if there is no in-house can transport will be coordinated with the designated facility vendor.

Based on observations, interviews, and record review, the facility failed to provide treatment and care to meet the needs of residents by 1.) failing to ensure alterations in skin were identified and treated for one resident (#316) of two residents sampled for skin conditions, and 2.) failed to ensure residents were assessed for a change in condition for one (#366) of five residents sampled for discharges. Findings included: A review of Resident #316's medical record revealed Resident #316 was admitted to the facility on [DATE], with a readmission on 2/22/2024, with diagnosis of sepsis, urinary tract infection, and Diabetes Mellitus. An observation was conducted on 3/5/2024 at 9:09 AM of Resident #316 in the resident's room. Resident #316 was observed resting in bed and dressed in a hospital gown. Resident #316 was observed to have several red colored abrasions on the upper right side of his chest. The skin surrounding the abrasions was observed slightly red in color. A review of Resident #316's physician's orders did not reveal treatment orders related to the abrasions on Resident #316's chest. A review of Resident #316's progress notes did not reveal documentation related to the abrasions on Resident #316's chest. A review of Resident #316's weekly skin check, dated 2/28/2024, did not reveal documentation related to the abrasions on Resident #316's chest. An interview was conducted on 3/6/2024 with Staff B, Licensed Practical Nurse (LPN) and Unit Manager (UM), Resident #316's assigned nurse. Staff B, LPN UM stated she was not aware Resident #316 had abrasions on his chest and the skin condition was not reported to her. Staff B, LPN UM observed the abrasions to Resident #316's upper right chest and stated the condition should have been reported to her. An interview was conducted on 3/6/2024 at Staff C, Certified Nursing Assistant (CNA), Resident #316's assigned CNA. Staff C, CNA stated if a new skin condition is identified on a resident, the condition is reported to the nurse. Staff C, CNA also stated she had not observed Resident #316's skin during care recently and she was not aware Resident #316 had abrasions on his upper right chest. An interview was conducted on 3/7/2024 at 2:12 PM with the facility's Director of Nursing (DON). The DON stated CNA staff should be observing resident's skin for any skin alterations while assisting resident's with care and should notify the nurse if any new skin alterations are identified. The DON also stated when the nurse is notified of a skin alteration, the nurse should assess the resident to determine if the alteration is new or previously identified. The nurse should also complete an incident report, skin assessment, and pain evaluation in the resident's record and notify the resident's physician for any required treatment orders. A review of the facility policy titled Standards and Guidelines: Prevention of Skin Impairments/Pressure Injury, last revised in January 2024, revealed under the section titled Monitoring/Documenting, staff are to evaluate, report, and document potential changes in skin, notify the physician and the resident/resident representative of changes in the skin, and review the interventions and strategies for effectiveness on an ongoing basis. 20311 Review of Resident #366's medical record revealed the resident was admitted to the facility on [DATE] with a diagnosis to include orthopedic aftercare following surgical amputation. Review of the resident's Brief Interview For Mental Status (BIMS) score dated 8/5/23 revealed a score of 15, indicating cognitively intact. Review of a Summary of Skilled Services note, dated 8/5/2023 at 9:37 PM, revealed Resident is alert-oriented able to make needs know, tolerated meds well. No signs or symptoms of distress, IV-line patent no signs of infiltration. Complaint of SOB [shortness of breath], will continue to monitor. Review of a Medication Administration note, dated 8/6/2023 at 11:37 AM, revealed medication held resident dizzy NP [Nurse Practitioner] aware Review of a Nursing note dated 8/7/2023 at 6:01 AM revealed This writer went to flush resident's right arm line. This writer observed line detached from resident's right arm. When asked what happened, the resident said, I pulled it out. oncoming nurse notified. Review of the SBAR [Situation Background Assessment and Recommendation] Summary for Providers dated 8/7/2023 at 8:14 AM revealed: Pulse Oximetry Oxygen Saturation of 94% while receiving oxygen via nasal cannula Altered level of consciousness Needs more assistance with ADLs (activities of daily living), general weakness, decreased