Every finding on record at Magnolia Lane Nursing and Rehabilitation Center

Based on record review, and resident and staff interviews, the facility failed to communicate the facility's efforts to address concerns and document in writing the facility's response and rationale to concerns voiced during Resident Council meetings for 5 of 10 Resident Council meetings reviewed (January 2025, March 2025, June 2025, July 2025, and August 2025).Findings included:The Resident Council minutes for December 2024 (no day listed) noted that residents voiced a concern regarding the daily menus were not being posted again. The Resident Council minutes for January 2025 (no day listed) revealed residents voiced they had noticed the daily menus were being posted but they would like more variety. There was no further details documented of the facility's response, actions and rationale taken to address of the facility concern.The Resident Council minutes for February 2025 (no day listed) revealed no documentation of the facility's response, actions and rationale taken to address the food concerns voiced during the previous meeting or if the concern was still ongoing.The Resident Council minutes for March 2025 (no day listed) revealed residents voiced they would like more consistency in who cooks and they were still unhappy with the menu. The Resident Council minutes for April 2025 (no day listed) revealed there was no documentation of the facility's response, actions and rationale taken to address the dietary concerns regarding food and menus voiced during the previous meetings. It was noted that residents had stated, the food has been better, been worse with no further details documented. The Resident Council minutes for May 2025 (no day listed) revealed the residents stated they had not noticed any concerns related to the food quality or temperature. There was no documentation of the facility's response, actions and rationale taken to address the food concerns voiced during previous meetings. The Resident Council minutes for June 2025 (no day listed) revealed residents voiced concerns regarding Nurse Aides (NAs) not making beds even on bath days and not turning the light off after care was provided, residents were still unhappy with the corporate menu, and residents had to remind dietary staff to post the daily menus in all of the menu holders, not just some. The Resident Council minutes for July 2025 (no day listed) revealed residents voiced concerns that the menus were not being posted in all the menu holders, NAs were forgetting to turn the light out after care was provided and beds were still not being made satisfactorily. There was no documentation of the facility's response, actions and rationale taken to address the concerns voiced during the previous meeting.Further review of the Resident Council minutes revealed a new document was utilized starting August 2025 for documentation of the minutes that included a sections for Old Business, New Business, Resident Rights Reviewed, Date of Next Meeting, and Signature Line for the staff member completing the minutes.The Resident Council minutes for August 13, 2025, revealed under old business residents voiced that menus were not to the residents' liking and sometimes the menus were not posted in the menu holders. Under new business, it was noted the residents would like additional bath days. There was no documentation of the facility's response, actions and rationale taken to address the concerns voiced during the previous meeting.The Resident Council minutes for September 10, 2025, revealed under old business the Administrator attended the meeting to introduce himself to the residents and to provide resolution to concerns voiced in the previous Resident Council meeting. The topics of resolution discussed with residents attending the meeting included special menu items, call light response times on evening and night shifts, and annual outing. There was no new business noted. There was no documentation of the facility's response, actions and rationale taken to address the dietary concerns and additional bath days voiced by residents during the previous meeting. The facility's grievance logs for the period December 2024 through September 2025 were reviewed and revealed no concerns were filed on behalf of the members of the Resident Council following the monthly meetings. A Resident Council group interview was conducted on 12/16/25 at 3:19 PM with Resident #9, Resident #32, Resident #44 (Resident Council President), and Resident #51 in attendance. Resident #9 stated when they voiced concerns during meetings they rarely received communication from facility staff regarding what was done to address the concerns. Resident #9 also stated they would like more communication regarding what the facility was doing to address the concerns they voiced and to be a part of the solution. When asked, Resident #32, Resident #44 and Resident #51 all stated they agreed with Resident #9.During an interview on 12/16/25 at 4:02 PM, the Activity Director revealed she had only been in her position for a few months and was still learning the process. She explained she had only facilitated two (2) resident council meetings, 10/17/25 and 11/03/25. She stated she had reviewed the minutes from previous meeting and during the meetings she facilitated she asked the residents if they had any grievances/complaints they would like to discuss. She stated the residents rarely mentioned any concerns during the Resident Council meetings but then would voice concerns during activities. The Activity Director explained when concerns were voiced by the residents either during the Resident Council meetings or activities, she didn't document the concerns on a resident grievance or group concern form, but she did share the concern(s) voiced by residents with the Administrator and other Department Managers during the daily team meetings. The Activity Director stated she would listen during the next team meeting to see what was done to address the concerns and if nothing was mentioned, she would ask what was done. The Activity Director stated once she received the resolution from the person who addressed the concern, she verbally provided the resolution to the individual resident voicing the concern the next time she saw the resident. During an interview on 12/19/25 at 3:17 PM, the Administrator revealed he started at the facility in August 2025. He confirmed the Activity Director would share with him any concerns voiced by residents during the Resident Council meetings. He explained the concern would be assigned to the appropriate Department Manager to investigate and provide a written response. He stated that once the concern had been addressed, it was discussed during the next daily team meeting that included the Activity Director and the Activity Director was the person responsible for communicating the resolution to the Resident Council. Other than the minutes of previous meetings, the Administrator was unable to provide any documentation of investigations or written resolutions for concerns voiced during Resident Council since starting his employment in August 2025.

Based on record review and staff interviews, the facility failed to submit a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) determination for residents who were admitted to the facility with serious mental health disorders for 4 of 4 residents reviewed for PASRR (Resident #37, Resident #7, Resident #52 and Resident #50).Findings included: 1. A PASRR Determination Notification letter dated 07/15/25 revealed Resident #37 had a Level I PASRR with no expiration date. Resident #37 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, post-traumatic stress disorder (PTSD) and bipolar disorder. A staff progress note dated 10/01/25 at 1:44 PM written by the Social Worker (SW) revealed a baseline care plan meeting was held with Resident #37. The SW noted Resident #37 shared a history of significant trauma, including experiences related to war, and had diagnoses of PTSD and bipolar disorder. A physician's progress note dated 10/03/25 revealed Resident #37 had a diagnosis of chronic PTSD that was managed with divalproex sodium (anticonvulsant). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Resident #37's active psychiatric/mood disorder diagnoses included depression (other than bipolar) and PTSD. He received anticonvulsant medications during the MDS assessment period. A psychiatric note dated 10/09/25 revealed Resident #37 received divalproex sodium every night at bedtime for treatment of chronic PTSD with major depressive disorder. It was noted the medication was effective, Resident #37's mood had been stable and no changes to the medication was recommended. Resident #37 had a planned discharged home on [DATE]. He was readmitted to the facility on [DATE] with diagnoses that included major depressive disorder, recurrent and PTSD. The October 2025 Medication Administration Record revealed Resident #37 received the following medications: *A physician order dated 10/28/25 for divalproex sodium 500 milligrams (mg) two tablets by mouth twice a day at 8:00 AM and 8:00 PM for mood disorder. *A physician order dated 10/28/25 for olanzapine (antipsychotic) 5 mg at bedtime for mood disorder. A physician progress note dated 10/29/25 revealed Resident #37 had diagnoses of major depressive disorder, recurrent episode and chronic PTSD. A Nurse Practitioner progress note dated 10/30/25 revealed Resident #37 had a diagnosis of major depressive disorder, recurrent episode with a plan to continue olanzapine and divalproex sodium for mood disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. He received antipsychotic and anticonvulsant medications during the MDS assessment period. Review of Resident #37's medical record revealed there was no documented evidence of a Level II PASRR evaluation. The facility was unable to provide documentation that a request for an evaluation for a Level II PASRR determination had been submitted for Resident #37. During an interview on 12/18/25 at 8:36 AM, the admission Coordinator revealed if a resident was accepted for admission, she ensured they had a PASRR and if not, she would request one. The admission Coordinator revealed she applied for PASRR evaluations by entering information into the North Carolina Medicaid Uniform Screening Tool (NC MUST, internet-based application utilized to communicate and manage PASRR requests) such as the resident's medications, mental health diagnoses, nursing notes and the Medicaid Long Term Care FL2 form (describes an individual's medical condition and the level of care needed). She revealed if a resident had a Level I PASRR determination and a mental health diagnosis, she informed the Social Worker (SW). The admission Coordinator revealed she had been employed at the facility for two weeks and since starting her position, she had not requested any Level II PASRR evaluations. During an interview on 12/16/25 at 2:07 PM, the SW confirmed she had not been informed by the clinical team to submit a request for an evaluation for a Level II PASRR for Resident #37. The SW stated ideally when a resident admitted with a mental health diagnosis with a Level I PASRR, a request for a Level II evaluation should have been done and was overlooked. During an interview on 12/18/25 at 3:48 PM, the Administrator revealed PASRR was discussed during daily clinical meetings and if it was determined that a resident needed a Level II PASRR evaluation, the SW would be responsible for submitting a request for a Level II PASRR evaluation determination. The Administrator acknowledged a request for an evaluation for a Level II PASRR determination should have been submitted for Resident #37 and was overlooked. 2. A PASRR Determination Notification letter dated 07/05/10 revealed Resident #7 had a PASRR Level I with no expiration date. Resident #7 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder and anxiety disorder. The most recent comprehensive Minimum Data Set (MDS) significant change in status assessment dated [DATE] revealed Resident #7 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Resident #7's active psychiatric/mood disorder diagnoses included bipolar disorder and depression, and antidepressant and anticonvulsant medications were taken during the assessment lookback period. The care plan last revised on 09/09/25 revealed Resident #7 had diagnoses that included bipolar disorder, anxiety, and depression. Resident #7 received psychotropic antidepressant and antianxiety medications with the potential for side effects. Interventions included evaluate effectiveness and side effects of medications for possible reduction or elimination of psychotropic drugs. Review of Resident #7's medical records revealed there was no documented evidence that a request for an evaluation for a PASRR Level II determination was made. A Nurse Practitioner (NP) progress note dated 12/04/25 revealed Resident #7 was seen for ongoing medication management and symptom monitoring for bipolar disorder with anxiety. The NP noted Resident #7's bipolar disorder was in partial remission, and the most recent episode was depression and Resident #7 currently denied any anxiety or depression. The NP noted Resident #7's mood was stable and continued escitalopram (antidepressant) 10 milligrams (mg) daily for depression, depakote (anticonvulsant) 125 mg twice a day for mood stabilization, trazadone (antidepressant) 50 mg at hour of sleep for insomnia, and bupropion (antidepressant) extended release 100 mg daily for depression. The facility was unable to provide documentation that a request for an evaluation for a Level II PASRR had been submitted for Resident #7. During an interview on12/16/25 at 2:07 PM, the Social Worker (SW) revealed PASRR was discussed during the morning meetings and included review of psychotropic medications, and she would be informed if a request for a PASRR evaluation needed to be submitted. The SW revealed no request for a Level II PASRR evaluation had been completed for Resident #7 and stated ideally when a resident admitted with a mental health diagnosis and had a PASRR Level I, a request for re-evaluation should have been done. During an interview on 12/18/25 at 8:36 AM, the admission Coordinator revealed if a resident was accepted for admission, she ensured they had a PASRR and if not, she would request one. The admission Coordinator revealed she applied for PASRR evaluations by entering the resident's medications, mental health diagnoses, nursing notes, and the Medicaid Long Term Care FL2 form. She revealed if a resident had a PASRR Level I determination and a mental health diagnosis she informed the SW. The admission Coordinator revealed she had not requested PASRR reevaluations since she had started her position. An interview was conducted on 12/18/25 at 3:48 PM with the Administrator. The Administrator revealed PASRR was discussed during morning meetings and the re-evaluation for Resident #7 was missed. The Administrator revealed the process for when a resident had a mental health diagnosis and a PASRR Level I, a request for reevaluation would need to be submitted and it was the SW's responsibility for requesting PASRR evaluations. 3. There was no PASRR Determination Notification letter included in Resident #52's medical records. A screenshot copy of the PASRR lookup and tracking included in the medical records revealed Resident #52 had a PASRR Level I with no expiration date. There was no date to show when Resident #52 was screened and the PASRR Level I remained valid. Resident #52 was admitted to the facility on [DATE] with cumulative diagnoses that included diabetes mellitus, bipolar disorder, moderate major depressive disorder, and toxic encephalopathy (exposure to toxic substances that alters brain function). The care plan initiated on 10/18/25 revealed Resident #52 received psychotropic medications for the diagnoses of depression and bipolar disorder that had the potential for cardiac and gastrointestinal side effects. Interventions included monitor for mood, behaviors, physical aggression, feeling unsafe and document and notify the physician, administer medications per physician's orders, and monthly and as ordered pharmacy review of medications. A Medical Doctor (MD) progress note dated 10/22/25 revealed Resident #52 was seen for a new patient admission and toxic encephalopathy. The MD noted Resident #52's past history of bipolar disorder, depression, anxiety, and insomnia and continued the current medications aripiprazole (antipsychotic) 10 mg daily for depression related to bipolar disorder, sertraline (antidepressant) 25 mg once a day and 100 mg at bedtime for depression, trazodone (antidepressant) 50 mg at bedtime for insomnia, divalproex sodium (anticonvulsant) 250 mg twice a day for mood. The MD noted Resident #52 had positive effects and the psychotropic medications were used to benefit mental and physical wellbeing and were without any reported or noted side effects. The admission MDS assessment dated [DATE] revealed Resident #52 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Resident #52's active psychiatric/mood disorder diagnoses included bipolar disorder and depression, and antipsychotic, antidepressant and anticonvulsant medications were taken during the assessment lookback period. Review of Resident #52's medical records revealed there was no documented evidence that a request for an evaluation for a Level II PASRR was made. The facility was unable to provide documentation that a request for an evaluation for a Level II PASRR had been submitted for Resident #52. During an interview on 12/16/25 at 2:07 PM, the Social Worker (SW) revealed PASRR was discussed during the morning meetings and included review of psychotropic medications, and she would be informed if a request for a PASRR evaluation needed to be submitted. The SW revealed no request for a PASRR review had been done for Resident #52 and stated ideally when a resident admitted with a mental health diagnosis and had a PASRR Level I, a request for re-evaluation should have been done. During an interview on 12/18/25 at 8:36 AM, the admission Coordinator revealed if a resident was accepted for admission, she ensured they had a PASRR and if not, she would request one. The admission Coordinator revealed she applied for PASRR evaluations by entering the resident's medications, mental health diagnoses, nursing notes, and the Medicaid Long Term Care FL2 form. She revealed if a resident had a PASRR Level I determination and a mental health diagnosis she informed the SW. The admission Coordinator revealed she had not requested PASRR reevaluations since she had started her position. An interview was conducted on 12/18/25 at 3:48 PM with the Administrator. The Administrator revealed PASRR was discussed during morning meetings and the re-evaluation for Resident #52 was missed. The Administrator revealed the process for when a resident had a mental health diagnosis and a PASRR Level I, a request for reevaluation would need to be submitted and it was the SW's responsibility for requesting PASRR evaluations. 4. A Pre-Admissions Screening and Resident Review (PASRR) Determination Notification letter dated 10/14/23 revealed Resident #50 had a Level I PASRR with no expiration date. Resident #50 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), chronic kidney disease stage 4, and diabetes mellitus type 2, post-traumatic stress disorder (PTSD), major depressive disorder, obsessive-compulsive disorder (OCD), and anxiety. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. He received antipsychotic, antianxiety, antidepressant, and anticonvulsant medications during the MDS assessment period. Resident #50's active psychiatric/mood disorder diagnoses included anxiety disorder, major depressive disorder and PTSD. A Psychiatric progress note dated 12/04/25 revealed Resident #50 was seen for ongoing medication management and symptom monitoring of depression and anxiety with impulsivity and obsessive-compulsive symptoms, history of self-harm and inappropriate sexual actions toward staff. Resident #50 was taking sertraline (antidepressant) daily for OCD and depression, trazodone (antidepressant) for insomnia, and divalproex sodium (anticonvulsant) for mood stabilization. He was taking clonazepam for anxiety, which has changed from 0.5 mg three times per day as needed to 0.5 mg twice a day scheduled for 8:00 am and 2:00 pm as well as 0.5 mg once a day as needed. Review of Resident #50's medical record revealed there was no Level II PASRR evaluation. The facility was unable to provide documentation that a request for an evaluation for a Level II PASRR had been submitted for Resident #50. During an interview on 12/18/25 at 8:46 AM, the admission Coordinator revealed she was responsible for verifying if a resident had a PASRR in the North Carolina Medicaid Uniform Screening Tool (NC MUST) before admission to the facility. If the resident had a valid PASRR in NC MUST she would accept the resident, if the resident did not have a valid PASRR she would submit the application for a Level I PASRR evaluation. She stated the PASRR application required the residents' diagnoses. If the resident had a mental health diagnosis the PASRR application would be elevated to a Level II PASRR which required additional information that included the resident's medications, history and physical, FL2 form (form used by medical providers to communicate health status and care requirements of a resident to care facilities), and medical provider notes provided to NC MUST. The admission Coordinator also confirmed that Resident #50 had a Level I PASRR assigned before admission to the facility, therefore a request for a Level II PASRR evaluation had not been submitted. An interview was conducted with the Social Worker (SW) on 12/16/25 at 2:07 PM. The SW stated the PASRR process included the admission Coordinator would confirm the residents had a Level I PASRR or Level II PASRR determination upon admission to the facility. During the clinical team meeting, the team reviewed psychotropic medications and the resident diagnoses and informed the SW if a PASRR re-evaluation or significant change request was needed. The SW also revealed she had not been asked to submit a request for an evaluation for a Level II PASRR for Resident #50 until 12/16/25, when she was asked to provide documentation of the Level II PASRR. An interview with the Administrator on 12/18/25 at 3:47 PM revealed residents were discussed in daily clinical team meetings and if it was determined that a resident needed an evaluation for a Level II PASRR the SW would be responsible for requesting the evaluation for a Level II PASRR. The Administrator acknowledged a request for a level II PASRR evaluation should have been submitted for Resident #50 by the SW due to Resident #50's mental health diagnoses.

Based on observations and staff interviews, the facility failed to discard food past its use-by date in 1 of 1 walk-in cooler and store food off the floor in 1 of 1 walk-in freezer. These practices had the potential to affect food served to residents. The findings included:a. During an initial observation of the facility's kitchen with the Dietary Manager on 12/15/25 at 9:59 AM, the walk-in cooler had two (2) one-quart sized containers of lemon-flavored thickener with a use-by date of 10/28/25.b. During an initial observation of the facility's kitchen with the Dietary Manager on 12/15/25 at 10:12 AM the walk-in freezer was noted to have the following concerns:-Three (3) boxes of frozen turkeys, four turkeys per box, placed on the floor in the center of the walk-in freezer.-One (1) box of french toast sticks placed on the floor in the center of the walk-in freezer.An interview with the Dietary Manager on 12/16/25 3:14PM revealed that food items should not be available to be served to residents past the use-by date and the turkeys and french toast sticks were not stored correctly in the walk-in freezer. The Dietary Manager discarded the food items from the walk-in cooler that were past the use-by date. The Dietary Manager stated that all dietary staff had the responsibility to check dates on food items weekly and food items past the used-by date should be discarded. He further stated that food items in the walk-in freezer should not be placed on the floor. He revealed the facility had given turkeys to the staff for the holidays and the freezer had limited space to store the extra turkeys. He stated staff had to move the turkeys and french toast sticks to get food items off the shelf and did not put the turkeys and french toast sticks back on the shelf.An interview with the Administrator on 9/25/2025 at 1:22 PM revealed that all dietary staff should have checked use-by dates on food items daily and that food items past the use-by date would be discarded. In addition, the dietary staff should report the food items past the use-by date to the Dietary Manager. The Administrator stated food items should not have been placed on the floor of the walk-in freezer and if dietary staff discovered food items placed on the floor of the walk-in freezer they should inform the Dietary Manager.

Based on record review and staff interviews, the facility failed to ensure the Do Not Resuscitate (DNR) form was signed by the physician and part of the medical record after the physician ordered for the resident to be Do Not Resuscitate for 1 of 21 residents reviewed for advanced directives (Resident #2). The findings included:Resident #2 was admitted to the facility on [DATE]. Review of the physician's signed orders dated [DATE] revealed admission to Hospice with diagnosis of malignant neoplasm (a cancerous tumor) of the gallbladder. Review of the physician's signed orders dated [DATE] revealed an order for Resident #2 to be a Do Not Resuscitate (DNR).An interview with the former Assistant Director of Nursing (ADON) who entered the DNR order was attempted but unsuccessful. Review of Resident #2's electronic medical record revealed no evidence a DNR form was completed and signed by the physician.An attempt to contact Resident #2's Responsible Party (RP) was made but unsuccessful.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #2 was severely cognitively impaired. Resident #2 had a condition or chronic disease that may result in a life expectancy of less than 6 months and was on Hospice.Review of the care plan dated [DATE] revealed Resident #2 was documented as do not resuscitate (DNR) (lifesaving efforts such as Cardiopulmonary Resuscitation (CPR) were not to be conducted). Goals included advance directives will be honored per established documents/ documentation through next review. Interventions included do not resuscitate. A joint interview with the Administrator and the Corporate Consultant on [DATE] at 2:02 PM revealed that advanced directives were discussed in interdisciplinary team (IDT) daily meetings. The Administrator stated nursing should review the advanced directive orders and fill out the DNR or MOST form and have the physician review it with the resident or resident representative and sign the form. The Corporate Consultant further revealed that the facility had just completed an audit of advanced directives on [DATE] and Resident #2 was overlooked. The Corporate Consultant further stated that when an advanced directive was changed the medical record should be updated with all correct information and forms within 24 hours.

