Every finding on record at Hillcrest Home

Based on observation, policy review, and staff interviews the facility failed to ensure all medications were dated when opened for six residents (Resident #23, #27, #31, #32, #44, and Resident #52). The facility reported a census of 51 residents. Observation on 7/1/26 at 4:08 p.m. revealed the medication cart contained the following medications stored and ready for use: Resident # 23, an open bottle of Latanoprost Ophth lacked an open date. Resident #27, an open bottle of Fluticasone Spray 50 microgram (mcg) lacked an open date. Resident #27, an open bottle of Dorzolamide Solution 2% lacked an open date. Resident #31, an open bottle of Lantanoprost Solution 0.005% lacked an open date.Resident #32, an open bottle of Polymyxin B/SolutionTrimethoprim lacked an open date.Resident #44, an open Atrovent Aerosol Inhaler lacked an open date.Resident #52, an open bottle of Dorzolamide Solution 2% lacked an open date.On 7/1/26 at 4:30 p.m., Staff J, Licensed Practical Nurse (LPN) stated the pharmacy placed yellow stickers on them that the nurses were supposed to fill out that said the date opened, expiration date and where they were supposed to initial it. Staff J stated that they were supposed to fill those out and put open dates on the medication when they open the bottle/medication. Staff J stated that the 3rd shift was supposed to check this. On 7/2/26 at 10:45 a.m. with the Director of Nursing (DON) stated the expectation of the nurses was to put an open date on the bottle of medication when it initially got opened. Review of the policy titled Labeling of Drugs dated April 2019 revealed, All medications are to be clearly and accurately labeled .All drugs are to be labeled in accordance with accepted pharmacy practice standards, and individual resident prescriptions include a clear, typewritten label, with no strikeovers.

Based on staff interview, clinical record review, and policy review the facility failed to protect residents from misappropriation of property when resident medication became missing from the facility for 2 of 2 residents reviewed (Resident #40 and Resident #49). The facility reported a census of 51 residents. Findings include:A Facility Self Report to the Department of Inspections, Appeals and Licensing (DIAL) by the Administrator on 6/21/26 at 3:50 p.m. revealed 54 doses of Hydromorphone (a highly potent, semi-synthetic opioid analgesic (narcotic) used to treat moderate to severe pain) for Resident #40 and on 6/26/26 13 doses of Hydrocodone (a potent, semi-synthetic opioid prescribed to manage severe chronic pain and suppress coughs) for Resident #49 was missing from the narcotic drawer in the medication cart. On June 20th, 2026 at approximately 7:30 p.m. Staff K, Certified Medication Aide (CMA) went to give Resident #40 his Hydromorphone out of the bubble pack per his request. Staff K noted the bubble pack was missing. Staff K notified Staff D, Licensed Practical Nurse (LPN) and Staff K, Staff D, and Staff L, Registered Nurse (RN) immediately began looking for the bubble pack. The Director of Nursing (DON) and Administrator were notified of the missing narcotic. At approximately 8:10 p.m. Staff D found the torn top of the bubble pack for the hydromorphone with Residents Name on it in the shred box. They continued the search and found Resident #40's Lorazepam narcotic count sheet was missing. Resident #40's hydromorphone narcotic sheet was located in the binder. Through the investigation they also found on 6/26/26 Resident #49's Hydrocodone bubble pack and narcotic count sheet was missing. According to the pharmacy, it was filled for 30 doses on 4/13/26 and the last card was empty on 4/17/26. Since 4/17/26, she has only received 17 doses, so there should be 13 doses remaining. 1. Resident #40's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severely impaired cognition. The MDS included diagnoses of heart failure, hypertension, non Alzheimer's disease, anxiety and depression. The MDS also reported Resident #40 was dependent to roll left and right, for sit to lying, for sit to stand, for chair/bed to chair transfer, and toilet transferThe Care Plan initiated on 11/10/24 revealed Resident #40 had chronic pain related to aging and took medication as needed. The Care Plan directed staff to anticipate Resident #40's need for pain relief and respond immediately to any complaint of pain (intervention dated 11/10/24). The Physician Order dated 4/16/26 for Resident #40 revealed, Hydromorphone Hcl Oral Tablet 2 milligrams (MG), with directions to give 0.5 tablet by mouth every 2 hours as needed for shortness of breath(SOB)/pain. The June 2026 Medication Administration Record (MAR) revealed the resident took multiple doses of the medication in June 2026. 2. Resident #49's Minimum Data Set (MDS) assessment dated for 4/17/26 identified a BIMS score of 11 out of 15, indicating moderately impaired cognition. The MDS included diagnoses of non Alzheimer's disease, anxiety and depression. The MDS also reported Resident #49 was dependent for sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed to chair transfer. Per this assessment, the resident took opioid medication. The resident's pain interview completed as part of the MDS assessment revealed the resident occasionally experienced pain or hurting over the last 5 days which occasionally made it hard to sleep at night, and occasionally limited participation in rehab therapy sessions and day to day activities. The Care Plan revised on 3/18/26 revealed Resident #49 had acute pain related to a fracture of right humerus, fracture of T11-T12 vertebra, and dislocation of left humerus. The Care Plan directed staff to administer pain medications per order, if non-medication interventions were ineffective, evaluate effectiveness of pain relieving interventions, evaluate for non-verbal indicators of pain, and evaluate pain (interventions dated 10/24/25). The June 2026 MAR directed hydrocodone-acetaminophen oral tablet 5-325 MG, Give 1 tablet by mouth every 6 hours as needed for pain (ordered 2/17/26). Per the MAR, the last dose shown given was on June 16, 26. The facility was not able to provide the Controlled Drug use Record June 2026, due to it missing. A facility form titled Between Shift Narcotic Count Sign-off Log for [NAME] and Midwest medication carts documented staff who signed the form, acknowledge transfer of responsibility for the narcotic count and have found that the quantity of each medication counted to be in agreement with the quantity stated on the Narcotic Count Sign-off Log. The record required documentation of the Nurse on signature and the Nurse off signature for each shift. Review of the count record for [NAME] and Midwest Narcotic Count Sign-off Log revealed lack of staff signatures, indicating reconciliation of controlled medications for [NAME] and Midwest hall did not occur on the following month of June 2026, dates and shifts:Review of the narcotic count sign off log on 6/30/26 at 12:04 pm for the [NAME] to Midwest medication cart:6/14/26 at 10:00 p.m. only one signature6/17/26 at 6:00 a.m. only one signatureEast medication cart narcotic count sign off log revealed:6/14/26 6:00 p.m. only one signature6/14/26 at 10:00 p.m. only one signature6/15/26 at 2:00 p.m. only one signature6/15/26 at 10:00 p.m. only one signature6/20/26 at 6:00 a.m. only one signature6/20/26 at 2:00 p.m. no signature6/20/26 at 10:00 p.m. only one signature6/24/26 at 2:00 p.m. only one signatureInterview on 6/30/26 at 10:45 a.m. with Staff K confirmed that she worked June 19th, 20th and 21st, 2026 and came into work at 2:00 p.m. on June 20th, 2026. Staff K acknowledged that she didn't count the narcotics with Staff M, Registered Nurse (RN) due to the fact that she had been there since 6:00 a.m. Staff K stated she went to give Resident #40's Hydromorphone around 7:30 p.m. and went to get into the narcotic drawer and the whole medication pack was gone. Staff K stated that she called Staff D and let her know and she came back in and they looked through all the medication carts and the narcotic sheets and that is when they found Resident #40's Lorazepam narcotic sheet was gone. The Hydromorphone narcotic count sheet was still in the binder. Staff K stated they looked through the East medication cart and it wasn't in there either. Staff K stated that Staff D contacted the Administrator, Director of Nursing (DON), and police of the missing narcotics. Interview on 6/30/26 at 12:45 p.m. with Staff D, Licensed Practical Nurse (LPN) revealed she worked June 20th, 2026 at 2:00 p.m. Staff D stated that she was the desk nurse which meant she was responsible for all nursing duties except to pass medication. Staff D stated that she went home early that night and came back in when Staff K called and let her know there were missing narcotics. Interview on 6/30/26 at 2:24 p.m. with Staff J, LPN verified that she worked June 19th and 20th. She stated she wasn't aware of any missing narcotics. Staff J stated that she didn't count narcotics on the morning of the 20th when she left for the day. Staff J stated that she was giving report to the nurses and two nurses came up and grabbed the keys, so she figured they were going to count together. Staff J stated that when she came into work the night of the 20th, they counted narcotics and the only medications missing were the hydromorphone. Interview on 6/30/26 at 4:18 p.m. with Staff N, LPN verified that she worked June 19th, 20th and 21st. Staff N verified that she was not on the medication cart on June 19th. Staff N verified on Saturday that she was on the West/Midwest medication cart training another nurse. She was with her until 2:00 p.m. that day until Staff K came in. She stated that she gave Staff K the keys to the medication cart. Staff N acknowledged that she did not do narcotic count with Staff K. Staff N acknowledged that the staff normally did not do narcotic count and they don't seem to be worried about it either. Interview on 6/30/26 at 8:17 p.m. with Staff P, verified that she worked the weekend of June 19th, 20th and 21st, she stated that she was not on the medication cart that weekend. Staff P stated that she was the skin nurse on the 19th and then on the 20th she was the desk nurse. Staff P stated that on a very rare occasion the nurses would count the narcotics. Staff P stated that the nurses would sign at different times that the narcotic count was completed. Staff P stated that when that happened, she would count the narcotics twice in the medication cart she was assigned to. Interview on 7/1/26 at 8:38 a.m. with Staff M, RN, verified that she was in training on June 19th, 20th and 21st. She stated that she didn't have access to the medication cart, but did not see anyone do the narcotic count. Staff M stated that Staff P left and Staff K came in and Staff M didn't see them do narcotic count. Staff M didn't believe her and Staff K did narcotic count together either. Staff M stated that it was Saturday night after [Staff M] left they discovered the medication missing. Staff M stated that when [Staff M] asked the nurses about narcotic count they stated that we don't do narcotic count. Interview on 7/1/26 at 12:52 p.m. with Staff L, RN verified that she worked June 19th and June 20th. Staff L verified that she did not do a narcotic count the morning of June 19th. Staff L stated she was late to work and the nurses gave her the keys and said they did count and everything was okay. Staff L stated that she was assigned to the main and east medication cart. Staff L stated she did a narcotic count herself and everything was accounted for. Staff L stated that when she left for the evening on the 19th that the nurses refused to do narcotic count with her. Staff L stated that when she arrived the morning of the 20th, they again did not do narcotic count. Staff L stated that they generally don't do narcotic count. Staff L stated that at first it bothered her but now she was like whatever. Staff L stated that Staff K came over to her medication cart on June 20th at 8:00 p.m. and went through the medication cart due to the hydromorphone missing. Staff L stated it wasn't in either main or east medication cart. On 7/2/26 at 8:49 a.m., re-interview with Staff K verified that on June 20th at 2:00 p.m. she did not do a narcotic count on west and midwest medication cart. Interview on 7/1/26 at 12:20 p.m. with the DON revealed the expectation was to do the narcotic count anytime the cart changes possession of the staff member. The DON stated that the two staff members sign off at the same time. Review of the facility policy named Nursing Facility Abuse Identification, Prevention, Investigation, Protection and Reporting Policy revealed, in part, all residents have the right to be free from misappropriation of property. The definition of misappropriation of property per the policy revealed the following: the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a Resident's belongings or money without the Resident's consent. This includes misappropriation or diversion of resident medications. Review of the facility policy named Narcotic Count dated June 2019 revealed the purpose is to ensure an accurate count of each individual's residence narcotics supply, to ensure safe storage of narcotics, and to ensure drugs are disposed of appropriately. The narcotic supply is to be kept under two locks at all times in the medication room.The Procedure Section revealed the following: The licensed nurse going off duty and the licensed nurse going on duty must count and justify accuracy of narcotic supply for each individual resident at the change of each shift. Schedule Two narcotics are required to be counted. Other controlled medications are counted according to facility policy. Narcotic records are reconciled by a physical count of the remaining narcotics supply at the change of each shift by the oncoming and outgoing licensed nurse. Records are retained for at least one year. Emergency kits containing narcotics will be checked at the same time to be sure the seal has not been broken or will be reconciled if kit is not sealed. Narcotic keys will be accounted for at the same time. No more than one prescription for a controlled substance is entered on one individual residence narcotic sheet. After the supply is counted and justified, each nurse must record the number of narcotic records, the date, and their signature verifying that the account is correct. If the account is not accurate the nurse going off duty is to remain on duty until the count is reconciled or the nurse supervisor approves leaving the facility. Discrepancies found at any time, change of shift or other, are to be immediately reported to the Director of Nursing. The Director of Nursing will investigate to determine the cause of inaccuracy and will contact the pharmacist for assistance as needed. To destroy any narcotics always have two nurses present. Use a drug disposal system and follow a manufacturer's instructions.