mobility. Personality change. that the resident had a change in condition related to an altered mental status. Continued review of Nursing observations, evaluation, and recommendations are: AMS [Altered Mental Status] not at base line with conversation. Primary Care Physician responded with Recommendations: family request resident be transferred to [name of hospital] ER [emergency room ] for evaluation and treatment. Resident surgeon works out of [name of hospital]. NP say AMA [Against Medical Advice] due to resident using non emergency to be transported to hospital. Review of the nursing note dated 8/7/2023 at 12:50 PM revealed that the resident was transported by a transport service to an emergency room for evaluation and treatment. Review of Resident #366's physician's order dated 8/7/2023 revealed Ok to send resident to ER via non emergent per family request. Review of Resident #366's hospital record revealed a History and Physical dated 8/7/23 documenting: History of Present Illness . Patient presented back to the emergency room today brought by family for altered mental status, weak, not eating or drinking well, no fever or chills. Blood pressure 161/91, respiratory rate up to 28, heart rate up to 110, white count 30.55 (Reference Range: 4.40-10.50), Neutrophils Absolute 25.91 (Reference Range 1.50-7.50), Glucose 287. Active problems: Community acquired bacterial pneumonia Plan: Sepsis secondary to right lung pneumonia. Patient is tachypnea, tachycardia, with leukocytosis and identified focus of infection. The resident remained in the hospital until 8/21/2023. Interview on 03/07/2024 at 1:53 PM with the Director of Nursing (DON) revealed the resident was transferred out of the facility for a change in condition per the SBAR. She reported she was not in the facility at the time of the transfer, but per the SBAR the change of condition was due to the resident not being at baseline for conversations. She reviewed the resident's progress notes and reported that she was unsure if the resident was assessed for dizziness on 8/6/23 and for pulling out her PICC line on 8/7/23.

Based on observations, record review, and interviews, the facility failed to ensure physician orders were obtained related to care and services for catheters, and catheters were appropriately covered for 1 (#218) of 3 residents sampled for catheters. Findings included: Review of Resident #218's record revealed he was admitted to the facility on [DATE], with diagnosis that included stage 5 chronic kidney disease, polycystic kidney, and malignant neoplasm of prostate. Observations of Resident #218 on 03/04/24 at 10:48 AM from the hallway revealed a catheter bag hanging on the side of the bed, with urine visible and no privacy bag noted. Review of the residents record revealed there were no current orders for a catheter or for catheter care. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for the month of March 2024 revealed there was no documentation indicating monitoring or provision of care to the residents catheter. Review of the resident care plan revealed there was no care plan in place that would address the presence and care of a catheter. Interview on 03/06/24 at 11:05 AM with Staff G, Licensed Practical Nurse (LPN) revealed she was assigned to Resident #218 and she was aware of the presence of a catheter. She reported the Certified Nursing Assistant (CNA) provides catheter care based on the facility policy. She reported there should be a physician order in place for the use and care of the catheter. Interview on 03/06/24 at 11:10 AM with Staff I, Registered Nurse (RN), Unit Manager revealed catheter bags should be covered, orders should be in place, and the facility policy is the admitting nurse should put in the orders, and on the next business day nursing management works on orders and medications are reviewed. Interview with the Director of Nursing (DON) on 03/07/24 at 10:28 AM revealed there should have been a leaf on the catheter bag to cover it. She reported if the staff see the catheter bag exposed they should fix it or change bag to the appropriate bag that allows the catheter bag to be covered. The DON reported Resident #218 was admitted from the hospital with an uncovered catheter bag, which should have been changed. Review of the facility policy titled Catheter Care-Quality of Care dated 10/2020, with a revised date of 01/2024 revealed the following: 3. Ensure the drainage spigot is not touching the floor, the tubing is free of kinks, the catheter is kept at an appropriate level to promote urine flow, and dignity is maintained. Catheter coverings are not required when drainage bags are out of sight from the public or per the resident's preference.