Based on record review and staff interviews, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, a form used by skilled nursing facilities to inform residents about potential costs and coverage limitations for services that may not be covered by Medicare) to beneficiaries who intended to continue services and the SNF believed the services may not be covered under Medicare prior to discharge from Medicare Part A skilled services for 3 of 3 residents reviewed for beneficiary notification review (Residents #6, #16, and #76).Findings included:1. Resident #6 was admitted to the facility on [DATE].A Notice of Medicare Non-Coverage (NOMNC) revealed the notice was discussed with and signed by Resident #6 on 09/19/25 which indicated his Medicare Part A coverage for skilled services would end on 09/23/25. Resident #6 remained in the facility. Resident #6's medical record revealed no evidence a SNF ABN was reviewed with or provided to Resident #6. During an interview on 12/16/25 at 10:05 AM, the Business Office Manager revealed the therapy team reviewed the NOMNC with the resident or their Responsible Party (RP) when Medicare Part A services were ending, had them sign the form and then returned the form to her to keep. She stated due to a miscommunication between her and the therapy team; she was not aware that SNF ABNs were not being provided along with the NOMNC. The Business Office Manager stated she had since requested that the therapy team inform her when a resident's therapy services were ending so that she had time to provide a SNF ABN to the resident or their RP, if applicable. The Business Office Manager confirmed a SNF ABN was not issued to Resident #6 prior to Medicare Part A skilled services ending on 09/23/25.During an interview on 12/19/25 at 3:17 PM, the Administrator revealed he would have expected Resident #6 to have received a SNF ABN as required when his Medicare Part A services were ending. He stated going forward, the Social Worker would be responsible for ensuring a SNF ABN was provided to the resident or their RP as required. 2. Resident 16 was admitted to the facility on [DATE].A Notice of Medicare Non-Coverage (NOMNC) revealed the notice was discussed with and signed by Resident #16 on 08/15/25 which indicated his Medicare Part A coverage for skilled services would end on 08/18/25. Resident #16 remained in the facility. Resident #16's medical record revealed no evidence a SNF ABN was reviewed with or provided to Resident #16. During an interview on 12/16/25 at 10:05 AM, the Business Office Manager revealed the therapy team reviewed the NOMNC with the resident or their Responsible Party (RP) when Medicare Part A services were ending, had them sign the form and then returned the form to her to keep. She stated due to a miscommunication between her and the therapy team; she was not aware that SNF ABNs were not being provided along with the NOMNC. The Business Office Manager stated she had since requested that the therapy team inform her when a resident's therapy services were ending so that she had time to provide a SNF ABN to the resident or their RP, if applicable. The Business Office Manager confirmed a SNF ABN was not issued to Resident #16 prior to Medicare Part A skilled services ending on 08/18/25.During an interview on 12/19/25 at 3:17 PM, the Administrator revealed he would have expected Resident #16 to have received a SNF ABN as required when his Medicare Part A services were ending. He stated going forward, the Social Worker would be responsible for ensuring a SNF ABN was provided to the resident or their RP as required. 3. Resident #76 was readmitted to the facility on [DATE].A Notice of Medicare Non-Coverage (NOMNC) revealed the notice was discussed with and signed by Resident #76 on 08/22/25 which indicated her Medicare Part A coverage for skilled services would end on 08/25/25. Resident #76 remained in the facility until her discharge on [DATE]. Resident #76's medical record revealed no evidence a SNF ABN was reviewed with or provided to Resident #76.During an interview on 12/16/25 at 10:05 AM, the Business Office Manager revealed the therapy team reviewed the NOMNC with the resident or their Responsible Party (RP) when Medicare Part A services were ending, had them sign the form and then returned the form to her to keep. She stated due to a miscommunication between her and the therapy team; she was not aware that SNF ABNs were not being provided along with the NOMNC. The Business Office Manager stated she had since requested that the therapy team inform her when a resident's therapy services were ending so that she had time to provide a SNF ABN to the resident or their RP, if applicable. The Business Office Manager confirmed a SNF ABN was not issued to Resident #76 prior to Medicare Part A skilled services ending on 08/25/25.During an interview on 12/19/25 at 3:17 PM, the Administrator revealed he would have expected Resident #76 to have received a SNF ABN as required when her Medicare Part A services were ending. He stated going forward, the Social Worker would be responsible for ensuring a SNF ABN was provided to the resident or their RP as required.

Based on record review, observations and staff interviews, the facility failed to ensure a qualified staff member with the necessary skills and licensure inserted a peripheral intravenous (IV) catheter when a Medication Aide used the needle from an IV catheter kit and inserted it into a resident's arm (Resident #78). The deficient practice was identified for 1 of 5 nursing staff reviewed for sufficient and competent nurse staffing (Medication Aide #1). Findings included: Resident #78 was admitted to the facility on [DATE] with diagnoses that included arthritis, dementia, Alzheimer's disease, and diabetes mellitus. Resident #78 was discharged from the facility on 11/16/25. The admission Minimum Data Set assessment dated [DATE] revealed Resident #78 was severely impaired cognitively, was dependent or required substantial to maximum assistance with activities of daily living, and had taken antianxiety, antibiotic, antiplatelet medications during the lookback period of the assessment.Review of Resident #78's physician's order dated 06/01/25 to administer one (1) liter of 0.9% sodium chloride intravenously at 100 milliliters (ml) per hour for one day for hydration. Review of Nurse #1's progress note dated 06/01/25 revealed she had received a physician's order to administer one liter of 0.9% normal saline at 100 ml/hour intravenously to Resident #78. Nurse #1 noted attempts to start the IV were unsuccessful.An interview was conducted on 12/17/25 at 4:25 PM with Nurse #1. Nurse #1 stated she received a physician's order to administer IV fluids for Resident #78 on 06/01/25, but her attempt for intravenous access was unsuccessful. Nurse #1 stated she had left the room and did not observe Medication Aide #1 attempt to insert the IV catheter. She stated Medication Aide #2 was in the room and saw what happened and reported the incident to the former Assistant Director of Nursing (ADON) #2. Nurse #1 stated she was not made aware of the incident until the next day (06/02/25) when the former ADON #2 called her at home. Nurse #1 stated she had not witnessed a staff member attempt something out of their scope of practice but if she had she would immediately report it by following her chain of command.Review of Medication Aide #1's typed statement revealed she was in the room with Nurse #1 and was there to help calm Resident #78 and assist Nurse #1. The statement indicated Nurse #1 was successful in obtaining a blood draw but was unable to successfully get the IV started and had left the room. After Nurse #1 left the room Medication Aide #1's statement indicated she asked Resident #78 if she could try to start the IV and Resident #78 stated, yes that was fine. The statement indicated Medication Aide #1 made one attempt to insert the peripheral IV catheter and was able to get blood return but unsuccessful in maintaining the IV when the vein collapsed. Medication Aide #1's statement indicated she was attending nursing school and had practiced starting an IV and she meant no harm to Resident #78. The statement was signed on 07/29/25 by Medication Aide #1 and the former Administrator.Attempts to speak with Medication Aide #1 by phone on 12/17/25 at 2:26 PM were unsuccessful. The contact number provided by the facility was not a working number. Review of Medication Aide #2's written statement revealed on 06/01/25 she observed Medication Aide #1 opening an IV catheter kit and stick Resident #78 in the arm in attempt to insert a peripheral IV catheter. The statement indicated the attempt was unsuccessful and Medication Aide #2 used gauze and a band aid to cover the area and stop the bleeding and had spoken to the nurse about what to do.A telephone interview was conducted with Medication Aide #2 on 12/18/25 at 9:00 AM. Medication Aide #2 stated she saw Medication Aide #1 attempt to start an IV on 06/01/25 and described what she saw was Medication Aide #1 stick Resident #78 in the left arm. After the attempt to start the IV, Medication Aide #2 recalled Resident #78 stated she was, okay. Medication Aide #2 stated she told the former ADON #2 about what happened and was asked to write a witness statement. Medication Aide #2 indicated she and Medication Aide #1 were interviewed by the former ADON #2 who discussed scope of practice and told Medication Aide #1 she could not start an IV. Medication Aide #2 stated she had received multiple educational in-services related to knowing your scope of practice and she knew not to attempt injections or attempt to insert an IV catheter.A telephone interview was conducted on 12/19/25 at 12:39 PM with the former ADON #2. The former ADON #2 stated she was not at the facility on 06/01/25 when Medication Aide #1 attempted to insert an IV catheter for Resident #78. She stated she was told there was no nurse in the room, but the incident was witnessed by Medication Aide #2. She questioned both Medication Aide #1 and Medication Aide #2 and Medication Aide #1 confirmed she attempted to start an IV for Resident #78. She reinforced Medication Aides do not start an IV and informed the former Administrator who took over the investigation. A telephone interview was conducted on 12/19/25 at 1:53 PM with the former Administrator who stated after the incident was reported she spoke with Medication Aide #1 who confirmed she had attempted to start the IV. The former Administrator stated during her investigation Medication Aide #1 was suspended, and the Board of Nursing was called to report the incident. The former Administrator revealed she and the Staff Development Coordinator provided education to the nurses, medication aides, and nurse aides (NA) about scope of practice that included Medication Aides were not trained to start an IV.A telephone interview was conducted on 12/19/25 at 3:28 PM with the former Staff Development Coordinator. The Staff Development Coordinator revealed she had conducted a job skills fair approximately 2 months prior to her leaving her position in September 2025. She reviewed scope of practice, competency and skill checks for medication aides, nurses, and nurse aides. The skills check included medication administration, and she reinforced with the medication aides to ensure they understood scope of practice, and they were not competent or had the skills to start an IV.Review of a typed statement dated 8/1/25 revealed the former Director of Nursing (DON) had notified the state Board of Nursing on 8/6/25 to report Medication Aide #1.Attempt to interview the former DON on 12/19/25 at 1:47 PM was unsuccessful. An interview was conducted on 12/19/25 at 3:53 PM with the current Administrator revealed on 06/01/25, Medication Aide #1 attempted to insert an IV catheter into Resident #78's arm. The Administrator stated medication aides and/or nurse aides were not licensed for and did not have the required competency or skills to attempt to insert an IV catheter and must be immediately stopped and reported to the nurse, Director of Nursing (DON), or the Administrator.

Based on record review, observations, and staff interviews, the facility failed to maintain oral hygiene for a dependent resident unable to brush their teeth for 1 of 3 residents reviewed for activities of daily living (Resident #31). The findings included: Resident #31 was admitted to the facility on [DATE] with diagnoses including autoimmune disease affecting the central nervous system, paralysis or severe weakness affecting the ability to move, and visual impairment. A review of the dental visit note dated 10/13/25 revealed Resident #31's periodontal health was documented as red tissue with a heavy buildup, plaque and calculus as heavy and oral hygiene as poor. The recommendations were for routine oral hygiene and follow up as needed.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was severely impaired cognitively, had upper extremity range of motion impairment on both sides, and was dependent on staff for oral hygiene. The care plan revised on 10/23/25 revealed Resident #31 required assistance with activities of daily living related to diagnoses and upper extremity contractures and was dependent on staff assistance for oral hygiene. During an interview on 12/16/25 at 9:32 AM, the Responsible Party (RP) stated Resident #31 required total care with oral hygiene and it was not routinely done. The RP revealed when family visited they had observed Resident #31's teeth were not clean and needed to be brushed, and they provided oral hygiene care. An interview and observation was conducted on 12/16/25 at 11:59 AM with Resident #31. When asked Resident #31 showed she had no lower teeth, and her upper front teeth had a white colored buildup of debris at the gum line and around several of her front teeth. When asked if staff brushed her teeth Resident #31 nodded her head as to say no. An observation on 12/17/25 at 3:41 PM revealed no change in Resident #31's front upper teeth and a white colored buildup of debris remained on the teeth and gums. An interview and observation was conducted on 12/18/25 at 11:40 AM with Nurse Aide (NA) #1. NA #1 revealed Resident #31 was dependent on staff and required total assistance with activities of daily living care. NA #1 revealed he had not offered or provided oral hygiene care for Resident #31 and stated he usually provided oral care during the afternoon. Upon request Resident #31 showed NA #1 her front upper teeth which continued to have the white colored buildup of debris on the teeth and along the gums and needed to be brushed. An observation and interview was conducted on 12/18/25 at 12:05 PM with the Director of Nursing (DON). The DON observed Resident #31's upper front teeth had a white colored buildup of debris and asked the resident if she wanted her teeth brushed. Resident #31 nodded her head as to say yes. The DON asked Resident #31 if she had been offered to have her teeth brushed and Resident #31 nodded her head as to say no. It was explained to the DON, Resident #31's teeth was observed to have a white colored buildup on 12/16/25, 12/17/25, and 12/18/25. The DON stated oral hygiene care should be done at least daily. During an interview and observation on 12/18/25 at 12:51 PM, NA #2 offered to brush Resident #31's upper teeth. NA #2 brushed Resident #31's upper teeth and the white colored buildup of debris was easily removed. NA #2 indicated oral hygiene care was done daily as part of the morning care. During an interview on 12/18/25 at 4:30 PM, the Administrator revealed oral hygiene care should be done at least daily.

Based on record review and interviews with the Pharmacy Operation Manager and staff, the facility failed to have effective systems in place for the return of controlled medications to the pharmacy for 3 of 3 residents (Resident #15, Resident #25 and Resident #79).The findings included:a. The physician's order dated 03/19/25 revealed Resident #15 was to receive hydrocodone-acetaminophen (a combination of a narcotic opioid analgesic and a non-narcotic medication to relieve pain) 5-325 milligrams (mg) every 4 hours as needed (PRN) for left leg pain.The controlled substance count record dated 03/20/25 revealed Resident #15 had 30 tablets of hydrocodone-acetaminophen 5-325 mg with the RX# (prescription number) 17427852. Starting on 03/20/25, nurses signed the form indicating the medication was removed and administered to Resident #15 as follows: one dose on 3/20/25, one dose on 3/21/25, one dose on 3/24/25, one dose on 3/26/25, one dose on 3/31/25, one dose on 4/1/25, one dose on 4/8/25, one dose on 4/11/25, one dose on 4/12/25, one dose on 4/13/25, two doses on 4/14/25, one dose on 4/16/25, one dose on 4/17/25, two doses on 4/18/25, one dose on 4/21/25, two doses on 4/22/25, and one dose on 4/23/25. Following the last dose that was administered on 4/23/25, Resident #15 had 10 tablets left remaining.The March 2025 medication administration record (MAR) revealed starting on 03/20/25 Resident #15 received a total of 5 tablets of hydrocodone-acetaminophen 5-325 mg. The medication was documented as administered per physician order on 3/20/25 at 7:28 PM, 3/21/25 at 8:09 PM, 3/24/25 at 7:34 PM, 3/26/25 at 8:15 PM, and 3/31/25 at 8:24 PM. No further doses were documented as administered for the remainder of the month.The April 2025 MAR revealed Resident #15 received a total of 15 tablets of hydrocodone-acetaminophen 5-325 mg. The medication was documented as administered on 4/1/25 at 12:45 AM, 4/8/25 at 9:40 PM, 4/11/25 at 9:08 PM, 4/12/25 at 7:56 PM, 4/13/25 at 8:27 PM, 4/14/25 at 7:42 PM and 11:50 PM, 4/16/25 at 8:30 PM, 4/17/25 at 8:11 PM, 4/18/25 at 4:40 AM and 8:03 PM, 4/21/25 at 8:15 PM, 4/22/25 at 4:50 AM and 8:23 PM, and 4/23/25 at 8:03 PM. No further doses were documented as administered for the remainder of the month.The physician's order dated 03/19/25 for Resident #15's hydrocodone-acetaminophen 5-325 mg was discontinued on 04/28/25.The Pharmacy Return of Drugs form dated 4/28/25 and signed by Medication Aide #1 revealed Resident #15's RX #17427852 for hydrocodone-acetaminophen 5-325 mg with 10 tablets remaining was being returned due to the medication being discontinued.b. The physician's order dated 03/27/25 revealed Resident #25 was to receive one tablet of oxycodone (opioid) 5 milligrams (mg) by mouth every 8 hours as needed (PRN) for post-surgical pain.The controlled substance count record dated 03/27/25 revealed Resident #25 had 30 tablets of oxycodone 5 mg with the RX# (prescription number) 17469121. Starting on 04/13/25, nurses signed the form indicating the medication was removed and administered to Resident #25 starting as follows: one dose on 4/13/25, one dose on 4/14/25, one dose on 4/15/25, one dose on 4/16/25, one dose on 4/17/25, two doses on 4/18/25, one dose on 4/19/25, one dose on 4/21/25, two doses on 4/22/25, one dose on 4/23/25, and one dose on 4/24/25. Following the last dose that was administered on 4/24/25, Resident #25 had 17 tablets left remaining.The April 2025 MAR revealed Resident #25 received a total of 13 tablets of oxycodone 5 mg. The medication was documented as administered on 4/13/25 at 7:58 PM, 4/14/25 at 7:48 PM, 4/15/25 at 6:27 AM, 4/16/25 at 8:24 PM, 4/17/25 at 8:40 PM, 4/18/25 at 6:06 AM and 8:10 PM, 4/19/25 at 7:56 PM, 4/21/25 at 8:20 PM, 4/22/25 at 5:18 AM and 8:03 PM, 4/23/25 at 7:51 PM, and 4/24/25 at 8:00 PM. No further doses were documented as administered for the remainder of the month.The physician's order dated 03/27/25 for Resident #25's oxycodone 5 mg was discontinued on 04/25/25.The Pharmacy Return of Drugs form dated 4/28/25 and signed by Medication Aide #1 revealed Resident #15's RX #17469121 for oxycodone mg with 17 tablets remaining was being returned due to the medication being discontinued.c. The physician's order dated 03/10/25 revealed Resident #79 was to receive one tablet of oxycodone-acetaminophen (a combination of a narcotic opioid analgesic and a non-narcotic medication to relieve pain) 5-325 milligrams (mg) one tablet every 4 hours as needed (PRN) for pain. The controlled substance count record dated 04/23/25 for the RX# (prescription number) 17508525 revealed Resident #79 had 30 tablets of oxycodone-acetaminophen 5-235 mg. There were no signatures indicating the medication was administered.The physician's order dated 03/10/25 for Resident #79's oxycodone-acetaminophen 5-235 mg was discontinued on 04/25/25.The Pharmacy Return of Drugs form dated 4/28/25 and signed by Medication Aide #1 revealed Resident #79's RX #17508525 for oxycodone-acetaminophen 5-235 mg with 30 tablets remaining was being returned due to the medication being discontinued.The initial allegation report dated 06/21/25 revealed on 06/20/25 at 10:45 AM the facility became aware that discontinued medications thought to have been sent back to the pharmacy at the end of April 2025 did not make it to the pharmacy. An investigation was initiated and law enforcement was notified.The investigative report dated 07/01/25 revealed the facility determined that 10 tablets of hydrocodone 5-325 mg and 47 tablets of oxycodone 5 mg that were presumed to have been sent to the pharmacy around 4/28/25 were unaccounted for. The facility's investigation included interviews with licensed nursing staff who reported no knowledge of the missing medications and a thorough search of the medication carts and medication rooms. The facility validated the medications were unaccounted for but were not able to substantiate that there was any drug diversion or misappropriation.Included in the facility's investigation documentation were statements dated 06/23/25 and 06/24/25 written and signed by Medication Aide (MA) #1. MA #1 indicated that on 04/29/25 she verified that Resident #15, Resident #25 and Resident #79 all had discontinued medication in an unsealed, controlled return bag stored in the narcotic drawer on the Main Hall medication cart. MA #1 indicated she had put the medications in the same bag, notified Unit Manager #1 and was standing at the medication cart when Unit Manager #1 started filling out a return of drug form, but she did not see what Unit Manager #1 wrote on the form. MA #1 noted she could not recall if she faxed the return of drug form to the pharmacy but did verify the medications remained on the Main Hall cart and were accounted for when she turned over the medication cart to Unit Manager #1 at 3:00 PM on 4/29/25.MA #1 was no longer employed and telephone attempts made on 12/17/25 at 2:26 PM and 3:59 PM for an interview were unsuccessful.During an interview on 12/17/25 at 2:30 PM, Unit Manager #1 explained the evening shift (7:00 PM to 7:00 AM) nurses were the ones who prepared medications for return to the pharmacy. She explained in April 2025, the process was the nurse would place the medications in a clear bag with a number stamped on the front of the bag, the number of the bag was written on the return of drugs form, the return of drug form was faxed to the pharmacy to arrange pick-up, and the bag was left unsealed and placed in the locked narcotic drawer in the Main Hall medication cart until picked up by the pharmacy. Unit Manager #1 revealed when the Administrator was informed by the pharmacy that they had not received the medication listed on the return of drug form dated 04/28/25, she was asked by the former Administrator to review all residents with physician orders for narcotic medications to determine if the residents actually needed it and if not, work with the provider to get the medication discontinued. Unit Manager #1 stated when reviewing residents narcotic substance count sheets and medication administration records, the only residents identified with medications unaccounted for were Resident #15, Resident #25 and Resident #79. Unit Manager #1 stated she personally saw the medication card for Resident #15 that had 10 tablets remaining. Unit Manager #1 stated the medication was placed in the unsealed bag to return to pharmacy and the only information she wrote on the return of drug form was Resident #15's name, RX number, name of the medication, reason for return and quantity. Unit Manager #1 stated she did not fill out the information for Resident #25 and Resident #79 that was listed on the return of drug form. She was not sure who placed the medications for Resident #25 and Resident #79 in the bag along with Resident #15's or filled out the information on the return of drugs form. She stated MA #1 confirmed it was not her handwriting. During a follow-up interview on 12/19/25 at 7:48 AM, Unit Manager #1 verified Resident #15's medications were in the bag to return to the pharmacy and stated the return of drug form must have been with the bag because the information for Resident #25 and Resident #79 were added to the form after the fact. Unit Manager #1 explained at the time (April 2025), when the pharmacy courier arrived at the facility for a scheduled pick-up, after the medication was counted, the pharmacy courier would seal the bag in front of the nurse and then sign the return of drug form.Telephone attempt on 12/19/25 at 1:47 PM for an interview with the former Director of Nursing (DON) was unsuccessful.During a phone interview on 12/19/23 at 2:13 PM, the former Administrator revealed in June 2025 (could not recall the exact date), she received an email from the pharmacy stating they had reason to believe that back in April 2025 medications were not returned to the pharmacy. The former Administrator stated she asked the pharmacy why they were reaching out 2 months later to inquire about the medications but didn't really get an answer. She stated on the same day she had received notification from the pharmacy, both she and the former DON looked through all the pharmacy forms. She stated they found the return of drug form dated 04/28/25 with the pharmacy courier's signature indicating the medications were picked up and she faxed the signed form to the pharmacy. The former Administrator explained when the return of drug form was placed in the DON's box with the nurse's and pharmacy courier's signatures, which was the process at the time, they would not have had any reason to think anything was wrong and the medications had been picked up by the pharmacy courier just like any other day. The former Administrator stated she didn't hear anything from the pharmacy until Wednesday the following week at which time she was informed by the pharmacy that when the courier signature was compared to other signed documents, the signature did not appear authentic. The former Administrator explained the pharmacy courier that signed the return of drug form was the main courier for the facility and if you pulled previous forms she had signed, her signatures were different each time. She stated when she and the former DON had looked at other forms the facility had that the pharmacy courier had signed, the signature appeared ok but since the pharmacy stated it wasn't the courier's signature, an investigation was initiated. The former Administrator stated as part of the facility's investigation, they had Corporate come to the facility to help with audits and interviews were conducted with nursing staff who had worked on the medication cart. She stated the nursing staff interviewed all recalled the medications were written up on the return of drug form and placed in the locked narcotic drawer of the medication cart, but they could not recall anything else. The former Administrator stated based on the facility's investigation, they could determine the medications were in fact missing but they were unable to determine how or what happened to the medications. The former Administrator stated the incident was discussed with the Medical Director and QAPI committee to develop a corrective action plan.During a phone interview on 12/18/25 at 2:30 PM, the Pharmacy Operation Manager revealed on 06/20/25, she received an envelope that contained a note from someone at the facility (did not state who) regarding a concern about narcotic medications for Resident #15, Resident #25 and Resident #79 that needed to be looked into. The Pharmacy Operation Manager stated she could not find any records of medication returns for the 3 residents, the pharmacy had not received a return of drug form from the facility and there was no record of receipt of returned medications. She stated she contacted the facility and had them fax her the return of drug form with the courier's signature. When she received the return of drug form dated 04/28/25, she looked through faxes, hard copies and emails but could not find any records that the medications were returned to the pharmacy or that the pharmacy had received the return of drug form request the facility provided. The Pharmacy Operation Manager stated she then pulled previous documents the courier had signed to compare with the signature on the return of drug form dated 04/28/25 and the signature did not appear authentic. She stated she also had her manager review the signatures who also agreed the courier's signature did not appear authentic. She then spoke with the courier who validated the signature on the return of drug form dated 04/28/25 was not hers. The Pharmacy Operation Manager stated at that point, she notified the facility and cooperated in the facility's investigation. The Pharmacy Operation Manager explained the process for medication returns was the facility fills out the return of drug form, faxes the form to the pharmacy and then the courier was notified to pick up the medications from the facility. If the form was faxed before 5:30 PM, the medications were picked up and brought back to the pharmacy the same day to be checked in and processed by the Pharmacist and Technician to make sure everything was accurate as indicated on the return of drug form. She stated for controlled substances (medications), it was the pharmacy's policy that couriers do not count the medications with facility nurses, and the courier does not seal the bag after the medications were counted. She stated the courier receives notification of the bag number to be picked up and once at the facility, the courier checks the number on the bag to confirm the number matches the number provided by the pharmacy and then signs the return of drug form. During interviews on 12/17/25 at 2:30 PM and 12/19/25 at 1:24 PM, the Corporate Consultant revealed they had determined through nurse interviews that the medications for Resident #15, Resident #25 and Resident #79 were prepared for return to the pharmacy per the facility process. The Corporate Consultant stated the facility believed the medication had been picked up by the pharmacy courier on 04/28/25 since the medications were no longer on the medication cart and at that time, the former DON had no reason to believe otherwise. She stated on 06/20/25 the facility was notified by the pharmacy they had concerns that the courier's signature on the return of drug form dated 04/28/25 was forged and the facility started an investigation. The Corporate Consultant stated Unit Manager #1 confirmed she only wrote the information on the return of drug form for Resident #15's medications that were being returned and MA #1 indicated the handwriting on the return of drug form that listed the medications being returned for Resident #25 and Resident #79 was not hers. She explained when they interviewed nursing staff that had worked on the medication cart 2 months after the medications were assumed to have been returned to the pharmacy, no one knew anything about the missing medications for Resident #15, Resident #25 and Resident #79. The Corporate Consultant stated during the investigation, there were some accusations that came up but nothing they could prove as there had been several nurses and medication aides who had worked on the medication cart and they just couldn't determine what had happened to the missing medications. She stated following this incident, they did a company-wide systematic change to the process for returning narcotic medications to the pharmacy.The facility provided the following corrective action plan with a completion date of 06/26/25:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:On 6/20/25 it was reported to the facility that medications were missing from the narcotic lock box for 3 residents. The medications had already been discontinued and prepared by the staff to be sent back to the pharmacy. The resident's and medications were as follows: Resident #79 had 30 tablets of oxycodone 5-325 milligrams (mg), Resident #25 had 17 tablets of Oxycodone 5mg, and Resident #15 had 10 tablets of Hydrocodone 5/325 for a total of 57 tablets. On 6/20/25, the pharmacy manager had a phone conversation with the Director of Nursing and the Licensed Nursing Home Administrator (LNHA) stating that the medications were not received from the pharmacy. The signature could not be confirmed as authentic upon review of the packing slip, during the facility investigation as the staff's signature. The pharmacy could not confirm during their investigation that the signature was the courier's authentic signature. An investigation was initiated by the Licensed Nursing Home Administrator (LNHA) immediately. The medications were written up to be sent to the pharmacy to be disposed of on 4/28/25. The courier picked up medications the following night on 4/29/25 from the facility.At the time of the reported incident, Resident #15 had 10 tablets of Hydrocodone 5/325 mg that had been discontinued on 4/28/25 and a return of drug sheet had been filled out and ready to return to the pharmacy. Resident #79 had 30 tablets of oxycodone 5-325mg that had been discontinued on 4/25/25 and a return of drug sheet had been filled out and ready to return to the pharmacy. Resident #25 had 17 tablets of Oxycodone 5mg tablets that had been discontinued on 4/25/25 and a return of drug sheet had been filled out and ready to return to the pharmacy. The medications were placed on the Main medication cart in narcotic lock box in an unsealed plastic bag.On 6/24/25 pain assessments were completed by the licensed nurses for Resident #79, Resident #15, and Resident #25. No concerns for pain were identified for these residents.Address how the facility will identify other residents having the potential to be affected by the same deficient practice:On 6/20/25, the Administrator initiated an audit of 100% of all residents' Controlled Substance Count sheets in comparison to the narcotic medication blister packs in the medication cart to ensure there were no discrepancies in the count of the medications. The audit was completed on 6/22/25. There were no issues or concerns identified.On 6/20/25, the Administrator initiated an inspection of the narcotic blister pill packages for any tampering of medications. The inspection was completed on 6/22/25, and no issues or concerns were noted.On 6/23/25, the Clinical Consultant initiated an audit of the ordered narcotic medications since April 2025 to ensure the medications were in the medication cart, administered, or returned to pharmacy per protocol. The audit was completed on 6/25/25. The Administrator will initiate an investigation for any identified areas of concern.On 6/24/25, drug screenings were obtained for 100% of all Licensed Nurses/Medication Aides who had access to the medication cart. No positive screenings were noted.On 6/24/25, the Hall Nurses initiated assessment of all residents for pain. The Hall Nurses will initiate non-pharmacological interventions, pain medication, and/or physician notification for any identified areas of concern during the audit. The audit will be completed by 6/24/25.On 6/24/25, the Social Worker completed interviews with all alert and oriented residents regarding (1) Do you have any concerns with medication administration to include pain medication? (2) Do you have any concerns regarding misappropriation? A concern form will be completed for any identified area of concern and will be addressed by the Administrator.On 6/24/25, the Staff Development Coordinator initiated questionnaires with all Nurses and Medication Aides regarding: Do you have any concerns with medications being administered that have not been reported and addressed? The questionnaires will be completed by 6/24/25. Any Nurse or Medication Aide that has not completed the questionnaire by 6/24/25, will complete the questionnaire prior to their scheduled shift the Staff Development Director. Any issues or concerns reported will be addressed by the Administrator.On 6/24/25, the Payroll/Human Resources Bookkeeper completed an audit of all nurses and medication aides' license verification and Health Care Personnel Registry checks. All areas of concern will be addressed during the audit by the Administrator.On 6/23/25, the Clinical Consultant initiated an audit of packing slips since April 2025 to ensure all narcotic medications were checked in appropriately and accounted for. The audit was completed on 6/25/25. The Administrator will initiate an investigation for any identified areas of concern.Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not occur: On 6/23/25, the Staff Development Coordinator initiated an in-service with all nurses and medication aides regarding Controlled Substance Diversion to include: the definition, implications, and the new process for returning narcotic medications. The process for returning narcotic medications to the pharmacy is as follows: the nurse writes the narcotic medications on the return of medication form and has a second nurse verify the correct medication and amount. The form is then faxed to the pharmacy with only 2 medications per form/per bag. The purpose of only sending 2 cards per bag is so the pharmacy courier can verify the cards, and the nurse can continue to count with the cards placed back-to-back with the bag sealed. This is a new process. The medication is placed in a sealed clear/numbered bag supplied by the pharmacy and placed back in the narcotic lock box. The nurse on the cart will continue to count the medication as usual until the courier picks up the medication at their next delivery. At the time of pick-up, 1 nurse will verify the count with the courier prior to the medications being removed from the cart and the cards will be marked as removed from the cart on the declining count sheet, the courier and nurse will sign the form and 1 copy remains in the facility and remain in the Director of Nursing office. The other copy will leave with the courier and the medication. The in-service will be completed on 6/24/25. After 6/24/25, all nurses or medication aides to include contract or agency staff that have not worked and received the in-service will complete upon their next scheduled shift by the Staff Development Director. On 6/24/25, the Staff Development Coordinator initiated an in-service with all staff regarding Misappropriation and to report any concerns of misappropriation or diversion to the Administrator immediately. This in-service education also placed an emphasis on the following: the definition of misappropriation (the illegal use or redirection of prescription narcotics from their intended use). The in-service will be completed on 6/24/25. After 6/24/25, all staff to include contract and agency staff that have not worked and received the in-service will complete upon their next scheduled shift by the Staff Development Director. Any newly hired staff will receive the in-service upon hire by the Staff Development Director. At the conclusion of the investigation, it was determined that the facility failed to verify the medications being written on the return of drug form were correct in count by 2 nurses prior to placing the medications in the numbered bag, form faxed to the pharmacy, and being sealed to await pick-up by the courier.Indicate how will the facility plans to monitor its performance to make sure that solutions are sustained:Beginning on 6/30/25, a 100% audit of all ordered narcotic medications for all 3 medication carts to include an cart inspection was reviewed by the Staff Development Coordinator weekly x 4 weeks and compared to the Controlled Substance Count Sheets, medication administration record, and/or return of drug slips to ensure the narcotic medications were being administered or have been returned to the pharmacy as required per policy and there were no signs of drug diversion utilizing a Controlled Substance Audit tool. All areas of concern will be addressed during the audit including re-educating nurses. The Administrator will review and initial the audits weekly x 4 weeks then monthly x 1 month to ensure all areas of concerns were addressed appropriately.The Administrator or Director of Nursing will present the findings of the audit tools to the Quality Assurance Performance Improvement Committee monthly for 2 months. The Quality Assurance Performance Improvement Committee will meet monthly for 2 months and review the audit tools to determine trends and/or issues that may need further interventions and the need for additional monitoring. The Quality Assurance Performance Improvement meetings were held on 10/08/25 for July and August.Date of Compliance: 6/26/25.Validation of the corrective action plan was completed onsite 12/19/25 by reviewing the staff education conducted along with the corresponding sign-in attendance sheets, interviews conducted with staff and residents, and monitoring tools put into place. Review of the monitoring tools revealed narcotic medications on all medication carts were audited weekly beginning 06/30/25 through 07/28/25 and were initialed as reviewed by the former Administrator with no concerns identified. The results were reported to the QAPI committee for suggestions and/or recommendations.Observations of medication administration revealed nurses and MAs reviewed the physician orders, the medication label, and MAR prior to administering resident medication. All the medications were administered as ordered without any issues. Residents with controlled narcotic medications had a declining count record that matched the remaining amounts.Interviews with nurses and MAs on various shifts revealed they had received in-service education related to Misappropriation of Resident's Property which included immediately reporting any discrepancies and were able to describe the process for returning discontinued medications to the pharmacy. Interviews with alert and oriented residents and family members of cognitively impaired residents revealed no concerns related to medication administration or uncontrolled pain.The corrective action plan completion date of 06/26/25 was validated.