Based on electronic health record (EHR) review, the Centers for Medicare and Medicaid Services (CMS) Long term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025, and staff interview the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) assessment after a resident discharged off hospice services for 1 of 2 residents reviewed on hospice services (Resident #22). The facility reported a census of 51 residents.Findings include:Resident #22's Clinical Census reviewed on 7/1/26 documented a change in primary payer from Hospice Medicaid to Medicaid primary payer effective 10/30/25.The MDS 3.0 Summary page in Resident #22's EHR revealed the facility failed to complete the SCSA MDS when hospice services had ended when Resident #22 remained in the facility.On 7/1/26 at 11:05 AM, Staff E, Health Information Manager acknowledged hospice services ended on 10/30/25.On 7/1/26 at 12:19 PM, Staff A, MDS Coordinator acknowledged she was responsible for completing the MDS assessments. Staff A confirmed adherence to the RAI manual for assessment procedures. The Staff A stated that a SCSA assessment was required when a resident initiated hospice services or exhibited significant improvement. Staff A acknowledged Resident #22 was admitted on hospice at the time of admission to the facility, and subsequently discharged from hospice services several months ago. Staff A acknowledged that a SCSA MDS assessment wasn't completed upon the resident's discharge from hospice, stating that the assessment should have been performed.On 7/1/26 at 12:53 PM, the Director of Nursing (DON)identified that Staff A was responsible for the completion of the MDS assessments. The DON confirmed the facility expectation that all MDS assessments were completed in accordance with the RAI manual. The DON acknowledged that a SCSA assessment should've been completed when Resident #22 was discharged from hospice services.A Hospice Client Coordination Note Report dated 10/30/25 revealed the date of discharge as 10/30/25. The reason for discharge documented Resident #22 was no longer terminally ill. Review of page A-5 of the CMS LTC Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 revealed, If a nursing home resident elects the hospice benefit, the nursing home is required to complete an MDS Significant Change in Status Assessment (SCSA). The nursing home is required to complete an SCSA when the resident comes off the hospice benefit (revoke).

Based on a review of the electronic health record (EHR) review, facility records, facility policy, and staff interviews, the facility failed to submit a PASRR update upon a new diagnosis of Post-Traumatic Stress Disorder (PTSD) for 1 of 1 resident reviewed (Resident #3). The facility reported a census of 51 residents.Findings Include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of 4/23/25. The MDS documented Resident #3 wasn't currently considered by the state Level II PASRR process to have a serious mental illness, and/or intellectual disability or a related condition. The MDS included a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. The MDS documented Resident #3 had no hallucinations or delusions, and listed diagnoses of anxiety, depression, psychotic disorder, and PTSD.The Notice of PASRR Level I Screen Outcome dated 3/27/25 determined nursing facility placement was appropriate for Resident #3. The document further revealed no further Level I screening was required unless the resident was known to have or suspected of having a serious mental illness, an intellectual or developmental disability, and exhibit a significant change in treatment needs. The Level I report listed a mental health diagnosis of major depression. A Nursing Home Audio Visual Visit note dated 6/19/25 revealed the following visit diagnoses: 1.Generalized anxiety disorder2.Psychosis3.PTSDNew orders included the following:1.Lorazepam 0.5 milligram (mg) per g-tube (gastrostomy tube) every 6 hours as needed.2.Mirtazapine 15 mg per g-tube nightly. Review of the EHR Medical Diagnoses listed a date of 6/19/25 for the following diagnoses:1.Generalized anxiety disorder2.Psychosis3.PTSDOn 6/30/26 at 3:23 PM, Staff C, Social Service, confirmed it was her responsibility to submit PASRR updates. Staff C stated she was recently trained that updates were required upon receipt of a new medical diagnosis or if the document was missing at admission. Staff C confirmed Resident #3's last PASRR was completed prior to admission on [DATE] and acknowledged the resident received a PTSD diagnosis on 6/19/25. Staff C was unable to state if a formal facility policy for submitting PASRR updates existed. On 6/30/26 at 3:32 PM, the Administrator acknowledged that an updated PASRR should've been submitted for Resident #3. The Administrator was unsure if a formal facility policy or procedure existed for submitting updated PASRRs, but acknowledged that a change in mental health condition necessitated the completion of a new PASRR.Review of the undated PASRR Step-by-Step Policy provided by the facility defined the purpose of the policy was to establish a consistent process for completing and coordinating PASRR activities before admission, upon significant change, and during transitions of care for individuals with a known, suspected, newly evident, or possible serious mental disorder, intellectual disability, or related condition.The policy directed when a resident with a known PASRR condition experiences a significant change in physical or mental status, or when any resident develops a newly evident or possible serious mental disorder, intellectual disability, or related condition, the facility must promptly refer the resident to the appropriate state-designated mental health or intellectual disability authority for review according to the state PASRR process.