Based on observation, record review and interview the facility failed to ensure care and services related to Intravenous (IV) fluids were provided for a one resident (#68) out of 1 of four residents with IV access in the facility. Findings included: Observations on 03/04/24 at 10:20 AM of Resident #68 revealed the resident sitting up in his bed. An empty Intravenous (IV) bag was noted hanging at his bed side, but not connected to the peripheral line. During an attempt to interview the resident at this time, the resident was unable to verbalize why or how long he has had the peripheral line. Observations on 03/04/24 at 03:48 PM of Resident #68 revealed the resident seated in his wheelchair next to his bed. The empty IV bag was noted to be hanging at the bed side, but not connected to the peripheral line. Continued observations of Resident #68 at this time revealed the peripheral line inserted into the residents right hand and the dressing noted to be soiled, lifting and with no date. Review of Resident #68's record revealed he was readmitted to the facility on [DATE], with diagnosis that included: Sepsis, and cellulitis of left lower limb. The resident had a Brief interview For Mental Status dated 1/29/24 with a score of 13 (Cognitively intact). Review of the resident's record revealed a physician order dated 3/2/2024 for Insert Peripheral. May use 1% Lidocaine for insertion. Review of the IV access vendor documentation revealed the vendor inserted a peripheral line for IV fluids in the residents right hand. Interview on 03/04/24 at 03:54 PM with Staff J, Licensed Practical Nurse (LPN) revealed the resident was on IV for fluids due to dehydration. She reported the IV team placed the IV, but that she did not see orders for care of the IV line. Interview on 03/04/24 at 04:06 PM with Staff I, Registered Nurse (RN), Unit Manager. revealed right now is the first time he was aware the resident had a IV line. He reported the IV team should have dated the dressing for the IV line, and that if there was no date the nurses should have followed up and ensured that care was provided. Interview on 03/07/24 on 09:28 AM with the Director of Nursing (DON) revealed if the peripheral line dressing is not dated or soiled, staff are to remove the dressing, re-apply the dressing and then date it. She reported the peripheral line is monitored every shift. The DON reported she was unsure as to why the staff did not notice the soiled, undated dressing. The DON reported the role of Unit Manager is to oversee the staff of the unit, review admissions and do meet and greet with new residents as well as review the physician orders for the newly admitted residents. She reported new admissions are reviewed as part of clinical meetings which is done every day. Review of the facility policy titled Peripheral IV Dressing Changes dated 05/2019 and a revised date of 11/2023 revealed the following: -Standard: This purpose of this procedure is to minimize catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. -Procedure: 1. Change the dressing if it becomes damp, loosened or visibly soiled and at least every 5 to 7 days.

Based on observations, interviews, and record reviews, the facility failed to provide respiratory care and services in accordance with professional standards of practice by failing to ensure respiratory equipment was stored in a sanitary manner for two (#218 and #103) of two residents sampled for respiratory care. Findings included: Observations of Resident #218 on 03/04/24 at 10:48 AM revealed a CPAP (continuous positive air pressure) machine on the resident's nightstand. Closer observations at this time revealed the CPAP mask laying unbagged face down on the nightstand. Observations on 03/05/24 at 11:45 AM revealed the resident's CPAP mask laying unbagged, face down on the residents nightstand. Review of Resident #218's record revealed he was admitted to the facility on [DATE]. The record revealed there was no current order for the use of the CPAP, no current order for the care of the CPAP and no care plan in place for the use, monitoring and care of the CPAP. Review of the history and physical dated 3/1/24 revealed the plan it indicated CPAP nightly Review of the progress note dated 3/1/24 revealed per resident wife, resident is to wear BPAPP (sic) machine to bed at night Interview on 03/06/24 at 11:05 AM with Staff G, Licensed Practical Nurse (LPN) revealed that she was assigned to the resident. She reported the residents CPAP goes on at nighttime. She reported there should have been a physician order in place for the use of the CPAP and that it should be bagged when not in use. Interview on 03/06/24 at 11:10 AM with Staff I, Registered Nurse (RN), Unit Manager revealed that CPAP masks should be bagged when not in use, orders should be in place, and the facility policy is that the admitting nurse should put in the orders, and on next business day nursing management works on orders and that medications are reviewed. Interview with the Director of Nursing (DON) on 03/06/24 at 11:26 AM revealed when staff take off the CPAP mask they are to place it in a bag. She reported it should not be left on the nightstand uncovered. She reported the expectation is the nurse is supposed to notify the physician of the CPAP and put the order into the electronic system. She reported admission charts are normally reviewed by the admitting nurse to ensure orders are in. She reported the supervisory nurses would review the orders and chart on the next business day. Review of the facility policy titled CPAP/BIPAP usage dated 04/2020, with a revised date of 01/2023 revealed the following: -Under procedure: 2. Review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure (CPAP, BIPAP, and EPAP) for the machine. -Under general guidelines for cleaning 4. Storage: Store mask and tubing in a hygienic manner. 