Based on record review, observation, and interviews with the Registered Dietitian (RD) and staff, the facility failed to follow the physician's diet order for double portions at breakfast and the enriched meal program for 1 of 5 residents reviewed for nutrition (Resident #52). Findings included: Resident #52 was admitted to the facility on [DATE] with diagnoses including adult failure to thrive and moderate protein-calorie malnutrition. The admission Minimum Data Set assessment dated [DATE] revealed Resident #52 was severely impaired cognitively, required partial to moderate assistance with eating, had no swallowing disorders, weighed 101 pounds with no documented weight changes, and had a stage two (partial-thickness loss of skin with exposed dermis) pressure ulcer that was present on admission. Review of the RD progress note dated 10/27/25 included recommendations Resident #52 participated in the enriched meal program and received double portions at breakfast. Review of the physician's orders revealed a diet order dated 10/27/25 for double portions at breakfast and participation in the enriched meal program. The nutrition care plan initiated on 11/06/25 identified risk for weight changes related to varied intake and diagnoses. Interventions included to provide diet as ordered.During an observation on 12/16/25 at 8:12 AM, Resident #52 had received a breakfast meal that consisted of 2 pieces of bacon, 3 French toast sticks, a container each of orange and grape juice. Resident #52's diet card indicated, Special diets: double portion breakfast, enhanced meal program, 8 ounces of chocolate milk, and 8 ounces of oatmeal and listed grits as a dislike. However, the tray did not include chocolate milk or oatmeal. An interview was conducted on 12/16/25 at 8:18 AM with Nurse Aide (NA) #3. NA #3 revealed he helped serve breakfast trays to the residents on the unit but did not serve Resident #52. NA #3 read the diet card instructions and confirmed Resident #52 was supposed to receive double portions and there was no oatmeal or chocolate milk on the tray. NA #3 did not know what the enriched meal plan meant. During an interview on 12/16/25 at 3:14 PM, the Dietary Manager revealed the dietary staff member who placed Resident #52's breakfast tray on the serving cart was responsible for ensuring the food served matched the instructions on the diet card. A second interview was conducted on 12/17/25 at 3:30 PM with the Dietary Manager. The Dietary Manager revealed for double portions, Resident #52 should have received four pieces of bacon and four French toast sticks. The Dietary Manager further revealed that on 12/16/25 cheese grits were served as the enhanced meal food item but was listed as a dislike on Resident #52's diet card. The Dietary Manager revealed Resident #52 should have received the substitute for the enriched meal plan which was fortified milk or an essential breakfast drink. An interview was conducted on 12/19/25 at 2:51 PM with the RD. The RD explained Resident #52 was underweight with a stage two pressure ulcer at admission. The RD explained the enriched meal program included food items like oatmeal that was made with sugar and milk for extra calories and double portions were ordered because Resident #52 consumed more at breakfast. The RD confirmed meals served should match the diet card.During an interview on 12/19/25 at 3:49 PM, the Administrator stated the food served to Resident #52 should match the physician's order and diet card.

Based on record review, observations, and staff interviews, the facility failed to implement their infection control policy and procedures for Enhanced Barrier Precautions (EBP) when Nurse #2 did not put on a protective gown prior to a high contact care activity that involved administering a nutritional supplement and water flushes through a resident's (Resident #45) feeding tube (a medical device inserted into the stomach). This occurred for 1 of 5 staff members reviewed for infection control practices (Nurse #2). Findings included: The facility's Infection Control Policy and Procedures guideline for initiation of precautions last revised on 6/13/24 read in part, isolation precautions for EBP was utilized by staff for residents who had an implanted medical device when providing care and precautions included to wear a gown. A continuous observation on 12/15/25 at 12:04 PM through 12:27 PM revealed an EBP sign was posted on the door of Resident #45's room with instructions staff must wear a gown for high contact resident care activities. High contact care activities listed included use of a feeding tube. An over-the-door storage bin was in place and contained protective gowns available for use. Nurse #2 accessed Resident #45's feeding tube to administer water flushes and a nutritional supplement. Nurse #2 did not wear a protective gown during high-contact care of Resident #45's feeding tube. During an interview on 12/19/25 at 11:31 AM, Nurse #2 revealed Resident #45 had been on contact precautions, but she was told the precautions had been removed. Nurse #2 revealed she was not aware Resident #45 was under any type of precautions at the time she completed the tube feeding. An interview was conducted on 12/19/25 at 10:27 AM with the Staff Development Coordinator/Infection Preventionist in the presence of the Director of Nursing (DON). The Staff Development Coordinator/Infection Preventionist revealed she recently started at the facility, and she and the DON worked together on Infection Control. The Staff Development Coordinator/Infection Preventionist stated Nurse #2 should have put on a protective gown when she administered the water flushes and nutritional supplement for Resident #45's feeding tube. An interview was conducted on 12/19/25 at 10:27 AM with the DON. The DON revealed she worked with the Staff Development Coordinator/Infection Preventionist because she recently started her position at the facility. The DON revealed Nurse #2 should have put on a protective gown when she administered the water flushes and nutritional supplement for Resident #45's feeding tube.