Based on record review, review of physician orders, staff interview, and facility policy review, the facility failed to include high risk medications on resident care plans for 2 of 4 residents reviewed (Resident #6 and Resident #23). The facility reported a census of 51 residents. Finding include: 1. Resident #6's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderate cognitive impairment. The MDS documented diagnoses of heart failure, osteoporosis, and included a prognosis of life expectancy of less than 6 months. The MDS also indicated the resident took the following high risk drug classes during the last 7 days: anticoagulant and diuretic medications. The Order Summary Report, signed by the physician on 6/18/25 documented the following high risk medication orders with black box warnings: Tramadol (an opioid medication used to treat moderate to moderately severe pain) 50 milligram (mg) by mouth every 12 hours as needed. Furosemide (a diuretic medication) 40 mg by mouth twice daily. Apixaban (a blood thinner) 2.5 mg by mouth twice daily. A Fax from the local hospital, signed by the physician on 4/23/26 documented orders for the following high risk medication order with black box warnings: Abixaban, Furosemide, and Hydrocodone-Acetaminophen (an opioid pain medication). Review of residents #6's Care Plan initiated 6/18/25 lacked documentation use for tramadol (opioid), furosemide (diuretic), and apixaban (blood thinner) use. On 7/1/26 at 12:24 PM, Staff A, Minimum Data Set (MDS) Coordinator acknowledged high risk medications with black box warnings should be included in care plans. 2. Resident #23's Minimum Data Set (MDS) dated [DATE] documented a BIMS score of 15 out of 15, indicating intact cognition. The MDS documented diagnoses of polyneuropathy, restless legs syndrome, and diabetes. The MDS also indicated the resident took the high risk drug class of opioid during the last 7 days. The resident's annual MDS assessment dated [DATE] also revealed the resident had taken an opioid during the last 7 days. The Medication Review Report signed by the physician on 6/1/26 documented orders for Hydrocodone-acetaminophen 5-325 mg (an opioid pain medication) 1 tablet by mouth one time daily and every 6 hours as needed for pain. Review of Resident #23's Care Plan, revised on 10/9/25, did not address the use of an opioid. On 7/1/26 at 12:24 PM, Staff A, Minimum Data Set (MDS) Coordinator acknowledged high risk medications with black box warnings should be included in care plans. The facility policy named Care Plans dated 10/18/2022 revealed, It is the policy of the nursing facility to have individualized care plans for each resident. 1. The nursing facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the Comprehensive Assessment. The care plan will describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Any services that would otherwise be required but are not provided due to the resident's exercise of rights including the right to refuse treatment. 2. A comprehensive care plan must be: Developed within 7 days after the completion of the comprehensive assessment; Prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff and disciplines as determined by the residents needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and Periodically reviewed and revised by a team of qualified persons after each assessment.

Based on clinical record reviews, staff interviews and policy review, the facility failed to ensure interventions were consistently implemented to prevent elopement for 1 of 1 resident reviewed (Resident #36). Resident #36, identified at risk for elopement, failed to have their wander alert device consistently checked to ensure proper function. The facility reported a census of 51 residents.Findings include:Resident #36's MDS assessment dated [DATE] showed the Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severely impaired cognition. The MDS also documented diagnoses of non Alzheimer's dementia, depression and heart failure. The MDS also documented that Resident #36 wandered daily, and the resident's current behavior status, care rejection, or wandering had worsened in comparison to the prior assessment. The Care Plan dated 7/24/24 revealed, in part, Resident #36 was an elopement risk/wanderer related to impaired safety awareness. The care plan intervention dated 7/24/24 revealed Resident #36 wore a wander alert to the left ankle.On 7/2/26 at 10:35 a.m. Staff I, Certified Nursing Assistant (CNA) stated they believed the wander guard checks were to be done daily by the CNAs. Staff I presented the wander guard box that they were to check the wander guards with to ensure they were working properly. Staff I stated then they were supposed to sign off on the monthly sheet that was in the binder at the nurses station daily. Staff I explained there was no designated shift response to check them. Review of the binder with the form for the wander guard checks revealed there was no sheet made for the month of July 2026 and for the month of June 2026 they were signed off three times on June 2nd, 14th and 25th. For the month of May 2026 they were not signed off on the 9th, 10th, 12th, 13th, 16th, 17th, 23rd, 24th, 30th and 31st. The binder failed to have a form for the month of March and April 2026. For the month of February 2026 they were not signed of for 2nd, 3rd, 5th, 9th, 11th, 12th, 13th, 14th, 15th, 18th, 19th, 20th, 21st, 24th, 25th, 26th, 28th, 29th, 30th and 31st. Interview with the Director of Nursing on 7/2/26 at 10:45 a.m. acknowledged that the checks were not getting done correctly. The expectation was that they were completed daily. The DON stated that they were assigning new staff to complete this daily. Review of the facility policy named [Brand Redacted] Transmitter revised 6/8/21 revealed the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. To provide a safe and secure environment for residents while meeting their physical, emotional, and social needs. The [Brand Redacted] Transmitter will be initiated if the resident is at risk for unsafe wandering/potential for elopement. The [Brand Redacted] Transmitter can be placed on the wrist or ankle of a resident. [Brand Redacted] Transmitter placement and function test will be completed daily by ward aides and recorded in the sign off sheet located in the private dining . The [Brand Redacted]Transmitters will be available in the nurse's station, with a sign out sheet to be filled out (resident name, date, reason new/replaced) when a transmitter is taken, to track transmitter usage.

Based on electronic heath record review, policy review, and staff interviews the facility failed to account for a resident's experiences and potential triggers that might cause re-traumatization for 1 of 1 resident diagnosed with Post Traumatic Stress Disorder (PTSD) (Resident #3) . The facility reported a census of 51 residents. Findings include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of 4/23/25. The MDS included a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. The MDS documented Resident #3 had no hallucinations or delusions, and listed diagnoses of anxiety, depression, psychotic disorder, and PTSD.On 6/8/25 at 9:22 PM, a Communication - with Physician note documented resident is showing signs of increased anxiety and reports she is feeling very anxious and restless. She has been having delusional thoughts thinking she in is [City Redacted] at the [Business Name Redacted] drinking alcohol and going to tennis meets. May we have a PRN (as needed) for anxiety?On 6/9/25 at 3:59 PM, a Communication-with Physician note documented resident is having increased confusion, hallucinations. Therapy has also reported that she seems more depressed lately. Wondering if an increase of sertraline would be appropriate or maybe a referral to [Name Redacted] with tele-psych?On 6/10/25 at 10:16 AM, a Communication-with Physician note documented per Advanced Registered Nurse Practitioner (ARNP) resident to see telehealth. On 6/14/25 at 7:01 PM, a Behavior Note documented resident stated to staff, I have a problem, my dead arm here isn't attached to my body. Staff reassured that her arm was in fact still attached. Resident stated, Okay While holding left arm with right arm.On 6/15/25 at 2:47 PM, a Behavior Note documented resident has been restless in bed, excessive call light use for nonsensical things. Interventions .were all unsuccessful. Resident was put in wheelchair and brought to the nurse's station to be supervised. Resident was restless and anxious about going back to room. Then resident utilized her personal cell phone to call 911. [Redacted] county dispatch called facility and talked to this nurse stating, I have received phone call from one of your residents [Resident #3 Name Redacted], she says that she needs help. Explained to dispatch that resident was in wheelchair at nurse's station. Safe and supervised. Assured her that the facility didn't need extra help at this time. Resident was then laid back down in her bed. On 6/15/25 at 5:50 PM, a Behavior Note documented called to residents' room due to residents was playing and pulling at the tube feed, placement was verified with 10cc of water, and resident was asking for beer for her guests that comes and see her, cares and reposition was done, call light within reach.On 6/15/25 at 6:42 PM, a Behavior Note documented resident has her call light on stating that the people who are cooking on the TV are here and that she needs to get up and help with the cooking, resident was directed several times and continues to think she needs to get up and help with the cooking. at this time resident is in bed in low positioned and call light within reach.On 6/19/25 at 5:29 PM, a Physician Rounds note documented seen today via telehealth. New orders received to start Mirtazapine (antidepressant) 15 mg nightly and Lorazepam (benzodiazepine that acts as a central nervous system (CNS) depressant, anxiolytic, and sedative-hypnotic) 0.5 mg every 6 hours as needed. The Progress Notes of the EHR lack documentation of new diagnoses form the telehealth visit.A Nursing Home Audio Visual Visit note dated 6/19/25, revealed the following visit diagnoses: 1.Generalized anxiety disorder2.Psychosis3.PTSDNew orders included the following:1.Lorazepam 0.5 mg per g-tube (gastrostomy tube) every 6 hours as needed.2.Mirtazapine 15 mg per g-tube nightly.The Care Plan for Resident #3, initiated on 4/25/25, did not address her mental health diagnoses, mental health medications, triggers, goals, focus areas, or interventions when the new diagnoses were received on 6/19/25.On 7/2/26 at 8:38 AM, Staff H, [NAME] Aide/Certified Nursing Assistant (CNA)/Cook verbalized Resident #3 did have PTSD. Staff H didn't know what interventions were in place to identify resident triggers. Staff H verbalized she could kind of tell when she was nervous and anxious. Staff H verbalized she talked with the resident and provided comfort care. On 7/2/26 at 8:48 AM, Staff I, CNA acknowledged Resident #3 had PTSD. Staff I revealed interventions included shutting curtains, holding her hand and letting her know she was ok. Staff I revealed Resident #3 didn't like men. On 7/2/26 at 8:54 AM, Staff G, CNA verbalized Resident #3 had anxiety. Staff G didn't know of any interventions in place to identify Resident #3's triggers. Staff G reported staff sat and talked with her. On 7/2/26 at 10:11 AM, Staff D, License Practical Nurse (LPN) acknowledged Resident #3 had a diagnosis of PTSD. Staff D revealed she was not aware of any interventions and wasn't sure what her PTSD was from. Staff D acknowledged no interventions were on the Care Plan for PTSD. Staff D reported no services have been provided specific to the diagnosis of PTSD. On 7/2/26 at 10:16 AM, Staff C, Social Services revealed she had not been trained on completing trauma assessments and didn't know when they were to be completed. Staff C wasn't sure what interventions were in place for Resident #3 related to her PTSD diagnosis. On 7/2/26 at 10:20 AM, the Director of Nursing (DON) acknowledged there were no interventions on the Care Plan for PTSD. The DON reported the only non-pharmaceutical interventions in place were for her anxiety. The DON verbalized trauma assessments were to be completed quarterly and acknowledged they hadn't been completed for Resident #3.Review of the Trauma Informed Care facility policy dated June 2019 directed the following: The facility will ensure that residents who are trauma survivors receive culturally-competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.1.The Social Services designee will assess the resident upon admission, quarterly and with significant changes.2.Resident who are trauma survivors will receive services directed toward their needs and requests.3.Services will be documented in the clinical record and Care Plan.4.Interventions to mitigate triggers will be included in the Care Plan.

