Every finding on record at Maple Manor Village

Based on clinical record review, Resident Assessment Instrument (RAI) manual, and staff interview the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days of a status change for 1 of 2 residents reviewed for hospice care (Resident #41). The facility reported a census of 36 residents. Findings include:Resident #41's MDS dated [DATE] lacked a completion date. Resident #41's Hospice admission Consent form, Medicare Hospice Benefit Election form and the Election of Medicaid Hospice Benefit form were signed and dated on 12/5/2025. Resident #41's Progress Note written 12/5/25 at 10:00 AM documented they would be admitted to hospice later that day. The Long-Term Care Facility RAI 3.0 User's Manual, version 1.20.1 dated October 1, 2025, instructed the MDS assessment must be completed no later than 14 calendar days after the determination of a significant change in the resident's status. It defined a hospice enrollment as a significant change. On 2/16/26 at 9:44 AM the Director of Nursing (DON) reported the facility currently didn't have a MDS Coordinator. Since late November the facility used an offsite group to complete the MDS'. On 2/17/26 at 10:17 AM the MDS/Reimbursement Specialist reported she didn't know about the 14 days from hospice elect. She treated all significant assessments changes the same but realized it when looking at the MDS table on page 2-17 of the RAI manual, itdocumented the determination date for significant changes plus 14 days to complete.