Based on record review and interviews with resident, staff, Medical Director (MD) and Pharmacy staff, the facility failed to have effective systems in place for acquiring and maintaining the supply of medications in the controlled medication emergency kit which resulted in an as needed pain medication not being available for Resident #1 when he was admitted to the facility. This deficient practice occurred for 1 of 3 residents reviewed for pharmacy services (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery, hypertension, type 2 diabetes mellitus. Resident #1 went to the emergency room within 24 hours of admission, returned to the facility, and discharged to the hospital on 9/1/2025.During a telephone interview on 9/3/2025 at 1:52 PM Resident #1 stated he arrived at the facility late in the evening on the day he was admitted and was told he would not get any medication for at least 12 hours. Resident #1 stated he rang the call light and staff responded, but his medication was not available. Resident #1 stated he knew they gave him something at the facility, but it wasn't the pain medication that helped, so he called 911 to go to the hospital to get his pain medicine.The physician's orders dated 8/19/2025 revealed Resident #1 had the following orders: Oxycodone HCL 5 milligrams (mg) give one tablet by mouth every 4 hours as needed for pain scale 4-6 for 7 days Tramadol HCL 50 mg give one tablet by mouth every 8 hours as needed for pain scale 1-3 for 14 days. Acetaminophen 325 mg give two tablets by mouth every 4 hours as needed for pain Hydromorphone HCL 2mg give 0.5 (half) tablet by mouth every 6 hours as needed for pain for 7 daysReview of Resident #1's hospital discharge summary revealed the facility physician's orders were accurately transcribed from the discharge summary.The physician's order dated 8/20/2025 revealed Resident #1 had the following orders: Tramadol 50mg HCL give 50mg by mouth one time only for pain for one dayThe August 2025 Medication Administration Record (MAR) revealed Resident #1 received: Tramadol HCL 50mg on 8/19/2025 at 11:15 PM Acetaminophen 650mg on 8/20/2025 at 2:05 AM. Tramadol HCL 50mg on 8/20/2025 at 2:30 AM. Hydromorphone 1mg on 8/20/2025 at 10:52 AM Hydromorphone 1mg on 8/20/2025 at 5:48 PM.Review of Resident #1's electronic medical record revealed an admission pain assessment was completed on 8/20/2025 at 1:27 AM, indicated Resident #1 had a pain level of 8, described as aching/penetrating to the right knee. The assessment also revealed Resident #1 had an as needed (PRN) medication ordered and it was effective in relieving pain.Review of a progress note written by Nurse #1 revealed Resident #1 arrived at the facility just prior to the start of her shift. Resident #1 rang requesting pain medication, and Nurse #1 explained the orders had to be verified by the doctor and entered into the system and not all of the medications would be available right away, which included the hydromorphone and oxycodone. Resident #1 was upset that all his medications were not all available. Nurse #1 administered Tylenol and Tramadol as ordered. Nurse #1 made several rounds on Resident #1 after the PRN pain medications were administered and Resident #1 was sleeping. Resident #1 rang for pain medication at 2:05 AM, Nurse #1 contacted the on-call Nurse Practitioner and received an order for a one-time dose of Tramadol HCL 50mg. Resident #1 yelled at Nurse #1 that he wanted to leave because the facility did not have his medications and were not prepared to take care of him. Nurse #1 prepared to call the hospital and was informed by Nurse #2 that Resident #1 had called 911 on his own. Nurse #1 called Emergency Medical Services (EMS) and the local hospital, gave report on Resident #1, the Director of Nursing (DON), on-call NP were notified, and Resident #1 was transported by EMS to a local hospital.During a telephone interview on 9/3/2025 at 5:17 PM Nurse #1 stated she worked a twelve-hour shift that started at 7:00 PM on 8/19/2025, when she arrived for her shift at approximately 6:45 PM the ambulance that had transported Resident #1 to the facility was still in the parking lot. Nurse #1 stated some hard scripts for pain medication had arrived with Resident #1 when he was admitted on [DATE], she thought it was for Tramadol and Hydromorphone, and possibly oxycodone, but she didn't remember specifically. Nurse #1 stated when she first assessed Resident #1, he did not complain of pain. Nurse #1 stated when Resident #1 complained of pain, Nurse #2 assisted Nurse #1 by entering Resident #1's orders, and acetaminophen and tramadol HCL were administered to Resident #1, since hydromorphone was not a stocked medication, and oxycodone was out in the controlled medication emergency kit. Nurse #1 stated Resident #1 was upset that all his medications were not available and Nurse #1 explained, they did not have the hard scripts and orders until Resident #1 arrived, and if the administered pain medication did not work Nurse #1 would call the on-call provider. Nurse #1 stated Resident #1 then went to sleep for a few hours and woke up and complained of pain again. Nurse #1 contacted the on-call provider since there was no oxycodone, and it was not time for another dose of Tramadol. Nurse #1 stated she reported to the NP what pain medications were available in the controlled medication emergency kit, and a one-time order for another Tramadol 50mg was received. Nurse #1 stated when she administered the second dose of Tramadol 50mg, Resident #1 grabbed the medicine cup from her and stated he wanted to go to the hospital. Nurse #1 stated as she prepared to call the hospital, she received a call from Nurse #2 that Resident #1 had called 911 to be taken to the hospital, and the hospital was on the phone to verify if transport was needed. Nurse #1 stated she spoke to the hospital and EMS and Resident #1 was transported to the hospital and did not return during the rest of her shift. Nurse #1 stated she did not recall another time the oxycodone had run out in the controlled medication emergency kit prior to 8/19/2025. Nurse #1 also stated there had been a few admits that same day. Nurse #1 stated she thought orders had to be in to the pharmacy by 4:00 PM in order for new admissions medications to be received that day. Nurse #1 stated Resident #1 had been admitted after the cut-off time for the pharmacy, so the medications that were not in back up would arrive in the delivery the following day.During a telephone interview on 9/3/2025 at 3:18 PM Nurse #2 stated she worked on 8/19/2025 from 7:00 PM to 7:00 AM but was not assigned to Resident #1. Nurse #2 stated she answered a phone call from Resident #1, and he stated he wasn't getting any pain medication. Nurse #2 looked at his electronic record and noted no orders had been entered and went to help Nurse #1. Nurse #2 stated she assisted Nurse #1, entered orders and obtained Tramadol from the controlled medication emergency kit. Nurse #2 stated the controlled medication emergency kit was out of oxycodone and that was not the first time that had happened but did not recall the other dates it had occurred.Unable to interview the Nursing Assistant (NA) assigned to Resident #1 on 8/19/2025.During an interview on 9/3/2025 at 12:14 PM the Medical Director (MD) stated Resident #1 was admitted on [DATE] with 3 different controlled medications for pain and the hydromorphone is the only pain medication that the facility did not stock in the controlled medication emergency kit. The MD stated Resident #1 arrived late in the evening on 8/19/2025 and only arrived with two pieces of paper from the hospital not the full discharge summary. The MD stated the facility was trying to cover Resident #1's pain with the controlled medication emergency kit medications until the hydromorphone was available, but Resident #1 called 911 himself early in the morning on 8/20/2025, was sent to the hospital, received pain medication and was sent right back to the facility. The MD stated the facility normally had oxycodone in the controlled medication emergency kit. The MD stated on 8/20/2025 an emergency order for Hydromorphone was sent to a local pharmacy.During a telephone interview on 9/3/2025 at 12:37 PM Nurse #3 stated she had not worked when Resident #1 was admitted but heard Resident #1 called 911 himself after being admitted . Nurse #3 stated there is a controlled medication emergency kit that contains medications that can be pulled for new orders or new admits. Nurse #3 stated they medications in the controlled medication emergency kit are not ordered consistently and there have been other times when medications that were supposed to be in the kit have run out. Nurse #3 stated she was assigned to Resident #1 a day or two after his admission and all his medications had arrived from the pharmacy.During an interview on 9/3/2025 at 12:45 PM Nurse #4 stated she worked 8/20/2025 from 7:00 AM to 7:00 PM and was assigned to Resident #1. Nurse #4 stated she thought Resident #1 had been admitted late in the evening on 8/19/2025, called 911 himself and was transferred to the hospital then returned from the hospital early during Nurse #4's shift. Nurse #4 stated that if new residents' orders were not sent into the pharmacy before 5:00 PM they would not arrive until the next day.During an interview on 9/3/2025 at 1:15 PM the admission Coordinator stated Resident #1 did not arrive until almost 7:00 PM on 8/19/2025 due to an issue with transportation. The admission Coordinator stated she was not involved with the resident's medication orders, they are given to the nurse to verify and be entered into the system. The admission Coordinator stated she completed paperwork with Resident #1 on the evening of 8/19/2025 and Resident #1 had not voiced any complaints of pain and did not appear to be in any distress. The admission Coordinator stated she had been told Resident #1 had gone out to the hospital after admission and returned to the facility. The admission Coordinator stated she checked in on Resident #1 on 8/20/2025, Resident #1 voiced he had some pain, but did not appear to be in distress and did not voice any complaints.During an interview on 9/3/2025 at 3:15 PM the Director of Nursing (DON) stated she checked the controlled emergency medication kit on Mondays and Fridays. The DON stated that when the controlled emergency medication kit needed to be refilled, she faxed the DEA 222 form to the pharmacy so they knew she needed the medication, and the courier would know it needed to be picked up. The DON stated the process had recently changed and now they did not receive the medication on the day she faxed the form; the medication came back a few days later after being processed by the pharmacy. The DON stated she completed the form on 8/18/2025 and faxed it to the pharmacy. The DON stated during the courier exchange on 8/18/2025 the pharmacy courier had left paperwork from the pharmacy tote on the desk, and it had not been taken back to the pharmacy. The DON stated she changed the date on the form to the 19th, because the forms were really expensive, and called the pharmacy to report the papers being left and was told the courier had been fired. The DON stated the medications did not arrive on 8/19/2025 so she refaxed the form and called the pharmacy regarding the medications that needed to be refilled. The DON stated on 8/20/2025 the medication for the emergency kit had still not arrived and she faxed the form again and called the pharmacy and was told she had to send the original form to the pharmacy for it to be filled. The DON provided a copy of the DEA 222 form she had referenced. The date on the DEA 222 form read 8/18/2025 that appeared to have been changed from 8/19/2025.During a telephone interview on 9/3/2025 at 3:59 PM the Pharmacist stated the facility ordered #12 oxycodone 5mg tablets on 6/18/2025 and 8/21/2025. The Pharmacist stated controlled medications for the emergency kit are only dispensed from an original hard copy of the DEA 222 form, never filled from a faxed form. The Pharmacist stated she would provide the policy for ordering medications for the controlled medication emergency kit. The Pharmacist stated they filled controlled medication emergency kits per the state guidelines.During a telephone interview on 9/3/2025 at 4:06 PM the Pharmacy Manager stated they did not have a record of a faxed DEA 222 form from the facility from 8/18/2025, 8/19/2025, 8/20/2025. The Pharmacy manager stated they did not refill the controlled medication emergency kit medication from a faxed form. The Pharmacy manager stated if the DON had called and reported there was an emergent need for the controlled medication emergency kit, they would send the medications to be delivered only if the original DEA 222 form was present at the facility for the courier to exchange, otherwise the normal process is the completed DEA 222 form is placed into the medication tote in an envelope labeled that the DEA 222 form in inside, for the courier to pick up, then the next day it is processed in the pharmacy and delivered back to the facility. The Pharmacy Manager provided an emailed copy of the DEA 222 form the pharmacy had received from the facility with a date of 8/19/2025. The form order number matched the copy provided by the DON.Review of the Policy titled: Procedure for the completion of DEA FORM 222 Policy: that was dated June of 2021 revealed under Procedure:2. If at any time a discrepancy in the entry of data on this DEA Form 222 is made, do not make corrections. [NAME] the form VOID in large letters, keep the voided form on file, and start over with a new form. The pharmacy cannot accept any form on which corrections or alterations have been made. 3. After completion of the DEA Form 222, the Purchaser (facility staff member) shall make a copy of the Form and send the original Form to [NAME] Medical Group via Pharmacy Courier. In an emergency, if the existing supply is out or nearly out and a refill supply is needed that evening, one may fax the DEA Form 222 to the pharmacy and place the original in the pharmacy delivery tote in an envelope labeled Attention Pharmacist, DEA Form 222. When the pharmacy courier reaches the facility, he will present a Pick-Up and Delivery form guiding him to pick-up the original copy of the DEA Form 222 in exchange for the emergency kit medications. 4. Retain the copy of DEA Form 222, fill in quantity of medication received, and date received (Part 5) when the replacement medications are actually received by the facility. Keep this copy on file in the facility for a period of not less than two (2) years.During a follow up interview on 9/4/2025 at 8:34 AM the Pharmacy Manager stated the pharmacy did not require a fax for the controlled medication emergency kit to be refilled, that was not part of the policy. The Pharmacy manager stated there was no record of calls or faxes regarding the controlled medication emergency kit from 8/18/2025 through 8/19/2025. The Pharmacy manager stated she was not aware of any papers that had been left out in a facility by a courier. The Pharmacy Manager stated the process for couriers is to pick up the pharmacy totes and contents at every delivery. If controlled medications are being returned the form must be faxed so the courier can match what is being picked up for verification. The Pharmacy Manager stated the DEA 222 form used to order the controlled medication emergency kit is supposed to be placed in the pharmacy tote for the courier to pick up. The normal process is the courier drops off a new tote and picks up the old tote on every delivery. The Pharmacy Manager stated if the facility had called and told them they were out of medication for the controlled medication emergency kit on 8/19/2025 they could have faxed the form, and the pharmacy would have done an emergency exchange for the original form. The Pharmacy Manager stated they do not have a copy of the inventory of the facility's emergency kit. The Pharmacy Manager stated medications can be ordered for replacement for the controlled medication emergency kit seven days a week. The Pharmacy Manager verified the most recent DEA 222 form received from the facility was dated 8/19/2025 and was received in the pharmacy on 8/21/2025 and filled that day.During a telephone interview on 9/4/2025 with the [NAME] President of the Pharmacy and the Pharmacy Manager, the [NAME] President of the Pharmacy stated normally the DEA 222 form is filled out, sealed in an envelope labeled Attention Pharmacist and placed in the tote then it could take 24 hours to be processed and filled. The [NAME] President of the Pharmacy stated the controlled medication emergency kit was an option the facility had and was not required. The [NAME] President of the Pharmacy stated the root cause of the issue was the late admission and the hospital sending the resident with unusual and multiple medications. The [NAME] President of the Pharmacy also verified the original DEA 222 form the pharmacy had was dated 8/19/2025.During a follow up interview on 9/4/2025 at 11:26 AM with the DON and Regional Corporate Nurse, the DON stated the pharmacy did not get the forms from the 8/18/2025 when it was left by the courier, so the date was changed, and it was refaxed on the 8/19/2025 and said it was an emergency. The DON verified the copy of the DEA 222 form she had provided looked like the date was changed from a 19 to 18 but stated she did not make that change. The DON stated she had a DEA 222 form with 8/18/2025 on it but was unable to provide the form. The DON was unable to provide the declining count sheet for the oxycodone from the controlled medication emergency kit from June and July of 2025 to show when the oxycodone had run out. The DON stated the completed declining narcotic sheets were normally placed in a binder after they were put in her box, but a new policy started the 3rd week of August, that the completed declining narcotic sheets were put in a black box that the DON could open with a key. The DON stated she was on vacation at the end of July, and the former Administrator and Staff Development Coordinator were supposed to cover and file them for the DON, but those staff members were no longer working at the facility. The DON stated she normally checked the controlled emergency medication kit on Mondays and Fridays but did not have a record of the inventory when it was checked. The DON stated she would just take a piece of paper, look at the declining inventory sheet and order what was needed, or sometimes the nurse on the hall would text her how many were left in the kit. The DON stated ideally the facility would have the medication ordered for the residents. The DON indicated she now knew the specifics of the policy to reorder the controlled medication emergency kit, and she would follow the policy from now on. The DON further stated she had been keeping up with it by herself but had support now.During an interview on 9/4/2025 the Administrator stated he expected the policy to be followed for the reordering of the medications in the controlled medication emergency kit, and he expected the facility to have medications available for the residents.

Based on observations, record review and staff interviews, the facility failed to dry insulated bases, lids, pans and baking sheets before they were stacked for use, failed to store perishable food off the floor, failed to remove a dented canned good item stored for use, and failed to discard expired food and food items with signs of spoilage stored in 1 of 1 walk-in cooler and main dining room refrigerator. In addition, the facility failed to cover facial hair during food preparations. These practices had the potential to affect food served to residents. The findings included: a. An initial tour of the kitchen occurred on [DATE] at 10:34 AM with [NAME] #1 which revealed stacked wet items on tray line and storage rack: - 12 of 50 insulated bases - 10 of 10 dome lids - 2 rectangular pans - 3 deep rectangular pans - 2 small, deep rectangular pans - 2 long, rectangular pans - 5 large baking sheets An interview with [NAME] #1 on [DATE] at 11:03 AM revealed all kitchen staff were responsible for making sure dishware was dry before stacking. During a combined interview on [DATE] at 12:26 PM with Nutrition Consultant #1 and Nutrition Consultant #2, they both expressed that all kitchen staff should be able to recognize when dishware was still wet before stacking and education to all kitchen staff was conducted. They also verbalized they ordered additional plastic racks to store clean equipment and dishware to allow air drying. b. During an initial tour of the kitchen on [DATE] at 10:46 AM, a box of potatoes was found on the floor with one potato on the floor inside the dry storage room. An interview with [NAME] #1 on [DATE] at 11:01 AM revealed she was in a hurry when preparing breakfast and placed the box of potatoes on the floor. Dietary staff #1 threw out the box of potatoes on [DATE] at 11:03 AM. An interview with the Dietary Manager (DM) on [DATE] at 12:26 PM revealed the food items should be placed on top of plastic milk carts found in the dry storage area. c. During an initial tour of the kitchen on [DATE] at 10:50 AM, one 6.63-pound (lb) can of beef stew was found on the shelf ready for use was observed with a dent around the rim/seal of the lid approximately of 1.5 inches in length and 0.5 inches deep. An interview with the DM on [DATE] at 12:28 PM revealed there was no dedicated area to place dented cans. He verbalized that the facility would assign an area where to place dented cans. d. The following food items were observed in the walk-in-cooler on [DATE] at 10:54 AM. A bag of shredded mixed cheese opened but not dated. A 5 pound sealed sour cream container with expiration date on [DATE]. A tub of pimiento spread unsealed, not dated and observed with black, green substance on lid edges and around the top of the container. The expiration date was unable to read. An Italian pasta salad container was opened and not dated with expiration on [DATE]. An interview with [NAME] #1 on [DATE] at 11:01 AM revealed that whoever opened, stocked, or used the food items last were responsible for labeling and dating food items. During an interview on [DATE] at 12:32 PM, the DM stated that all kitchen staff were responsible in labeling, dating and throwing away expired food items. The DM stated the kitchen staff would label food items when they came in from the supplier. e. Review of facility policy regarding outside foods indicated that food items must be approved by and cleared through the licensed supervisor, hall nurse, administrative nurse, or the Director of Nursing before being given to the resident. During an observation on [DATE] at 12:34 PM, a 30 fluid ounce container of mayonnaise with a best by date of [DATE] and 16 ounce thousand island dressing with best by date of [DATE] were found inside the refrigerator in the dining room at the Main Hall. An interview with the DM on [DATE] at 12:54 PM stated the refrigerator in the dining room was not monitored or observed by the dietary. He stated he was not aware who was responsible for that refrigerator. He stated he had only been at the facility for 3 months and was still learning his duties. A follow-up interview with the DM on [DATE] at 12:50 PM revealed one resident ordered food items online and placed them inside the refrigerator and would get upset if his food items were thrown away. f. During an observation on [DATE] at 12:08 PM, NC #1 was observed doing food temperatures without a beard guard. NC #1 had hair covering his jaws, around the mouth and chin. The DM was observed without a hair net or beard guard. The DM's head was shaven, and he had hair covering around his mouth and chin. NC #2 was wearing a hair net but had no beard guard. NC #2 has hair covering his chin. Both the DM and NC #2 were standing by the steam table while the cook was plating food. An interview with the DM on [DATE] at 1:05 PM revealed that hair nets were available for staff to use as they walked into the kitchen. The DM verbalized he did not wear a beard guard if he was not near food. NC #2 verbalized he thought a certain length of beard would require the use of beard guards. During an interview on [DATE] at 2:15 PM, the Administrator verbalized the DM had only been with the facility for a couple of months. The Administrator stated the pimiento spread was not on the facility's menu and there was a resident that preferred pimiento spread for sandwiches. She said it was an oversight of the kitchen staff for not throwing out the pimiento spread.

Based on observations and staff interviews, the facility failed to maintain the grounds surrounding one of two trash dumpsters free of broken equipment and to keep the grease trap surrounding area clean and free from debris. These failures had the potential to impact sanitary conditions and to attract pests and rodents. The findings included: An observation of the dumpster area was conducted on 09/24/24 at 12:53 PM with the Dietary Manager (DM). The trash observed around one of two dumpsters were the following: - dirty linen/cart containing cardboard boxes, plastic bags, rinse aid pail with cover - one recliner - 4 folded wheelchairs - Four, 15-gallon plastic containers - bleach, laundry detergent, fresh liquid alkali (concentrated laundry builder that prepares the fabric for the washing process), liquid detergent - 2 1/2 wooden pallets resting on the building wall - one stainless steel rack - 3 wooden planks resting on the building wall An observation of the grease trap was conducted on 09/24/24 at 1:00 PM with the DM. The area surrounding the grease trap included old cardboard, paper towels, cellophane wrappers, plastic lids, pine straw, cigarette butts and food scraps. During an interview with the DM on 09/24/24 at 1:05 pm, the DM stated he was aware of the items around the dumpsters and the grease trap but stated he did not know who to report the issue to nor was he aware that it was his responsibility to ensure the areas were maintained. An interview was completed on 09/25/24 at 2:15 PM with the Administrator. She verbalized that the DM had only been with the facility for a couple of months. The Administrator stated the facility would have done something different if they knew that broken equipment was out there. The Administrator verbalized that it was an oversight on their part.

Based on observations and staff interviews, the facility failed to maintain the privacy of a resident's record by leaving a medication cart laptop unattended with resident health information exposed in an area accessible and visible to the public on 1 of 2 medication carts (medication cart #1). The findings include: During a continuous observation of Main Hall on 9/24/24 from 3:38 PM to 3:40 PM, medication cart #1 was observed unattended. The laptop screen was open and displayed resident information including, names, medications, and diagnosis. Several staff members and two visitors were observed passing by medication cart #1 while the laptop screen was open with the resident information exposed in an area accessible and visible to the public. On 9/24/24 at 3:40 PM Nurse #2 was observed returning to medication cart #1 from the nurse's desk that was approximately 20 feet away. An interview with Nurse #2 was completed on 9/24/24 at 3:40 PM. Nurse #2 reported she usually would have minimized the patient information screen to hide resident information when walking away from the medication cart. Nurse #2 went on to say she was just standing at the nurse's station and did not think about minimizing the screen, but normally she would. An interview was completed on 9/25/24 at 12:21 PM with the Director of Nursing (DON). During the interview the DON stated resident health information on the laptop screen should have been hidden by either minimizing the screen or locking/closing the laptop anytime the Nurse or Medication Aide walked away from the medication cart. The DON went on to say Nurse #2 should have made sure the laptop screen was hidden, and no personal health information was visible before she walked away from the medication cart.

Based on observations, record reviews, resident, staff, Pharmacy Consultant and Medical Director (MD) interviews, the facility failed to protect the resident's rights to be free from misappropriation of controlled substance for 1 of 1 resident reviewed for misappropriation of resident property (Resident #43). The findings included: Resident #43 was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome and phantom limb syndrome with pain. A review of the Physician orders for Resident #43 showed an order with a date of 10/3/23 for Oxycodone 10 milligrams (mg) (narcotic pain medication/controlled substance) to be given by mouth three times a day. A review of the electronic medication administration record (eMAR) for 3/1/24 through 3/21/24 revealed Resident #43 had received the Oxycodone 10 mg three times a day for the entire month. A review of the packing slip from the Pharmacy dated 3/22/24 showed 60 tabs of Oxycodone 10 mg had been delivered for Resident #43 and signed by Nurse #7. A review of the controlled substance count record dated 3/22/24 showed there were 6 tablets of Oxycodone 10 mg remaining for Resident #43. Review of the shift change controlled substance count check sheets revealed missing information between 3/5/24 and 3/28/24. Review of the eMAR for 4/1/24 through 4/30/24 showed Resident #43 had received the Oxycodone 10 mg three times a day every day of the month. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was cognitively intact and received routine pain medication during the 7-day lookback period. Review of the Initial allegation Report dated 4/4/24 read that there had been a suspected controlled substance diversion of Resident #43's narcotic pain medication following an attempt by the Assistant Director of Nursing (ADON) to refill narcotic medication from the pharmacy. There were 6 tablets of Oxycodone left on Resident #43's medication card. The ADON spoke with the pharmacist and was told there had been 60 tablets of Oxycodone delivered on 3/22/24. After reconciliation of the medication rooms and medication carts in the facility it was noted 19 tablets of Oxycodone was missing. The Administrator, Pharmacy, and Nurse Consultant were notified immediately. The Department of Public Safety was also notified. Nurse #7 was mentioned in the investigation and was suspended. A review of a statement by Nurse #8 signed and dated 4/4/24 read in part: Nurse #8 remembered counting narcotics on 3/28/24 with Nurse #7 who was leaving from the night shift. Nurse #8 reported there were additional sheets that had to be removed on the Shift Change Controlled Substance count check form. Nurse #8 stated she had not seen the previous Shift Change Controlled Substance count check form. Nurse #8 voiced she would always check the count twice, counting sheets and medications. Nurse #8 also reported she had not had any issues with the count being incorrect. A review of a statement by Nurse #7 signed and dated 4/5/24 read in part: Nurse #7 remembered signing the 3/22/24 delivery slip for Oxycodone, 60 tablets, 2 cards for Resident #43. Nurse #7 signed the sheets as she normally would do. Nurse #7 remembered starting the new card of Oxycodone on 3/28/24 and there were 56 tablets in total that morning. Nurse #7 reported she did not remember throwing away the empty card the night before but started a new card the morning of 3/28/24. Nurse #7 reported signing off with Nurse #8. Investigational Summary dated 4/7/24 was reviewed and it revealed the following information: On 4/4/24, the ADON was assisting the Nurse Practitioner (NP) in ensuring residents had scripts for controlled substances prior to the weekend. The ADON noted Resident #43 needed medication and spoke to the pharmacy who sated Resident #43 was not eligible for Oxycodone 10 mg to be refilled due to having received 60 tablets on 3/22/24. The DON was notified immediately and upon further investigation the DON noted Resident #43 had 6 tablets on the current medication card. Resident #43 was scheduled for 10 mg tablet three times a day and he had received his medications with no missed doses. An interview was completed on 9/24/24 at 10:28 AM with Resident #43. During the interview Resident #43 reported he received routine pain medication, Oxycodone three times a day and recalled that he did not miss any of the doses of medication between the end of March 2024 and the beginning of April 2024 or have unrelieved pain. During an interview conducted on 9/24/24 at 1:03 PM with the ADON, she recalled the missing Oxycodone for Resident #43 and what steps had been taken following the discovery of the missing medication. She said all medication sign-in sheets and medication count sheets for the Main Hall medication cart were audited. During the audit it was noted the medication sign-in sheets and medication count sheets were missing. The ADON notified the Administrator and local police once the missing medication was discovered and Nurse #7, the nurse that checked in the narcotic medication, had been suspended. The ADON further explained there had been back-up Oxycodone kept in the facility and that was why Resident #43 had not missed any doses of the medication. The ADON reported since the incident anytime narcotic medications were delivered two nurses had to sign for them and all information was verified including how many medications and medication cards were received. An interview was completed on 9/24/24 at 3:23 PM with the Pharmacy Consultant. The Consultant was able to recall there had been an episode of drug diversion in the building in April 2024. She went on to say she had been notified of the incident and recalled anyone that had access to the medication cards and medications carts were drug tested and all the narcotic count sheets had been audited. The Consultant was unsure if missing 19 tablets of a narcotic medication, Oxycodone, was significant and did not see the need to contact any State of Federal agencies. On 9/24/24 at 4:36 PM a telephone interview was completed with the Medical Director (MD). During the interview the MD reported he was aware of the missing narcotic medication for Resident #43. The MD further explained 19 tablets of missing narcotics would be a significant amount and the loss should have been reported to himself, the police, and any other State or Federal agencies that were necessary. A telephone interview was completed on 9/24/24 at 5:33 pm with Nurse #7. During the interview Nurse #7 reported she was the Nurse that signed for the medications that had been delivered from the pharmacy on 3/22/24 for Resident #43. Nurse #7 reported she would administer medications to Resident #43 at times but could not recall when she last administered the medications. Nurse #7 went on to say she remembered checking and signing for 60 tablets of the narcotic medication, Oxycodone, for Resident #43 on the night of 3/22/24. During an interview with the Administrator on 9/24/24 at 6:31 PM she revealed as soon as she had been notified of the missing narcotic medication, she, along with the ADON and the Director of Nursing (DON) went to both medication carts to make sure the missing medication had not been misplaced. She went on to say witness statements were gathered from the nurses that had administered or checked in the medication from pharmacy. The Administrator also said the local Police and members of the facility corporate team had been notified of the missing medication and Nurse #7 was suspended. An additional interview was completed with the Administrator on 9/25/24 at 2:58 PM. The Administrator reported she had spoken with Resident #43 following the incident and notified him that the missing narcotic medication would be replaced at the cost of the facility. The Administrator explained after the incident the following entities were contacted; the pharmacy that delivered the medication, Adult Protective Services (APS), the local police department, the facility corporate office, Resident #43, and the facility Nurse Consultant. The Administrator voiced she felt like the missing 19 tablets of narcotic medication could be significant, but when she looked at the big picture, 19 tablets was a big number, but saying it was significant was subjective. The Administrator further explained that since the incident the facility corporate office made it clear on who and what entities needed to be contacted, but at the time they thought they were doing everything they should be doing.