Based on observation, electronic health record (EHR) review, facility document review, policy review, and resident and staff interviews, the facility failed to consistently respond to activated call lights within a timely manner for 1 of 17 residents reviewed (Residents #47). The facility reported a census of 51 residents.Findings Include:Resident #47's Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS listed Resident #47 required partial/moderate assistance for toileting hygiene and for toilet transfers. The MDS included diagnoses of urinary tract infection, osteoporosis, hyperlipidemia, and renal insufficiency. The Care Plan Focus initiated 5/29/26 identified Resident #47 had impaired mobility. The Interventions included to ensure the call light was available to the resident and to evaluate the resident's ability to activities of daily living (ADLs) (everyday tasks).The Care Plan Focus initiated on 5/29/26 for Resident #47 revealed, Safety. Interventions directed staff to use safety measures including strategies to reduce the risk of infection, fall, or injury. The Care Plan Focus initiated on 5/30/26 identified a functional performance deficit related to increased weakness from transient ischemic attack (a temporary blockage of blood flow to the brain that produces stroke-like symptoms). Interventions directed staff that Resident #47 required limited assist (one-person physical assist) for ambulation, personal hygiene, toilet use, and transfers. The Care Plan Focus initiated on 6/16/26 identified Resident #47 at risk for falls related to increased weakness and history of falls. Interventions directed staff to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. An Incident Report note on 6/24/26 at 9:21 PM, documented the resident had fallen when family had assisted the resident with transfer. A 24-hour Follow-up to Incident Report note dated 6/25/26 at 9:25 PM recommended an intervention of staff to assist resident when transferring. On 6/29/26 at 3:27 PM, Resident #47 was observed sitting in her recliner with her call light in reach. Resident #47 voiced she activated her call light 3 minutes prior but a gal shut it off stating she couldn't help. Resident #47 stated it took 20 minutes for them to respond. Resident #47 revealed it occurred often that the call light was shut off without assistance being provided. Staff F, Call Light Monitor acknowledged she did shut the call light off and was unable to assist the resident to the bathroom. Review of the Excess Response Alarms reports revealed the following for Resident #47:6/21/26 9:26 AM Emergency call cord pressed and cleared at 9:43 AM-response time 17.3 minutes6/23/26 9:47 AM Emergency call cord pressed and cleared at 10:20 AM-response time 33.2 minutes6/27/26 6:28 PM Emergency call cord pressed and cleared at 6:48-response time 20.5 minutes6/27/26 7:53 PM Emergency call cord pressed and cleared at 8:10 PM-response time 16.7 minutes6/28/26 6:30 AM Emergency call cord pressed and cleared at 6:53 AM-response time 23.2 minutes6/28/26 7:59 AM Emergency call cord pressed and cleared at 8:29 AM-response time 29.8 minutes6/29/26 10:26 AM Emergency call cord pressed and cleared at 10:50 AM-response time 43.7 minutes6/29/26 11:23 AM Emergency call cord pressed and cleared at 12:21 PM-response time 57.3 minutesOn 7/2/26 at 8:54 AM, Staff G, Certified Nursing Assistant (CNA) verbalized staff were alerted to activated call light thru the [Brand Name Redacted] server (an end-to-end wireless nurse call and emergency alert system). Staff G reported an appropriate response time for an activated call light was between 1-15 minutes. Staff G acknowledged resident have waited longer than 15 minutes for assistance. Staff G verbalized there wasn't enough staff to respond to call lights. On 7/2/26 at 10:16 AM, Staff D, Licensed Practical Nurse (LPN) reported an appropriate response time to an activated call light was under 15 minutes. Staff D verbalized call lights have exceeded 15 minutes at times. On 7/2/26 at 10:20 AM, the Director of Nursing (DON) verbalized staff were to respond within 15 minutes of an activated call light. The DON acknowledged call lights have exceeded 15 minutes. The DON revealed the Call Light Monitors were to respond to the call lights and if there was something they cannot do, they were to shut the call light off and turn it back on and alert a CNA. Review of the Call Light facility policy dated 7/20/25, identified an objective that all staff will respond to an engaged call light to rule out emergency situations. The policy directs the following: 1.All Staff will respond to a call light in the on position to rule out an emergency situation.2.Non-Licensed Non-Certified personnel will be able to take care of tasks that would not require the services of a Certified or a Licensed employee. This may include giving the Resident Kleenex, turning off /on TV, etc.3.Resident needs transferred from bed to chair, taken to the bathroom, dressed, etc. will be addressed by Nursing Staff in a timely manner.

Based on electronic health record (EHR) review, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual review, and staff interviews revealed the facility failed to submit 2 completed Minimum Data Set (MDS) assessments for 1 of 5 residents reviewed. The facility reported a census of 43 residents. Findings include: A review of the EHR MDS detail listing for Resident #197 revealed the following: 5/23/2025 - Quarterly - None PPS / M D S 3.0 - In Progress 2/25/2025 - Admission - None PPS / M D S 3.0 - Completed 2/18/2025 - Entry / M D S 3.0 - Completed A review of all completed but not accepted MDS's for Resident #197 documented the unit is neither Medicare nor Medicaid certified and MDS data is not required by the state. The submission information for all completed but not accepted MDS's for Resident #197 documented do not submit to the Centers for Medicare and Medicaid Services (CMS). During an interview on 5/14/25 at 1:19 PM, Staff A, Business Office Manager revealed the facility is dually certified for all beds with CMS. During an interview on 5/14/25 at 2:46 PM, the Director of Nursing (DON) revealed the facility follows the RAI manual for completing and submission of the MDS assessments. The DON revealed the facility had utilized a third party for completion of the MDS assessments in the interim of hiring for the MDS Coordinator position. The DON acknowledged the entry and admission MDS had not been submitted to CMS as required. A review of the Long-Term Care Facility RAI 3.0 user's manual Version 1.19.1, October 2024 revealed nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set (MDS) records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source. Skilled nursing facilities (SNFs) and non-critical access hospitals (non-CAH) with a swing bed agreement (swing beds) are required to transmit additional MDS assessments for all Medicare beneficiaries in a Part A stay reimbursable under the SNF Perspective Payment System (PPS). All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES). Required MDS records are those assessments and tracking records that are mandated under OBRA and SNF (PPS). Assessments that are completed for purposes other than OBRA or SNF PPS reasons are not to be submitted to iQIES, examples include, but are not limited to, private insurance and Medicare Advantage Plans (i.e., Medicare Part C). After completion of the required assessment and/or tracking records, each provider must create electronic transmission files that meet the requirements detailed in the current MDS 3.0 Data Submission Specifications available on the CMS MDS 3.0 website at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation.html. The provider indicates the certification or licensure of the unit on which the resident resides in item A0410, Unit Certification or Licensure Designation. In addition to reflecting certification or licensure of the unit, this item indicates the submission authority for a record. o Value = 1 Unit is neither Medicare nor Medicaid certified and MDS data is not required by CMS or the State. o Value = 2 Unit is neither Medicare nor Medicaid certified but MDS data is required by the State. o Value = 3 Unit is Medicare and/or Medicaid certified.

