Every finding on record at Millington Healthcare Center

Based on interview, record review, and review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to transmit Minimum Data Sets (MDSs) for 2 (Resident #35 and Resident #86) of 6 residents reviewed for resident assessments. Specifically, at the time of survey, both Resident #35 and Resident #86 had discharge MDS assessments that were not transmitted to the Centers for Medicare and Medicaid Services (CMS) within the required timeframes. Findings included: During an interview on 07/31/2026 at 11:47 AM, the [NAME] President of Operations stated the facility used the Resident Assessment Instrument (RAI) and did not maintain a separate MDS policy. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025, indicated, Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). An admission Record revealed the facility admitted Resident #35 on 03/05/2026. According to the admission Record, the resident had a medical history that included diagnoses of metabolic encephalopathy, type 2 diabetes mellitus, and end stage renal disease. A discharge MDS, with an Assessment Reference Date (ARD) of 05/06/2026, revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #35's electronic medical record indicated the resident's discharge MDS, with an ARD of 05/06/2026, was completed on 05/19/2026 and accepted on 07/30/2026. The acceptance date was 72 days after completion and coincided with the survey. An admission Record revealed the facility admitted Resident #86 on 02/19/2026. According to the admission Record, the resident had a medical history that included diagnoses of hydronephrosis, senile degeneration of the brain, and cognitive communication deficit. A discharge MDS, with an ARD of 03/12/2026, revealed Resident #86 had a BIMS score of 10, which indicated the resident had moderate cognitive impairment. Resident #86's electronic medical record indicated the resident's discharge MDS, with an ARD of 03/12/2026, was completed on 03/26/2026 and accepted on 07/30/2026. The acceptance date was 126 days after completion and coincided with the survey. During an interview on 07/30/2026 at 10:49 AM, the MDS Nurse stated she had forgotten to submit the discharge MDS assessments for Resident #35 and Resident #86. She stated that there was a report that flagged any Omnibus Budget Reconciliation Act of 1987 (OBRA) assessments that had not yet been submitted, but the report did not flag either resident. She stated she believed that was because both Resident #35 and Resident #86 were managed care residents. The MDS Nurse stated she would submit both discharge assessments immediately. During an interview on 07/31/2026 at 8:26 AM, the Administrator stated that the MDS Nurse was responsible for timely submissions of MDS assessments. The Administrator stated her expectation was that discharge MDS assessments be submitted as soon as they were completed. During an interview on 07/31/2026 at 8:49 AM, the Director of Nursing (DON) stated that the MDS Nurse was responsible for timely submissions of MDS assessments. The DON stated her expectation was that discharge MDS assessments be submitted as soon as they were completed.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure supplemental oxygen was administered according to a physician's order for 1 (Resident #3) of 3 residents reviewed for respiratory care. Findings included: A facility policy titled, Administration of Drugs, dated 01/2026, indicated, Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director. The policy also indicated, Drugs must be administered in accordance with the written orders of the attending physician. An admission Record indicated the facility admitted Resident #3 on 10/21/2025. According to the admission Record, the resident had a medical history that included a diagnosis of asthma. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/23/2026, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident required oxygen therapy. Resident #3's Care Plan Report, included a focus area initiated 03/17/2026, that indicated the resident received oxygen therapy. Interventions directed staff to give medications as ordered by the physician, and the resident received supplemental oxygen at 5 liters (L) binasal canal (BNC) continuously. Resident #3's Order Summary Report, with active orders as of 07/31/2026, contained an order dated 07/24/2026 for supplemental oxygen at 5L via BNC continuously every shift for shortness of breath or decreased oxygen saturation related to other asthma. During an observation on 07/27/2026 at 11:05 AM, Resident #3's oxygen concentrator setting was set to 4 liters per minute (LPM). During an interview on 07/28/2026 at 2:10 PM, Resident #3 stated they were dependent on staff to change the settings on the oxygen concentrator. During an observation on 07/28/2026 at 2:15 PM, Resident #3's oxygen concentrator setting was set to 4 LPM. During an observation on 07/29/2026 at 10:15 AM, Resident #3's oxygen concentrator setting was set to 4 LPM. During a concurrent observation and interview on 07/29/2026 at 10:25 AM, Registered Nurse (RN) #7 stated Resident #3 was dependent on staff to change their supplemental oxygen settings and confirmed the resident's oxygen concentrator was set to 4 LPM. During an interview on 07/29/2026 at 10:33 AM, RN #7 reviewed Resident #3's supplemental oxygen orders and stated the resident's supplemental oxygen orders dated 07/24/2026 were for 5 LPM. During an interview on 07/29/2026 at 1:27 PM, Nurse Practitioner (NP) #4 stated she expected staff to follow the