Based on observation, staff and resident interviews, and record review, the facility failed to provide assistance with oral care for 1 of 2 dependent residents (Resident #30) reviewed for activities of daily living (ADL). The findings included: Resident #30 was admitted to the facility on [DATE] With a diagnoses of hemiplegia following cerebrovascular disease affecting left non-dominant side, muscle weakness, and chronic pain. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 required set-up assistance with oral care, and he had obvious or likely cavities, broken teeth, and inflamed or bleeding gums with loose natural teeth. A review of the Care Area Assessment (CAA) dated 2/11/24 showed Resident #30 had natural teeth that were in poor repair. Within the CAA, reference to a physician note date 1/8/2024 revealed Resident #30 had a diagnosis of necrotizing periodontal disease, chronic periodontal disease and gingival disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #30 was cognitively intact and required set-up assistance with oral hygiene. No behavioral symptoms or rejection of care were noted. Review of care plan last updated on 7/23/24 revealed the following problem: Care deficit pertaining to the teeth or oral cavity characterized by altered oral mucous membrane, problems with natural teeth/gums or other oral dental health problems related to broken teeth, gums in poor condition. Goal in place for Resident #30 to be free of infection in the oral cavity through the next review. Interventions included provide/assist with oral hygiene as needed. There were no care plan in place for refusal of ADL care. A review of the Dental Hygienist note date 8/12/2024 showed oral care was provided to Resident #30 that included hand scaling, paste polish, and flossing. Per Hygienist, oral hygiene was poor, and most teeth were broken, and thick, heavy plaque was present on teeth. Instructions were given to resident and a recommendation for Staff to assist/brush Resident #30's teeth twice a day. An observation was made of Resident #30 on 9/22/24 at 11:06 AM that showed teeth were with thick yellowish substance on teeth and chipped and missing teeth. An additional observation was made on 9/25/24 at 10:03 AM of Resident #30. A toothbrush was observed in a wash basin on the bedside table that was across the resident. There was no toothpaste observed on the table or in the wash basin. The wash basin was dry. A review of Resident #30's ADL documentation dated 9/10/24 through 9/25/2024 revealed there had not been any refusals of hygiene. A review of Resident #30's progress notes dated 8/2/24 through 9/24/24 did not show any episodes of refusal of care, specifically oral care. An interview was completed on 9/24/24 at 8:45 AM with Nursing Assistant (NA)#2. During the interview NA #2 reported Resident #30 would not let staff assist him with oral care, but he could benefit from additional assistance. NA # 2 went on to say Resident #30 will brush his teeth himself at times, but staff should be assisting to make sure he gets good oral care. An interview and additional observation of Resident #30 was conducted on 9/24/24 at 11:41 AM. Resident #30's teeth remained coated in a thick yellowish substance. Resident #30 reported he needed assistance brushing his teeth and his teeth should at least be brushed at night. Resident #30 denied any pain or discomfort. An interview with the Director of Nursing (DON) was completed on 9/24/24 at 1:09 PM. During the interview the DON reported recommendations from the Dentist were handed to the nurse and then given to the Physician when he was in the building. The Physician would sign off and return the recommendations to either the DON or the Assistant Director of Nursing (ADON) then uploaded into the computer system. The DON went on to say Resident #30 refused to have his teeth brushed but staff were supposed to provide set-up. The DON further explained staff needed to be at least applying toothpaste to Resident #30's toothbrush and assist with positioning and be sure to document any refusals of care. The DON further explained Resident #30's teeth were not being bushed as often as they needed to be. On 9/25/24 at 10:05 AM an interview was completed with NA #4, who was familiar with Resident #30. During the interview NA #4 revealed mouth care was offered daily, prior to each meal. NA #4 went on to say Resident #30 preferred to do mouth care himself and did not like staff helping him, but there was nowhere to document any refusals. NA # 4 reported if a resident ever did refuse oral care, he would notify the nurse, and the nurse could document refusals in the notes. During an interview with NA #6, who was familiar with Resident #30, on 9/25/24 at 10:09 AM it was revealed that anytime a resident refused care it should be documented in the NA charting. NA #6 further explained that if a resident had repeated refusals, the nurse would be notified. NA #6 also said she was not aware of any documentation showing Resident #30 refused oral care. An interview was conducted with Nurse #5 on 9/25/24 at 10:13 AM. Nurse #5 reported if a NA came to her about repeated refusals she would document those refusals in the resident's notes. Nurse #5 went on to say Resident #30 was independent with oral care and did not need assistance, however he was not able to get to his toothbrush or toothpaste. On 9/25/24 at 2:45 PM an interview was completed with the Administrator. The Administrator reported any resident that needed assistance with ADL care should receive that assistance and if they refused the care those refusals should be documented in the NA documentation and/or nurse's notes. The Administrator said Resident #30 was admitted with oral problems and did not allow staff to assist with oral care. The Administrator also reported oral care was kind of hit or miss and ADL care such as peri-care and bathing was looked at closer due to the ramifications of those care areas not being completed.

Based on observations and staff interviews, the facility failed to label tube feeding formula with the date and time the formula was hung and flow rate for 1 of 1 resident reviewed for tube feeding (Resident #26). The findings included: Resident #26 was admitted to the facility on [DATE] with diagnoses which included unspecified severe protein-calorie malnutrition and gastrostomy status (medical procedure where a tube is inserted through the abdominal wall and into the stomach). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was rarely/never understood and rarely/never understands. The nutritional approach while a resident was via feeding tube. Review of Resident #26's baseline care plan dated 05/29/24 revealed the resident was dependent on gastrostomy (G) tube for eating. The goal for Resident #26 was to maintain or achieve the highest practical level of functioning. Review of a physician order dated 08/05/24 revealed an order for Resident #26 to receive feeding formula infused at 55 milliliters (ml) per hour administered for 20 hours via pump infusion. Flush the enteral tube with 150 ml of water every 4 hours via pump. Tube feeding to be held for 4 hours daily at scheduled times (12 midnight). An observation conducted with Resident #26 on 09/23/24 at 10:03 AM revealed the resident's tube feeding formula bag was not labeled with the resident's name, date and time it was hung and flow rate based on order. The pump was running at 55 ml per hour. Another observation conducted on 09/24/24 at 10:05 AM revealed Resident #26's tube feeding formula bag was labeled with the resident's name and date but no time and rate. An interview with Med Aide (MA) #1 on 09/24/24 at 10:10 AM revealed that she can only stop, hold, and resume a feeding pump. She verbalized that the nurses were the ones responsible for giving medications, flush, disconnect, and reconnect feeding tube to the pump. NA #4 said she had basic training in tube feeding during orientation. During an interview on 9/24/24 at 10:19 AM, Nurse #3 confirmed she was currently assigned to care for Resident #26. Nurse #3 stated the nurse working night shift was responsible for labeling the tube feeding as a new set of feeding formula and tubing were required. Nurse #3 stated the label should indicate the name of the resident, the rate, the time and date the tube feeding was placed and the name or the initials of the nurse. Nurse #3 revealed she received her basic training in tube feeding during orientation. An interview conducted with the Director of Nursing (DON) on 09/25/24 at 1:25 PM revealed the nurses in the facility received training in tube feeding during orientation with each resident receiving tube feeding. They did a demonstration and return demonstration before they were assigned to these residents. The DON verbalized that the facility conducted in-service training and education modules. The DON mentioned several nursing responsibilities such as checking tube placement and properly labeling the formula. The DON also said the nurses have worked there for a long time. She thought the nurses became complacent in labeling because of doing things repeatedly.

Based on observations, record review, and staff, facility Corporate Dietitian, Dialysis Center Registered Dietitian, and Medical Director interviews the facility failed to obtain a physician order for the resident to receive dialysis, monitoring of the dialysis access site, and fluid restrictions for 1 of 1 resident reviewed for dialysis (Resident #4). The findings included: a. Resident #4 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD) and Dependence Upon Renal Dialysis. A review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had moderate cognitive impairment with unclear speech and required substantial to partial assistance with activities of daily living (ADLs). The MDS further showed Resident #4 received dialysis. During a review of Resident #4's care plan that was last updated on 7/9/2024 revealed Resident #4 was at risk for complications due to hemodialysis and attended dialysis 3 days a week, Monday, Wednesday and Friday. The goal read as follows; Will not experience complications from dialysis treatment without appropriate intervention. Interventions included Dialysis 3 days a week, communicate with dialysis treatment center as indicated for adjustments in resident's care and/or treatment plan, maintain dressing as ordered, monitor access site for bleeding and/or signs of infections, and Dressing to dialysis port to remain intact between dialysis days. A review of Resident #4's active orders revealed no order for dialysis that included frequency and no order for monitoring of access site. A review of Resident #4's electronic and hard copy medical record revealed the last communication sheet from the dialysis center was received July 10, 2024. Review of a progress note dated 9/23/24 showed a dialysis port to upper right side of chest with dressing that was clean, dry, and intact. A review of Resident #4's electronic medication administration record (eMAR) and electronic treatment administration record (eTAR) for the month of September revealed no place for documentation of access port care or place to document visits to the dialysis center. An interview with Nurse #2 on 9/24/24 at 10:19 AM revealed she was unsure of a dialysis book; however, the Facility Receptionist was the one that kept track of all appointments and paperwork from appointments. On 9/24/24 at 10:34 AM and interview with the Facility Receptionist revealed there was not a dialysis book, but the nurse would check the resident's vital signs and put it on a piece of paper that was sent with the residents to their appointments. During an interview with Nurse #3 on 9/24/24 at 4:56 PM she reported if there were no dialysis orders or access site orders in place for a resident then the MD would need to be contacted to give orders, otherwise the care needed for a resident would not be clear. On 9/25/24 an interview was completed with the Director of Nursing (DON). During the interview the DON reported the dialysis orders should have been restarted when Resident #4 returned to the facility following a hospital stay in March 2024 since he continued to need dialysis and attended dialysis 3 times a week, but the orders had not been restarted. The Assistant Director of Nursing (ADON) was interviewed on 9/24/24 at 10:57 AM. During the interview the ADON reported there was a dialysis form that was sent with the resident but it was usually not sent back to the facility. The ADON went on to say even though the dialysis center did not send back the communication form the facility was able to call and request the form be sent back. The ADON went on to say once the communications forms were received, they would be uploaded into the electronic record. The ADON was unable to speak on why there were no dialysis communication forms in the system since July 10, 2024, for Resident #4. The ADON interview further revealed residents with any kind of access must be checked upon return from dialysis and there should be an order set in place for all dialysis residents. The ADON reported there should have been dialysis orders in place for Resident #4 as well as orders to check the access port. An interview was completed on 9/24/24 at 4:24 PM with the Medical Director (MD). During the interview with the MD, it was revealed he did not believe an order for dialysis or access care was necessary if a diagnosis of ESRD was in place, but it would be nice to have orders for clarification. An interview was completed with the Facility Administrator on 9/24/24 at 4:00 PM. During the interview the Administrator reported Resident #4 had been out at the hospital in March of 2024 and orders for dialysis and access site care had not been restarted upon his return. The Administrator reported the expectation was to have orders in place for dialysis residents. b. During a review of Resident #4's care plan that was last updated on 7/9/2024 it showed Resident #4 had the potential for or actual fluid volume deficit due to fluid restrictions related to a renal diet, Dialysis 3x week, 1200 cubic centimeters (cc)/24-hour fluid restrictions. The goal in place for Resident #4 was to not demonstrate signs or symptoms of dehydration through the next review period. Interventions included restricted fluids to 1200ml/day. Review of Registered Dietitian (RD) note dated 7/15/2024 revealed Resident #4 was on a Renal diet, 1.2Liter fluid restrictions in place. A review of Resident #4's orders last reviewed on 9/5/2024 revealed there was no order in place for 1200 cc/day fluid restrictions. An observation on 9/22/2024 at 1:43 PM of Resident #4's meal ticket showed resident was on 1200cc /day fluid restrictions. There was one 8 ounce cup of fluid observed on the meal tray that equaled 236 cc's. During an additional observation of Resident #4's meal ticket on 9/25/2024 at 8:40 AM it read, 1200 cc daily fluid restrictions (840cc dietary/360cc nursing). There was an 8 ounce cup of fluid (236 cc's) and a smaller, 4 ounce cup of fluid (199 cc's) that equaled 355 cc of fluid on the tray. An interview was completed on 9/25/24 at 8:40 AM with Nursing Assistant (NA) #4. During the interview NA #4 reported he looked at the meal ticket before passing out any tray and he would ask the nurse about anything on the meal ticket that was different from what was on the tray, including fluids and fluid restrictions. NA #4 went on to say information could also be found under the resident care guide. Observation of the resident care guide for Resident #4 on 9/25/24 at 8:44 AM with NA #4 revealed the resident was on fluid restrictions per dialysis of 1200cc day. Interview with Nurse #5 on 9/25/24 at 8:49 AM revealed she would check a resident's orders for any discrepancies that was discovered or brought to her attention including diet orders and if there was no order in place she would notify the Physician. Nurse #5 was not aware there was not an order for Resident #4 in place for fluid restrictions. On 9/25/24 at 10:44 AM an interview was completed with the Facility Corporate Dietician. During the interview the Facility Corporate Dietician revealed any recommendations and changes in diet would usually be communicated with the Registered Dietician (RD) at the Dialysis facility. The Corporate Dietician went on to say if a resident was on fluid restrictions, then there should be an order in place stating what kind of fluid restrictions there should be. Corporate Dietician was not aware there was not an order in place for fluid restrictions for Resident #4, but there should have been one. A telephone interview was completed on 9/25/24 at 11:35 AM with the Dialysis Center Registered Dietician (RD) that Resident #4 attended. During the interview the Dialysis Center RD reported she was aware Resident #4 was to be on 1200cc/day fluid restrictions. The RD also reported, several attempts had been made to contact the facility via telephone and fax regarding Resident #4's nutrition orders/fluid restrictions and no one had returned the communications following the departure of the former facility RD in March of 2024. The Dialysis Center RD went on to say if a resident was on fluid restrictions, then there should be an order in place stating how much fluid should be received during the day from dietary and nursing. During an interview with the Director of Nursing (DON) on 9/25/24 at 2:22 PM it was revealed that Resident #4's previous orders should have been updated following his return from the hospital. She went on to say, usually an audit was completed of all new admissions, readmission, and order changes during morning meeting. The DON also reported a communication form was sent with residents to dialysis so changes, including any nutritional changes, could be communicated. The DON was not able to speak on why there were no dialysis communication forms in the electronic health system for Resident #4 since July 10, 2024. The DON concluded the interview by saying there should have been an order for fluid restrictions. On 9/2/24 at 2:54 PM an interview was completed with the Administrator where she reported staff attempted to have Resident #4 take in fluids due to his poor intake at times. She went on to say anytime there was a change in diet it would go on a dietary slip and be communicated with the dietary department. The Administrator did say there should have been an order for fluid restrictions if that was what was communicated from the RD.

Based on observations, record review, and resident and staff interviews, the facility failed to determine a resident's food preferences and failed to offer an alternative option. This occurred for 1 of 1 resident reviewed for choices (Resident #23). The findings included: Resident #23 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #23 was cognitively intact. A review of Resident #23's medical record revealed no food preference form. During an interview on 9/22/24 at 11:14 am Resident #23 stated he did not like chicken and did not wish to eat it. Resident #23 stated he did not ask staff for an alternate because he did not know he could. Resident #23 stated staff had not offered him an alternative when chicken was left on his plate. The resident stated he had not told a specific person that he did not eat chicken, but that he had complained about it to the staff that delivered and picked up his tray, when chicken came on his tray, which the resident stated was about 6 days a week. While in Resident #23's room on 9/22/24 at 1:23 pm, Nurse Aide (NA) #2 was observed to lift the lid on Resident #23's lunch plate which revealed two full pieces of chicken that remained untouched. Resident #23 told NA #2 he left the chicken on the plate and wrote on the tray ticket that he did not like chicken. NA #2 told Resident #23 she was sorry and knew the facility had chicken a lot then took the tray and left the room without offering Resident #23 an alternative food option. During an interview on 9/24/24 at 9:26 am NA #2 stated she would offer the resident a sandwich if the resident had untouched food on their tray and then contact the kitchen to let them know that a resident didn't like what was served. NA #2 confirmed that on 9/22/24 she had not offered an alternate to Resident #23 when there was untouched chicken on the plate and Resident #23 told her he did not like it and wrote that on the diet slip. NA #2 stated she didn't want to bother the resident since he had a visitor in the room. Review of Resident #23's breakfast meal ticket on 9/23/24 at 9:04 am revealed there were no dislikes listed. During an interview on 9/24/24 at 9:11 am Nurse #3 stated if a resident left food untouched on a plate, she would expect to be told by the NA that picked up the tray. Nurse #3 stated she would assess to see if that was a normal occurrence, if not, an assessment would be completed. Nurse #3 stated that if a resident told a NA they didn't like a certain food or wrote it on the diet slip, she would expect the NA to bring the diet slip to a nurse and the nurse would let dietary know or ask social work, admissions or activities to follow up about preferences. Nurse #3 stated the NAs that picked up meal trays should ask the resident if they wanted something else if they saw food left on a plate, and that leaving the room without offering another option was not the appropriate response because the resident should have been offered an alternate for the food left on the plate. During an interview on 9/24/24 at 9:17 am NA #1 stated if there was untouched food on a residents' tray, she would ask why they didn't eat and offer to get them something else and then let a nurse or dietary know. During an interview on 9/24/24 at 9:22 am Nurse #2 stated if a NA saw untouched food on a plate when it was picked up, she would expect them to tell the nurse, for the nurse to assess and find out what the resident would want to eat. Nurse #2 said it had not been reported to her that Resident #23 did not like chicken. During an interview on 9/24/24 at 9:41 am the Admissions Coordinator stated a food preferences form was completed by admissions, normally on the day a resident was admitted . The Admissions Coordinator explained they had an old form that was not very good, but a new form had been introduced on 07/25/24. The Admissions Coordinator expected the Dietary Manager to be notified by the NA or nurse if a resident had not eaten or if they didn't like a specific food. The Admission Coordinator stated that a preference sheet for Resident #23 had not been completed upon his admission. During a follow-up interview with the Admission Coordinator on 9/25/24 at 8:41 am he stated that the old food preference form had not been completed on Resident #23 because they had stopped using the old form on 7/25/24 and he had until 10/01/24 to have it completed. He further stated he was working on getting all the forms completed for every resident in the building, including new residents and it took him approximately 40 minutes to complete each new food preference form on the tablet. The Admission Coordinator said food preference forms were typically done during admission or as soon as he could. During an interview on 9/24/24 at 10:16 am the Nutrition Consultant #1 stated the Dietary Manager could review food preferences for residents and the staff should offer an alternate if a resident had untouched food on their plate and notify dietary staff to make sure the disliked item was on the diet card. He stated the Dietary Manager should speak to the resident about food preference if a dislike was reported and fill out a grievance if warranted. The Nutrition Consultant #1 stated he did not know of a policy for when food preferences should be completed. During an interview on 9/24/24 at 10:20 am the Dietary Manager stated staff should offer an alternate and there should be notes for preferences on the diet card. The Dietary Manager stated nurses should tell dietary when a resident voiced a dislike. He was not aware of when food preferences were required to be completed. During follow up interview on 09/25/24 at 8:51 am the Nutrition Consultant #1 stated the food preference form should be done as soon as possible, he was not aware who was responsible at this facility but had heard it was the Admission Coordinator. The Nutrition Consultant #1 stated that a resident admitted on [DATE] and not having food preferences completed until 9/24/24 was too long. Baseline preferences should be done within 24-72 hours of admission. During a follow up interview completed on 9/25/24 8:57 am the Dietary Manager stated he had not been notified before 9/24/24 that Resident #23 did not like chicken. He explained the food preference form was normally received within a couple days of a resident's admission. He further explained staff should offer an alternate meal if food was left untouched or a resident stated they didn't like an item on the plate. During an interview on 9/25/24 at 11:17 am the Administrator stated she would expect for dietary to know the food preferences of a resident within the first week after a resident's admission. The Administrator did not know why Resident #23 did not have a food preference form completed before 9/24/24, but was aware a new form had been introduced.

Based on observations and staff interviews, the facility failed to post a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, the home and community based service programs, and the Medicaid Fraud Control Unit. This observation occurred for 3 of the 4 days during the onsite recertification survey. The findings included: Observations of the entire facility were completed on 9/22/24 at 2:37 pm and on 9/23/24 at 10:35 am. The observations revealed no signage or postings which included name and contact information for the State Survey Agency, complaint intake, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, or the Medicaid Fraud Control Unit. On 9/24/25 at 5:19 pm, a tour of the facility was completed. The main hallway (upper level) which included the dining room, did not have postings of all pertinent State agencies, advocacy groups, home and community based service programs, or the Medicaid Fraud Control Unit. Further observation of the facility revealed the main entrance, lobby and central hallway did not have postings of all pertinent State agencies, advocacy groups, home and community based service programs, or the Medicaid Fraud Control Unit. Continued observation of the facility revealed the Magnolia Hall (lower level) including the dining area and front lobby area did not have postings of all pertinent State agencies, advocacy groups, home and community based service programs, or the Medicaid Fraud Control Unit. An observation was completed with the Administrator on 9/24/24 at 5:29 pm of the entire facility. The observation revealed no postings of all pertinent State agencies, advocacy groups, home and community based service programs, or the Medicaid Fraud Control Unit. There was an enclosed signage station affixed to the wall adjacent from the nurse's station on the left side of the wall for postings in the lower level, but it was observed to be empty. An interview was completed with the Administrator on 9/24/24 at 6:03 pm. The Administrator stated the information should be posted with Regional, State, Local Ombudsman contact information and telephone number. The Administrator also stated the State Agency, advocacy groups, home and community based service programs, and the Medicaid Fraud Control Unit contact information and telephone numbers should be posted as well. The Administrator explained it had been posted previously but the building had undergone renovations, and the information must have been taken down and not reposted.