Based on record review, staff and medical provider interviews, and policy review the facility failed to implement root cause analysis interventions for previous falls resulting in a fall with fracture, and to thoroughly assess a resident for possible injury after a fall for 1 of 3 residents reviewed for falls (Resident #1). The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 4 indicating severe cognitive impairment. The MDS documented she was dependent on staff for eating, toileting, transferring, and does not walk. The MDS also informed she had diagnoses of compression fracture of the third (3rd) lumbar vertebra (spine in the lower back), anxiety, and depression. Record review of a Progress Note dated 2/12/2025 at 1:59 PM for Resident #1 documented she had an unwitnessed fall in her room at 1:53 PM and was found sitting in her doorway with her back against the door frame facing into the room and during active range of motion she admitted to having some pain to her left leg and was not able to bear weight to her left leg or able to bend at the hip past 90 degrees, and may have a possible fracture to the left hip/leg. Record review of a Progress Note dated 2/12/2025 at 2:10 PM for Resident #1 documented she had an unplanned/emergent discharge at this time as her medical status was unstable and left the facility by ambulance. Record review of Resident #1 Care Plan on 2/25/25 documented the following falls and interventions implemented since her admission to the facility: a. Fall 12/24/24, high low bed, date initiated: 1/1/25 b. Fall 12/26/24, high low bed, date initiated: 1/1/25 c. Fall 1/2/25, education to Certified Nurse Aide (CNA) who left Resident #1 bed in high position that it need to be in lowest position, date initiated: 1/8/25 d. Fall 1/31/25, do not leave out of sight in retreat room, date initiated: 2/14/25 e. Fall 2/10/25, offer toileting on walking rounds, date initiated: 2/10/25 f. Fall 2/12/25, motion sensor in room and/or personal alarm attached when in bed, wheelchair, recliner, date initiated: 2/12/25 Record review of an untitled statement by Staff I, Certified Medication Aide (CMA) dated 2/14/25, documented she found Resident #1 on the floor in her doorway on 2/12/25 and heard and saw Resident #1 yelling my hip, my hip while on the floor then when she came back she saw her sitting in her wheelchair. Record review of a Discharge Summary dated 2/17/25 from a local hospital for Resident #1 documented she was diagnosed with a left hip closed fracture on 2/12/25. During an interview on 2/27/25 at 11:45 AM the Administrator revealed she spoke with Resident #1 after her fall on 2/12/25 and she could not remember if her hip hurt before or after the staff got her up off of the floor, she also informed she would expect staff not to move a resident if complaining of hip pain. During an interview on 2/27/25 at 11:40 PM the Director of Nursing (DON) reveled Resident #1, prior to her fall on 2/12/24, was not able to walk with facility staff, but was able to transfer with one (1) staff member by pivoting to desired locations. She then informed she educated Staff E immediately after Resident #1 fell and informed her residents are not to be moved from the floor if they are complaining of pain or other signs of possible broken bones and to immediately call the ambulance. She then informed the facility is looking at every residents prior falls and current Care Plans to ensure interventions implemented were appropriate and still relevant to meet the residents needs. During an interview with Staff E, Registered Nurse (RN) on 2/27/25 at 12:58 PM revealed she was the nurse that assisted Resident #1 with her fall on 2/12/25 and informed she found her in the doorway of her room on the floor, informed Resident #1 said she was embarrassed and forgot to call for help. Staff E then informed when staff assisted her to stand with three other staff Resident #1 had pain when standing. During an interview on 3/4/25 at 10:05 AM with Resident #1's Primary Care Provider, Staff H, Advanced Registered Nurse Practitioner (ARNP) informed Resident #1 has memory issues at times and at others can be spot on. She informed when Resident #1 fell on [DATE] she would expect staff not to move her especially if there were signs of rotation of the hip joint or shortening of the legs and wait for the ambulance to transfer her safely. She informed she also saw Resident #1 today at the facility and she is doing well and making progress in therapy and rarely complains of pain. Record review of Falls Incident/Accident Prevention dated June 2024 lacked documentation the facility will implement root cause analysis related to each fall.

Based on record review, staff and family interviews, and policy review the facility failed to make prompt efforts to resolve and investigate a complaint/grievance and actively work toward resolution for 1 of 1 complaint letters reviewed (Resident #2). The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #2 document a Brief Interview for Mental Status (BIMS) of 11 indicating she was moderately cognitively impaired. The MDS also documented she needed supervision or touching assistance with transfers, toileting, and walking. The MDS informed she had diagnoses of diabetes mellitus, heart failure, depression, anxiety, and a prognosis with a life expectancy of less than six (6) months to live. Record review of a letter to the facility dated 1/7/25 from Family Member #1 for Resident #2 informed the facility of the following concerns identified with the care of their loved one: a. Delay in receiving pain medication for Resident #2 when actively dying on 12/22/2024 b. Incompetent nursing knowledge of state regulations regarding Staff C, Licensed Practical Nurse (LPN) c. Lack of sufficient staff in the building on 12/22/24 d. Lack of Hospice and facility integrated nursing care on 12/22/24 Record review of a untitled document from the Administrator dated 1/10/25 documented an investigation completed into Staff C interactions with Resident #2 Family Members and Staff C. Record review of a statement email from Staff C, Licensed Practical Nurse (LPN) dated 2/25/25 documented interactions had with Resident #2 family on 2/22/25. Record review of a statement email from Staff B, Registered Nurse (RN) dated 2/26/25 documented interactions had with Resident #2 family on 2/22/25. During an interview with the Administrator on 2/27/25 at 11:45 AM revealed she received a letter dated 1/7/25 by mail from Family Member #1 for Resident #2 regarding care received at the facility on 12/22/2024 and revealed when she read the letter she could not believe the family was upset with the care provided to Resident #2. She informed she spoke with them on 12/23/24 and they were complimentary of the care received at the facility. She revealed Family Member #1 called her roughly three (3) weeks after receiving the letter and questioned what she was able to find out, she revealed she informed her she was not able to disclose specific actions and was taking care of any issues that she found. She then revealed Family Member #1 became upset and asked, Am I just supposed to believe you?. She then informed she never provided Family Member #1 with a formal response to her concerns from her letter dated 1/7/25 about the following key areas of concern for Resident #2. a. Delay in receiving pain medication for Resident #2 when actively dying on 12/22/2024 b. Incompetent nursing knowledge of state regulations regarding Staff C, Licensed Practical Nurse (LPN) c. Lack of sufficient staff in the building on 12/22/24 d. Lack of Hospice and facility integrated nursing care on 12/22/24 Review of the facilities Grievance Policy last revised 12/2/2022 instructed the following: a. The grievance official will be responsible for overseeing the process, receiving, and tracking all grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary considering specific allegations. b. The grievance official will notify the individual who filed the grievance that it has been received and explain the process of the investigation if it was completed verbally or in writing. The investigation will be informal but thorough, affording all interested persons and their representatives an opportunity to submit evidence relevant to the grievance. c. The grievance official will issue a written decision determining the validity of the grievance no later than 30 days after its filing. d. The grievance official will take appropriate corrective action in accordance with the Iowa law if the alleged violation of the resident's rights is confirmed by the facility or if an outside entity having jurisdiction, such as the state survey agency, quality improvement organization, or local law enforcement agency confirms a violation of any of these resident's rights within its area of responsibility.