supplemental oxygen orders. NP #4 stated it was important to have the correct supplemental oxygen settings and Resident #3 was not able to change the settings on their oxygen concentrator. During an interview on 07/30/2026 at 10:56 AM, Certified Nursing Assistant (CNA) #8 stated Resident #3 was dependent on staff and was not able to change their settings on the oxygen concentrator. During a concurrent observation and interview on 07/30/2026 at 11:07 AM, Licensed Practical Nurse (LPN) #9 observed Resident #3's oxygen concentrator and stated that the resident's oxygen concentrator setting was set to 4.5 LPM. LPN #9 stated that it was important to have the resident's supplemental oxygen on the correct setting. During an interview on 07/30/2026 at 12:22 PM, the Medical Director (MD) stated Resident #3 was not able to change the settings on their oxygen concentrator, and he expected the staff to follow the supplemental oxygen orders. During a phone interview on 07/30/2026 at 1:42 PM, LPN #5 stated Resident #3 was dependent on staff to change the settings on their oxygen concentrator. During an interview on 07/30/2026 at 3:36 PM, the Director of Nursing (DON) stated she expected the staff to follow physician orders. During an interview on 07/30/2026 at 3:49 PM, the Administrator stated she expected the staff to follow the physician's orders.

Based on interview and record review, the facility failed to update the medical record for 1 (Resident #2) of 5 sampled residents reviewed for medication regimen review after a nurse practitioner (NP) agreed with a pharmacy recommendation for a trial dose reduction. Findings included: An admission Record indicated the facility admitted Resident #2 on 10/20/2017. According to the admission Record, the resident had a medical history that included diagnoses of other recurrent depressive disorders, anxiety, and insomnia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/23/2026, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident had insomnia due to a medical condition. Resident #2's Care Plan Report, included a focus area initiated 03/11/2018, that indicated the resident was at risk for adverse reactions due to the use of psychotropic meds related to an anxiety, depression, and psychotic disorder with hallucinations. Interventions directed staff to administer medications as ordered and to monitor for side effects and adverse reactions to psychoactive medications. Resident #2's gradual dose reduction/medication regimen review (GDR/MRR) dated 04/30/2026 revealed NP #4 signed the form on 05/13/2026 and marked that she agreed to the pharmacist's recommendation to decrease Resident #2's trazodone 50 milligrams (mg) every night at bedtime to 25 mg every night at bedtime. Resident #2's Order Summary Report, with active orders as of 07/29/2026, contained an order dated 05/23/2025 for trazodone 50 mg with instructions to give one tablet by mouth in the evening. Resident #2's Medication Administration Record [MAR] for the timeframe from 05/01/2026 through 07/28/2026 revealed staff documented that the resident continued to receive trazodone 50 mg one tablet by mouth in the evening. During an interview on 07/29/2026 at 1:22 PM, NP #4 stated that on 05/13/2026 she reviewed the GDR/MRR for Resident #2 and had agreed with the recommendation to decrease the resident's trazodone. NP #4 stated she then gave the document to a nurse to update in the system. Upon review of Resident #2's current medical records, NP #4 stated she was unable to find that it was updated in the resident's medical records, and the resident had continued to be given trazodone 50 mg. NP #4 stated it was important for the recommendations to be updated in the medical records. During an interview on 07/30/2026 at 12:30 PM, the Medical Director (MD) stated that if he or an NP agreed with the pharmacy recommendation, he expected the facility staff to update the medical record. During an interview on 07/30/2026 at 1:13 PM, the Director of Nursing (DON) stated that when the NP agreed to the pharmacy recommendation, she expected her to update Resident #2's medical record. During a phone interview on 07/30/2026 at 1:39 PM, Licensed Practical Nurse (LPN) #5 stated she was not given Resident #2's GDR/MRR because NP #4 would update Resident #2's medical record when the pharmacy sent in any recommendations. During an interview on 07/30/2026 at 3:36 PM, the DON stated she expected the staff including the NP to carry out the pharmacy recommendations if the NP or MD agreed on the recommendation. During an interview on 07/31/2026 at 9:05 AM, the Administrator stated the only policy they had related to medication regimen reviews were the medication administration or physician policy. The Administrator stated she expected the staff or NP to update the resident's medical record when a medication recommendation was agreed upon by the NP or MD.