Based on interviews, observations, and record review, the facility failed to ensure medications were not diverted for 5 of 5 residents reviewed (Residents #1, #2, #3 #4 and #5). Resident #1, #3, #4, and #5 all had a narcotic pain pill missing from one of the facility's medication cart's controlled substance locked drawer. Resident #2's Controlled Substance card was missing when the count was checked. The medication card contained clonazepam (Klonipin) (an antianxiety medication) that was to be administered daily at noon. The card that was to be counted showed this once a day medication was given at 7:40 a.m. This card also showed there was 1 pill missing. There was no reason documented that showed this resident received the medication early. Nor is a medication to be given prior to the time it is to be received without a doctor's order. The facility reported a census of 34.Findings include:1. A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #1 included anxiety, reduced mobility, and diabetic polyneuropathy (nerve damage caused by high blood sugar levels over time). A Brief Interview for Mental Status (BIMS) revealed a score of 7 out of 15, which indicated severe cognitive impairment. Resident #1 had pain frequently in the past 5 days. Pain occasionally made it hard for Resident #1 to sleep and pain frequently limited Resident #1's participation in rehabilitation therapy sessions in the past 5 days. It documented that over the past 5 days the resident was frequently limited in her day-to-day activities due to pain. A Minimum Data Set (MDS) dated [DATE], documented that diagnoses for Resident #1 included anxiety. A Brief Interview for Mental Status (BIMS), documented a score of 15 out of 15, indicating Resident #1 had intact cognition. Resident #1 had pain occasionally in the past 5 days. Pain occasionally made it hard for #1 to sleep in the past 5 days. It documented that over the past 5 days the resident was occasionally limited in her day to day activities due to pain. A Care Plan with a target date of 11/7/25, documented that Resident #1 had complaints of pain described as chronic greater than 3 months related to sacrum (tail bone area) pressure ulcer and osteoarthritis to right hips. The interventions included to administer pain medications per physician orders and encourage/assist to reposition frequently to position of comfort. A Medication Administration Record/Treatment Administration Record (MAR/TAR), for the month of May 2025, directed staff to do a pain evaluation daily. The beginning date was 5/6/25. On 5/29/25, Staff A, Licensed Practical Nurse (LPN), documented that Resident #1's pain level was at an 8 out of 10, which indicated severe pain.This MAR documented that hydrocodone-acetaminophen oral tablet 5mg(milligrams)-325mg could be given by mouth, 1 tablet every 6 hours as needed for pressure ulcer of sacral region. It documented that Staff A administered 1 tablet on 5/29/25 at 7:33 a.m. for a pain level of 9 and again administered 1 tablet at 2:13 p.m. for a pain level of 6.Progress Notes reviewed for 5/29/25 through 5/30/25. No mention of pain was documented. A Controlled Substance Medication Record for Resident #1, was signed by Staff A on 5/29/25 at 7:30 a.m., 5/30/25 at 3:30 p.m., and on 5/30/25 at 7:04 a.m. Bringing the count from 23 to 20. An FRI (Facility Reported Incident) of suspected controlled substance diversion, investigation report dated 6/16/25, Resident #1, had an order for Hydrocodone/APAP Tab 5-325 mg every 8 hours as needed. A 42-tab card was received from pharmacy on 5/15/25. 22 doses were signed off as administered on the Controlled Substance Medication Record as of the morning of 5/30/25. There were 19 tablets in the card leaving one tablet unaccounted for. 10/8/25 at 4:00 p.m., A Certified Nurse Aide (CNA) went into the resident's room and shut the door. The CNA said 'Cares' then gave permission for this writer to go into the room. The CNA left and stated she needed to get another staff person. Talked with Resident #1 after CNA left the room. When asked if she was in pain, Resident #1 stated she was feeling some pain, that's why she had turned on her call light to be repositioned. She felt this would help with the pain. She felt she was on the appropriate pain medications and felt she received this medication when she needed it.2. An MDS dated [DATE], documented diagnoses for Resident #2 included anxiety disorder, intellectual disabilities, and mood disorder. A BIMS revealed a score of 0 out of 15, which indicated severely impaired cognitive functioning. the resident had behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 4-6 days, but less than daily in the 7 day observation period prior to this MDS.A MAR dated May 2025, directed to administer Klonopin (clonazepam) 0.5 mg 1 tablet at noon. The start date for this medication was 5/5/23. The MAR documented that Staff A administered this medication on 5/30/25 at noon. The MAR did not document this medication was administered out of the accepted and prescribed time. The MAR directed staff starting on 5/30/25 at 2:00 p.m., to monitor the use of psychotropic medications. The staff's initials indicate the absence of signs and symptoms of side effects and sedation (difficult to arouse, sleeping more than normal). This medication is treating the targeted behaviors noted in the care plan. Use code NN (other/see nurses notes) if side effects are present and complete documentation every shift.A Care Plan for Resident #2 directed the following: Resident #2 utilizes psychotropic medication related to generalized anxiety disorder for targeted behavior of excessive anxiety and worry occur most days for at least six months; difficulty controlling the worry restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep problems, striking out at staff and others. The goal with a target date of 1/15/26, documented that Resident #2 would remain free of complications related to use of psychotropic medications.This care plan directed staff to:administer medications as ordered.Assess for side effects and complications such as abnormal involuntary movements.Attempt nonpharmacological interventions prior to use of psychotropic medications.Monitor behaviors per facility protocol.Monitor for changes in cognition, mood and behavior.It documented to try the following non-pharmacological interventions: going for a walk or stroll outside when nicemusic therapyoffer a snack offer to lay down and restoffer toileting or anticipating the needs of the residenttalk therapy ask about life events or interests.Progress Notes (to include nurses notes) for Resident #2, lacked documentation to support early administration of clonazepam for anxiety or behaviors on 5/30/25. There was no documentation at all in these progress notes from 5/21/25 to 6/18/25.A Controlled Substance Medication Record for Resident #2, documented this record was for the administration of clonazepam tab 0.5 mg-1 tablet by mouth daily at noon for anxiety wear gloves. Staff A had documented on 5/30/25 at 7:20 a.m., 1 clonazepam tab had been given, bringing the count from 1 left in the card to 0 left in the card. This card also revealed that on 5/29/25 at 10:00 a.m., Staff A had administered a clonazepam 1 tab, bringing the count from 3 to 2. The following two entries signed and lined through by Staff A documented that Clonazepam 1 tab was given bringing the count from 2 to 1. Staff A wrote 'error' by the struck through entries and then signed her initials. On 5/29/25 at 10:00 p.m., this count sheet was signed as 'count' 1 tab by Staff B, LPN, and Staff C, Registered Nurse (RN). On 5/30/25, Staff A signed the card at 7:20 a.m., putting the count from 1 to 0. An FRI of suspected controlled substance diversion, investigation report dated 6/16/25, documented that during the count, it was noted that Resident #2 had an order for Clonazepam tab 0.5 mg daily at noon and this card was missing from the drawer. Staff A reported that she had given the medication early, even though she knew she wasn't supposed to do that and signed it out on the Controlled Substance Medication Record as administered at 7:20 a.m. on 5/30/25. On 10/15/25 at 11:16 a.m., the Director of Nursing (DON) stated that on 5/30/25 at around 9:30 a.m., she went through the controlled medication cards with Staff A to ensure the count was correct for the controlled medications. The DON noted that Resident #2's medication card containing clonazepam was missing. She then looked at Resident #2's Controlled Substance Medication Record count sheet and noted the clonazepam was given at 7:20 a.m. on 5/30/25. The medication was not supposed to be given until noon. DON stated that Staff A said that she knew she wasn't supposed to give the medication early, but gave no reason as to why she administered the clonazepam outside of the parameters.3. A MDS dated [DATE], documented diagnoses for Resident #3 included chronic pain syndrome and postlaminectomy syndrome (persistent pain following spinal surgery). A BIMS revealed a score of 14 out of 15, which indicated intact cognition. the resident had pain almost constantly during therapy activities, sleep, and day to day activities in the past 5 days. A Care Plan for Resident #3 with a target date of 6/10/25, directed that the resident had complaints of pain described as chronic pain related to arthritis and postlaminectomy syndrome. Resident #3 utilized opioids for pain management. The interventions included to administer pain medications per physician orders and encourage/assist to reposition frequently to position of comfort. The Census page for Resident #3, revealed he was discharged to the hospital on 6/3/25. The resident did not return to the facility. Resident #3's MAR for the month of May 2025, directed that Oxycodone 20 mg tablets could be given 1 tablet every 6 hours as needed for pain. This MAR documented that Staff A administered 1 dose to Resident #3 at 9:47 a.m. for a pain level of 9 on 5/29/25 and another dose at 6:16 a.m. on 5/30/25 for a pain level of 9. Staff A documented that the effectiveness of the dose given on 5/30/25 was unknown.There was nothing documented in the resident's progress notes on 5/29/25 nor on 5/30/25.On a Controlled Substance Medication Record for Resident #3's as needed oxycodone, Staff A documented that she had given 1 tab at 6:35 a.m. and again at 1:45 p.m. on 5/29/25. Both of these entries had scribbles over the numbers and were difficult to read. The MAR documented only one dose was given by Staff A on 5/29/25. Staff A documented that she had given Resident #3 a dose of Oxycodone 20 mg at 6:16 a.m., bringing the countdown to 26. An FRI of suspected controlled substance diversion, investigation report dated 6/16/25, Resident #3 had an order for Oxycodone tab 20 mg every 6 hours as needed. A 30-tab card was received from pharmacy on 5/19/25. Four doses were signed off as administered on the Controlled Substance Medication Record as of the morning of 5/30/25. There were 25 tablets in the card leaving one tablet unaccounted for.4. A MDS dated [DATE], documented diagnoses for Resident #4 included fracture of right humerus (long bone of the upper arm). A BIMS revealed a score of 8 out of 15, which indicated moderately impaired cognitive functioning. Resident #4 had pain almost constantly. It documented that Resident #4 had pain frequently while sleeping, participating in therapy activities, and during day to day activities in the past 5 days.A Care Plan with a target date of 11/22/25 documented that Resident #4 had complaints of pain described as acute. 1 month related to fracture of right humerus. Resident utilizes scheduled APAP (acetaminophen/Tylenol), as needed opioids, and ice packs. Interventions included administer pain medication per physician orders and encourage/assist to reposition frequently to position of comfort. A MAR, for the month of May 2025, documented that oxycodone 5 mg could be given, 1 tablet every 6 hours as needed for pain. It documented that Staff A administered 1 tablet on 5/29/25 at 7:16 a.m. for a pain level of 7 and again administered 1 tablet at 2:13 p.m. for a pain level of 8.The resident did not have any entries in her progress notes on 5/29/25.A Controlled Substance Medication Record for Resident #4's as needed oxycodone, documented that Staff A gave tablets on 5/26/25 at 7:30 a.m., bringing the count from 9 to 8. The following entry is difficult to read as it is scribbled over. Off to the side it is documented 'dropped' with initials by Staff A. On 5/29/25 at 2:13 p.m., Staff A documented that she gave one tablet, bringing the number from 7 to 6.An FRI of suspected controlled substance diversion, investigation report dated 6/16/25, Resident #4 had an order for Oxycodone tab 5 mg every 6 hours as needed. A 28-tab card was received from pharmacy on 5/14/25. 22 tabs were signed off as administered on the Controlled Substance Medication Record as of the morning of 5/30/25. There were 4 tablets in the card leaving two tablets unaccounted for.5. A MDS dated [DATE], documented diagnoses for Resident #5 included chronic pain. The BIMS documented that resident was rarely/never understood and staff assessment documented that he was severely impaired. The staff assessment for pain or possible pain for the past 5 days, documented that none of the following signs were observed or documented: non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning); vocal complaints of pain (e.g., that hurts, ouch, stop); facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw), or protective body movements or postures (e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement).A MAR for the month of May 2025, documented that Hydrocodone/Acetaminophen 5-325 mg 1 tablet could be given every 8 hours as needed for pain. Staff A administered 1 tablet on 5/19/25 at 3:55 p.m., and one tablet on 5/29/25 at 6:50 a.m. A Controlled Substance Medication Record for Resident #5 documented that Staff A gave one as needed Hydrocodone/APAP 5-325 mg tab on 5/29/25 at 6:30 AM, which brought the count from 6 to 7 (instead of 8 to 7). The last number on this form was 7 tabs were to be in the medication pack. This Controlled Substance Medication Record also had a date that was illegible that brought the count from 9 to 8. It was given in between a dose that was given on 5/28/25 by another nurse and the dose that was given by Staff A on the morning of 5/29/25. This was not signed out as given on the MAR. There was a dose signed out on 5/11/25 by Staff A as well that at that time brought the number from 13 to 12. Staff A did not sign the MAR for administering this medication on that day. (Staff A signed for administering 4 doses on this Controlled Substance Medication Record but only signed as administering this medication twice on the MAR. An FRI of suspected controlled substance diversion, investigation report dated 6/16/25, Resident #5 had an order for Hydrocodone/APAP Tab 5-325 mg every 8 hours as needed. A 30-tab card was received from pharmacy on 3/10/25. 23 tabs were signed off as administered on the Controlled Substance Medication Record as of the morning of 5/30/25. There were 6 tablets in the card leaving one tablet unaccounted for. On 10/7/25 at 4:45 p.m., Staff B stated that Staff A had seemed distracted during the controlled substance count at 2:00 p.m. on 5/29/25. This count was done when Staff B arrived for her shift and Staff A was ending her shift. Staff B stated she couldn't remember the exact residents or medications but Staff A had signed a pill out, then crossed one out that she had given. Staff B stated Staff A was discombobulated that day. Staff B said that by the time they finished counting everything, all medication was accounted for. Staff B said that Staff A thought she had dropped a pill, but then said she had not dropped the pill but had actually given it to a resident. On 10/13/25 at 1:29 p.m., Staff C stated that she counted the controlled substances at the end of her shift and the beginning of Staff A's shift on 5/29/25 at 6:00 a.m., and the count was correct. Staff C stated she counted the controlled substances again when she came back into work on 5/29/25 at 10:00 p.m., with Staff B and it was not correct. Staff C stated along with Staff B, they then made sure all the count was correct at that time. Staff C stated there were entries that were lined through and it didn't appear right. She stated that she went through all the medications in the count with Staff B and made sure the count reflected/was correct at that time and left a note for the DON. Staff C stated she asked Staff A what she had done on Resident #5's controlled substance card, and Staff A said she just didn't really know why she had done that. Staff A's balance was all off and she fell over when she was trying to tie her shoe. Staff C said the morning of the 29th, Staff A came in and pulled out the roller chair. Staff A sat down to tie her shoe on the roller chair and fell off the chair and was lying on the floor and she was tugging at her shoe. Staff C stated that Staff A then got up and went to the shower to get a towel for a med cart and stumbled into the wall. Staff C asked Staff A what was wrong, and Staff A said she thought she had a sinus infection. Staff C said that Staff A then came up to the medication cart and was standing with her feet together and almost fell over again. She then widened her stance and was fine. On 5/29/25 at 10:00 p.m., Staff C stated she was counting with Staff B and they noted that Staff A had changed the number from the day before on one of the resident's card. Staff A had just scribbled everything out and changed the number, didn't put a new date or anything new, she had just changed the number. She didn't put a new line and sign and subtract any of that. Resident #5 should have had one or two pills given that day. Staff C stated that on the morning of 5/30/25, Staff A was fine, she was her normal self again. After Staff C wrote her note (to the DON), Staff B did remind Staff C that Staff A did take sleeping pills. Staff C stated she could not remember exactly if the count was on for the other residents. The whole thing was just wrong. Staff C stated she did kind of remember that there might have been other residents with one pill missing. Staff C stated she wrote down Resident #5's because of the scribbling on the count sheet.On 10/9/25 at 2:20 p.m., the DON stated that Staff C, the night shift nurse, had notified The DON via a post it note in her mailbox. The DON found the note around 9/9:30 a.m. on 5/30/25. The DON went out and asked Staff C to do the controlled substance count with the DON. The DON stated the very first resident's card they checked was not right. The DON pulled that card out and put it to the side. The DON went through the rest of the cards pulling out ones that weren't right and set them aside. The DON stated that they started counting and Staff A kept laughing. The DON told Staff A that this (the count being off) was serious and not okay. The DON didn't know if it was a nervous laugh or what. The DON stated they were counting maybe Resident #5's card and Staff A started to mark on the sheet. The DON told Staff A to stop marking on the sheet. Staff A didn't give an explanation to any of the cards when the DON told Staff A the count was off on the cards that the DON was setting aside. The DON took the medication cart keys from Staff A and went into the office. The DON pulled up the resident's MARs and started comparing the MARs to the count sheet. They were all lining up except for the day before on 5/29/25. The DON asked Staff A when she last gave a controlled medication to Resident #5. Staff A stated it had been about 2 days. The DON said that Staff A had signed that she had given him a hydrocodone that morning. The DON brought all the cards and the sheets up to the administrator's office and showed the administrator what the DON had found. Staff A was then sent home. On 10/14/25 at 3:55 p.m., the Licensed Nursing Home Administrator (LNHA)(Administrator), stated that on 5/30/25, the DON had come to the LNHA mid morning. The DON had seen a note, and did a controlled substance count with Staff A. The DON had seen that there were a few discrepancies. The DON then took the keys and the cards and tried to figure out where the discrepancies were. The DON took Staff A off of the medication cart. After the DON and the LNHA looked at the count together, they noticed that the discrepancies were coming from Staff A. When we asked her about these, Staff A was unable to explain anything. Staff A did say she had a sinus infection and she did sound congested. They ended up sending her home. They then called Staff B. Staff B said that the count was different. Staff B told them that she didn't realize the count was off until she counted the meds with Staff C that evening. That's how they discovered the count was off. The LNHA reviewed video the following week and saw some strange and concerning things. The LNHA stated in the video she saw Staff A open the narcotic drawer and pop several pills into a medication cup. They then brought Staff A back in and showed her the videos of her popping the pills out into the med cup and a video of when Staff A took a pill out of the drawer with her hand. The LNHA stated that Staff A's eyes got kind of big when she saw both videos, like she couldn't believe what she was seeing and looked surprised. Staff A stated she didn't know why she would have done that, Staff A could give no reason behind it.An FRI of suspected controlled substance diversion, investigation report dated 6/16/25, included the following documentation:On 6/4/25, the Administrator reviewed camera footage from 5/29/25 - At approximately 6:45 AM, Staff A was observed standing at the South medication cart. She flips through several pages of the Controlled Substance Medication Record binder and writes on two pages. She unlocks the narcotic drawer and pulls the back card and dispenses one pill into a medication cup. The back card in the drawer is Oxycodone tab 20 mg for Resident #3. Staff A then pulls the front card and appears to dispense two pills into the same medication cup. The front card in the drawer is Hydrocodone/APAP Tab 5-325 mg for Resident #1. Staff A pulled another card towards the middle of the stack and appears to dispense two pills into the same medication cup, and then pulls one more card and dispenses one pill into the same medication cup. She writes one entry in the Controlled Substance Medication Record. She carried the medication cup down the southwest hallway. She returned to the nurses' station approximately two minutes later. At approximately 7:15 AM, Staff A appeared to dispense a group of medications into a medication cup. She takes the medication cup and a cup of water to Resident #4 in the dining room and Resident #4 takes the medication. Staff A did not unlock the narcotic drawer to dispense any narcotics at this time. She charted that she administered Oxycodone 5 mg to Resident #4 at 7:16 AM. At approximately 9:50 AM, Staff A unlocks the narcotic drawer and pulls a card towards the back of the drawer. She appears to dispense a tablet into her hand. She goes into the nurses' station. She charted that she administered Oxycodone tab 20 mg to Resident #3 at 9:47. She did not leave the nurses' station from approximately 9:35-10:00 AM. At approximately 2:00 PM, Staff A completed the narcotic count with Staff B. Staff A was looking at the binder and Staff B was looking at the medication cards. There appears to be one discrepancy in which both nurses search for a missing tablet in and around the drawers. They are then observed to both write in the Controlled Substance Medication Record binder. All other cards appear to be counted with no discrepancy. Upon further interview with Staff B on 6/5/25, regarding the narcotic count, Staff B stated they typically first count the total number of medication cards and then count how many tablets are left in each card. Staff B noted that Resident #4's Oxycodone count was off. Staff A told Staff B that she thinks she gave Resident #4 two pills, but she couldn't remember for sure. Staff A said that she must have dropped it, so they looked for it, then signed it out as dropped on the record sheet. Staff B reported there was another card that had one too many tablets. Staff A said she forgot to give it, so she dispensed it from the card and said she'd give it then. Staff B does not recall if Staff A went down the hall to give the medication or not. Staff B reported that Staff A seemed to have difficulty concentrating during the narcotic count. Staff B reported during the count at the next shift change at 10:00 PM with Staff C they noted that Resident #5's Hydrocodone/APAP Tab 5-325 was one tablet short. They also noted there were several pages in the Controlled Substance Medication Record with entries crossed off or changed. Staff C left a note for the DON to notify her about missing narcotic/s and altered records. The Administrator and the DON completed follow-up interview with Staff A on 6/10/25. Administrator showed Staff A the Controlled Substance Medication Records and questioned if she could explain the entries that were crossed out or altered. Staff A pointed to the altered date on a line signed by another LPN and stated that she knows she shouldn't do this, but when she notices an error she has to correct it. The Administrator responded that line didn't appear to be an error until it was altered and that Staff A denied altering that line when first asked on 5/31/25. Staff A reviewed the other Controlled Substance Medication Records and was unable to explain the other errors and alterations. This Administrator then showed Staff A the camera footage from 5/30/25 (5/29/25) of Staff A dispensing several tablets from the narcotic drawer into one medication cup. Staff A stated that she doesn't know why she would have done this and that is not her normal practice. Staff A became tearful and stated that she has been having some health issues recently and has noticed memory loss. She reports that she has an appointment with her doctor for scans to test for a brain tumor or early-onset Alzheimer's Disease. Administrator questioned why Staff A had not reported this to a supervisor or HR previously and Staff A stated she didn't know and that she knows she should have. Due to the serious nature of the concerns identified, Staff A was notified that her position was terminated effective immediately.Review of available footage, revealed there was footage missing. The footage available was from 5/29/25 from 6:35 a.m. to 6:50 a.m. and from 9:45 a.m. to 10:00 a.m. The footage showed Staff A popping out several pills into one medication cup from different narcotic cards around 6:45 a.m. Staff A left the cart around 6:42 a.m. The footage also showed Staff A appearing to pop 1 pill into her hand from the narcotic drawer and then Staff A going into the nurses' station with that pill. A Controlled Medication Storage and Count Policy revised October 2023, directed the following:Purpose: To maintain safe storage and an accurate count of Scheduled II controlled medicationsProcedureNarcotics are stored under a double lock systemAfter removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication is takenAfter administration of the controlled medication, the nurse/medication aide will sign off the eMAR (electronic Medication Administration Record)If the controlled medication needs to be wasted, a second nurse should witness the wasting of the controlled medication and both nurses will sign the medication sheet (a certified medication aide and licensed nurse can waste controlled medication) NOTE: 2 certified medication aides are NOT authorized to waste controlled medicationsAny narcotic count discrepancy will be immediately reported to the Director of NursingNarcotic counts are completed at the beginning and end of each shift or at the time when there is an exchange of medication cart keysRequires two nurses (or one nurse and one certified medication aide)Oncoming nurse validates medication count on the medication card, off-going nurse validates medication count on the paper documentBoth nurses are required to sign off on the shift-to-shift count record