Based on record review and staff, resident, and Medical Director interviews the facility failed to assist a resident with a transfer from the wheelchair to bed when Nurse Aide (NA) #1 stood behind Resident #4 and allowed the resident to transfer independently. Resident #4's leg slipped, the resident fell on to the bed and experienced shoulder pain. Resident #4 sustained a left humeral head fracture of the shoulder as was noted on the CT (computed tomography) scan on 7/20/2023. This was for 1 of 3 residents reviewed for supervision to prevent accidents. The findings included: Resident #4 was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), primary osteoarthritis of the left shoulder, stroke, atrial fibrillation, and left hemiplegia. Review of the physician orders for Resident #4 included Apixaban (blood thinner) 5mg (milligrams) by mouth twice a day for Atrial Fibrillation. Ordered 6/19/2023. A review of the physical therapy evaluation conducted on 6/21/2023 by the Physical Therapist revealed Resident #4's prior level of skill for transfers from bed to chair before 6/23/23 was modified independence, assistive device or extra time needed, to current level of assistance after the incident on 6/23/23 was documented as moderate assist, 26-75% assistance. Review of the facility incident report dated 6/23/2023 at 8:00 PM revealed NA #1 went to offer stand-by assist to resident (Resident #4). NA #1 stood behind resident's wheelchair, after positioning resident's wheelchair to the side of the bed with the wheels locked. Resident was dressed and had on sneakers. Resident used her right hand to pull herself up into a standing position with the bed rail. Resident's foot began to slide out and NA #1 went around the wheelchair and was unable to prevent the resident from falling onto the bed onto her left side. Resident landed on the mattress only. Bedroom lights were on, and the room was free from clutter. Resident had decreased range of motion to her left arm and shoulder and reported pain of 6/10. The on call provider was notified and orders for x-ray of left shoulder two views. Standing order for Tylenol initiated and new order for Norco 5-325mg (narcotic pain medication) give one by mouth every 6 hours as needed for moderate pain. Signed by the Director of Nursing. Review of the physician order's for Resident #4 revealed an order for a left shoulder, two view x-ray dated 6/24/2023. Review of the x-ray report dated 6/24/2023 revealed: Severe degenerative changes of the gleno-humeral (head of the humerus that contacts the glenoid cavity or fossa of the scapula (shoulder blade) joint. No obvious fracture as best can be determined due to limitations. Short follow-up exam is recommended. CT (computed tomography is a diagnostic scan that used a combination of x-rays and computer technology to produce images of the inside of the body) should be considered if there is high suspicion for fracture. Review of Resident #4's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact and required one-person extensive assist with transfers. She was coded for balance as not steady, only able to stabilize herself with staff assistance, and transfers as not steady, only able to stabilize herself with staff assistance for surface-to-surface transfer (transfer between bed and chair or wheelchair). Further review of Resident #4's medical record revealed Tylenol Arthritis 8-hour ER (extended release) 650mg was ordered by mouth three times a day for shoulder pain on 6/28/2023 and Norco 5-325mg was ordered by mouth every six hours as needed for pain on 7/12/2023. Review of the care plan dated 7/13/23 for Resident #1 revealed the following care areas: ADL self-care deficit related to history of CVA with left side hemiplegia. Initiated 6/27/23. Interventions included assist resident with showers and baths, and assist resident with ADL care, resident is an extensive assist of one person. Fallls related to left sided hemiplegia. Initiated 7/13/23. Interventions included: fall mat beside bed when resident in bed and education of resident on calling for assistance before transfers. A review of the Medical Director progress note dated 7/17/2023 revealed: Resident #4 has had chronic shoulder pain bilaterally: left worse than right. She had a fall into the bed, getting into the bed in late June; initial evaluation appeared to be a fall with contusion (bruise), bruising and exacerbating the left chronic shoulder arthritis; She was on anticoagulant for A Fib (atrial fibrillation) which led to increased bruising and ecchymosis (a discoloration under the skin resulting from bleeding underneath, typically caused by bruising) of the left upper arm. Concern for some bleeding in the muscle as well. Pain meds were adjusted, and she has had some improvement, however, pain seems to be persisting despite bruising in stages of resolution: will repeat x-rays and CT at hospital. Review of the CT scan dated 7/20/23 of Resident #4's upper left extremity without contrast revealed: Incomplete healing of the left humeral head and surgical neck fracture. Advanced glenohumeral joint osteoarthritis. Acromioclavicular joint (one of four joints that forms the shoulder complex) osteoarthritis. An interview was conducted with Resident #4 on 8/1/2023 at 8:10 AM: Resident #4 stated she remembered the incident where she fell on to her bed and hurt her left shoulder. She revealed, I don't really know what happened, I was getting up out of my wheelchair, we locked my wheelchair wheels, the Nurse Aide was behind my chair, when I stood up, my foot slid, I lost my balance and fell on to the bed. I landed on my left shoulder. The Nurse Aide yelled for help and the Nurse came in and checked me out. My shoulder hurt so she gave me some Tylenol and some other pain medicine and my shoulder felt better. She indicated she had an x-ray of her shoulder the next morning. A follow up interview was conducted with Resident #4 on 8/2/2023 at 2:28 PM. Resident #4 stated that staff did not help her with transfers, she transferred herself. She revealed she did not feel she needed assistance to transfer because she could transfer herself. She clarified and stated staff do not use a gait belt or any type of hands-on assistance for transfers before or and after the fall. An interview was conducted with Nurse Aide (NA) #1 on 8/1/2023 at 4:00 PM. She stated she was the NA that was assigned to Resident #4 on 6/23/2023 when she fell and hurt her left shoulder and it was the first time she had been assigned to Resident #4. The fall happened around bedtime. Resident #4 was starting to get into bed by herself. NA #1 went into assist her by standing behind the wheelchair. NA #1 stated she grabbed the back of Resident #4's pants when her left foot started to slide, and resident started to fall onto the bed. Resident #4 lost her balance and fell on to the mattress onto her left shoulder. NA #1 stated that to her knowledge, Resident #4 only hit the mattress and did not hit the footboard. After she fell on to the bed, she was half on and half off the bed, NA #1 used the draw sheet to pull Resident #4 onto the bed completely. Resident #4 was complaining of pain, so she went and notified Nurse #1 and Nurse #1 came in and assessed Resident #4 and to her knowledge, did not find any injuries. NA #1 stated that she would check the shift report to see how to a resident was to be transferred. She stated she would not normally check the resident's care guide (guide in the computer that instructed the aides on how to care for the resident, to include resident's transfer status) to see how a resident was to be transferred. She stated she was told by another NA, but does not remember who told her, that Resident #4 could transfer by herself. She stated she received training from the Director of Nursing after the incident for the proper way to transfer a resident. NA #1 revealed she should have checked the resident care guide prior to transferring Resident #4, so she would know what level of assistance the resident needed. A telephone interview was conducted with Nurse #1 on 8/1/2023 at 7:42 PM. Nurse #1 stated she was the nurse assigned to Resident #4 on 6/23/2023 when she fell and hurt her left shoulder. She revealed that NA #1 had told her that she had been helping Resident #4 get into the bed around 7:30-8:00 PM, when she fell on to the bed. Nurse #1 stated she went to check on Resident #4 and she was complaining of some pain in her left shoulder, but she did sleep all night and really did not fuss that much about pain. Nurse #1 stated she could not remember what level of pain Resident #4 had on the pain scale, but she was hurting worse the next morning. The Director of Nursing relieved Nurse #1 on the medication cart the morning of 6/24/2023 and the Director of Nursing called the on-call provider and got an order for an x-ray and pain medication. She revealed she did not give Resident #4 anything for pain after the incident except for Tylenol that was already scheduled. Nurse #1 indicated she did not call the on-call provider about the fall on the night of 6/23/2023 because she did not feel like the resident fell , because landing on the bed did not mean the resident fell and the resident did not appear to be in more pain than usual. Nurse #1 stated she did not remember what transfer status Resident #4 was when she fell , but that NA #1 should have checked the resident care guide if she was unfamiliar with the resident or did not know how to transfer Resident #4. The care guide for each resident is located on the Kiosk (computer on the wall). She revealed she did not put an intervention in place, to help prevent further falls, after the incident, because she did not feel like Resident #4 had a fall, she just lost her balance. She stated that should have put an intervention in place as she now understood that Resident #4 did have an actual fall. An interview was conducted with NA #2 on 8/2/2023 at 1:10 PM. NA #2 stated she was familiar with Resident #4 and that she was cognitively intact and able to follow instructions. She revealed that Resident #4 had a lot of pain in her left shoulder, she did not complain daily, but did complain to her about pain before and after the fall. She notified her assigned nurse so pain medication could be given. NA #2 stated she transferred Resident #4 with a gait belt around her waist, then guide her for the transfer. She revealed this was how she transferred Resident #4 prior to her fall and now her transfer status had been changed after the fall to two-person physical assist with transfers. She stated that Resident #4 was able to stand up and have the gait belt around her waist, she (NA) would then hold on to the back of the gait belt to give Resident #4 some support and helped guide her onto the bed or her wheelchair. NA #2 indicated that Resident #4 was a 1-person physical assist which meant the resident needed a staff member to put their hand on the resident to assist with the transfer. NA #2 revealed if she was unfamiliar with a resident's transfer status, she would check the resident care guide, it tells you everything you need to know about how to take care of the resident. An interview was conducted with NA #3 on 8/2/2023 at 1:19 PM: NA #3 revealed Resident #4 was and extensive assist for transfers with a one-person physical assist. He revealed he transferred Resident #4 this way prior to the fall and after the fall, she had been changed to two-person physical assist for transfers. He stated he used a gait belt to support Resident #4 when she stood to transfer, but he assisted her by touching her, guiding her, and supporting her during the transfer. NA #3 revealed that each resident had a care guide that told the staff how to care for that resident, it included how they eat, transfer, bed mobility, how they moved around the facility and if they needed specific equipment or had special needs. He stated that Resident #4 was unsteady on her feet from her stroke. An interview was conducted with the Physical (PT) Therapy Director: She stated that all falls were reviewed by therapy to determine if therapy was needed. She revealed that Resident #4 was on the therapy caseload when she fell on [DATE]. PT stated it was her understanding that there was some confusion originally after the fall because the staff were trying to determine if Resident #4 had an actual fall or not, since she lost her balance and fell on to the bed. She stated that Resident #4 was cognitively intact, and she was re-educated on not trying to transfer herself, but to ask staff for assistance. PT stated that at the time of the fall, Resident #4 was a physical assist of one person for transfers and that the NA should have physically assisted by putting her hands on the resident during the transfer and used a gait belt. She stated she was unaware at the time of the fall that Resident #4 had been transferring herself instead of calling for assistance. An interview was conducted with the Medical Director (MD) on 8/2/2023 at 10:09 AM. He stated that Resident #4 had severe osteoporosis, and bilateral shoulder capsulitis (also known as frozen shoulder, an inflammatory condition characterized by shoulder stiffness, pain, and significant loss of passive range of motion (when a therapist caused the movement of a joint), worse on the left from the right. He revealed that with her severe osteoporosis, that it would not take much force for a bone to break. The MD stated he was trying to give her some time to heal and treat her conservatively, because there were days that she had good days with her left hemiplegia and did not have as much pain. She had chronic daily pain from her osteoarthritis. The Medical Director explained that Resident #4 was also on a blood thinner, Eliquis, and when she fell , she had extensive bleeding into the muscle. He revealed he did not stop the Eliquis, after the fall, because the risk of not taking he Eliquis for her Atrial Fibrillation was worse than the side effects. He revealed that Resident #4's shoulder injury was worse than he had originally thought, he had thought maybe a hair line fracture, but it was an impacted (a fracture where the broken ends of the bone are jammed together by the force of the injury. The MD revealed when he became aware of the incident, he adjusted her pain medication several times. He indicated he had to talk Resident #4 into having the CT exam, because she did not want to have surgery. He stated he believed now that she had hit the footboard with her shoulder instead of just hitting the soft mattress. He stated he did not feel it was an issue to wait so long to obtain a CT exam because he was trying to manage her conservatively. An interview was conducted with the Director of Nursing (DON) on 8/2/2023 at 9:27 AM. She stated she became aware of Resident #4's fall on 6/24/23 when she relieved Nurse #1 on the medication cart. The DON stated the Nurse should have called the medical provider on call at the time of the fall for further instructions. The DON stated that each resident has a care guide that details what was needed to take care of the resident, how they transfer was included on the care guide. She indicated that NA #1 had worked at the facility previously and had been trained on how to use the care guide and she was also trained again during her orientation for this employment. The DON stated that Nurse #1 told her in report the morning of 6/24/2023 that Resident #4 had slipped when transferring back to bed and landed on the mattress of the bed. Nurse #1 told her that she gave Resident #4 some Tylenol but that she really did not complain of pain too much during the night. Resident #4 was now complaining of more pain, so the DON called the on-call provider for further instructions. She gave her some pain medication and ordered an x-ray of her left shoulder. She indicated that the Medical Director was monitoring her and since she continued to complain of pain and her range of motion was worse that we would order a CT scan. The CT scan was completed on 7/20/2023 and when we got the results back, she called the MD and notified him that Resident #4's shoulder was broken. He gave her an order for send to the orthopedist.

Based on observations, record review, resident interview, staff interview, and physician interview, the facility failed to put an effective plan in place to prevent 1 of 4 sampled residents who smoked from smoking inside the building (Resident #44) which placed Resident #44 and all the other residents in the facility at risk of the facility catching on fire. Immediate Jeopardy began on 03/08/18 when Resident #44 was caught a second time smoking in his room. Nursing notes revealed Resident #44 continued to exhibit evidence of smoking in the facility via smoke smells and to have smoking materials on his person. Immediate Jeopardy was removed on 08/30/18 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring system put into place are effective related to supervision to prevent accidents. The findings included: Review of the facility's Smoking Policy with a revision date of 02/01/18 included the following: *Smoking is not allowed inside of this facility, under any circumstances, at any time. *All resident smoking materials are maintained in a secured area and are accessible only through the assistance of the facility's staff. *When the Smoking Evaluation identifies a resident with any potential hazard risk, the resident will be allowed to smoke only during this facility's designated smoking times with direct staff supervision. Resident #44 was originally admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #44's annual Minimum Data Set ((MDS) dated [DATE] coded him with having intact cognition, and requiring supervision only for activities of daily living skills including ambulation. A Smoking Evaluation dated 03/01/18 noted he did not deposit lit items correctly in the ashtray. The outcome was that he was a safe smoker and may smoke independently. A care plan was developed on 03/01/18 noting he could smoke independently. The resident acknowledged the rules and criteria related to smoking and was able to demonstrate safe smoking. The care plan was updated 03/02/18 indicating he needed to be supervised related to noncompliance with the rules. A Social Progress note dated 03/03/18 at 10:14 AM, stated that Due to unsafe behavior in room, resident is now a supervised smoker and MUST turn in cigarettes when returning in the building. Social notes dated 03/03/18 at 10:15 AM, stated the resident understood his supervised smoking status. Nursing notes dated 03/05/18 at 11:57 AM stated the resident was assessed and is a supervised smoker due to a change in mental status and behaviors. The resident was aware of status change and smoking times. The smoking care plan was updated 03/05/18 which indicated he needed to be supervised while smoking due to noncompliance. He was to check in with staff every time he returns from [MEDICAL TREATMENT] and give up his smoking items. A Social Progress note dated 03/08/18 at 10:09 AM stated Social worker was informed of caught smoking in his room again. Social worker spoke with resident. He stated he did not remember smoking again, but when social worker mentioned staff and the smoke, he nodded. Social worker confiscated cigarettes and temporarily terminated resident's smoking privileges. Will reevaluate in a month. Progress notes revealed the following related to Resident #44's smoking: *03/10/18 at 7:35 AM nursing note: Room smelled of smoke, said he was not smoking in room. *03/10/18 at 7:10 PM nursing note: Room smelled of smoke. No cigarettes observed. No lighter in presence of resident. Resident denies any smoking. DON (Director of Nursing) aware. SW (social worker) area (sic for aware). Resident's door is open and nursing staff watching closely. Will continue to monitor. *03/12/18 at 12:24 PM social note: Upon safety search of resident's room, two unsmoked cigarettes were found along with a smoked one. They are in the social worker's office. *03/13/18 at 8:50 AM nursing note: The Administrator and DON discussed with the resident the importance of not smoking in his room and going out for supervised smoke breaks. Informed him if he smoked again he was subject to receive a 30 day discharge notice. He acknowledged understanding. *03/15/18 at 11:30 AM interdisciplinary meeting with resident present: Resident stated that he gets cigarettes and lighter from [MEDICAL TREATMENT]. Staff spoke of hazards and the oxygen room being 2 doors down and there are 50 canisters of oxygen at any given time. Resident agreed to turn in smoking materials when returning from [MEDICAL TREATMENT]. Resident will receive 2 cigarettes at [MEDICAL TREATMENT] and lighter. If caught one more time, a 30 day discharge will be issues. Resident and sister in agreement. *04/13/18 at 10:52 AM social note: Social worker notified sister of behavior last night (previous note was 04/11/18 with no behaviors documented) and smoking in the room. Sister has been notified of 30 day discharge notice. *04/13/18 at 6:30 PM nursing note: Resident returned from [MEDICAL TREATMENT] and was asked if he had cigarettes and a lighter and resident stated, 'No'. About ten minutes later resident exited bedroom and smelled of smoke. Nurse immediately went into patient's room and the room had a fog in it and smelled of cigarette smoke. When nurse asked resident, resident denied smoking or having smoking tools. Nurse observed resident hid lighter in his hand. Resident refused to give lighter to nurse. Cigarette butts were found in trashcan in bedroom. Resident finally gave nurse red lighter. Nurse educated resident on the importance of not smoking and following safety guidelines. Resident laughed at nurse. 1 on 1 supervision was immediately initiated. Interview with the Administrator on 08/30/18 at 9:32 AM revealed he found information regarding the 04/13/18 incident from the previous administration which indicated Resident #44's 1 on 1 supervision lasted 5 days. On 04/20/18 at 7:01 PM nursing notes stated Resident returned from [MEDICAL TREATMENT] at 5:00 PM. No cigarettes on resident. Resident did have a lighter in his pocket and it was locked in the med room. Interview with the Ombudsman on 08/30/18 at 12:06 PM revealed that she went to the facility after receiving a phone call from Resident #44's sister who expressed concern about the discharge related to if he would be in a facility close to her and still be able to get [MEDICAL TREATMENT]. The Ombudsman stated that upon her arrival the previous administrator followed her into Resident #44's room and announced that she was rescinding the discharge notice due to no placement was found for the resident and there was inappropriate documentation of the discharge issues. The Ombudsman stated she only provided family and administration technical education on ensuring a safe discharge. Resident #44 had a quarterly MDS dated [DATE] which coded him with intact cognition and requiring supervision for all activities of daily living including ambulation. He was coded with no behaviors. Progress notes related to Resident #44 smoking continue: *Nursing notes dated 05/13/18 at 2:40 AM revealed Smoke was smelled dowm (sic) adm. (administrative) hall. Resident came through double door. Strong odor of smoke smelled. Resident came down to room. When questioned about smoking down there, resident deny. (name of administrator) called. Resident was checked good for cigarettes and lighter. Found 2 butts wrapped in tissue paper. No lighter found. Resident said he had not been smoking or had lighter. Resident on 15 min. (minute) checks. Reminded resident he is not to go through double doors. *Nursing notes dated 05/22/18 at 8:44 PM revealed the resident was in bathroom of his room and cigarette smoke smell was noted. Resident #44 denied smoking. The nurse asked him again and Resident #44 admitted to smoking in his bathroom. Upon administrative direction, Resident #44 was checked and one pink lighter was found. The plan was for Resident #44 to be placed on 15 minute checks and if he goes out to smoke staff is to do 1 on 1 supervision with him while he is smoking. *Nursing notes dated 05/30/18 at 9:06 PM, written by Nurse #4, stated the nurse went into his room and cigarette butts were on his bed. Located resident in the main hall and asked him if he had any cigarette butts and he said no. When told of finding the 3 cigarette butts and showed them to him he cursed. He was re-educated on the smoking policy. *Nursing notes dated 06/02/18 at 3:27 AM, written by Nurse #5, stated the 7P-7A charge nurse reported to this writer that nurse aide had turned in 6 cigarette butts and one green lighter which was retrieved from the resident after he had been to the 8 PM smoke break. Nurse aide reported he was provided 1 on 1 observations while he was smoking. *Nursing notes dated 06/02/18 at 11:25 AM, written by Nurse #3, revealed the central hall charge nurse checked the resident after the 11 AM smoke break and he was found to have 2 cigarette butts in his front pocket. Follow up nursing note dated 06/02/18 at 11:31 AM revealed the nurse verified he was provided 1 on 1 supervision during that smoke break. *Social note dated 06/04/18 at 4:49 PM stated resident allowed the social worker to check him upon return from [MEDICAL TREATMENT]. Only red lighter found and put in smoke box. *Nursing note dated 06/09/18 at 11:29 AM stated staff went into resident's room and it smelled like cigarette smoke. Staff checked room and found beer cans and a liquor bottle. Nurse called DON and Administrator. A Smoking Evaluation for Resident #44 dated 06/11/18 noted that he smoked in areas other than the designated smoking area and he was assessed as an unsafe smoker and required direct supervision while smoking. Nursing notes dated 07/01/18 at 11:00 PM, written by Nurse #4, stated the nurse aide reported resident was smoking in his bathroom. The nurse knocked on the bathroom door and informed the resident it was the nurse. The resident had the door cracked open and nurse saw the resident with his head in raised window and bathroom smelled of smoke. Resident was reeducated on smoking in the facility. Nurse aide had found 3 cigarette butts in his room. Resident #44 was again assessed as requiring supervision while smoking per his Smoking Evaluation dated 07/11/18 for smoking outside designated areas. The quarterly MDS dated [DATE] coded Resident #44 has having intact cognition, no behaviors and requiring supervision with all activities of day living skills. Nursing notes dated 08/06/18 at 8:35 PM, written by Nurse #4, revealed the nurse aide and first shift nurse reported a strong smoke smell in the resident's bathroom. With the window up. The nurse aide found 2 cigarette butts and a whole cigarette. The resident was re-educated about smoking policy. Nursing notes dated 08/13/18 at 9:58 PM written by Nurse #3, revealed resident was smoking in the bathroom of his room. Found 6 cigarette butts in his bathroom and one in the toilet. Asked how he lit it and he responded saying he rubbed 2 sticks together. This nurse asked for the lighter and he would not give it up. Checked his pockets and no lighter was found. Nurse #3, who wrote the 8/13/18 nursing note was interviewed via phone on 08/29/18 at 8:30 PM. Nurse #3 stated she smelled smoke and found Resident #44 in the bathroom. He denied smoking but cigarette butts including one in the toilet were found. She stated she did not check him thoroughly for smoking materials although she thought about it. She could not give a reason why she did not check him. She reported it to the Assistant Director of Nursing (ADON). Nurse #3 stated that Resident #44 was permitted to take 2 cigarettes with him to [MEDICAL TREATMENT]. Nursing notes dated 08/24/18 at 2:51 PM revealed the resident was educated that he was expected to abide by the smoking policy. Resident understands the policy and signed the policy and stated he will follow the policy. On 08/28/18 at 5:46 PM Nurse Aide (NA) #1 stated she had never caught Resident #44 smoking but had smelled smoke in his room before. She stated each time staff smell smoke, they check Resident #44 for lighters and cigarettes. Observations on 08/28/18 at 5:47 PM revealed Resident #44's room had an odor from smoke coming from the bathroom he was using. His room was located at the very end of the hall and had a connecting bathroom to the room next door. In the adjacent room resided Resident #40 who had an oxygen tank at bedside. On 08/28/18 at 5:49 PM Resident #44 was observed walking down the hall. On 08/28/18 at 5:51 PM Nurse #1 stated she had never caught Resident #44 smoking in his room but suspected he smoked in the building due to the smell of cigarette smoke. Nurse #1 accompanied the surveyor to Resident #44's bathroom and confirmed she smelled smoke. She further stated that last week Resident #44 was suspected of smoking in his room and his roommate was moved out of his room since his roommate used oxygen. She further stated that Resident #44 was checked for smoking materials after each [MEDICAL TREATMENT] trip. She said last week he had a lighter and cigarette in his belt upon his return from [MEDICAL TREATMENT]. The Administrator stated on 08/28/18 at 6:00 PM that Resident #44 signed an agreement to be checked for smoking materials after [MEDICAL TREATMENT]. The Administrator stated that still Resident #44 is able to hide smoking materials. Resident #44 had been seen throwing cigarettes out of the window when staff are coming near. The facility has completed a new FL2 form on which his level of care was changed from needing skilled care to assisted living. The social worker is looking for placement. On 08/28/18 at 6:07 PM the Administrator and Nurse #2 with the surveyors went to check Resident #44 for smoking materials. The only thing found was a cigarette butt in his front pocket. When Resident #44 was asked about smoking in the building, he stated he did not do so this date. When asked about being caught last week he did not admit or deny smoking in the facility. At this time Resident #44 was able to say he was not to smoke in the facility for the safety of the other residents. The Administrator stated during interview on 08/28/18 at 6:15 PM that either the receptionist or the nurse checked Resident #44 for smoking materials each time he returned from [MEDICAL TREATMENT]. In the past they tried 1 on 1 smoking with him so that staff could provide attention only to Resident #44 while smoking and not watch the whole group at one time. He stated the resident has been observed picking cigarette butts off the ground. The Administrator stated he was reconsidering 1 on 1 smoking for Resident #44 again. The Administrator was unable to say why the discharge in (MONTH) was never completed as it was before he was the administrator. The Director of Nursing stated during interview on 08/29/18 at 2:30 PM that someone has to walk Resident #44 from the door to his room after he returns from [MEDICAL TREATMENT] to check for smoking materials. She stated checking Resdient #44 after [MEDICAL TREATMENT] was implemented approximately a month ago. She stated that a week ago a nurse aide checked him following [MEDICAL TREATMENT] and later he was found to have smoking materials in his waist band. At that time his roommate who used oxygen was moved to a different room. She had not thought of Resident #40, who was in the adjacent bedroom that shared the bathroom with Resident #44, having oxygen in use also. The Administrator stated on 08/30/18 at 9:32 AM that he started working in the facility in (MONTH) (YEAR). During his time at the facility he stated that if staff placed Resident #44 on 1 to 1 supervision or 15 minute checks, that supervision only lasted 24 hours if he was not found violating the smoking rules. He stated the 1 on 1 supervision was only provided while Resident #44 was taken to smoke. The Administrator was unable to provide documentation related to this supervision. The ADON was interviewed on 08/30/18 at 10:47 AM. She stated she was informed about the smoke in the hall that was documented on 08/13/18. She stated that [MEDICAL TREATMENT] lets him do anything he wants to do while there and the facility sends him with 2 cigarettes but no lighter to [MEDICAL TREATMENT]. ADON stated that once the smoke was reported on 08/13/18 she did not search him for smoking materials. She stated when she was a nurse on the floor she would search him. ADON stated Resident #44 was very noncompliant and would not listen to instructions. Nurse #4 was interviewed on 08/30/18 at 11:06 AM. She stated Resident #44 had been caught smoking in the facility over a year ago. She stated that more recently housekeepers had reported seeing him blow smoke from his bathroom window when he resided in a different room. She stated she has checked for smoking materials and would sometimes find them in his closet, waist band, etc. She described him as very fast when getting cigarette butts from the outdoor ashtrays. She stated he has been known to leave the [MEDICAL TREATMENT] center and go to the store for cigarettes and beer. Resident #44's physician was interviewed on 08/30/18 at 12:55 PM. He stated he has been kept informed of Resident #44's noncompliance with the smoking policy. He stated that Resident #44 is not truthful, knows what he is doing, and tries to cheat the system. He stated the facility has searched him and doing what they can to keep him compliant. The Administrator was informed of Immediate Jeopardy on 08/30/18 at 11:33 AM. On 08/30/18 at 6:04 PM, the facility provided the following Credible Allegation of Immediate Jeopardy removal: * Plan of correcting the specific deficiency: The plan started on (MONTH) 13, (YEAR) because incidents related to potential smoking in non-designated areas for resident #44 were addressed with interventions, that were then tapered based on resident behavior. On (MONTH) 13, (YEAR), Resident #44 was found by nurse where there were 6 cigarette butts found in residents bathroom. Resident #44 has history of non-compliance with smoking which care plan was developed on (MONTH) 24, (YEAR) but facility failed to follow care plan to ensure that resident did not have smoking materials, due to staff knowledge deficit. When Resident #44 was found with cigarette butts reeducation was not done until (MONTH) 24, (YEAR). Re-education of resident provided by facility has not been effective long term for resident # 44, despite a 15 BIM score, because of resident making poor and non-compliant choices. During the investigation the root cause of non-compliance was identified that reeducation of Resident #44 was not done promptly and care plan was not updated promptly post event to prevent reoccurrence. On 8/6/18 resident # 44 was assessed to have a BIMS of 15. On 8/13/18 resident # 44 was found by nurse with 6 cigarette butts. On 8/24/18 resident # 44 was re-educate by ADON on the smoking policy. On 8/28/18 approximately 5pm resident #44's bathroom was noted to have faint smell of cigarette smoke. Resident #44's room was not noted to have visible smoke, and resident denied smoking. Resident #44 was noted with a partially smoked cigarette butt in top shirt pocket, no lighter upon facility staff check after faint smell noted. On 8/28/18 at approximately 5:15pm resident # 44 was placed on 1 to 1 smoking supervision by facility. This intervention was put into place to decrease risk resident would gather smoking materials such as cigarette butts during designated smoke times and bring back into facility. On 8/29/18 resident #44 was placed on 1 to 1 supervision when in facility to prevent smoking in unauthorized locations. This intervention will continue as long as resident resides in facility. On 8/29/18 resident #44's pockets were checked by facility staff after [MEDICAL TREATMENT] for smoking materials. No smoking materials found in resident clothing. On 8/30/18 resident # 44 was seen by psychiatric nurse practioner (PNP) in the facility for behaviors including smoking in undesignated areas. On 8/29/18 and 8/30/18 resident #44's care plan related to smoking, including non-compliance, was reviewed and updated by the DON, ADON, administrator, and corporate consultant team. PNP did not order a level of care change for resident during visit. Resident is followed by PNP with visits every 3 months and as needed. On 8/29/18 and 8/30/18 resident #44's care plan related to smoking, including non-compliance, was reviewed and updated by the DON, ADON, administrator, and corporate consultant team with intervention for 1 to 1 supervision, this intervention will not resolve until resident no longer resides in facility. Interventions are specific to resident and behavior including ensuring smoking materials secure upon return from [MEDICAL TREATMENT] and 1 to 1. Resident was educated on several occasions and is in agreement with plan as evidenced by conversation with administrator on 8/30/18. The group activity log proves resident participates in group activities including Bingo and church services. On 8/29/18 the ADON began an in-service with all staff on resident #44s interventions, resident to be checked upon return from appointment, 1 to 1 supervision for smoking, 1 to 1 supervision, resident to be checked when returns from smoke break, to ensure safety related to smoking. No staff will be allowed to work after 8/30/18 until in-service has been completed. This in-service will be part of the orientation for newly hired staff. On 8/30/18 resident #44 was provided with re-education by administrator on the smoking policy, including scheduled smoking times, location of smoking area, consequences for not following policy including discharge. Resident verbalized education back to administrator. On 8/30/18 resident #44 was moved to different room, which is in closer proximity to a nurse's station for supervision, and with no window in bathroom. On 8/30/18 resident #44's belongings were checked for smoking paraphernalia by administrator with none noted. Beginning 8/31/18 facility will send a staff member to [MEDICAL TREATMENT] with resident #44 to provide supervision prior to and after each treatment and during transportation. The staff member that will supervising resident will be provided with the all staff in-service and will be in addition to the contracted transportation service driver. This will provide additional supervision to reduce the potential of resident concealing smoking paraphernalia when on appointment. This intervention will continue as long as resident resides in facility. *The procedure for implementing the acceptable plan of correction for the specific deficiency cited: On 8/28/18 the corporate facility consultant audited all resident rooms for smoking paraphernalia. No additional negative findings noted. On 8/29/18 the administrator and DON completed an audit of all resident rooms, including resident #44's room, for smoking paraphernalia with no negative findings. On 8/30/18 the facility staff completed an audit of all resident rooms, including resident #44's room, for smoking paraphernalia with no negative findings. *In-servicing: 1. On 8/29/18 the assistant director of nursing (ADON) began an in-service with licensed nursing staff on independent smokers, including they must return smoking materials when return in facility. This in-service will be completed by 8/30/18. After 8/30/18 no licensed nurse will be allowed to work until in-service is complete. This in-service will be part of the orientation for newly hired licensed nurses. 2. On 8/29/18 the ADON began an in-service with all staff on resident #44s interventions to ensure safety related to smoking. No staff will be allowed to work after 8/30/18 until in-service has been completed. This in-service will be part of the orientation for newly hired staff. 3. On 8/30/18 all staff will be in-serviced by the ADON on 1. Resident must be supervised to prevent incidents and accidents, including smoking, 2. If a resident has a concern related to safety you must intervene immediately, this includes smoking. 3. Notify Don and administrator of any residents smoking or suspected of smoking in their room or any undesignated area and place resident on 1 to 1 supervision until further instructions are received by DON/Administrator. This in-service will be completed on 8/30/18. No staff will be allowed to work after 8/30/18 until in-service complete. Starting 8/30/18, no staff will be permitted to work until education is received and post-test is administered. On 8/31/18, any staff not in-serviced will be mailed via USPS certified mail a copy of the in-services and a post test. The employee will not be allowed to work until this education, including post-test is complete. Compliance will be ensured and tracked by the DON, and ADON. *The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements: The director of nursing (DON), ADON, and/or administrator will review 50% of residents' rooms weekly x 12 weeks to ensure no smoking paraphernalia is present in room. Based on the smoking policy all resident smoking materials are maintained in a secured area and are accessible only through the assistance of the facility's staff. This audit will be documented on the resident room audit tool. The DON, ADON, administrator, social worker, and/or licensed nurse will audit once daily seven times per week x 12 weeks to include weekends, and varying times to ensure scheduled supervised smoking times are supervised by facility staff as designated by residents' care plans. This audit will be documented on the smoking audit tool. 1 to 1 supervision, including during [MEDICAL TREATMENT] appointments will be verified 5 times weekly by the administrator and/or DON using the documentation log. This audit will continue until resident no longer resident no longer resides in facility. The DON, ADON, administrator, and or licensed nurse will audit resident #44s room daily 7 times weekly x2 weeks, then 5 times weekly x 10 weeks for smoking paraphernalia. This audit will be documented on a room check audit tool. The monthly QI committee will review the results of the resident room audit tool and room check audit tool for 3 months for identification of trends, actions taken, and to determine the need for and/or frequency of continued monitoring, and make recommendations for monitoring for continued compliance. The administrator and/or DON will present the findings and recommendations of the monthly QI committee to the quarterly executive QA committee for further recommendations and oversight. The Quarterly QAPI Committee met, including medical director, on 8/30/18 at 145pm and reviewed resident #44's smoking and safety interventions; and the credible allegation for supervision to prevent accident and incidents. *The title of the person responsible for implementing the acceptable plan of correction: The administrator and DON will be responsible for the implementation of the plan to ensure the facility provides supervision to prevent accidents and incidents, including related to smoking. Corporate oversight will be provided by the corporate regional vice president (RVP), and or the facility consultant by onsite or offsite reviews to ensure the administrator and DON implements and monitors the plan of correction. Immediate Jeopardy was removed on 08/30/18 at 7:40 PM when interviews with direct care and supervisory staff from all 3 shifts confirmed they had been inserviced on the policy and procedures for smoking, including who could smoke independently and how smoking materials were managed for those residents requiring supervision. In addition staff were aware of the specific needs of Resident #44 including the 1 on 1 supervision at all times. Observations revealed Resident #44 was under 1 on 1 supervision and his room had been changed to be closer to the nursing station. Resident #44's care plan had been updated, as well as other residents who smoked. The facility remains out of compliance at a lower scope and severity.