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were labeled and stored in accordance with professional standards for 1 (Resident #97) of 2 residents reviewed for storage of medications. Findings included: A facility policy titled, Physician's Orders, dated 06/2025, revealed, Resident medications, treatments, and services must be ordered by a licensed physician or licensed practitioner. The policy revealed, 2. All medications administered to the resident must be ordered by the resident's attending physician. A facility policy titled, Self-Administration of Medication, dated 06/2025, revealed, General Guidelines: 1. A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team. 2. Should the resident's attending physician permit the resident to administer his/her medication(s), the following conditions will apply: a. The physician's order must be given prior to self-administration; b. Storage of medications in the resident's room must be such that it will prevent access by other residents; c. Only the medications permitted for self-administration shall be left at the bedside; d. The interdisciplinary Care Plan Team must record in the resident's medical record that self-administration has been authorized and shall identify the name, strength, and quantity of each medication retained at the bedside. The policy revealed, 6. Failure of a resident to comply with these policies must be promptly reported to the Director of Nursing Services and/or the resident's attending physician. A facility policy titled, Storage of Medications, dated 06/2025, revealed, Drugs and biologicals should be stored in a safe, secure, and orderly manner. The policy revealed, 1. Drugs and biologicals are stored in the containers in which they are received. Transfer between containers is performed only by the issuing pharmacy. 2. Drug containers having soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels are returned to the pharmacy for proper labeling before storing. Further review revealed, 6. Compartments containing drugs and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended. (Compartments include, but are not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) 7. Drugs are stored in an orderly manner in cabinets, drawers, or carts. These compartments are of sufficient size to prevent crowding. Each resident is assigned a cubicle or drawer to prevent the possibility of a drug for one resident being given to another resident. An admission Record revealed the facility admitted Resident #97 on 07/18/2026. According to the admission Record, the resident had a medical history that included diagnoses of atrial fibrillation, Sjogren syndrome, and essential hypertension. A Psychosocial Evaluation dated 07/23/2026 revealed Resident #97 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #97's Order Summary Report, with active orders as of 07/27/2026, revealed no orders for Lumigan eye drops or brimonidine tartrate eye drops and no order for self-administration of medications or to keep medications at bedside. Resident #97's Care Plan Report dated 07/28/2026 revealed no evidence of a category/approach that indicated the resident could self-administer their medications or have medications at their bedside. Review of the medical revealed no documented evidence that a Self-Administration Assessment was completed for Resident #97. During an observation and interview on 07/27/2026 at 10:19 AM, Resident #97 was observed lying in bed. There were two bottles of Lumigan 0.01 percent (%) eye drops and one bottle of brimonidine tartrate 0.2% observed on the resident's bedside table, with no resident-specific identification nor open date or expiration date. Resident #97 stated a family member brought the eye drops in over the weekend. During an observation and interview on 07/27/2026 at 1:40 PM, eye drop medications were observed on Resident #97's bedside table. Resident #97 stated that the eye drops were for glaucoma. Resident #97 stated they administered one drop of Lumigan once a day at night and one drop of the brimonidine twice daily. Resident #97 stated no staff or nurses had asked about the eye drops. During an interview on 07/29/2026 at 10:17 AM, Certified Nursing Assistant (CNA) #1 stated she had not seen any medications or eye drops at Resident #97's bedside. CNA #1 stated that if she noticed medications at the bedside, she would let the nurse know. She stated residents should not have medications at the bedside. During an interview on 07/29/2026 at 10:26 AM, Licensed Practical Nurse (LPN) #2 stated that the process for medications left at the bedside was to take the medications from the bedside. She stated there should be an order for those medications as well. She stated residents should not have medications at the bedside. During an interview on 07/29/2026 at 10:39 AM, LPN #3 stated she had not seen any medications at the bedside. She stated she took care of Resident #97 on 07/27/2026. She stated she did not see any eye drops on the bedside table. She stated that if she noticed medications at the bedside, she would remove them, lock them up in the medication cart, label the medications, and have the family pick them up. During an observation and interview on 07/29/2026 at 11:48 AM with LPN #2, Resident #97's eye drops were observed in the top drawer of LPN #2's medication cart. The eye drops were labeled with the resident's name and room number. LPN #2 could not find an order for either eye drop medication. She stated she did not administer any eye drops to Resident #97. During an interview on 07/29/2026 at 1:30 PM, Nurse Practitioner (NP) #4 stated she was not aware until that day that Resident #97 had eye drop medications at bedside. She stated LPN #2 notified her that day around 12:30 PM that Resident #97 had eye drop medications for glaucoma. She stated she would be putting physician's orders in for the eye drop medications once she was able to verify the history and prescription. Resident #97's Medication Administration Record [MAR] for July 2026, revealed a transcription of an order dated 07/29/2026, for Lumigan ophthalmic solution 0.01%, with instructions to instill one drop in both eyes at bedtime for glaucoma. Further review revealed staff documented that they administered