Based on record review, staff and family interviews, and policy review the facility failed to promptly implement a new order for 1 of 3 residents reviewed for pain (Resident #2). The order given was to increase the dosage of as needed (PRN) Morphine (narcotic liquid pain medication) for an actively dying resident. The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #2 document a Brief Interview for Mental Status (BIMS) of 11 indicating she was moderately cognitively impaired. The MDS also documented she needed supervision or touching assistance with transfers, toileting, and walking. The MDS informed she had diagnoses of diabetes mellitus, heart failure, depression, anxiety, and a prognosis with a life expectancy of less than six (6) months to live. Record review of Resident #2 Controlled Drug Record for her morphine dated 12/21/24 documented the last dose of morphine at 0.25 mL was given on 12/22/24 at 1:30 PM. Record review of a document titled, Fax Transmittal from Resident #2 Hospice provider dated 12/21/24 at 1:52 PM revealed a signed order to increase her morphine order at this time to give 0.5 mL every hour as needed. Record review of Resident #2 Controlled Drug Record for her morphine dated 12/21/24 documented the first dose of morphine at 0.5 mL was given on 12/22/24 at 4:45 PM. During an interview on 2/25/2025 at 9:23 AM with Family Member #1 for Resident #2 revealed on 12/22/24 Staff C, Licensed Practical Nurse (LPN) delayed giving Resident #2 pain medication for almost two hours and by then it was two hours too late. She saw her mom in pain and having difficulty getting air. Staff C finally checked the fax machine and saw the order and said maybe she should have checked it earlier. She then informed a family member would have to go and get Staff C to make sure Resident #2 would get pain medication, the facility never would come and check on her by themselves, it was like a skeleton crew working and she ended up passing away that night. During an interview on 2/25/25 at 5:30 PM with Family Member #3 for Resident #2 revealed on 12/22/24 she could tell sometimes that there was distress or discomfort from Resident #2 and the staff would give her pain medication and then it would be better. During an interview on 2/25/25 at 4:26 PM with Hospice Nurse #1, Register Nurse (RN) Clinical Manager revealed a delay in increasing the pain medication for several hours could cause the resident to be in distress depending on if she is having pain or air hunger and could make the resident be uncomfortable. During an interview on 2/27/25 at 11:45 AM the Administrator revealed she would expect orders be implemented as soon as they come in and not be delayed. During an interview on 2/27/25 at 11:40 AM the DON revealed she would have expected Resident #2's order to increase pain medication be implemented immediately when it came in. During an interview with Resident #2 Primary Doctor on 3/4/25 at 3:33 PM revealed he would expect an as needed pain medication be given timely if signs of pain or air hunger were being shown.

Based on record review, staff, family, and provider interviews, and policy review the facility failed to obtain an order to increase an as need (PRN) morphine (liquid pain medication) order for 1 of 3 residents reviewed who was actively dying (Resident #2). The facility also failed to obtain orders prior to suctioning a resident during end of life cares for 1 of 1 residents (Resident #2). The facility reported a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #2 document a Brief Interview for Mental Status (BIMS) of 11 indicating she was moderately cognitively impaired. The MDS also documented she needed supervision or touching assistance with transfers, toileting, and walking. The MDS informed she had diagnoses of diabetes mellitus, heart failure, depression, anxiety, and a prognosis with a life expectancy of less than six (6) months to live. Record review of Resident #2 discontinued, current, and completed morphine orders in her Electronic Health Record (EHR) on 2/25/25 at 12:15 PM revealed a new order for morphine 1 mL was received on 12/22/24 at 20:45 PM. Record review of Resident #2 Progress Notes on 2/27/2025 at 3:45 PM lacked documentation of the Doctor who prescribed the increased morphine order from 0.5 mL to 1 mL on 12/22/24 and revealed it was ordered by a Hospice Nurse. During an interview on 2/25/25 at 4:26 PM with Hospice Nurse #1, Registered Nurse (RN) Clinical Manager revealed the Hospice provider only gave orders for Resident #2 pain medication to be increased on 12/22/24 from 0.25 mL to 0.5 mL and does not have record of them increasing it to 1 mL. She then informed she spoke with the Director of Nursing (DON) at the facility today and they are unable to find documentation as well. During an interview on 2/27/25 at 11:45 AM the Administrator revealed she would expect to be able to locate a signed order for the increased dose of morphine to 1 mL for Resident #2 on 12/22/2024. During an interview on 2/27/25 at 11:40 AM the DON revealed if a new order is obtained from a Doctor regardless of what it is she would expect a paper trail like a telephone order or fax to show the Doctor signed and approved the order. During an interview with Resident #2 Primary Doctor on 3/4/25 at 3:33 PM revealed he does not have record of ordering Resident #2 morphine medication from 0.5 mL to 1 mL however if signs at the time of being given revealed her pain was not under control it would have been reasonable to prescribe 1 mL to keep her comfortable. 2. During an interview on 2/25/2025 at 9:23 AM with Family Member #1 for Resident #2 revealed Staff C, Licensed Practical Nurse (LPN) suctioned Resident #2 on 12/22/2024 and informed the family she probably made their mother very mad. During an interview on 2/25/25 at 5:30 PM with Family Member #3 for Resident #2 revealed on 12/22/24 she could tell sometimes that there was distress or discomfort from Resident #2 and the staff would give her pain medication and then it would be better. During an interview on 2/25/25 at 4:26 PM with Hospice Nurse #1, Registered Nurse (RN), Clinical Manger revealed suctioning is something we do not encourage our nurses to do as a Resident can become extremely agitated. We try to avoid that at the end of life. The secretions are not just in their mouth, they are deep down lower in their lungs, and you are unable to get to them with suctioning. During an interview on 2/27/25 at 11:40 PM the Director of Nursing (DON) revealed she does not think Resident #2 had an order for suctioning, and Staff C suctioned Resident #2 on 12/22/24 because her family was asking for them to suction her and she tried to make the family comfortable.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to provide services that met professional standards regarding following physician orders with insulin administration for 1 of 5 residents reviewed for medication administration (Resident #16). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #16 revealed the resident had a Brief Interview for Mental Status (BIMS) of 10 indicating moderately impaired cognition. The MDS further revealed the resident had a diagnosis of diabetes mellitus (DM) and had received insulin 7 out of the past 7 days. Review of physician orders for Resident #16 revealed an order for blood glucose four times a day related to diabetes mellitus. Physician orders further revealed an order for Humalog (insulin) 30 units subcutaneously (SQ) one time a day to be given at 7:30 AM and to hold the insulin if blood sugar is less than 120 with a start date of 3/14/24. During an observation 6/19/24 at 7:22 AM observed Staff B, Registered Nurse (RN) completed an accu-check on Resident #16 and obtained a reading of 102. During an observation 6/19/24 at 7:38 AM observed Staff B, RN administer 30 units of Humalog SQ to Resident #16. Clinical record review during reconciliation of medications revealed Humalog 30 units was to be held if Resident #16's blood sugar was less than 120. Review of facility policy titled, Administering Medications Policy, revised March 2023 revealed medications must be administered in accordance with the orders. During an interview 6/20/24 at 8:25 AM the Administrator revealed it is an expectation staff follow physician orders.

Based on personnel record review, staff interview, and policy review, the facility failed to ensure mandatory Dependent Adult Abuse training had been completed within 6 months of employment for 1 of 5 staff reviewed (Staff A). The facility reported a census of 45 residents. Findings include: Personnel record review for Staff A, Certified Nursing Aide (CNA) revealed a hire date of [DATE]. The personnel record revealed Staff A had previously completed Dependent Adult Abuse training [DATE] and it expired [DATE]. Staff A did not complete the mandatory training again until [DATE]. Review of facility policy titled, Abuse Prevention Policy, revised ,d+[DATE] revealed employees will receive training as required by state and federal regulations. Employees and staff members, who are mandatory reporters of dependent adult abuse,shall be required to receive two hours of training related to the identification and reporting of dependent adult abuse within six months of hire, as a part of orientation training, and every three years thereafter. During an interview [DATE] at 11:18 AM, the Administrator acknowledged Staff A should have completed mandatory Dependent Adult Abuse training within 6 months of employment after her previous training expired [DATE].

Based on facility record review, staff interview, and policy review the facility failed to have the minimum required members present at their quarterly Quality Assurance (QA) meetings as directed by Centers for Medicare and Medicaid Services (CMS). The facility reported a census of 45 residents. Findings include: QA meetings were conducted on the following dates: 4/11/23, 7/25/23, 10/10/23, 2/12/24, and 4/8/24. Review of the attendance sheets for the QA meetings revealed the required members attended the meetings on 7/25/23, 10/10/23, and 2/12/24. The attendance sheet for the QA meeting held on 4/11/23 revealed the Director of Nursing (DON) was not in attendance and the attendance sheet for the QA meeting held on 4/8/24 revealed the Infection Preventionist (IP) was not in attendance. In an interview on 6/18/24 at 1:55 PM, the Administrator stated she was not aware who was required to attend the QA meetings. She believed the required attendees were the Administrator, Medical Director and 5 other staff and was not aware the DON and IP were required to be in attendance at the meetings as well. She further stated it was the expectation the required staff be in attendance at the quarterly QA meetings per CMS guidelines. Per the facility provided Quality Assurance Performance Improvement (QAPI) Plan established 10/2013 and last updated on 1/24/22, the QAPI committee meetings were to be held at least quarterly and the QAPI committee members were to include at least the following: Medical Director, Administrator, DON, and direct care worker/caregiver.