Based on observations, interviews and record review, the facility failed to discontinue medication per discharging hospital physician's orders for 1 out of 3 residents reviewed (Resident #1). Resident #1 received 4 doses of Eliquis (an anticoagulant medication (treats and prevents blood clots)) after returning to the facility following a hospitalization. The orders from the hospital were to no longer administer Eliquis. The facility reported a census of 34. Findings include: A Minimum Data Set (MDS) dated [DATE], documented that diagnoses for Resident #1 included anemia and anxiety. A Brief Interview for Mental Status (BIMS), documented a score of 15 out of 15, indicating Resident #1 had intact cognition. The resident was always incontinent of stool. Resident #1 was taking an anticoagulant medication. A Hospitalist Discharge Summary printed on 9/22/25 at 1:43 p.m., documented that Resident #1 was admitted to the hospital on [DATE] and was discharged on 9/22/25 at 12:05 p.m. The Discharge Final Diagnosis was [NAME] (a form of blood in stool which refers to the dark black, tarry feces that are commonly associated with upper gastrointestinal bleeding). The Discharge Medication List directed to stop taking Eliquis 2.5 mg. A Medication Administration Record (MAR) for the month of September, directed that Resident #1 was to receive Eliquis oral tablet 2.5 mg twice a day (a.m. and supper) related to atrial fibrillation (an irregular and often very rapid heart rhythm. An irregular heart rhythm is called an arrhythmia. AFib can lead to blood clots in the heart. The condition also increases the risk of stroke, heart failure and other heart-related complications.) with a start date of 5/17/25. This MAR documented that starting with the supper dose on 9/17/25 through the morning dose on 9/22/25, Eliquis was not given due to the resident being hospitalized . It documented that Resident #1 was administered her supper dose of Eliquis upon her return on 9/22/25. She received two doses of Eliquis on 9/23/25 and the morning (a.m.) dose on 9/24/25 for a total of 4 doses. The medication was discontinued on 9/24/25 at 9:01 a.m.On 10/8/25 at 4:00 p.m., Resident #1 stated she guessed she shouldn't be taking a blood thinner for another 3 months. She stated she did not want to have a stroke. On 10/8/25 at 4:31 p.m., the Director of Nursing (DON), stated she was the one that wrote the Eliquis order. She stated it was a mistake. She was taking down the information from the hospital discharge and she didn't see the discontinuation order for the Eliquis, she only saw the Eliquis order. She stated she somehow skimmed right over the discontinuation wording as it was in smaller letters. The medications that were to be given were right above this and she thought the Eliquis was in with the medications to give directions. A Physician Orders/Transcription of Orders policy revised July 2023, directed the following: PURPOSE: To correctly and safely receive/transcribe physician's orders so correct order can be followed/administered. To ensure that patient medications, treatments, and plan of care are in accordance with the licensed providers orders.PROCEDURE:Physician's orders will be received by a licensed nurse, therapist, or dietitian.Orders may be received through written communication in the resident's chart, verbally or per telephone, via fax, or electronically entered in PCC (resident's electronic health record).When receiving a telephone or verbal order, the order should be repeated back to the Physician (MD)/Nurse Practitioner (NP)/Physician Assistant (PA) to assure accuracy.The order should be entered into the resident's medical record exactly as it was stated/written by MD/NP/PA.Orders must contain name, strength, route, dose, quantity, diagnosis/indication for use, and specific duration of therapy indicated. Order must contain specific and clear parameters if parameters indicated by MD/NP/PA. Orders for treatments must contain location for treatment if indicated. If for any reason, the attending physician in not available or cannot be reached by the nurse, the facility appointed medical director may be contacted for orders. Orders will be signed by the MD/NP/PA in accordance with state and federal guidelines. Medication and treatment orders will be entered in electronic medication administration record (eMAR) or electronic treatment administration record (eTAR) accordingly.Active orders should be followed and carried out as written/transcribed.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment for 2 of 5 residents reviewed (Resident #8 and #16). The facility documented the residents received insulin during the look back period when they did not. The facility reported a census of 32. Findings include: 1. Resident #8's MDS assessment dated [DATE] included a diagnosis of type 2 diabetes mellitus (a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels). The MDS reflected Resident #8 received one insulin injection during the lookback period. Resident #8's February 2025 Treatment Administration Record (TAR) lacked an order for insulin. The TAR included an order for Ozempic (an injectable medication to treat type 2 diabetes mellitus) 1 milligram (MG) subcutaneous (administered under the skin) solution once per week. 2. Resident #16's MDS assessment dated [DATE] included a diagnosis of type 2 diabetes mellitus. The assessment reflected Resident #16 received one insulin injection during the lookback period. Resident #16's January 2025 TAR lacked an order for insulin. The TAR included an order for Ozempic 1 MG subcutaneous solution once per week. During an interview on 2/19/25 at 10:46 AM, Staff A, Licensed Practical Nurse (LPN), acknowledged Resident #8 and Resident #16 had a diagnosis of type 2 diabetes mellitus. Staff A reported Resident #8 and #16 received ozempic. Staff A acknowledged Ozempic is a diabetic medication and is not classified as insulin. During an interview on 2/19/25 at 10:49 AM Staff B, Registered Nurse (RN)/Assistant Director of Nursing (ADON), with Staff C, RN / MDS Coordinator present, acknowledged the 2 residents most recent MDS documented they received 1 injection during the look back period. Staff B reported Resident #8 and Resident #16 received Ozempic every Friday. Staff B confirmed Ozempic is not an insulin. On 2/19/25 at 4:41 PM the Administrator acknowledged the facility followed the Resident Assessment Instrument (RAI) manual for completion of the MDS.