the medication starting on 07/29/2026 at bedtime. The MAR also included a transcription of an order dated 07/29/2026, for brimonidine tartrate ophthalmic solution 0.2%, with instructions to instill one drop in both eyes two times a day for glaucoma. Further review revealed staff documented that they administered the medication starting on 07/29/2026 at bedtime. During an interview on 07/29/2026 at 1:54 PM, the Director of Nursing (DON) stated the expectation for finding medications at the bedside would be to ask the resident where they came from, and she would expect the nurse to look for an order for the medications. She stated that the staff should notify the physician and family. She stated medications should not be at the bedside without an order or self-administration assessment. She stated she was notified about the eye drop medications that day by LPN #2. During an interview on 07/30/2026 at 8:44 AM, the DON stated Registered Nurse (RN) #6 found the medications on 07/27/2026 and removed them from the bedside. She stated RN #6 told the resident they should not have the medications at the bedside, and the family should not bring them in. During an interview on 07/30/2026 at 3:36 PM, RN #6 stated the process for when medications were found at the resident's bedside was that they would remove the medications, label them, lock them up, look to see if there was a physician order, and notify the physician. During an interview on 07/30/2026 at 4:13 PM, the Administrator stated that the expectation when medications were found at the bedside was that they would be removed and notify the doctor and family. She stated the expectation of staff was they should be looking for any safety hazards throughout their shift, including medications. She stated that the medications found in Resident #97's room should have been removed.

Based on policy review, medical record review, hospital record review, observation, and interview, the facility failed to provide appropriate pain management consistent with professional standards of practice for 2 of 6 (Resident # 9 and #17) residents reviewed for pain management. The facility's failure to appropriately manage pain resulted in Immediate Jeopardy (IJ) on [DATE], when Resident #17 was readmitted to the facility following a right below the knee amputation on [DATE]. Resident #17 was severely cognitively impaired and dependent upon staff for assistance with all aspects of care. Resident #17's pain level was assessed as a 5 (on a scale of 1 - 10 with 10 being the most severe) on admission. On [DATE], Resident #17's physician orders included Hydrocodone every 6 hours as needed for a moderate pain level of ,d+[DATE] and Ibuprofen 800 milligrams (mg) every 8 hours as needed for a mild pain level of ,d+[DATE]. The facility failed to administer Hydrocodone as needed for pain which resulted in Resident #17 experiencing uncontrolled pain as evidence by the Resident's restlessness and trembling of the extremity. Resident #17 developed a new behavior of climbing out of bed on [DATE] and on [DATE]. Resident #17 sustained an unwitnessed fall with head injury, was transferred to the hospital and diagnosed with subarachnoid hemorrhage and a periorbital fracture. The facility failed to have a system in place to assess pain of residents with cognitive impairment and appropriately address the pain. The failure of the facility to appropriately assess, monitor, and control Resident #9's pain resulted in Immediate Jeopardy with Actual Harm for Resident #17. On [DATE] at 1:15 AM, Resident #9 sustained an unwitnessed fall. At 9:15 AM, Resident #9 began to exhibit verbal complaints and nonverbal cues of intense pain, hollering out when her right leg was moved, grimacing, and guarding her right hip and femur (thigh bone). The practitioner was not immediately notified of Resident #9's pain and the Resident did not receive pain medication. A STAT (without delay, immediate) x-ray of the femur was ordered at 11:31 AM and was obtained approximately 2 hours later at 1:32 PM. The x-ray revealed Resident #9 suffered a periprosthetic fracture (fracture that occurs around or near an orthopedic implant). Resident #9 was transferred to the hospital at approximately 3:40 PM. Review of the medical record revealed Resident #9 did not receive pain medication prior to leaving the facility. The failure of the facility to appropriately assess, monitor, and control Resident #9's pain resulted in Immediate Jeopardy with Actual Harm for Resident #9. Immediate Jeopardy (IJ) is a situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-697 on [DATE] at 5:20 PM, and an amended IJ notification was provided on [DATE] at 6:47 PM, in the Administrator's office. The facility was cited Immediate Jeopardy at F-697 at a scope and severity of J which is substandard quality of care. A partial-extended survey was conducted [DATE] through [DATE]. An acceptable Removal Plan which removed the immediacy of the Jeopardy for F-697 was received on [DATE], and the Removal Plan was validated on-site by the surveyors on [DATE] through pain assessment review, medical record review, observation, review of education records, and staff interviews. The IJ began on [DATE] through [DATE] for F-697, the IJ was removed on [DATE]. The facility's noncompliance at F-697 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the undated facility policy titled, Pain Management, revealed, .The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice Review of the facility policy titled, Charting and Documentation, revised ,d+[DATE], revealed .All services provided to the resident .or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .The following information is to be documented in the resident medical record .Medications administered .Treatment or services performed . 