40775 A review of Resident #103's medical record revealed Resident #103 was admitted to the facility on [DATE] with diagnoses of end stage renal disease and chronic obstructive pulmonary disease. A review of Resident #103's physician's orders revealed an order, dated 10/25/2023, for oxygen at 2 liters per minute (LPM) via nasal cannula, as needed for shortness of breath per resident preference. Resident #103's physician's orders also revealed an order to change oxygen tubing/mask/bag weekly and as needed. An observation was conducted on 3/5/2024 at 10:00 AM in Resident #103's room. Resident #103 was observed resting in bed with an oxygen nasal cannula in place. Resident #103 stated she would usually wear her oxygen at night, but not during the daytime. An observation of Resident #103's oxygen tubing revealed the oxygen tubing was dated 2/24/2024. An observation was conducted on 3/6/2024 at 11:38 AM in Resident #103's room. Resident #103 was at an outside appointment at the time of the observation and was not in the room. Resident #103's oxygen tubing and nasal cannula was observed coiled on top of her oxygen concentrator on top of a white plastic bag. The oxygen tubing was dated 3/6/2024. An interview was conducted on 3/7/2024 at 2:06 PM with the facility's Director of Nursing (DON). The DON stated resident respiratory equipment should be stored inside of a bag, labeled with the resident's name and the date the bag was replaced. The DON also stated oxygen tubing and storage bags should be changed out weekly and per the physician's orders. A review of the facility policy titled Standards and Guidelines: Oxygen Administration, last revised in December of 2023 revealed under the section titled General Guidelines, staff are to store oxygen tubing in a hygienic manner (i.e. labeling bag with date tubing was changed). Photographic evidence obtained.

Based on observation, record review and interviews the facility failed to ensure physician ordered pain medication was prescribed for one resident (#72) out of three residents sampled. Findings Included: During an observation on 03/05/24 at 11:59 AM., Resident # 72 was observed in the hallway, fully dressed, propelling in her wheelchair towards Staff M, Licensed Practical Nurse (LPN). Resident #72 said she was in a lot of pain since last night and she has not received any of her pain medicine. She said that she has been waiting for her pain medication all night and the nurse told her that they did not have her medication. Resident # 72 was presented with signs of distress on her face. During an observation on 03/06/2024 at 2:00 PM., Resident was observed laying down in her bed with her feet placed on her wheelchair. She said she finally received her pain medication yesterday after having to ask for it multiple times. She said the nurses told her she was not able to receive her pain medication because they did not have it. She said this is not the first time this has happened to her. Review of Admission Record showed Resident #72 was admitted on [DATE] with diagnoses to include but not limited to unspecified diastolic (congestive) heart failure, chronic obstructive pulmonary disease, unspecified, lack of coordination, chronic tension-type headache, intractable, other chronic pain. Review of an Order Summary Report dated 03/06/2024 showed an active order, start date 5/24/2024, for Oxycodone- Acetaminophen Tablet 5-325 MG (milligram) give 1 tablet by mouth every 6 hours for non-acute pain. Review of care plan, dated 03/27/2023, showed Resident #72 was at risk for pain related to tension headaches, right breast cancer, constipation, chronic pain, backs/knees, as well as age related aches and pain. Review of the care plan interventions, dated 03/27/2023, showed administer analgesia medication as per orders, observe for and report to Nurse any resident complaints of pain, request for pain treatment and non-verbal signs and symptoms of pain. Medication Administration Records were requested to show the days and times Resident #72 did not receive her medication but was not provided for review. During an interview on 03/05/2024 at 12:00 PM., with Staff M, Licensed Practical Nurse (LPN), he said he was able to obtain the script from the resident's doctor, it took an hour to get it and they are waiting for pharmacy so they can get an authorization to pull her pain medication to administer it. He stated the