Based on observation, clinical record review, and staff interviews, the facility failed to develop and implement behavioral health concerns on the Care Plan for 1 of 1 resident sampled (Resident #2). The facility reported a census of 32 residents. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified he had short- and long-term memory problems and had severely impaired cognitive skills for daily decision making. He could recall the staff names and faces. The assessment indicated he had inattention continuously present, and it didn't fluctuate. He experienced other behavioral symptoms not directed towards (examples physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) others daily. The MDS included diagnoses of epilepsy (seizure disorder), psychotic disorder (mental health disorder), chronic pain and severe intellectual disabilities. Throughout a continuous observation on 2/17/25 at 1:35PM till 2:10 PM observed Resident #2 sitting in the black recliner in the south common area picking at the hole in the foot rest. Saw Resident #2 pulling foam out and putting it on the floor. The hole size look approximately 4 inches around. During the observation, witnessed 3 other residents also sitting in the day room. Observed the staff walked by several times and the nurses stood around the office right next to the day room as Resident #2 continued to pick and pull foam out. No staff stopped to redirect or try interventions to stop his behavior. Observation on 2/17/25 at 3:53 PM saw Resident #2 sitting in black recliner in the south common area. Resident #2 had his fingers in the opening on the foot rest with cushion material on the floor. During a continuous observation on 2/19/25 at 7:00 AM until 8:08 AM witnessed Resident # 2 sitting in the black recliner in the south common area with his feet flat on the floor. He had his right hand picking at the open area on the foot rest. At the time a housekeeper vacuumed the common area as other numerous staff members passed through the common area without redirecting Resident #2 with his picking behavior. At the time 2 other residents sat in the common area. Resident #2's Care Plan lacked documentation about his picking behavior and/or interventions to prevent it. The Care Plan Focuses with a Goal target date of 4/7/25 a. Directed staff to offer snacks during periods of anxiety or behaviors to assisting with calming Resident #2. b. Indicated Resident #2 enjoyed activities such as games (likes to play catch and throw a ball, stuffed monkey or stuffed bull); independent (enjoys relaxing in recliner in the south-needs assistance with operating the T.V. to turn it on/off and select channels/enjoys [NAME] movies, and sports like football); music (staff to sit resident out for musical activities-likes to sit in the back so can leave easily if wants to/seems to enjoy listening to music in the south lounge); reading (seems to enjoy listening to short stories read to them); van rides (staff to ensure resident has helmet on to promote safety). Resident has diagnosis of severe intellectual disability, and can only communicate by sounds and gestures. c. Documented Resident #2 had an alteration in communication related to impaired cognition form severe intellectually disability and aphasia (inability to speak). They will make facial expressions, noises, and even hit staff to get their attention. i. The Intervention instructed if he became anxious or restless staff are to attempt to provide one-on-one (1:1), diversional activity, take them for a van ride, or walk with him. During an interview on 2/19/25 at 1:05 PM the Director of Nursing (DON) reported the facility didn't do anything to address Resident #2's picking behaviors and making a hole in the footrest while in the recliner. She reported he owned the recliner and he picked at it but the hole has not been as big of a hole as it is at that time. She reported he tried to do it in other recliners as well so the staff brought out his own to the common area. She reported if someone gave him something to hold in his hands he just throws it. She didn't know for sure if Resident #2' s picking is due to not meeting his needs or if it is just a behavior. In an interview on 2/19/25 at 2:29 PM the Administrator reported they didn't have a policy specific to behaviors.