2. Review of the medical record revealed Resident #17 was readmitted to the facility on [DATE], following hospital discharge with diagnoses including Acquired absence of right leg below the knee due to a below the knee amputation on [DATE], Dementia, and Peripheral Vascular disease. Review of the hospital discharge physician orders for Resident #17 dated [DATE], revealed Hydrocodone-Acetaminophen ,d+[DATE]mg 1tablet every 4 hours as needed for pain. Review of the admission assessment dated [DATE] at 6:30 PM, revealed Resident #17 was experiencing pain rated as 5, which frequently caused difficulty sleeping and led to limitations of day-to-day activities. Review of the physician orders for Resident #17 dated [DATE] revealed the following: (a). Order date [DATE]. Start date [DATE]. Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] MG. Give 1 tablet by mouth every 6 hours as needed for MODERATE PAIN (,d+[DATE]) for PERIPHERAL VASCULAR DISEASE, UNSPECIFIED (b). Order date [DATE]. Start date [DATE]. Ibuprofen 800 MG give 1 tablet by mouth every 8 hours as needed for MILD PAIN (,d+[DATE]) for PERIPHERAL VASCULAR DISEASE. (c). Assess Pain Level and score every shift and as needed. 0 for No Pain. ,d+[DATE] for Mild Pain. ,d+[DATE] for Moderate Pain. ,d+[DATE] for Excruciating Pain related to PERIPHERAL VASCULAR DISEASE. Review of the Medication Administration Record dated [DATE] through [DATE] revealed the following: (a). On [DATE] at 7:36 PM, Licensed Practical Nurse (LPN) E administered Ibuprofen 800 MG for Resident #17's pain rated as 6. (b). On [DATE] at 6:02 AM, LPN E administered Ibuprofen 800 MG for Resident #17's pain rated as 7. (c). On [DATE] at 4:04 PM, LPN D administered Ibuprofen 800 MG for Resident #17's pain rated as 4. (d). On [DATE] at 12:54 AM, LPN E administered Ibuprofen 800 MG for Resident #17's pain rated as 7. (e). On [DATE] 9:44 AM, LPN B administered Ibuprofen 800 MG for pain rated as 7. Review of the baseline care plan dated [DATE], revealed no documentation of interventions related to pain assessment or pain management. Review of Resident #17's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The drug regimen review indicated no concerns were identified related to significant medications. The MDS assessment dated [DATE], did not identify potentially clinically significant medication issues related to inadequate management of Resident #17's pain, as evidenced by Hydrocodone was not administered as per the physician's order for pain rated ,d+[DATE]. Review of the progress notes for Resident #17 revealed the following: (a). On [DATE] at 5:39 PM, Registered Nurse (RN) J documented that Resident #17's right below the knee amputation incision had 29 staples and a fluid filled blister was observed on the left lower extremity (LLE) and the left foot was cyanotic (bluish color from poor circulation) and cold. RN J documented a deep tissue (pressure) injury was observed on the Resident's left great toe and left heel. (b). On [DATE] at 6:27 PM, LPN D wrote, This nurse called pharmacy to see if resident hydrocodone-acetaminophen ,d+[DATE] was in transit and pharmacy said they never received a script [prescription] for this medication. (c). On [DATE] at 6:44 PM, RN F wrote, Fluid filled blister [on left lower extremity] has ruptured . Review of the Occupational Therapy (OT) evaluation dated Saturday [DATE] at 3:05 PM, revealed Resident #17 experienced bilateral lower extremity pain at rest and with movement, described the pain as terrible and rated the pain a 10 on ,d+[DATE] scale. The OT pain assessment revealed Resident #17 verbalized pain and indicated the pain limited the Resident's functional activities, the Resident experienced impaired sensation, and coordination and reported to the OT that she felt a burning sensation in her foot sometimes. The OT documented the Resident's right lower extremity amputation site was closed with staples. The OT's clinical impression revealed Resident #17 was non-weight bearing (NWB) of the right lower extremity due to a recent below the knee amputation which resulted in the Resident's decreased functional mobility and coordination. Risk Factors identified for Resident #17 were at risk for falls. Review of Resident #17's Physical Therapy evaluation dated [DATE], revealed .significant LLE [left lower extremity] pain .hindering her mobility .attempts made at standing but pt [patient/Resident #17] with complaints of significant LLE pain and thus unable .the patient is at risk for falls . Review of the provider note dated [DATE], by Nurse Practitioner (NP) H revealed . patient [Resident #17] with pain to stump following BKA [below the knee amputation] . [Resident #17] continues to complain of pain to the R [right] BKA .The weekend staff also requested pain medication from the on-call NP .None has been sent from the pharmacy . Review of the provider note dated [DATE], by NP I revealed, . [Resident #17]'s pain is currently not controlled . Review of the nurses note dated [DATE] at 2:35 PM, by LPN B revealed, .Called to room by CNA [certified nursing assistant]. [Resident #17] was sitting on the floor with back facing the bed. Patient [Resident #17] could no [not] state what happened but did state that she hit her head. Patient did not have on any socks or shoes and patient has a new RBKA [right below the knee