Based on observations, record reviews and staff interviews the facility neglected to provide treatments as ordered by a wound care physician for reoccurrence of a stage 4 pressure ulcer that developed in the facility for 1 of 3 residents sampled for pressure ulcers (Resident #53). The findings included: Resident #53 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #53 was moderately impaired in cognition for daily decision making. The MDS indicated Resident #53 required extensive assistance with activities of daily living and was at risk for development of pressure ulcers. A review of a nurse's note dated 08/31/15 at 3:48 PM documented by the treatment nurse indicated a pressure ulcer to coccyx was resolved. A review of a physician's orders [REDACTED]. A review of documents dated 09/02/15 from a wound center titled Discharge Instruction Summary indicated Resident #53 had a stage 4 pressure ulcer on his sacrum with measurements of 8.0 cm length x 4.7 cm width x 2.0 cm depth. A section labeled primary wound dressing indicated [MEDICATION NAME] Alginate on top of wound but not inside, sacral border dressing, skin prep on intact skin around wound bed and change daily and as needed for soiling and barrier cream to anal and perineal area to reduce excoriation of skin. A review of a treatment record dated 09/02/15 through 09/08/15 revealed there were no treatments documented for a pressure ulcer. During an interview on 09/09/15 at 9:37 AM with Nurse Aide (NA) #10 she stated there was redness on Resident #53's buttocks but he went to the wound clinic and all they had to do was to keep him clean and dry. She stated she was not aware of any barrier cream for Resident #53's skin on his buttocks. During an observation and interviews on 09/09/15 at 10:12 AM the Director of Nursing (DON) and treatment nurse entered Resident #53's room and the treatment nurse stated she had received a skin referral to evaluate Resident #53 ' s sacrum. Resident #53 was turned to his left side and the treatment nurse removed an adhesive dressing from Resident #53's sacrum and there was a large open area that was dark in the center of the wound with raw skin around the edges with skin peeled back and an open hole at bottom of wound. The treatment nurse measured the wound and stated the wound was 10 cm length x 8.5 cm width x 1.2 cm depth and was unstageable because she could not see the wound bed. The DON stated staff were supposed to check Resident #53's skin on his shower days and if they saw skin problems they were supposed to report it to the nurse. She further stated Resident #53 did not like to turn off his back and frequently he slid down in bed with his bottom in a depression that was caused by a fold in the air mattress when the head of the bed was raised. The treatment nurse explained Resident #53 looked like he was sitting in a ditch when he slid down into the crease of the mattress and he would not reposition himself. She stated she was very surprised to see the pressure ulcer on Resident #53's sacrum and thought when staff had pulled him up in bed they had sheared the skin off his bottom and now the skin had dried out and had eschar (dead tissue). She further stated Resident #53 had previously had a stage 4 pressure ulcer on the right side of his sacrum that had a small hole with exposed bone but it was not in the same location as the current pressure ulcer. During an interview on 09/10/15 at 10:38 AM Nurse #1 explained she was assigned to care for Resident #53 last week and she stated she remembered his bottom was red but did not remember anything else about his skin. She stated she might have put a dressing on his bottom since it was red but could not remember exactly what she did. She further stated she was not aware of treatment orders from the wound clinic on 09/02/15 and had not received reports from other nurses that Resident #53 had a new pressure ulcer or had new treatment orders from the wound clinic on 09/02/15. During an observation on 09/10/15 at 12:15 PM Resident #53 was in bed with the head of the bed raised and was flat on his back with his bottom down in the depression in the fold of an air mattress which was set on a low pressure setting at a control unit located on the footboard of the bed. During an interview on 09/10/15 at 12:25 PM with the Physician's Assistant she stated it was her expectation for nursing staff to assess resident's skin and let her or the physician know if there were problems or issues. She explained nursing staff could call anytime 24 hours a day or they could leave a note in the physician's communication book and they would see residents when they made rounds. She further stated if a wound was worse or looked infected they should let her or the physician know about it. She explained she felt wound treatments were not always provided consistently and she was not always informed about wounds that needed treatment. She stated staff in the facility were their eyes and ears and staff had to tell her or the physician when something needed to be addressed. She explained she had made rounds in the facility on 09/07/15 but she did not see Resident #53 because she was not aware he had a wound on his sacrum. She further stated she expected staff to turn and reposition Resident #53 even if he did not want to turn to keep him off his bottom to prevent skin breakdown. During an observation on 09/10/15 at 3:04 PM Resident #53 was lying flat on his back with the head of the bed up with his bottom down in the depression in the fold of the air mattress. During an observation on 09/10/15 at 5:39 PM Resident #53 was lying flat on his back in bed with the head of the bed up with his bottom down in the depression in the fold of the air mattress. During a telephone interview on 09/11/15 at 9:11 AM with the wound care physician he confirmed he had seen Resident #53 earlier that morning and he had a big wound on his sacrum that had to debrided (surgical removal) of necrotic (dead) tissue. He stated he was very surprised to see the condition of the wound since Resident #53 had a healing wound when he was seen in the wound clinic in August. He further stated he could not remember specifics about the wound because he did not have the resident's chart in front of him but the nurse would provide the information. He explained he had ordered wet to dry dressings on Resident #53's wound since he had removed dead tissue from it that morning and it was his expectation for dressings to be changed as ordered, turn and reposition Resident #53 and provide an air mattress to relieve pressure. He further stated pressure should be avoided to promote wound healing. During an interview on 09/11/15 at 9:58 AM with a facility transporter who also was a Nurse Aide (NA) she verified she had transported Resident #53 to the wound clinic earlier that morning and she stayed with the resident in the treatment room when he saw the wound physician. She stated Resident #53 had a large wound on his bottom that did not smell good and it looked worse than the previous time she had transported him to the wound clinic on 09/02/15. She stated prior to that on 08/30/15 the wound on his bottom was looking really good. She further explained the wound clinic usually sent paperwork back with the resident to the facility and she gave the paperwork to the nurse. During a follow up interview on 09/11/15 at 10:32 AM with the treatment nurse she explained she saw Resident #53's skin on 08/31/15 and the pressure ulcer she had been treating on his coccyx had healed and was pink with scar tissue. She stated she called the nurse practitioner who discontinued the treatment orders and she called the wound clinic to tell them the pressure ulcer had healed. She explained she did not realize Resident #53 went to his scheduled appointment at the wound clinic on 09/02/15 because no one had told her he had gone or that he had a new pressure ulcer until she got a skin referral on 09/09/15 and saw Resident #53 on 09/10/15. She confirmed the dressing she removed on 09/10/15 was a [MEDICATION NAME] sacrum border dressing but she did not know how long the dressing had been on the resident or who had put the dressing on because staff did not initial dressings with a date when a dressing was applied. She stated the facility had used staff from other facilities to fill in vacant positions and it was possible staff had not done treatments since they were not always familiar with residents or routines. She explained staff should turn and reposition Resident #53 to alleviate the pressure but it was a challenge because he preferred to lay on his back and did not like to turn or get out of bed. She further explained the new pressure ulcer on his sacrum looked like his skin had been sheared off when he had been pulled up in bed. She confirmed she was the wound treatment nurse in the facility but had also been assigned to work as a nurse on the halls to fill in for vacancies so she had to rely on nurses to let her know if resident's had red or broken areas of skin. She explained it was her expectation for staff to put a skin referral in the computer if a resident had skin breakdown so that she could assess them. She stated nurses had access to dressings and wound supplies and when she was not on duty they should have done treatments and should have told her about Resident #53's new pressure ulcer. She explained, after review of Resident #53's treatment records, there were no treatments documented for Resident #53's pressure ulcer from 09/02/15 through 09/08/15 because there was no documentation of Resident #53's clinic visit notes or orders in his medical record She explained usually the transporter brought back paperwork from the wound clinic and gave it to a nurse but she did not know if it was lost or what had happened. She verified nurses were supposed to write their initials on the treatment record when they provided treatments but since there were no initials the treatments were probably not done. She explained since she had not seen the wound clinic notes dated 09/02/15 other nurses were probably not aware of the treatment orders either and that could explain why treatments weren't done. During a telephone call on 09/11/15 at 11:00 AM from a nurse at the wound center she reported the following clinic visits for Resident #53: 09/02/15 wound measurements 8.0 cm length x 4.7 cm width x 2.0 cm depth with treatment of [REDACTED]. 09/11/15 wound measurements 11.7 cm length x 9.0 cm width x 2.3 cm depth with treatment of [REDACTED]. During an interview on 09/11/15 at 5:40 PM the DON stated it was her expectation for the transporter to bring orders from the wound clinic to the nurse when a resident returned to the facility. She further stated the nurse assigned to the resident needed to review the orders and the treatment nurse needed to review the orders and follow through with the treatment orders. She stated they needed to improve the communication system and if the nurse was not available when the transporter brought the resident back to the facility or the treatment nurse was not available the documents should be given to the DON. She confirmed there was no system for weekly skin checks but they needed a better system for skin assessments and skin referrals. She stated it was her expectation for treatments to be done daily or as ordered by the physician and if there was no treatment nurse on duty the nurse assigned to the resident should do the treatments. She further stated if there were no staff initials on the treatment records she interpreted it as the treatment was not provided.