resident's scheduled pain medication has been out since yesterday and the resident was scheduled to get it every 6 hours. During an interview on 03/06/2024 at 12:47 PM., with Staff B, Unit Manager. She said Resident #72 is on pain medication because of low back pain. She has been receiving pain medication since she was admitted to the facility. She gets Oxycodone and Tylenol mix every 6 hours since May 24 of 2023. She gets a Diclofenac sodium one percent for pain in her left knee. She said the Nurse Practitioner wrote a script for 7 days for the resident pain medication Oxycodone and it ran out over the weekend on Sunday evening. They called the on-call doctor to send the script to the pharmacy. The Pharmacy said they did not receive the script or a call from the doctor. Staff B said on Monday when she got to the facility, she called the on-call provider number to have them call in the script for the resident to receive her pain medication. She said when the on-call doctors did not call her back immediately, she went to the Director of Nursing to follow-up and call the doctor. Staff B said she called the pharmacy to make sure they received the scripts so that they can pull the medication to administer it to the resident. The pharmacy told her she has to wait ten to 15 minutes then she was able to go in to request the medication. Resident #72 was supposed to get her pain medication every 6 hours. The last time she received her pain medication was on 3/3/24 at 5:37 pm on Sunday. She did not receive it again until 03/4/24 at 1:10 pm because we did not have a script for her medication. Resident #72 went 20 hours without her pain medication. She said that she was not made aware until Monday about the resident medication. The process is the nurse on the floor should have made sure that the resident scripts were filled on Friday. Standard practice is on Friday the nurse is supposed to go through what scripts need to be filled with the Nurse Practitioner or the doctor to make sure that scripts are filled for the weekend. She said she does not know why this process was not followed out. During an interview on 03/07/2024 at 10:00 AM., with the Director of Nursing. She said the facility process is if the nurses on the floor passing medication see that a resident doesn't have a medication available, they are supposed to notify the physician, family and call the pharmacy for a refill. We do have an in-house medication bank that does have some medication available. Narcotics are the only medication that the nurses would not be able to pull from the medication bank because they would have to reach out to the provider for a new script. The nurse should have called the physician to get a new script and notify the family to ensure Resident #72 had her pain medication. She stated the process was not followed for Resident #72's medications. The facility did not have a policy to provide for this citation.

Based on observations, interviews, and record review, the facility failed to maintain a medication error rate of less than 5%. A total of 25 medication administration opportunities were observed with 3 medication errors for two (#84 and #61) of three residents sampled for medication administration, which resulted in a medication administration error rate of 12%. Findings included: A review of Resident #84's medical record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus and hypertension. A review of Resident #84's physician's orders revealed the following orders: - An order, dated 2/9/2023 for Aspirin 325 milligrams (mg) by mouth (PO) one time a day. - An order, dated 2/9/2023 for Citalopram Hydrobromide 20 mg PO one time a day. - An order, dated 6/22/2023 for Divalproex Sodium 125 mg PO every morning and at bedtime. - An order, dated 2/13/2023 for Cholecalciferol 1000 units PO one time a day. - An order, dated 1/18/2024 for Insulin Glargine 100 units/milliliter (ml) via pen-injector, inject 26 units subcutaneously one time a day. - An order, dated 2/9/2023 for Lisinopril 10 mg PO one time a day. - An order, dated 3/3/2024 for Gemfibrozil 600 mg PO two times a day. - An order, dated 7/31/2023 for Fish Oil 1000 mg PO one time a day. An observation of medication administration was conducted on 3/6/2024 at 8:30 AM with Staff D, Registered Nurse (RN) on the 100 unit of the facility. Staff D, RN prepared the following medications for administration to Resident #84: - Aspirin 325 mg PO, one tablet. - Citalopram Hydrobromide 20 mg PO, one tablet. - Divalproex Sodium 125 mg PO, one tablet. - Cholecalciferol 1000 units PO, one tablet. - Insulin Glargine 100 units/ml pen-injector - Lisinopril 10 mg PO, one tablet. - Gemfibrozil 600 mg PO, one tablet. - Fish oil 1000 mg PO, one capsule. Staff D, RN removed the PO medications from the medication cart and placed them inside of a medication cup. Staff D, RN removed Resident #84's Insulin Glargine pen injector and applied a needle to the tip of the pen. Staff D, RN dialed the pen's dosage selector to 26 units, gathered an alcohol preparation pad and PO medications for the resident, and entered the resident's room. Staff D, RN