Based on clinical record review, policy review, resident, and staff interviews, the facility failed to offer or ensure a resident received dental services for 1 of 1 resident reviewed for dental services (Resident #1). The facility reported a census of 32 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included a diagnoses of dental caries (cavities). The Nutrition Assessment completed 9/2/24 documented both dentures in good condition with no chewing or swallowing issues. The Nutrition Assessment completed 12/9/24 by the Dietitian documented Resident #1 had full upper and lower dentures but they didn't have their lower ones due to them being broken. Resident #1 reported some chewing but no swallowing issues. Resident #1 requested a dental appointment. During an interview on 2/17/25 at 3:55 PM Resident #1 reported the staff dropped his bottom denture when cleaning them and it broke. He reported he still didn't have new ones or the current one repaired yet because staff said they can't get him to a dentist. In an interview on 2/19/25 at 2:25 PM Staff D, Licensed Practical Nurse (LPN), reported Resident #1's bottom dentures are broken but they didn't know for how long. Staff D reported she didn't know if he had an appointment to see a dentist. In an interview on 2/19/25 at 2:28 PM Staff A, LPN, reported she knew about Resident #1's broken bottom denture, but she didn't know how they got broke. She added the facility has tried to get him into a dentist but they didn't take his insurance. Staff A didn't know for sure how long Resident #1's dentures were broken. On 2/19/25 at 2:30 PM the Director of Nursing (DON) reported Resident #1 had 2 sets of bottom dentures but she didn't know if they both fit. She reported she didn't know when or how his denture broke. During an interview on 2/19/25 at 2:35 PM the Administrator reported she didn't know about Resident #1's broken dentures but would look into it. In an interview on 2/19/25 at 3:10 PM the Administrator reported she didn't know before about Resident #1's broken dentures. She reported the Office Manager made calls to dentists but hit road blocks with them not taking his insurance. As of the first of the year Resident #1 had new insurance so they planned to call around to see if a dentist would take his new insurance. She verbalized she called Corporate about his broken dentures to find out if they should pay for them due to the staff dropping them. On 2/20/25 at 9:00 AM the Administrator reported the facility would pay to fit Resident #1's dentures. The facility policy titled Dental Services revised April 2023 instructed if the resident's dentures are damaged, the facility will promptly (within 3 days) refer the resident and if not, they must provide documents showing what the facility did to ensure the resident could still eat and drink while waiting for dental services. In addition, they must indicate the extenuating circumstances that led to the delay. The policy added if the dentures got damaged by staff then the facility is responsible to pay for the dentures.