amputation] Noted swelling by her left eye and a skin tear on her right hand .Received new order to send patient to ER [emergency room ] for head CT [computerized tomography scan - a detailed x-ray to diagnose conditions] . Review of the hospital Emergency Department (ED) records for Resident #17 dated [DATE] beginning at 4:02 PM, revealed, .presents to the ED after a fall. Patient recently had a below the knee amputation on her right leg .Not oriented, does not obey simple commands .Diagnoses Subarachnoid bleed [also referred to as subarachnoid hemorrhage, is bleeding into the area between the innermost layer of the brain's protective membranes and the layers that surround the brain] .Left lateral orbital fracture [broken bone in the side wall of the eye socket usually resulting from blunt force trauma] . During an interview on [DATE] 2:29 PM, LPN E stated she gave Resident #17 Ibuprofen because the pharmacy had not delivered the Hydrocodone. LPN E was asked why the hydrocodone wasn't delivered from the pharmacy and LPN E stated it was a common occurrence for medications not to be available until the following day. LPN E was asked how Resident #17 was assessed for pain. LPN E stated she looked for non-verbal signs of pain. During an interview on [DATE] 2:54 PM, Registered Nurse (RN) J stated she was aware on Saturday [DATE], Resident (#17) did not have Hydrocodone available for pain. RN J was asked if she, as the RN on duty, was responsible for assisting with follow up to ensure residents have appropriate pain medications available. RN J stated the nurse assigned to the resident is responsible. During an interview on [DATE] 3:24 PM, Resident #17's family member (FM) stated Resident #17 appeared to be in pain, was restless, and unable to answer questions about pain. The FM stated the nurse kept saying the Hydrocodone would probably be in the next pharmacy delivery date to the facility. FM stated Ibuprofen didn't seem to control Resident #17's pain. During an interview on [DATE] 3:32 PM, NP H stated she saw Resident #17 on [DATE], and the Resident was rubbing her leg/BKA site. NP H confirmed during interview it was reasonable to believe the Resident was in pain following the amputation despite receiving Ibuprofen 800 mg for pain. NP H confirmed Resident #17's nurse called the on-call NP on [DATE] to inquire about an order for Hydrocodone. During an interview on [DATE] 3:47 PM the facility pharmacy representative stated Resident #17's admission orders were received on [DATE], and stated no order was received for Hydrocodone for pain. The pharmacy representative stated the facility nurse was told on [DATE], an order was needed to dispense and deliver the Hydrocodone for Resident #17. During an interview on [DATE] at 9:41 AM, the Director of Nursing (DON) was asked if Ibuprofen was appropriate pain management for Resident #17 on admission following a pain assessment that revealed a new right BKA and pain rated at 5. The DON stated, No, the order states for pain rated 4 or greater, Hydrocodone should have been administered. The DON confirmed it was reasonable to believe Ibuprofen 800 mg was inadequate to control Resident #17's pain. During an interview on [DATE] 11:48 AM, LPN D stated, I didn't give [Resident #17] Hydrocodone because it wasn't delivered to the facility. I assessed her pain and rated it as a 5 based on her physical symptoms, she [the Resident] had facial grimacing and appeared to be in pain. LPN D was asked if Resident #17 should have received Hydrocodone for pain rated at 5. LPN D stated, Yes. LPN D was asked if the Emergency narcotic supply kit (E-Kit) on the medication cart contained Hydrocodone. LPN D stated, yes, but the E-Kit [Hydrocodone] was expired. LPN D confirmed Resident #17 was able to communicate and answer simple questions. LPN D was asked how Resident #17 was assessed for pain. LPN D stated she observed for nonverbal cues. During an interview on [DATE] at 12:12 PM, LPN G was asked how Resident #17 was assessed for pain. LPN G stated she assessed for nonverbal signs of pain. LPN G was asked if Resident #17 should have been receiving Hydrocodone as ordered for pain and LPN G stated, Yes, I believe [named Resident #17] should have been given Hydrocodone because the Ibuprofen was probably not enough since she'd just had an amputation a few days prior. LPN G was asked if Hydrocodone was available in the emergency narcotic kit on the medication cart. LPN G stated the nurses could not use the E-Kit because the pharmacy stated they had not received an order for Hydrocodone, and medications can only be removed from the E-kit narcotic supply box if the pharmacy has an order for the medication. LPN G stated Resident #17 was placed in a chair at the nurses' station on Sunday [DATE], because the Resident started trying to get out of bed. LPN G was asked if Resident #17 attempting to get out of bed was the result of insufficient pain management and LPN G stated she wasn't sure. During an interview on [DATE] at 1:45 PM, the Physical Therapist (PT) stated she conducted a physical therapy evaluation on Monday [DATE], prior to Resident #17's fall. The PT was asked to describe Resident #17's condition during the evaluation on [DATE]. The PT stated Resident #17 was very confused and in a lot of pain. The PT was asked if the Resident was able to communicate verbally about her pain. The PT stated the Resident reported having pain in the left lower leg. The PT was asked if Resident #17 had any other signs of pain. The PT stated the Resident was restless and trembled. The PT stated she