administered the PO medications to Resident #84 before performing hand hygiene and donning clean gloves. Staff D, RN administered Resident #84's insulin into the resident's lower left quadrant. Staff D, RN did not prime the insulin pen injector needle before administering the insulin to Resident #84. Staff D, RN performed hand hygiene and exited Resident #84's room. An interview was conducted following the observation with Staff D, RN. Staff D, RN stated she did not prime the insulin pen injector needle prior to administering insulin to Resident #84 because she didn't think it needed to be primed and the top of the insulin injector pen did not have any air bubbles in it. Staff D, RN was not able to state why the insulin pen injector needle needed to be primed prior to administration of the insulin. A review of Resident #61's medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric fracture of the right femur and diabetes mellitus. A review of Resident #61's physician's orders revealed the following orders: - An order, dated 12/21/2023 for Loratadine 10 mg PO one time a day. - An order, dated 10/9/2023 for Vitamin C 500 mg PO one time a day. - An order, dated 11/15/2023 for Aspirin 81 mg PO one time a day. - An order, dated 7/21/2023 for Doxazosin Mesylate 2 mg PO one time a day. - An order, dated 5/22/2023 for Duloxetine Hydrochloride (HCl) 60 mg PO one time a day. - An order, dated 5/1/2023 for Humulin 70/30 (Insulin Neutral Protamine [NAME] (NPH) Isophane & Regular insulin), 100 units/ml via pen-injector, inject 30 units subcutaneously one time a day. - An order, dated 8/8/2023 for Senna 8.6 mg PO one time a day. - An order, dated 4/28/2023 for Hydralazine HCl 50 mg PO two times a day. - An order, dated 10/8/2023 for artificial tears solution 0.2-0.2-1 % (Glycerin-Hypromellose-Polyethylene Glycol 400) 2 drops in each eye three times a day. - An order, dated 6/1/2023 for Ferrous Sulfate 325 mg PO three times a day. An observation of medication administration was conducted on 3/6/2024 at 8:50 AM with Staff B, Licensed Practical Nurse (LPN) and Unit Manager (UM). Staff B, LPN UM prepared the following medications for administration to Resident #61: - Loratadine 10 mg one tablet. - Vitamin C 500 mg one tablet. - Aspirin 81 mg one tablet. - Doxazosin Mesylate 2 mg one tablet. - Duloxetine HCl one tablet. - Humulin 70/30 pen-injector. - Senna 8.6 mg one tablet - Hydralazine HCl 50 mg one tablet - Artificial tears solution bottle. - Ferrous Sulfate 325 mg one tablet. Staff B, LPN UM removed the PO medications from the medication cart and placed them inside of a medication cup. Staff B, LPN UM gathered Resident #61's Humulin 70/30 pen injector, artificial tears solution bottle, an alcohol preparation pad, and PO medications for the resident, and entered the resident's room. Staff B, LPN UM administered the PO medications to Resident #61 before performing hand hygiene and donning clean gloves. Staff B, LPN UM applied a needle to the tip of Resident #61's Humulin 70/30 pen injector and dialed the pen's dosage selector to 30 units. Staff B, LPN UM administered Resident #61's insulin into the resident's left upper arm. Staff D, RN did not prime the insulin pen injector needle and did not mix the Humulin 70/30 solution before administering the insulin to Resident #61. Staff D, RN performed hand hygiene and donned clean gloves. Staff B, LPN UM administered artificial tears solution to Resident #61 before performing hand hygiene and exiting the room. An interview was conducted following the observation with Staff B, LPN UM. Staff B, LPN UM stated the Humulin 70/30 solution in the pen injector did not need to be mixed because it already came premixed in the pen injector. Staff B, LPN UM then stated, it probably does but she was not certain at the time it was administered to Resident #61. Staff B, LPN UM also stated the pen injector needle did not require priming before administering insulin. An interview was conducted on 3/7/2024 at 2:16 PM with the facility's Director of Nursing (DON). The DON stated when administering insulin via insulin injector pen, nursing staff must verify the dose they are administering, ensure they are administering the correct type of insulin, and ensure the pen injector needle is primed prior to administering the insulin. The DON also stated to prime the pen injector needle, nursing staff must apply the needle to the tip of the pen injector and inject a small amount of insulin into the needle to remove the air from the needle. The DON stated if the resident has an order for Humulin 70/30 insulin, staff must mix the insulin suspension by rolling the injector pen in their hands prior to administering the insulin. The DON also stated if staff do not prime the insulin pen injector needle or mix 70/30 insulin prior to administration, the resident may not receive an accurate dose. The DON stated she was not certain the nursing staff had specific education related to the use of insulin injector pens. A review of the facility policy titled Standards and Guidelines: Medication Administration, last revised in January 2024, revealed under the section