Based on employee file review, policy review, and staff interview the facility failed to ensure staff completed dependent adult abuse training within 6 months of hire for 1 of 5 employees reviewed. The facility reported a census of 27 residents. Findings include: The employee file for Staff A, dietary aide, documented a hire date of 9/1/23. The file contained the Iowa Department of Health and Human Services Dependent Adult Abuse Mandatory Reporter Training certificate dated 4/2/24. The facility policy titled Abuse Prevention, Training and Investigation, last reviewed on 12/30/20 documented new employees that have not previously taken a state approved curriculum on mandatory reporting of dependent adult abuse will complete the required 2 hour training within 6 months of hire. During an interview on 4/2/24 at 2:26 PM, Staff B, Human Resources, confirmed Staff A's hire date was 9/1/23. She acknowledged the 4/1/24 was 7 months post hire and the certificate was dated 4/2/24. During an interview on 4/2/24 at 5:00 PM, Staff A explained he had not worked in any other facility or position that required him to have the training. He explained he was taking the training for the first time that day. During an interview on 4/2/24 at 5:15 PM, the administrator explained she expects the training to be completed within 6 months of hire.

Based on record review, resident, and staff interviews the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 out of 8 residents reviewed( Resident #2 ). The facility failed to identify Resident #2 received a blood thinning medication. The facility reported a census of 19 residents. Findings include. 1. The Minimum Data Set (MDS) dated [DATE], identified Resident #2 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified Resident #2 received a 14 out of 15 on the Brief Interview for Mental Status which indicated no cognitive impairment. MDS revealed resident required limited assistance with transfer, dressing and personal hygiene. The MDS revealed resident received an anticoagulant (blood thinning medication) for 0 days during the last 7 days of the observation period. Interview on 8/9/21 at 1:41 p.m., Resident #2 revealed that they had received [MEDICATION(S)] a blood thinning medication. During record review of facility form titled, Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . During record review of Resident #2's Care Plan with target date of 8/1/21 revealed that Resident #2 received anticoagulant medication and was at an increased risk for abnormal bleeding. Interview on 8/11/21 at 9:15 a.m., Director of Nursing verified that [MEDICATION(S)] was not a new medication for Resident #2 and should have been indicated that resident received [MEDICATION(S)] on the MDS. The Director of Nursing stated the MDS nurse must have missed that. Interview on 8/11/21 at 10:12 a.m., MDS nurse, Staff A, verified that [MEDICATION(S)] should be indicated under the anticoagulant section for Resident #2.

Based on observation, clinical record review and staff interview, the facility failed to ensure staff provided proper services for one resident with a feeding tube. (Resident #17) The facility census was 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #17 had [DIAGNOSES REDACTED]. During observation on 11/26/19 at 3:40 p.m., Staff E, certified nurse aide, CNA and Staff F, certified medication aide, CMA provided range of motion exercises while the resident laid flat in bed with the feeding tube was running. At 3:50 p.m., staff felt resident was trying to cough and Staff F raised the head of her bed, while they continued to perform range of motion to the resident's upper extremities. At 3:53 p.m., Staff F lowered the residents head of bed back to the flat position as staff completed range of motion to the residents lower extremities. During interview on 11/25/19 at 4:02 p.m., Staff [NAME] and Staff F stated the resident was not to be lying flat in bed while the feeding tube was running. Staff [NAME] stated they do the residents restorative exercises after they lay the resident down at night and the feeding was disconnected during transfer. At the time the Co-Director of Nursing stated she would expect the residents head to be elevated at all times while the tube feeding was running.

Based on observation and staff interview, the facility failed to ensure expired eye drops were not administered to three residents with an order for [REDACTED]. Findings include: On [DATE] at 2:00 p.m., the medication cart contained Resident #7's Dorzolamide/[MEDICATION NAME] eye drops that were opened [DATE] and would have expired on [DATE]. (Manufacturer expiration date ,[DATE]), Resident #17's Azelastine 0.5% eye drops opened [DATE] and would have expired [DATE]. (Manufacturer expiration date ,[DATE]) and Resident #23's Travastan eye drops opened [DATE] and would have expired [DATE]. (Manufacturer expiration date ,[DATE]) The Medication Administration Record [REDACTED]. During interview on [DATE] at 3:30 p.m., the Director of Nursing stated she had confirmed the eye drops all expired 30 days after being opened and new ones had been reordered. The DON stated her expectation was eye drops would be dated when opened, labeled with the 30 day expiration date and be disposed of after 30 days.

Based on observation, clinical record review and staff interview, the facility failed to ensure oxygen tubing was properly labeled and changed out to prevent infection for one of one resident reviewed utilizing oxygen. (Resident #19) The facility census was 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #19 had [DIAGNOSES REDACTED]. Observation on 11/24/19 at 1:12 p.m., revealed the resident with oxygen at 3 liters per nasal cannula. The tubing had no date when changed last. Observation on 11/25/19 at 10:50 a.m., revealed the oxygen tubing remained undated as to when it was last changed. During interview at the time the Co-Director of Nursing stated she would expect the oxygen tubing to be changed every 2 weeks per the oxygen suppliers. During interview on 11/25/19 at 2:21 p.m., the Co-Director of Nursing reported the monthly infection surveillance was completed monthly through (MONTH) 2019.

Based on clinical record review and staff interview, the facility failed to notify the State Ombudsman's office when a resident transferred out for two of two residents reviewed. (Resident #22 & #19) The facility census was 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #22 had [DIAGNOSES REDACTED]. Nurse progress notes revealed the resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. The Ombudsman notification list for (MONTH) 2019 revealed the resident's name was not on the monthly list. During interview on 11/25/19 at 11:30 a.m., Staff A, Social Services Director acknowledged the resident's name was not on the notification list. Staff A stated she was off work during that time period and did not get the bed hold or ombudsman notification completed. 2. The MDS assessment dated [DATE], documented Resident #19 had [DIAGNOSES REDACTED]. Progress notes documented the resident was admitted to the hospital on [DATE] and returned on 11/3/19. The Notice of Transfer to Long Term Care Ombudsman failed to include the residents name.