Based on clinical record review, policy and procedure review, and staff interviews the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 5 resident reviewed. (Resident #1). The facility identified a census of 47 residents. Findings include: The Minimum Data Set (MDS) for Resident #1, with an assessment reference dated 3/5/24, documented diagnoses which included hypertension, Non-Alzheimer's Dementia, anxiety, and repeated falls. The MDS revealed the resident with a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired decision making abilities, has hallucinations and delusion, and required partial/moderate assistance with shower/bathing. The Plan of Care with an initiated date of 2/27/24, stated the resident had a functional performance self-care deficit related to dementia. Interventions include: Bathing/Showering: Resident is able to have a bath or shower. Bath days per Care Plan. Shower transfer EZ stand times 2 assist. Transfer/Ambulation: is contact guard assist of 1 with walker The Progress Notes dated 4/30/24 at 11:38 a.m., Incident Report: Describe Incident: Staff A, Certified Nursing Assistant (CNA), called this nurses office and asked if Staff B, CNA, came back into the building. Staff A reports that Staff B was to be giving resident a bath in the south tub room. The facility Administrator, immediately went to the tub room to check. The curtain had been pulled so resident wasn't seen until the Administrator pulled back the curtain, and found the resident sitting in her wheelchair in the tub room, without a call light. The Administrator then brought resident out of the tub room and notified floor staff that she had not gotten her bath. Vitals: not done, ROM and Pain: not done, Injuries noted: no injuries as resident was still sitting in her wheelchair. Treatment Provided: CNA's took resident and went to give her a shower. Interventions in place at time of Incident: Resident is to have a call light within reach when left unattended. Interview on 5/29/24, at 12:00 p.m., the facility Administrator and Staff C, Registered Nurse (RN) stated that they seen Staff B, CNA, on the video ring door bell leaving the facility at 8:50 a.m. The administrator stated that over the walkie talkie it was told that Resident #1 was not in the dining room for breakfast and if anyone had seen her. The administrator and Staff A started to look for Resident #1. Resident #1 was found in the shower room, with the lights off, shower curtain pulled around the resident, no call light with in reach, sitting in her wheelchair. Interview on 5/29/24 at 2:00 p.m., Staff D, CNA, stated that around 9:00 a.m. the kitchen staff were asking if anyone had seen Resident #1. Staff D stated that they started to ask if anyone had seen Resident #1 over the walkie talkie with no response from staff. Staff D stated that around 9:10 a.m., a voice came across the walkie talkie that Resident #1 was found in the shower room. Interview on 5/30/24 at 9:00 a.m., the facility Administrator confirmed and verified that the expectation of the staff are to treat all residents with dignity and respect. The Resident Rights policy with no date, given by the Administrator on 5/30/24 at 10:20 a.m., documented, the resident has a right to a dignified existence, self-determination, communication with and access to persons and services inside and outside the facility. The resident has a right to be treated with respect and dignity and to be cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing the resident individuality.

Based on record review, facility policy and procedure, and staff interviews, the facility failed to follow physicians orders for 2 of 4 residents reviewed for medication administration. (Resident #3 and Resident #4). The facility reported a census of 47 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 for which indicated no cognitive impairments. The MDS indicated the resident had diagnoses which included hypertension, seizure disorder, and cyst of pancreas. The MDS also revealed the resident received a diuretic and an antiplatelet in the last 7 days. Resident #3 Care Plan initiated on 4/12/22 indicated the resident will be prescribed the minimum amount of medications necessary. The interventions with an initiate date of 10/5/22 directed staff to consult pharmacist to review medications, Resident prefers not to be woke up for medications between 10:00 p.m.- 6:00 a.m. and prefers to take medications in her room to promote socialization when going to dining room for meals. Review of the Nurse Progress Notes dated 5/2/24 at 11:18 a.m., revealed Incident Report-Medication Event: This nurse noticed that this nurse gave resident the wrong medications this morning. Immediately this nurse notified the Director of Nursing (DON). Resident received the following medications: Metolazone 2.5 milligrams (mg) Carvedilol 6.25 mg Depakote 100 mg Eliquis 5 mg Januvia 25 mg Lisinopril 2.5 mg Metformin 100 mcg Protonix 20 mg Torsemide 20 mg Vitamin D3 2000 IU Resident was supposed to receive Calcium 120 mg Plavix 75 mg Depakote 500 mg Colace 100 mg Lasix 40 mg Gabapentin 100 mg Levetiracetam 500 mg Synthroid 75 mcg Lisinopril 30 mg Tylenol 500 mg Vital Signs will be taken every 1 hour for 24 hours. Blood sugars will be checked every 4 hours. A Root Cause Analysis Report dated 5/2/24, described that the event happened where two residents medications where set up at the same time to get medications done in a more timely manner and that staff felt the need to complete medication pass quickly and Resident #3 received the wrong medications. 2. The MDS dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairments. The MDS indicated the resident had diagnoses which included hypertension, seizure disorder, and cyst of pancreas. The MDS also revealed the resident received a diuretic and an antiplatelet in the last 7 days. Resident #4 Care Plan initiated on 6/30/21 indicated resident will be prescribed the minimum amount of medications necessary. The interventions with an initiate date of 8/24/21 directed staff to consult pharmacist to review medications, Resident will be administered medications in her room/hallway/common areas to promote socialization during meals. Resident would prefer not to be woken up between 10:00 p.m., - 6:00 a.m. for medication administration. (per interview). Review of the Progress Notes dated 5/17/24 at 9:37 a.m., documented, Incident Report-Medication event: On 5/10/24, resident had a critically low Potassium, new orders were received from the Doctor to give additional 40 meq for 3 days. The new cards were found in the bottom drawer of the medication cart with no doses popped out. When reviewing the emergency kit, it was noted that 1 dose was taken from the kit. It appears that resident didn't get 2 of the doses. The Potassium was 3.6 on redraw on 5/15/24. A Root Cause Analysis Report dated 5/15/24, described the event happened when medication cards were put in the bottom of the medication cart. The person working the medication cart was busy when the medications arrived and medication doses weren't checked when given, and didn't verify dose, so the resident missed 2 doses of potassium. Interview on 5/30/24 at 10:40 a.m., the facility Administrator confirmed and verified that the expectation of the staff are to follow the physicians orders as written and to follow the policy for giving oral medications. The Policy/Procedure for giving Oral Medication Administration with no date, documented the purpose: to provide a medication regiment safely and effectively, and to administer medications in a simple routine for the resident. *Seven Rights= right dose, right time, right route, right medication, right resident, right reason, right documentation.