titled Procedure, insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for that resident. The nurse follows manufacturer guidelines related to insulin pens. Review of the manufacturer's instructions for the Humulin 70/30 pen injector revealed the following under the section titled preparing your pen: - Step 1: Pull the pen cap straight off. Do not remove the pen label. Wipe the rubber seal with an alcohol swab. Do not attach the needle before mixing. - Step 2: Gently roll the pen between your hands 10 times. - Step 3: Move the pen up and down (invert) 10 times. Mixing by rolling and inverting the pen is important to make sure you get the right dose. - Step 4: Check the liquid in the Pen. Humulin 70/30 should look white and cloudy after mixing. Do not use if it looks clear or has any lumps or particles in it. - Step 5: Select a new needle. Pull off the paper tab from the outer needle shield. - Step 6: Push the capped needle straight onto the pen and twist the needle on until it is tight. - Step 7: Pull off the outer needle shield. Do not throw it away. Pull off the inner needle shield and throw it away. The manufacturer's instructions for the Humulin 70/30 pen injector also revealed the following under the section titled priming your pen: - Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. - Step 8: To prime your pen, turn the dose knob to select 2 units. - Step 9: Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. - Step 10: Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps 8 to 10, no more than 4 times. If you still do not see insulin, change the needle and repeat priming steps 8 to 10.

Based on observations, interviews, and review of facility policy, the facility failed to ensure proper storage, labeling, and security of medications and biologicals in one of four treatment carts in the facility, three of seven medication carts in the facility, and two of three medication rooms in the facility. Findings included: An observation was conducted on 3/6/2024 at 8:22 AM in the 100 unit of the facility. A medication cart was observed in the unit hallway with a medication cup containing crushed medications on top of it. A resident was observed in a wheelchair next to the medication cart. No staff were observed at the medication cart at the time of the observation. Staff D, Registered Nurse (RN) was observed approaching a treatment cart down the hallway from the medication cart and gathering treatment supplies. Staff D, RN approached the medication cart and an interview was conducted. Staff D, RN stated the crushed medications in the medication cup were for the resident observed near the medication cart. Staff D, RN also stated while preparing the medications, she noticed the resident had a skin tear and went to the treatment cart to gather supplies to care for the wound. Staff D, RN addressed the crushed medications should not have been left on top of the medication cart unattended. Staff D, RN gathered the medications and treatment supplies before assisting the resident to their room. An observation was conducted on 3/6/2024 at 8:26 AM of the treatment cart in the 100 unit hallway. The treatment cart was observed to be unlocked. No staff were observed in the unit hallway at the time of the observation. An inspection was conducted of the treatment cart without staff present. During the inspection, Staff L, Licensed Practical Nurse (LPN) and Unit Manager (UM) approached the treatment cart and requested to lock the treatment cart once the inspection was completed. After the inspection of the treatment cart, Staff L, LPN UM locked the treatment cart and an interview was conducted. Staff L, LPN UM stated the treatment cart should not have been left unlocked. An inspection of a medication cart on the 200 unit was conducted on 3/6/2024 at 2:09 PM with Staff E, LPN. A plastic bag containing five $1 bills was observed inside of the narcotics drawer of the medication cart, with hand written text $5 found in 232a closet with a hand written date of 1/12/24. The narcotics drawer also contained five computer mice were also observed inside of the narcotics drawer in the medication cart. Staff E, LPN was not able to state why the plastic bag of money was stored inside of the medication cart and was not able to state who the money belonged to. Staff, LPN stated the computer mice were used for the laptop on the medication cart but was not able to state why there were so many or why they were stored inside of the narcotics drawer. Following the inspection of the medication cart, an inspection of a medication storage room on the 200 unit was conducted with Staff E, LPN. During the inspection, the top shelf of a medication cabinet was observed to have several open medication boxes spread out on the shelf in an unorganized manner. The medications were difficulty to observe from the ground level. Staff E, LPN stated she was not aware any medications were stored on the shelf and was not able to state what medications were contained on the shelf. An inspection of a medication cart on the 300 unit was conducted on 3/6/2024 at 3:47 PM with Staff F, LPN. An unpowered, black