reported the Resident's pain to the nursing staff. During an interview on [DATE] 2:00 PM, CNA K stated she was assigned to Resident #17 on Saturday [DATE] and Sunday [DATE]. CNA K was asked if Resident #17 had signs or symptoms of being in pain. CNA K stated the Resident complained of pain. CNA K stated she believed Resident #17's pain was getting worse as the weekend progressed. CNA K was asked how she determined Resident #17's pain was getting worse over the weekend. CNA K replied, She started trying to climb out of bed and seemed anxious. She wasn't like that before her leg was amputated. So, we got her up in a chair and put her at the nurses' station. During an interview on [DATE] 9:05 AM, the Occupational Therapist (OT) confirmed she conducted an OT evaluation of Resident #17 on Saturday [DATE]. The OT was asked to describe Resident #17's level of pain during the evaluation. The OT stated Resident #17 was having significant pain and stated Resident #17 reported her left leg was causing pain. During an interview on [DATE] at 11:00 AM, the DON was asked how the nurses should assess pain for cognitively impaired residents. The DON stated the nurses should conduct a pain assessment using a tool designed to assess residents with cognitive impairment. The DON was asked to provide surveyors with a copy of the pain assessment tool referenced. The pain assessment tool was not provided to surveyors for review. The DON was asked if nurses should document details of pain assessment findings at the time pain medication was administered. The DON stated yes, a description of the pain assessment findings would be beneficial when a follow-up assessment was conducted to determine if the signs/symptoms of pain had resolved. During an interview on [DATE] at 2:20 PM, the Medical Director confirmed Resident #17's uncontrolled pain of the lower extremities could have led to agitation and was likely a contributing factor to the new onset of the Resident climbing out of bed. The Medical Director stated he would expect the staff to follow up on why Resident #17's Hydrocodone was not available. The Medical Director added, All it would have taken was a call from one of our providers to [named pharmacy] . if they have a script [prescription] and it's [Hydrocodone] in the e-kit, they can call and get a code [to administer the hydrocodone] . The pharmacy process is flawed . 3. Review of the medical records revealed Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Dementia, Diabetes, Anxiety, Periprosthetic Fracture Around Internal Prosthetic Hip Joint, and Pain in Right Knee. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 was rarely understood, exhibited short-term and long-term memory problems, and was assessed by staff with severe cognitive impairment for daily decision-making skills. Resident #9 was dependent on staff for most activities of daily living (ADLs). Review of a physician's order for Resident #9 dated [DATE], revealed give Acetaminophen 325 mg 3 tablets by mouth two times a day. Review of the Medication Admin (Administration) Audit Report dated [DATE]-[DATE], revealed Resident #9's Acetaminophen was scheduled to be administered at 7:00 AM and 7:00 PM. Review of the undated facility document titled, Med [Medication] Pass Time Frames revealed, .two times day .7 [7:00 AM]-10A [AM] or 7 [7:00 PM]-10p [PM] for pm . Review of the Nurses' Note for Resident #9 dated [DATE] at 1:15 AM, revealed staff at the Nurse's Station heard Resident #9 yelling for help. Resident #9 was found laying on the left side of the bed on the floor in her room with her head up against the bed mattress. Resident #9 exhibited no signs or symptoms of pain at that time. The staff began neuro-checks (an exam to assess the function of the nervous system) and the practitioner was notified with instructions given to continue the neuro-checks. The immediate intervention implemented was to place the call light within Resident #9's reach and put the Resident's bed in the lowest position. Review of the Neurologic Focused Evaluation dated [DATE] at 9:15 AM, revealed Resident #9 exhibited pain in the right hip and thigh and, unable to assign a pain score and Resident #9 exhibited non-verbal sounds or facial expressions of pain. The Evaluation included the statement, .PRN medication provided. See MAR [Medication Administration Record] for details. Indicators of pain: Protective body movements .Vocal complaints of pain .Facial expressions. Pain Note: Resident is hollering out during care and guarding her right hip and right femur . Review of the MAR for Resident #9 dated [DATE], revealed no documentation that pain medication was administered on [DATE]. Continued review of the MAR revealed a 6 documented in the box where the morning dose (scheduled from 7:00 AM-10:00 AM) should be signed out and LPN L's initials and a 3 in the box where the evening dose should be signed out. An explanation code at the bottom of the MAR indicated the number 6 meant the resident was hospitalized and the number 3 meant the resident was out of the facility. Review of the Nurses' Note for Resident #9 dated [DATE] at 11:31 AM, revealed Resident hollering out and guarding right hip and femur while care being provided, resident has [had] a fall in the early morning, [Named Nurse Practitioner H] .in facility and gave N.O. [New Order] for STAT right hip with pelvis and right femur [x-ray/radiology], resident with pain medication per orders, order placed with [Named Radiology Group] . Review of the physician's order for Resident #9 dated [DATE] at 12:36 PM, revealed an