Based on observation, record review, and staff interviews the facility failed to follow a physician order resulting in an emergency room visit for 1 out of 3 residents reviewed for medication administration (Resident #2). The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #2 had a BIMS score of 10 which indicates moderate impairment of cognitive status. The MDS indicated she had hallucinations and verbal aggression directed toward others. The MDS revealed Resident #2 has diagnoses of Anxiety and Depression. On 4/24/24 at 8:49 AM observed Resident #2 sitting in her wheelchair in her room. She responded to the nurse knocking on her door and refused her medications. She wanted them left in the room but the nurse explained she needed to watch her take them. The Director of Nursing came and talked to resident and convinced her to take the medications. Resident #2 Care Plan initiated on 9/20/22 indicated behavior problem (yelling/screaming, swearing, sad/tearful/crying, repetitive movement, repetitive questions, rejection of care, abusive language, agitation, anxious/restless, accusing others, physical aggression, hitting staff) due to not trusting staff or the way staff approach her. The interventions with a revision date of 9/8/23 directed staff to administer medications as ordered. Monitor/document for side effects and effectiveness. Review of the Nurse Progress Note dated 2/15/24 at 2:47 PM revealed anxious behaviors and the nurse contacted Resident #2 nurse practitioner. Noted it appears resident is having a panic/anxiety attack. A one time order for Lorazepam (medication to reduce anxiety) 1 milligram(mg) was given per the nurse practitioner. The Nurse Progress Note dated 2/15/24 at 3:15 PM revealed the one time dose of Lorazepam was administered. The Nurse Progress Note on 2/15/24 at 5:48 PM revealed nurse was called to room due to Resident #2 lowered to the floor. No injuries noted at this time. Vital signs: Blood pressure (BP) 70/43, Pulse (P) 120, Respirations (R) 20, Temperature (T) 97.5 degrees, Oxygen saturation (O2 sat) was 89 percent on room air. Resident assisted to her wheelchair and recheck of her vitals BP 106/62, P 103, R 18 and O2 sat 96% on room air. The Nurse Progress Note on 2/15/24 11:52 PM revealed the nurse called to Resident #2's room due to she was again lowered to the floor. During the assessment she was lethargic, unable to help stand. BP 70/43, P 120, R 20, T 97.5, O2 sat 89% on room air, recheck of the vitals after settled in her wheelchair revealed BP 106/62, P 103, R 18, O2 sat 96% on room air. No injuries noted. The Nurse Progress Note on 2/16/24 at 12:57 AM revealed a condition report was called to the physician on-call and an order was obtained to send Resident #2 to the emergency department. The Emergency Department Provider Note from 2/16/24 at 2:16 AM revealed at 5:48 PM on 2/15/24 her oxygen saturation was 89% on room air and 96% on room air soon thereafter. At 12:10 AM on 2/16/24, her oxygen saturation was 94% on room air. But at around 1:30 AM nursing home staff contacted the physician on call in the emergency department to inform us of hypoxemia again noted in the patient with an O2 sat of 79%. She was placed on low-flow supplemental oxygen, and emergency services notified. Responding medics placed her on 10 Liters non-rebreather mask at the time of transport. According to the review of her nursing home notes, the patient had been increasingly confused and somewhat combative/resistive with staff over at least the preceding day. She is normally well-oriented per staff. However she is now rather confused. According to her review of the notes, she did not know the year and did not know her son's name. This is not typical for her. In addition the patient was accidentally given Seroquel (antipsychotic medication) 12.5 mg earlier in the evening. This is not a medication that is prescribed to the patient. Resident #2 presented to the emergency department in acute hypoxemic respiratory failure with a significant oxygen requirement, requiring 10 Liters (L) by non-rebreather mask, She was acutely confused, possibility due to acute hypoxia. In the hours leading up to her decline and subsequent ER transfer, the patient had been given a benzodiazepine (Lorazepam) ordered by her primary care physician in addition to later being given a dose of Seroquel accidentally by nursing home staff. Chest imaging with plain radiographs and CT demonstrated no evidence of heart failure or pulmonary infectious process which would otherwise explain her hypoxemia. COVID-19, influenza and RSV testing was negative. Evaluation of concern for pulmonary embolism was within normal limits. Final diagnosis acute hypoxemic respiratory failure requires continuous at home supplemental oxygen. Medication administered in error, accidental or unintentional, bilateral lower leg cellulitis. A follow up visit Progress Note dated 2/19/24 from Resident #2 primary care nurse practitioner revealed follow up after ER visit last. Resident is not wearing oxygen, says she does not want to. Resident #2 O2 sat 95% on room air. Resident cognitively intact. Review of the Electronic Medication Administration Record (EMAR) for February 2024 revealed no order for Seroquel for Resident #2. On 4/24/24 8:54 AM the Director of Nursing(DON) stated Staff B, Certified Medication Aide (CMA) was terminated for giving someone a medication there was no prescription for. He admitted to doing it. No other problems with him prior to this incident. It was Resident #2 and she was having other health issues at the same time. She went to the emergency room for shortness of breath and she ended up having cellulitis of the leg. They do track medication errors in the risk management. On 4/25/24 at 8:35 AM Staff A, Registered Nurse (RN) reported on 2/15/24 Staff B, Certified Medication Aide (CMA) made a statement to her about doing something but probably not something he should tell her. He told her he gave another residents Seroquel (antipsychotic medication) to Resident #2. She stated it was about 5:30 PM when he told her and her shift ended at 6:00 PM so she passed it onto the oncoming nurse. On 4/25/24 at 9:46 AM with Staff B, CMA stated Resident #2 had behaviors on 2/15/24 and I went to the nurse in charge and asked if I could give her a Seroquel and she said she sure could use it so I interpreted it as to go ahead and give it. I gave her the Seroquel from another residents medications. He stated before administering a medication you should follow the 7 rights of medication administration and ensure you have the right person, right dose, right route, right medication, right time, right reason and right documentation, needs to be followed. He acknowledged you should never give a medication without a physician order and Resident #2 did not have a physician order on the EMAR for Seroquel. On 4/25/24 at 10:34 AM the Assistant Director of Nursing (ADON) stated on 2/15/24 Resident #2 appeared anxious and agitated, more than usual. A nurse got a one time order and administered Lorazepam (antianxiety medication) around 3 PM. Staff B, CMA came to my office and stated Resident #2 was out of control and needed to be sent out. I informed him she just had a dose of Lorazepam. Around 5:00 PM I was leaving for the day and stopped Staff B to ask how Resident #2 was doing and he stated not great. I visually saw her sleeping and Staff B did not say anything about giving her any medications. Sometime later in the evening the nurse made him call and he told me he did something he should not have and gave Resident #2 someone else medication. The facility provided a policy titled Oral Medication Administration with no date, the purpose is to provide a medication regimen safely and effectively. The procedure directed staff to: 1.) Open the MAR in computer, locate resident, review medications 2.) Obtain any vitals needed for medication monitoring 3.) Perform hand hygiene 4.) Locate residents bubble packs and take them out of the cart 5.) Complete 5 rights of medication administration before popping out medications into the med cup. (do not touch the medications) Review of Documentation of Verbal Warning dated 4/11/24 revealed Staff C, Licensed Practical Nurse (LPN) reported she had changed a residents medication order without obtaining an order first. You must get a doctors order to change the dosage of a medication before adjusting it. No longer tweak medications without obtaining an order first. During an interview on 4/25/24 at 8:54 AM the Director of Nursing stated the verbal warning for Staff C, LPN resulted from her entering Hospice orders for medication before the signed order from the physician was returned. For example when the Hospice nurse is here and we discuss medication changes and then she entered the order before the physician had signed the order. This only occurred one time I am aware of and I told her we can not do it. My expectations for administering medications is they follow the EMAR and they follow the rights of medication administration. Staff should not administer medication without a physician order. On 4/25/24 at 9:07 AM Staff D, Hospice Nurse, stated we collaborate with the facility nurse on appropriate medications and dosages and then contact the physician. The physician needs to agree to the recommendation for it to become an order. On 4/25/24 at 11:05 AM Staff C, LPN stated she did receive a verbal warning about when Hospice comes and they talk about different medications or dosages and then the physician will typically give us the order. I have put the order in the computer before the signed orders come back. The DON educated me to make sure the orders are the same and in case the physician would make a change in the order and also to make sure no mistakes were made writing the order. The facility provided an undated policy titled Receiving Physician Orders which stated Licensed nursing staff may take orders from a physician's office nurse for the attending physician. It is a legal procedure for a nurse to take a phone order from a physician's office nurse per Board of Nursing. The policy failed to address procedure for entering physicians orders into the computer for the medication administration record.

Based on clinical record review, Center for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) manual, and staff interview the facility failed to transmit a Minimum Data Set (MDS) discharge assessment record for 1 of 1 resident (Resident #12) reviewed. The facility identified a census of 51 residents. Findings include: An Electronic Health Record (EHR) Census Record Showed Resident #12 went to the hospital on paid leave on 7/26/22. A review of the EHR revealed MDS assessment records on 2/21/23 at 11:45 a.m. for Resident #12 had completed a 7/26/23 Discharge Return Not Anticipated Record in the EHR that had not been batched for submission to the CMS Quality Improvement and Evaluation System (QIES) Assessment and Submission and Processing (ASAP) system. The Discharge Return Not Anticipated Record had a completion date of 7/26/23 by the MDS Coordinator. During an interview on 2/22/23 at 1:27 p.m. the MDS Coordinator reported she tries to submit MDS records to the federal data base (QIES ASAP) system weekly. She reported Resident #12 had been on private pay skilled care. She had been taught when a resident is on private pay skilled care their MDS records are not submitted. It has to do with an insurance thing. She follows the MDS RAI manual for completing and transmitting MDS's. They have a consulting company and they have been reviewing her work for the past few months and trying to provide her more training. During an interview on 2/22/23 at 4:20 p.m. the Administrator reported the facility does not have an MDS policy. The facility follows the RAI manual for transmitting MDS records. During an interview on 02/23/23 at 8:26 a.m. the Director of Nursing (DON) reported she expects the MDS's to be submitted timely and accurately. The CMS RAI 3.0 User's Manual Version 1.17.1 October 2019, Chapter 2, page 2-17 directs a Discharge Return Not Anticipated Assessment is to be submitted within 14 calendar days after the MDS completion date.