colored cell phone was observed inside of the narcotics drawer of the medication cart. Staff F, LPN was not able to state who the cell phone belonged to or how long the cell phone was inside of the medication cart. Following the inspection of the medication cart, an inspection of a medication storage room on the 300 unit was conducted with Staff F, LPN. During the inspection, a large box containing several bottles of opened medications and several bags of opened medications was observed in a storage cabinet. Several more bags containing medications were observed deep in the storage cabinet. Some of the medications were observed to be labeled with resident names. Staff F, LPN was not able to state why the medications were stored in the large box or who the medications belonged to. An inspection of a medication cart on the 100 unit was conducted on 3/6/2024 at 4:16 PM with Staff D, RN. An undated and opened novolog pen injector was observed inside of a bag in the medication cart. The pink colored Date Opened sticker was observed blank. Staff D, RN was not able to state when the pen injector was opened and stated the pen injector should have a date labeled when it was opened. An interview was conducted on 3/7/2024 at 2:27 PM with the facility's Director of Nursing (DON). The DON stated she would not expect nursing staff to leave medications unattended and would expect medications be administered after they are dispensed. The DON also stated medication carts and treatment cart should be kept locked and secure at all times unless there is a nurse present at the cart. The DON stated the medication cart should not have any treatment supplies or personal items inside of it unless it is being stored securely off hours until it can be given to the Unit Manager. The DON was not able to state why there were several bags of personal medications stored inside of the medication room but assumed they must have been resident's personal medications. The DON stated resident's personal medications should be given back to the resident after discharge or to the resident's family. The DON also stated she would expect staff to ensure insulin pens were dated upon opening. A review of the facility policy titled Standards and Guidelines: Medication Storage and Labeling, last revised in January 2024, revealed under the section titled Standard drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include appropriate accessory and cautionary instructions, and the expiration date when applicable. The policy also revealed the following under the section titled Procedure: - Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. - Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Photographic evidence obtained.

Based on observations, interviews, and record reviews, the facility failed to maintain an accurate medical record by documenting treatments, which were not completed, for one (#103) of fifty two sampled residents. Findings included: A review of Resident #103's medical record revealed Resident #103 was admitted to the facility on [DATE] with diagnoses of end stage renal disease and chronic obstructive pulmonary disease. A review of Resident #103's physician's orders revealed an order, dated 10/25/2023, for oxygen at 2 liters per minute (LPM) via nasal cannula, as needed for shortness of breath per resident preference. Resident #103's physician's orders also revealed an order to change oxygen tubing/mask/bag weekly and as needed. An observation was conducted on 3/5/2024 at 10:00 AM in Resident #103's room. Resident #103 was observed resting in bed with an oxygen nasal cannula in place. Resident #103 stated she would usually wear her oxygen at night, but not during the daytime. An observation of Resident #103's oxygen tubing revealed the oxygen tubing was dated 2/24/2024. A review of Resident #103's treatment administration record (TAR) for February of 2024 revealed documentation of Resident #103's oxygen tubing and nasal cannula being changed on 2/26/2024. A review of Resident #103's TAR for March of 2024 revealed documentation of Resident #103's oxygen tubing and nasal cannula being changed on 3/4/2024. An interview was conducted on 3/7/2024 at 2:06 PM with the facility's Director of Nursing (DON). The DON stated resident respiratory equipment should be stored inside of a bag, labeled with the resident's name and the date the bag was replaced. The DON also stated oxygen tubing and storage bags should be changed out weekly and per the physician's orders. The DON stated usually the Central Supply personnel would change the oxygen tubing and nasal cannulas weekly, but the nursing staff should double check to ensure the respiratory equipment was changed before documenting in the TAR and nursing staff should not document the changing of the respiratory equipment if it was not completed. A review of the facility policy titled Standards and Guidelines: Oxygen Administration, last revised in December of 2023 revealed under the section titled General Guidelines, oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or other device per physician's orders and/or facility protocol.