Based on observations, record reviews and physician and staff interviews the facility failed to assess skin integrity, prevent reoccurrence of a stage 4 pressure ulcer that developed in the facility and failed to provide wound treatments as ordered from a wound clinic physician for 1 of 3 residents sampled for pressure ulcers. (Resident #53). The findings included: Resident #53 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #53 was moderately impaired in cognition for daily decision making. The MDS indicated Resident #53 required extensive assistance with activities of daily living and was at risk for development of pressure ulcers. A review of physician's orders [REDACTED]. Change dressing daily and as needed [MEDICATION NAME](antibiotic) 500 milligram by mouth twice daily for 2 weeks for wound infection. A review of a Wound Ulcer Flow sheet dated 07/30/15 at 2:10 PM indicated a stage 4 pressure ulcer on Resident #53's coccyx that occurred in facility with measurements of 1.0 centimeter (cm) length x 1.2 cm width x 0.3 cm depth with a small amount of drainage. The wound bed appearance was a small round open area at right of tail bone with a small amount of bone exposure noted and physician was notified. A review of treatment records revealed there was no documentation of pressure ulcer treatments for July 2015. A review of physician's orders [REDACTED]. A review of documents dated 08/05/15 from a wound center titled Discharge Instruction Details indicated Resident #53 had a stage 4 pressure ulcer on his coccyx. A section labeled primary wound dressing indicated [MEDICATION NAME] Alginate (for moderate to heavily draining wounds) on top of wound but not inside, 4x4 [MEDICATION NAME] border dressing, skin prep on intact skin around wound bed and change daily and as needed and barrier cream to anal and perineal area to reduce excoriation of skin. A review of a Wound Ulcer Flow sheet dated 08/06/15 indicated a stage 4 pressure ulcer on Resident #53's coccyx with measurements of 1.0 cm length x 1.1 cm width x 0.3 cm depth with a pin point piece of tail bone exposed with redness around the wound. The document further revealed the current wound treatment was Silver Alginate (used for infection) to wound and Prostat (protein powder) by mouth for wound healing. A review of a care plan dated 08/10/15 revealed Resident #53 was at risk for skin break down or development of pressure ulcers related to impaired mobility. The goals indicated Resident #53 would not develop a pressure ulcer and the interventions were if nutritional status deteriorated to arrange a dietary consult, inspect skin and notify nurse of abnormal changes per facility protocol and provide incontinence and perineal care after each incontinent episode. A review of documents dated 08/12/15 from a wound center titled Discharge Instruction Details indicated Resident #53 had a wound on his coccyx, use [MEDICATION NAME] Alginate on top of wound but not inside, place 4x4 gauze dressing and [MEDICATION NAME] border dressing on top of wound, may use skin prep on intact skin around wound bed, change dressing daily and as needed for soiling and may use barrier cream to anal and perineal area to reduce excoriation of skin. The notes further indicated instructions for off-loading to not sit for long periods of time and when sitting to shift from side to side at intervals to relieve pressure, provide a thick gel pad for wheel chair and Resident #53 did not need to be up more than 1 hour if he was up out of bed, continue to use air mattress, turn resident every 1-2 hours and as needed for any redness and have a dietician assess nutritional status and treat accordingly with protein for stage 4 pressure ulcer. The document revealed wound measurements were 0.7 cm length x 0.4 cm width x 1.9 cm depth. A review of a facility document dated 08/15/15 titled Norton Scale for Predicting Risk of Pressure Ulcer (quarterly review) indicated Resident #53's physical condition was fair with limited mobility, incontinent of bladder and bowel and received current treatments of Silver Alginate to a wound on coccyx. The document indicated in part Prostat, air mattress, turn and reposition, a high density foam/gel cushion for chair and barrier cream at bedside. A review of treatment records revealed there was no documentation of treatments on 08/15/15. A review of a Wound Ulcer Flow sheet dated 08/17/15 at 10:11 AM indicated a stage 4 pressure ulcer on Resident #53's coccyx that occurred in facility with measurements of 0.5 cm length x 0.4 cm width x 0.2 cm depth with tunneling and undermining. A review of treatment records revealed there was no documentation of treatments on 08/23/15 or 08/24/15. A review of a Wound Ulcer Flow sheet dated 08/25/15 at 4:10 PM indicated a stage 4 pressure ulcer on Resident #53's coccyx with measurements of 0.5 cm length x 0.5 cm width x 0.1 cm depth with a small pin point open area to sacrum with non-visible wound base. A review of treatment records revealed there was no documentation of treatments on 08/30/15. A review of a nurse's note dated 08/31/15 at 3:48 PM documented by the treatment nurse indicated wound to coccyx was resolved. A review of a physician's orders [REDACTED]. A review of documents dated 09/02/15 from a wound center titled Discharge Instruction Summary indicated Resident #53 had a stage 4 pressure ulcer on his sacrum with measurements of 8.0 cm length x 4.7 cm width x 2.0 cm depth. A section labeled primary wound dressing indicated [MEDICATION NAME] Alginate on top of wound but not inside, sacral border dressing, skin prep on intact skin around wound bed and change daily and as needed for soiling and barrier cream to anal and perineal area to reduce excoriation of skin. A review of a treatment record dated 09/02/15 through 09/08/15 revealed there were no treatments documented for a pressure ulcer. During an interview on 09/09/15 at 9:37 AM with Nurse Aide (NA) #10 she stated there was redness on Resident #53's buttocks but he went to the wound clinic and all they had to do was to keep him clean and dry. She stated she was not aware of any barrier cream for Resident #53's skin on his buttocks. During an observation and interviews on 09/09/15 at 10:12 AM the Director of Nursing (DON) and treatment nurse entered Resident #53's room and the treatment nurse stated she had received a skin referral to evaluate Resident #53's sacrum. Resident #53 was turned to his left side and the treatment nurse removed an adhesive dressing from Resident #53's sacrum and there was a large open area that was dark in the center of the wound with raw skin around the edges with skin peeled back and an open hole at bottom of wound. The treatment nurse measured the wound and stated the wound was 10 cm length x 8.5 cm width x 1.2 cm depth and was unstageable because she could not see the wound bed. The DON stated staff were supposed to check Resident #53's skin on his shower days and if they saw skin problems they were supposed to report it to the nurse. She further stated Resident #53 did not like to turn off his back and frequently he slid down in bed with his bottom in a depression that was caused by a fold in the air mattress when the head of the bed was raised. The treatment nurse explained Resident #53 looked like he was sitting in a ditch when he slid down into the crease of the mattress and he would not reposition himself. She stated she was very surprised to see the pressure ulcer on Resident #53's sacrum and thought when staff had pulled him up in bed they had sheared the skin off his bottom and now the skin had dried out and had eschar (dead tissue). She further stated Resident #53 had previously had a stage 4 pressure ulcer on the right side of his sacrum that had a small hole with exposed bone but it was not in the same location as the current pressure ulcer. During an interview on 09/10/15 at 10:38 AM Nurse #1 explained she was assigned to care for Resident #53 last week and she stated she remembered his bottom was red but did not remember anything else about his skin. She stated she might have put a dressing on his bottom since it was red but could not remember exactly what she did. She further stated she was not aware of treatment orders from the wound clinic on 09/02/15 and had not received reports from other nurses that Resident #53 had a new pressure ulcer or had new treatment orders from the wound clinic on 09/02/15. During an interview on 09/10/15 at 10:38 AM with NA #3 he stated he tried to do the best he could can for Resident #53 but it was a challenge to keep him off his back. He explained sometimes he was the only NA on the hall and he had difficulty making his routine rounds to reposition Resident #53. During an observation on 09/10/15 at 12:15 PM Resident #53 was in bed with the head of the bed raised and was flat on his back with his bottom down in the depression in the fold of an air mattress which was set on a low pressure setting at a control unit located on the footboard of the bed. During an interview on 09/10/15 at 12:25 PM with the Physician's Assistant she stated it was her expectation for nursing staff to assess resident's skin and let her or the physician know if there were problems or issues. She explained nursing staff could call anytime 24 hours a day or they could leave a note in the physician's communication book and they would see residents when they made rounds. She further stated if a wound was worse or looked infected they should let her or the physician know about it. She explained she felt wound treatments were not always provided consistently and she was not always informed about wounds that needed treatment. She stated staff in the facility were their eyes and ears and staff had to tell her or the physician when something needed to be addressed. She explained she had made rounds in the facility on 09/07/15 but she did not see Resident #53 because she was not aware he had a wound on his sacrum. She further stated she expected staff to turn and reposition Resident #53 even if he did not want to turn to keep him off his bottom to prevent skin breakdown. During an observation on 09/10/15 at 3:04 PM Resident #53 was lying flat on his back with the head of the bed up with his bottom down in the depression in the fold of the air mattress. During an observation on 09/10/15 at 5:39 PM Resident #53 was lying flat on his back in bed with the head of the bed up with his bottom down in the depression in the fold of the air mattress. During a telephone interview on 09/11/15 at 9:11 AM with the wound care physician he confirmed he had seen Resident #53 earlier that morning and he had a big wound on his sacrum that had to debrided (surgical removal) of necrotic (dead) tissue. He stated he was very surprised to see the condition of the wound since Resident #53 had a healing wound when he was seen in the wound clinic in August. He further stated he could not remember specifics about the wound because he did not have the resident's chart in front of him but the nurse would provide the information. He explained he had ordered wet to dry dressings on Resident #53's wound since he had removed dead tissue from it that morning and it was his expectation for dressings to be changed as ordered, turn and reposition Resident #53 and provide an air mattress to relieve pressure. He further stated pressure should be avoided to promote wound healing. During an interview on 09/11/15 at 9:58 AM with a facility transporter who also was a Nurse Aide (NA) she verified she had transported Resident #53 to the wound clinic earlier that morning and she stayed with the resident in the treatment room when he saw the wound physician. She stated Resident #53 had a large wound on his bottom that did not smell good and it looked worse than the previous time she had transported him to the wound clinic on 09/02/15. She stated prior to that on 08/30/15 the wound on his bottom was looking really good. She further explained the wound clinic usually sent paperwork back with the resident to the facility and she gave the paperwork to the nurse. During a follow up interview on 09/11/15 at 10:32 AM with the treatment nurse she explained she saw Resident #53's skin on 08/31/15 and the pressure ulcer she had been treating on his coccyx had healed and was pink with scar tissue. She stated she called the nurse practitioner who discontinued the treatment orders and she called the wound clinic to tell them the pressure ulcer had healed. She explained she did not realize Resident #53 went to his scheduled appointment at the wound clinic on 09/02/15 because no one had told her he had gone or that he had a new pressure ulcer until she got a skin referral on 09/09/15 and saw Resident #53 on 09/10/15. She confirmed the dressing she removed on 09/10/15 was a [MEDICATION NAME] sacrum border dressing but she did not know how long the dressing had been on the resident or who had put the dressing on because staff did not initial dressings with a date when a dressing was applied. She stated the facility had used staff from other facilities to fill in vacant positions and it was possible staff had not done treatments since they were not always familiar with residents or routines. She explained staff should turn and reposition Resident #53 to alleviate the pressure but it was a challenge because he preferred to lay on his back and did not like to turn or get out of bed. She further explained the new pressure ulcer on his sacrum looked like his skin had been sheared off when he had been pulled up in bed. She confirmed she was the wound treatment nurse in the facility but had also been assigned to work as a nurse on the halls to fill in for vacancies so she had to rely on nurses to let her know if resident's had red or broken areas of skin. She explained it was her expectation for staff to put a skin referral in the computer if a resident had skin breakdown so that she could assess them. She stated nurses had access to dressings and wound supplies and when she was not on duty they should have done treatments and should have told her about Resident #53's new pressure ulcer. She explained, after review of Resident #53's treatment records, there were no treatments documented for Resident #53's pressure ulcer from 09/02/15 through 09/08/15 because there was no documentation of Resident #53's clinic visit notes or orders in his medical record She explained usually the transporter brought back paperwork from the wound clinic and gave it to a nurse but she did not know if it was lost or what had happened. She verified nurses were supposed to write their initials on the treatment record when they provided treatments but since there were no initials the treatments were probably not done. She explained since she had not seen the wound clinic notes dated 09/02/15 other nurses were probably not aware of the treatment orders either and that could explain why treatments weren't done. During a telephone call on 09/11/15 at 11:00 AM from a nurse at the wound center she reported the following clinic visits for Resident #53: 09/02/15 wound measurements 8.0 cm length x 4.7 cm width x 2.0 cm depth with treatment of [REDACTED]. 09/11/15 wound measurements 11.7 cm length x 9.0 cm width x 2.3 cm depth with treatment of [REDACTED]. During an interview on 09/11/15 at 5:40 PM the DON stated it was her expectation for the transporter to bring orders from the wound clinic to the nurse when a resident returned to the facility. She further stated the nurse assigned to the resident needed to review the orders and the treatment nurse needed to review the orders and follow through with the treatment orders. She stated they needed to improve the communication system and if the nurse was not available when the transporter brought the resident back to the facility or the treatment nurse was not available the documents should be given to the DON. She confirmed there was no system for weekly skin checks but they needed a better system for skin assessments and skin referrals. She stated it was her expectation for treatments to be done daily or as ordered by the physician and if there was no treatment nurse on duty the nurse assigned to the resident should do the treatments. She further stated if there were no staff initials on the treatment records she interpreted it as the treatment was not provided.

Based on observations, record review and staff interviews, the facility failed to identify trends of fall circumstances and implement care planned interventions for 2 of 5 sampled residents reviewed for falls. Resident #99 fractured her arm when she fell the fourth time while ambulating by herself to the bathroom. Residents #99 and #106 did not have the care planned interventions in place to prevent falls. The findings included: 1. Resident #99 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Nursing notes dated 03/02/14 at 10:47 AM revealed a visitor alerted staff that Resident #99 was on the floor by the nursing station. She sustained a hematoma above her left eyebrow and was sent to the emergency room for evaluation. The incident report noted in response to the fall, a nonskid dycem pad was placed in her chair. The admission Minimum Data Set ((MDS) dated [DATE], indicated the resident had clear speech, was usually understood and could usually understand others, but cognitively impaired in that she could not answer any question on the brief interview for mental status. She was coded as having disorganized thinking, an altered level of consciousness and inattention. She had no behaviors during the assessment period. She was coded as requiring extensive assistance with bed mobility, transfers, and toileting. She was coded as ambulating only once or twice during the assessment period with no staff support. She was coded as always being incontinent of bowel and bladder and as having no toileting program. This MDS noted no falls prior to admission but having had 2 falls with no injury since admission. Nursing notes dated 03/04/14 at 8:00 PM stated Resident #99 was found sitting on the bathroom floor. The resident stated at the time that she went to use the bathroom alone and slipped. She was subsequently placed back into her wheelchair and then to bed and encouraged to use her call bell. In response, the incident report stated non slip strips were to be added to the floor by the bed, sink and toilet. A Quality Improvement (QI) note for falls was dated 03/05/14 which included review of 3 falls: one on 03/02/14 with dycem added; one on 03/03/14 when the resident fell from bed and a fall mat was added; and one for 03/04/14 when a chair alarm was added. A care plan for a risk for falls and actual falls due to impaired cognition and impaired mobility was initiated on 03/12/14. The goal was for Resident #99 to not sustain serious injury through the next review. Interventions included: *fall mat on floor when in bed; *nonskid strips on floor; *wheelchair with dycem when out of bed. This care plan did not include the intervention of the chair alarm. In addition another care plan developed on 03/12/14 included an intervention to transfer providing one-person constant guidance and physical assistance. A nursing note dated 03/28/14 as a late entry for 03/27/14 at 9:35 PM noted the resident was found sitting on the floor and the chair alarm was not turned on. Resident #99 stated that she had to use the bathroom. The QI note dated 04/01/14 noted the action taken was to remind the resident to use the call light for assistance for toileting and other needs. The chair alarm was replaced and her medications were reviewed due to behaviors. There was no investigation to determine how or why the alarm was not on. A nursing note dated 04/26/14 at 12:33 PM revealed Resident #99 was lying on the floor at the entrance to the bathroom. The wheelchair alarm's volume was turned down. The resident stated she fell trying to use the bathroom. The incident report revealed the resident and roommate both stated Resident #99 had asked the roommate to put the call light on for her. The incident report and the QI note dated 04/28/14 noted that staff were educated to check alarms for sound and function and the resident was asked to wait for staff assistance before transferring alone. The investigation did not include who was responsible for turning the alarm down. Resident #99 was noted on the investigation as being oriented to place and person only. A nursing note on 05/17/14 at 4:29 AM stated the resident was found sitting on the floor in front of the open door to her room with her legs bent and feet on the floor. She was holding her right arm with her left hand complaining of severe pain. She was unable to lift her right arm. The resident stated she was self ambulating from the bathroom back to bed. The nursing note stated a bed alarm was placed on the bed. Resident #99 was sent to the hospital for an X-ray of her arm. The hospital records dated 05/17/14 noted a closed fracture of the clavicle. She was subsequently treated with a sling. A follow up consult report dated 05/27/14 noted a 2 part humerus fracture with some displacement to be treated nonsurgically. The investigation did not include information as to whether the alarm was sounding at the time of the fall. Attempts to call the nurse who wrote the nursing note related to this fall were unsuccessful. She no longer worked in the facility. Review of the care plan for falls, which was maintained in the computer system, revealed the addition of a bed alarm was placed on the care plan on 05/17/14. This was the current care plan at the time of the survey for Resident #99. A significant change MDS dated [DATE] coded her with moderately impaired cognition, feeling down, tired and bad about self, moving or speaking slowly, having no behaviors, being nonambulatory, requiring extensive assistance with eating, having impairment on one side and being occasionally incontinent of bladder and always being continent of bowel. She was coded as being on no toileting plan and having one fall since the previous assessment with a major injury. In addition to the care plan, individual care guides were taped inside the closet door of each resident. The care guide for Resident #99 located in the closet door and dated 08/07/14 had the interventions including mat on floor bedside bed: non skid, sensory alarm to bed, dycem to wheelchair, and slip strips at sink and toilet in room. Resident #99 was observed awake in bed without an alarm or mat on the floor at the following times: 08/25/14 at 10:01 AM, 08/26/14 at 11:25 AM; 08/27/14 at 8:26 AM; 08/28/14 at 8:12 AM; 08/28/14 at 8:33 AM and 08/28/14 at 3:14 AM. There were also no nonskid strips observed on the floor at these same times. The Administrator and Director of Nursing were interviewed on 08/27/14 at 2:02 PM regarding Resident #99's falls and interventions. Neither were working at the facility at the time of these events. Both reviewed the nursing notes and incident reports. Both confirmed that Resident #99 fell 3 times taking herself to the bathroom (03/04/14, 03/27/14 and 04/26/14). They confirmed there was no evidence that Resident #99's repeated attempts to toilet herself at the time of each fall had been identified or addressed before she fell and fractured her arm on 05/17/14 when she again transported herself to the bathroom. On 08/28/14 at 8:46 AM, Nurse Aide (NA) #1 stated she has been in the facility about a month and has not seen floor mats or an alarm in use for Resident #99. She further stated on 08/28/14 at 8:50 AM stated she knew what individual care a resident needed by the posted care guide in the resident's closet. Interview with the current QI nurse on 08/28/14 at 11:32 AM revealed that up until a month ago she was the MDS nurse and then became the QI nurse. The previous QI nurse was no longer working in the facility. The current QI nurse stated that the previous QI nurse was responsible for tracking and trending falls and putting interventions in place specific to the trends. The former QI nurse then emailed the MDS nurse to update the care plans and care guides in the resident's closet. She stated the previous QI nurse should have identified the trend of Resident #99 falling when taking herself to the bathroom. She further stated that when working as the MDS nurse she never considered a toileting program during the time Resident #99 was falling as she was occasionally incontinent and dribbled. The QI nurse further stated that Resident #99 would take herself to the bathroom and she would have to be reminded not to take herself. Since the fracture, the QI nurse stated Resident #99 had undergone a significant change. The certified occupational therapy aide (COTA) who has worked with Resident #99 for months stated on 08/28/14 at 12:30 PM she could not recall an alarm being on her bed or if there was a mat on the floor or nonskid strips by the bed. She further stated that Resident #9 had moved rooms a couple of times since admission. Nurse #1 stated on 08/28/14 at 1:08 PM that she could not recall strips on the floor or a nonskid mat and she was not sure if an alarm had been on and/or when she last saw it. She further stated that often interventions were placed on residents, such as an alarm, and nurses were not informed about the addition of the intervention. Interview with the Director of Nursing on 08/28/14 at 2:28 PM revealed the care guides and care plans should match and interventions checked to see they were in place. Follow up interview with the DON on 08/28/14 at 4:09 PM revealed they have identified falls as a problem and currently review all accidents and circumstances surrounding a resident's fall. Each investigation is reviewed to ensure the intervention in place is appropriate. The DON also stated they were auditing each resident daily to ensure the alarm was on the resident as care planned. 2. Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #106 had the following falls and interventions per incident report review: *05/17/14 at 2:29 AM when she was hiding under her bed looking for the voices she was hearing. A bed alarm was initiated as an intervention to prevent further falls. *05/17/14 2:41 PM when she was found approximately 6 feet from her wheelchair on the floor. A chair alarm was added as an intervention to prevent further falls. *05/17/14 at 2:56 PM when she was found on floor in day room. A pillow and incontinent pad were removed from the seat of her wheelchair. *05/20/14 at 1:47 AM when she was found on the floor and she stated she slipped when exiting her chair. She had removed her nonskid socks so family was asked to encourage Resident #106 to wear them. The admission Minimum Data Set ((MDS) dated [DATE] coded her with severely impaired cognitive skills, requiring limited assistance with bed mobility, transfers, dressing and toileting. She walked with supervision and took antipsychotic medications. She had no history of falls prior to admission but had experienced falls since admission to this facility. A care plan was developed on 05/27/14 with a goal for Resident #106 to be free from falls. Care plan interventions included assisting her during transfers and mobility and to have a bed alarm and chair alarm in place. The Care Area assessment dated [DATE] noted Resident #106 had an unsteady gait. Per the incident report, Resident #106 fell on [DATE] at 4:36 PM when she was found on the floor on her back. She stated she was trying to get in bed and fell . The investigation did not identify if the chair alarm sounded or was in use at the time the resident was found. Under the section on the incident report for predisposing situational factors, a check was placed by "non-compliance", however, no further description was included in the remarks section. The action taken was an anti-rollback device added on her wheelchair. A Quality Improvement note dated 06/16/14 at 4:27 PM, related to this same incident, stated the nurse reported Resident #106 fell while transferring from the bed to her wheelchair. The note did not address the presence of either a chair or bed alarm. The care plan was updated on 06/24/14 with the intervention of anti-roll backs to her wheelchair. An incident report indicated Resident #106 fell on [DATE] at 6:24 AM when she rolled out of bed onto her face. This was a witnessed event. The nursing note stated that she was placed back in bed and the bed alarm was checked and in working order. Resident #106 fell on [DATE] at 3:46 AM when, per the incident report, she was found sitting in front of the bathroom door. The bed alarm was disconnected and the resident denied disconnecting it. There was no further documented investigation regarding how the alarm was disconnected. Interview with the Director of Nursing (DON) and Administrator on 08/27/14 at 2:02 PM while reviewing residents' falls, revealed this fall occurred on the DON's her first day of employment and it would have been discussed in morning meeting the next day. Neither the Administrator or DON could state what was investigated relating to the disconnected alarm. The Administrator further stated they were going to audit chair and bed alarms and refer to therapy after each fall. Resident #106 fell again on 07/11/14 at 2:00 AM per incident report when she was found sitting on the floor in front of her bed. She stated she was going to go to the bathroom. The Quality Improvement (QI) note dated 07/17/14 noted that nonslip socks were encouraged. Another QI note dated 07/21/14 stated an additional intervention was to place nonslip strips to the floor at the resident's bedside. This intervention was not added to the plan of care. The incident reports revealed Resident #106's last fall was on 07/31/14 at 11:13 PM when she fell trying to get into bed. The report did not specify if the resident transferred from her wheelchair or where she was previous to the fall. The incident report stated the roommate was hollering down the hall and the resident was observed sitting on the floor. The report did not address if the chair alarm was sounding. The interventions were noted on 08/01/14 that she already had a chair alarm and staff were instructed to check prior to shift change to anticipate needs. Resident #106 was observed on 08/26/14 at 4:20 PM laying across her bed without a bed alarm in place and without nonskid strips located by the bed or bathroom. No alarm was in bed when the resident was observed in bed on 08/27/14 at 8:34 AM and no nonskid strips were noted on the floor by her bed. She was observed on 08/27/14 at 3:13 PM with the DON sitting on the bed without a bed alarm in place and there were no nonskid strips on the floor by her bed or bathroom. Review of the resident care guide in the closet dated 08/14/14 revealed she was supposed to have a bed alarm and nonskid strips by bed and bathroom. The DON confirmed no bed alarm was in place and nonskid strips were not on the floor by her bed. The DON stated the interventions in the resident's care guide, used by nurse aides, and the interventions in the resident's care plan should match. The DON stated the interventions were to be checked as being in place by restorative nurse aides and weekend managers. Interview with the current QI nurse on 08/27/14 at 3:38 PM revealed the QI nurse would let the MDS nurse know what interventions were planned after the fall and the MDS nurse would then revise and update the resident's care plan and resident's care guide and they should match. The QI nurse stated the nonskid floor strips may have been placed at one time for Resident #6, but the resident had moved to a different room and staff failed to place these strips in the resident's new room. On 08/28/14 at 8:46 AM, Nurse Aide (NA) #1 stated she had worked in the facility about a month and she knew what individual care a resident needed by the posted care guide in the resident's closet. Review of the resident's falls and interventions with the DON and Administrator on 08/28/14 at 4:09 PM revealed that review of the medical record the care plans did not include the floor strips as a fall intervention.