Based on clinical record review, facility policy review and staff interview, the facility failed to notify the resident or resident representative of the bed hold policy for two of two residents reviewed. (Resident #22 and #17). The facility census was 27 . Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #22 had [DIAGNOSES REDACTED]. Nurse progress notes revealed the resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Documentation of notification of resident or their representative regarding the bed hold policy was absent from the resident's health record for the hospitalization . Review of the Reserved Bed Policy documented the resident or their responsible party must be given written notification about reserving their bed prior to an upcoming hospital absence or at the time of the hospital transfer, and before any home visit. The Private Pay Reserved Bed Form or Medicaid Reserved Bed Form, as applicable, must be used for this notification. Another option for the initial reserved bed notification is to provide the generic reserved bed notice to the resident upon transfer to the hospital with the appropriate follow-up done within one business day of the transfer by providing a Private Pay or Medicaid Reserved Bed Form. 2. 2. The MDS assessment dated [DATE], documented Resident #19 had [DIAGNOSES REDACTED]. Progress notes documented the resident was admitted to the hospital on [DATE] and returned on 11/3/19. Documentation of notification of resident or their representative regarding the bed hold policy was absent from the residents health record. During interview on 11/25/19 at 8:50 a.m., the Business Office Manager stated they were unaware of the need to complete bed hold.

Based on observation, clinical record review and staff interview, the facility failed to review and revise the plan of care for four of four residents reviewed. (Resident #6, #19, #9 & #14) The facility census was 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #6 had [DIAGNOSES REDACTED]. Observation on 11/24/19 at 10:32 a.m., revealed quarter side rails up on both sides of resident's bed. During observation on 11/25/19 at 7:45 a.m., the quarter rails were up on both sides of resident's bed. Review of a Care plan with an initiation date of 4/2/19, failed to identify the use of the quarter side rails. 2. The MDS assessment dated [DATE], documented Resident #19 had [DIAGNOSES REDACTED]. Observation on 11/24/19 at 1:12 p.m., revealed a quarter side rail up on one side of resident's bed. During observation on 11/25/19 at 7:45 a.m., the quarter rail was up on one side of resident's bed. Review of a Care plan with an initiation date of 4/29/19, failed to identify the use of the quarter side rails. During interview on 11/25/19 at 1:40 p.m., the Co-Director of Nursing stated she would expect side rails to be on the care plan when they are being utilized. 3. The MDS assessment dated [DATE], revealed Resident #14 had [DIAGNOSES REDACTED]. During observation on 11/24/19 at 9:50 a.m., the residents bed had a quarter side rail on the left (wall) side of the bed. The care plan failed to include the use of the side rail. 4. The MDS assessment dated [DATE], revealed Resident #9 had [DIAGNOSES REDACTED]. During observation on 9/24/19 at 9:20, a.m., bilateral quarter side rails were on the residents bed. The care plan failed to include the use of the side rail.

Based on facility record review and staff interview, the facility failed to ensure the required members of the Quality Assurance (QA) Committee were in attendance at the quarterly meetings. The facility census was 27 residents. Findings include: Review of the QA Committee attendance sheets from (MONTH) (YEAR) to (MONTH) 2019, revealed the Medical Director has not attended since (MONTH) of 2019. The Director of Nursing and Administrator were unable to find the attendance sheets for (MONTH) 2019 and (MONTH) 2019. The Medical Director did not attend the QA Meeting held 10/30/19. During interview on 11/26/19 at 10:08 am., the Administrator and Director of Nursing (DON) stated there was an interim administrator at the facility in July, (MONTH) and September. The current administrator started 9/30/19 and held the first QA meeting 10/30/19 to get it in that quarter. The DON acknowledged the Medical Director did not attend the (MONTH) 2019 meeting.

Based on clinical record review and staff interview, the facility failed to ensure the clinical record consistently reflected the resident's choices for resuscitation for one of 16 residents reviewed. (Resident #27) The facility census was 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #27 had included [DIAGNOSES REDACTED]. A hospital clinical discharge summary dated [DATE], included an order for [REDACTED]. Clinical record review revealed a physician order [REDACTED]. An Advance Directive Acknowledgement signed by the resident [DATE], documented the resident did request resuscitation efforts be initiated at the time of cardiopulmonary or respiratory arrest. The plan of care included a focus area of CPR (cardiopulmonary resuscitation) dated [DATE]. The problem included a goal that CPR will be performed if residents heart stops beating. During interview on [DATE] at 1:49 p.m., the Director of Nursing (DON) verified the physician order [REDACTED]. The DON stated at some point the residents order must have changed and it did not get changed in the care plan.

Based on observation, clinical record review and staff interview, the facility failed to ensure staff followed infection control practices for one of 16 residents reviewed. (Resident #15) The facility census was 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #15 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had an indwelling catheter for urinary output and was frequently incontinent of bowel. The Care Plan dated 12/31/13, documented the resident had recurring rash on all the folds of their body under arms, breasts, back fold, abdominal fold. During observation on 9/19/18 at 7:57 a.m., Staff A, Registered Nurse, RN washed hands and donned gloves. Staff A applied [MEDICATION NAME] cream (TMC) cream, a medication used to treat a variety of skin conditions, to the excoriated area under the residents breast using her right gloved hand and continued to an excoriated area on the residents abdominal fold and applied cream with same gloved hand. Staff A removed gloves and washed hands. The Director of Nursing present for the observation stated she would expect gloves to be changed when moving between the treatments of two different skin areas.

Based on observation, reword review and staff interview the facility failed to ensure appropriate cleansing of a universal blood sugar meter used for all residents for 1 out of 1 observation reported. The facility identified a census of 27 residents. Findings include: 1. Observation during medication pass on 6/12/17 at 11:00 a.m. Staff A, Registered Nurse used an universal blood sugar meter for a resident to check a resident's blood sugar. Staff A cleansed the blood sugar meter, after it's use, with an alcoholic wipe. Staff A reported the blood sugar meter is used for all residents. The facility has 2 blood sugar meters available to use for all the residents. An interview on 6/12/17 at 12:45 p.m., the Assistant Director of Nursing (ADON), Registered Nurse (RN), reported the cleansing policy for the blood sugar meters is to cleanse with the Sani-Wipe. The facility's undated policy for Accu-checks, directed the staff to clean the glucometer: Currently use Sani-Wipe, a 2 minute germicidal wipe, following manufacturer's guidelines. The glucometer must remain wet for 2 minutes and then may air dry. An interview on 6/14/17 at 8:10 a.m. the Director of Nursing (DON), RN, reported the policy for Accu-checks from the ADON is not the current policy (as above noted), as that policy is about 5 years old. The current policy for cleansing the meter is to use a Micro-Dot Wipe, rub vigorously and leave wet for 1 minute. There is a Minute hourglass to time it on the medication cart. The DON reported she would expect Staff A to use the Micro-Dot wipe as directed.

Based on observations, record review and staff interview, the facility failed to prevent the continued healing of an open pressure sore for 1 of 1 residents reviewed (Resident #1). The facility identified a census of 27 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had [DIAGNOSES REDACTED]. The resident had memory loss and severe impairment skills for making daily living decisions. The MDS showed the resident dependent on staff for all cares with limited range of motion to all extremities. The assessment showed the resident at risk for pressure ulcers and had a stage 2 pressure ulcer. The Care Plan updated on 4/24/17 identified the resident with a pressure ulcer to the left lower buttock. Interventions for this concern included: the use of pressure reducing devices on mattress and in wheelchair; off load the feet when in bed; turn and reposition every 2 hours; and wound treatments as ordered. A Weekly Pressure Ulcer Progress Report showed the resident had an open pressure ulcer on the left side on lower buttock identified on 3/27/17 with the most current measurement on 6/8/17 of 1.8 cm-0.7 cm. The staff indicated the pressure sore as a Stage 3, which indicates full thickness skin loss involving damage to the tissue. Observation on 6/12/17 at 9:45 a.m. showed the resident lying on the backside in bed with both feet propped up on a large foam wedge. The resident's buttocks were not off-loaded, the buttocks laid directly on the bed. Observation on 6/12/17 at 11:10 a.m. showed the resident lying on the backside in bed with both feet propped up on large foam wedge. The resident's buttocks were not off-loaded, the buttocks laid directly on the bed. Observation on 6/12/17 at 2:10 p.m. Staff B, Licensed Practical Nurse (LPN) performed wound cares. The pressure ulcer located on the resident's left ischium (the lower and posterior bone of the pelvis). The pressure ulcer had 2 separate small areas. Both were approximately 0.5 cm. by 0.5 cm. with a 0.1 or 0.2 depth. A small, thin healed area laid between the (now) 2 ulcers. Each wound had a small light yellow center with a red inside rim. Staff B and Staff C, Certified Nursing Aide (CNA) positioned the resident with both legs propped up on a large foam wedge, and a flat pillow onto the resident's left backside. The resident's buttocks laid on the bed. Observations on 6/12/17 at 3:00 p.m., 3:30 p.m. and 4:00 p.m. showed the resident lying on their backside in bed, buttocks flat and both feet up on the wedge. A flat pillow positioned under the resident's left upper back area, with the buttocks lying on the bed. Observation on 6/13/17 at 6:45 a.m. showed the resident lying on their backside in bed, buttocks flat on bed and both feet up on the wedge. A flat pillow positioned under the resident's left upper back area. Observation on 6/13/17 at 7:50 a.m., 10:30 a.m. and 2:00 p.m. showed the resident lying on their backside in bed, buttocks flat on the bed and both feet up on the wedge. A flat pillow positioned under the resident's right upper back area. Observation on 6/14/17 at 6:45 and 7:45 a.m. showed the resident lying on their backside in bed, buttocks flat on the bed and both feet up on the wedge. Observation on 6/14/17 at 10:05 a.m. with the Occupational Therapist revealed the resident lying in bed turned on their right side, turned further than had been positioned in the last 2 days. The resident's left buttock laid half way on the bed. The Therapist noted the resident could be positioned more on the side to off-load the left buttock. Both of the resident's feet were up on a high, foam wedge. The Assistant Director of Nursing (ADON), Registered Nurse, observed the same position and noted understanding of having the resident off load the buttock. An interview on 6/12/17 at 2:10 p.m. the Director of Nursing (DON), Registered Nurse reported the placement of the over lay air mattress for the bed did not occur until the current pressure ulcer re-opened. Resident #1 experienced a pressure ulcer to the buttocks 3 times this past year, the last time it re-opened on 3/27/17. The staff did not initiate the air mattress to the bed until 5/10/17. The facility's Pressure Ulcer Risk and Assessment and Documentation revised on 1/2011 stated residents will be assessed upon admission and re-admission for potential risk factors that may contribute to pressure ulcer development and interventions will be implemented to reduce that risk. The procedure for Prevention included: Assist with repositioning immobile residents a minimum of approximately every 2 hours (may need to reposition more frequently); positioning devices such as pillows or foam wedges may be used to keep bony prominence's from direct contact with each other.

Based on observations, record review and staff interviews, the facility failed to provide adequate supervision during an inappropriate transfer with a mechanical lift in order to prevent accidents and injury to Resident #1. The sample consisted of 4 residents and the facility reported a census of 29 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 2/10/17. The MDS indicated Resident #1 had short and long term memory impairments and severely impaired decision making abilities. The MDS indicated the resident required total dependence for assistance of two staff members for transfers, dressing, personal hygiene, and toileting, locomotion on and off the unit and extensive assist or two staff for bed mobility. A balance during transition and walking test identified the resident as not steady and only able to stabilize with staff assistance when surface to surface transfers. The MDS documented Resident #1 had limitations in range of motion on both sides of his/her upper and lower extremity. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had no falls since the prior assessment and no restorative programs. An Admission/Readmission Fall Risk Assessment and Interventions dated 8/26/12, documented potential fall risk factors included, assistance required with transfers, cardiovascular disease, cognitive impairment and decline in functional status, dementia diagnosis, hypertension, incontinence, psychotropic medications, use of assistive devices, unsteady gait, use of 9 or more medications, vision disturbances and wheelchair use. The Interdisciplinary Working Plan of Care, with a target dated 3/7/17, directed staff to see therapy alert for changes and details, assist of two with use of the mechanical lift (3/12/15), size small or medium. An intervention dated 3/22/17, directed staff to transfer with mechanical lift using sling that crisscrosses between the legs to prevent sliding. A record review of the Progress notes dated 3/22/17 at 10:27 a.m. (late entry) reflected the nurse called to the resident's room by staff to find the resident lying on the floor with head facing the doorway and feet facing the foot of the bed. The resident was lying in between the legs of the Hoyer (mechanical lift) with head towards the main/base end of the Hoyer. The floor was dry and uncluttered. All 4 straps to the Hoyer sling still intact correctly to the machines hooks. The staff stated the resident slipped out of the sling feet first and then once on the ground, rolled onto the left leg of the Hoyer lift and onto the left hip and left arm. The resident had severe contractions and unable to verbalize any acute pain at the time. This nurse noted some swelling starting to the resident's right ankle. Resident was then assisted with 4 staff members to bed using a crisscross sling and the sling lift machine. The Care Plan was updated following a fall to direct staff to only use the Hoyer slings that crisscross through the legs. Staff transferred the resident to the hospital emergency room for an evaluation and treatment. The x-ray report dated 3/22/17 documented Resident #1 with a right ankle fracture. The impression included: an oblique nondisplaced fracture involved the posterior malleolus (ankle) of the tibia (lower leg bone), subtle linear lucency in the distal metadiaphysis of the fibula (lower leg bone) could represent nondisplaced fracture and subtle linear lucency of the proximal shaft of the fifth metatarsal (fifth long bone in foot), could be due to technique or nondisplaced fracture. The resident returned back to the facility the same day with physician's orders [REDACTED]. On 3/29/17 at 9:44 a.m. the Administrator was interviewed and stated the staff used the correct lift and sling. Due to the fact the resident had lost some weight; the facility should have had the resident re-evaluated for a different lift and different size of sling. The Administrator stated since the incident, the resident is using the EZ Way lift and sling now. At the time of the fall, the staff used the Hoyer lift with a medium sling.