order for a STAT x-ray of the right hip with pelvis and right femur post fall and complaints of pain. Review of the Radiology Results Report for Resident #9 dated [DATE] at 1:32 PM, and reported to the facility at 1:50 PM, revealed an x-ray of the right femur identified an acute appearing periprosthetic fracture. Review of the Nurses' Note for Resident #9 dated [DATE] at 1:48 PM, revealed Spoke with residents [Resident #9's] son regarding residents [resident's] pain in right leg, x-ray tech [technician] suspects a fracture of femur, son agrees with sending resident to hospital for further evaluation. Review of the Practitioner Progress Note dated [DATE], revealed . [Resident #9] being seen today for follow up on fall that occurred this morning. Provider alerted by phone this am [AM] that patient had an unwitnessed fall from bed .found on floor .lying on her right side. Per reports, patient had no complaints of pain at that time .Nursing staff now reports patient with guarding. Upon examination, patient attempting to guard right thigh. It is tender to the slightest palpation and patient yells out in any attempt at PROM [passive range of motion]. Stat x-ray ordered of right femur, revealing acute appearing periprosthetic fracture .Acute pain .R/T [related to] Femur fracture, right . Review of the E-INTERACT FORM dated [DATE], revealed Resident #9 was transferred to the hospital at 3:41 PM. Review of the ER documentation for Resident #9 dated [DATE], at 3:43 PM, revealed .1625 [4:25 PM] pt [patient-Resident #9] here per stretcher from [Named Facility] for c/o [complaint of] fall .There is a minimally displaced oblique fracture [break at an angle to the long axis of the bone, the bone is broken all the way through] involving the proximal femoral diaphysis [break in the upper part of the thighbone, specifically in the area of the shaft near the hip] about the stem of the hip arthroplasty hardware [hip replacement device] . Review of the hospital Discharge Summary dated [DATE], revealed Resident #9 was discharged back to the facility in fair condition with discharge diagnoses of Principal Problem: Closed fracture of shaft of right femur .Periprosthetic fracture of femur at tip of prosthesis [near the metal stem of a hip replacement] . Observation in the resident's room on [DATE] at 3:21 PM, revealed Resident #9 lying in bed with her eyes closed, a fall mat was leaned against the wall opposite the Resident's bed, and the Resident's call light was in reach. During an interview on [DATE] at 1:33 PM, the DON stated, .[Resident #9] left out on ,d+[DATE] [2025] at 15:41 [3:41 PM] .this is the transfer form [provided the transfer form and payer change documentation] . The DON was shown Resident #9's MAR and asked did the Resident have any pain medication documented for [DATE]. The DON stated, No, she didn't. The DON was asked should Resident #9 have pain medication documented on the MAR for her pain. The DON stated, Yes .they would have had to call the nurse practitioner [to get an order]. During a telephone interview on [DATE] at 1:52 PM, NP H confirmed that she typically got to the facility about 10:00 AM. NP H was asked did staff tell her that Resident #9 was in pain. NP H stated, I don't recall .I got there, eval'd [evaluated] her [Resident #9], when I tried to move her leg she screamed, got that STAT x-ray and then we sent her out. NP H was asked did she give an order for pain medication. NP H stated, I did not because she was going out .she was never on pain medicine before the fall .they called the on call [Practitioner] .nothing was ordered because they were told there was no pain. NP H was asked when the resident [Resident #9] began showing signs and symptoms of pain at 9:15 AM, at that time should the staff have requested something for pain. NP H stated, They [the staff] should have told me she [the Resident] was doing that [showing signs and symptoms of pain]. I went in there [to the Resident's room] and attempted to move the leg and she [the Resident] said, 'No, don't, don't, don't [do that] to me, that hurts.' Literally it seems like the STAT x-ray was there within 30 minutes . [the Resident had] no grimacing when laying there, just on movement . NP H was asked in her professional opinion did she think harm there was to the Resident if she lay there in pain for several hours. NP H stated, It's distressing to lay there in pain. I would feel that that would cause harm .harm that couldn't be fixed, no . when they moved her, yeah, that would have produced pain . During a telephone interview on [DATE] at 2:10 PM, LPN L acknowledged she remembered Resident #9's fall on [DATE]. LPN L stated, They [night shift nurse in report] just said she [Resident #9] had fallen .she didn't have any injuries or anything. LPN L was asked did she assess the Resident. LPN L stated, I saw her [the Resident] when I passed out meds, she was just laying in bed like she normally was they hadn't gotten her up yet. LPN L was asked did she conduct a nursing assessment on the Resident or just pass medications. LPN L stated, I didn't do a full assessment, asked her [the Resident] if she was hurting. She didn't appear to be in any distress or anything .acting her same neurologically. LPN L was asked about her documentation of Resident #9's pain on [DATE] at 9:15. LPN L stated, I don't remember the times .just know when they went to get her ready to get up is when she started indicating she was hurting. LPN L was asked how she identified Resident #9's pain in her right hip and thigh. LPN L stated, She was rubbing it .crying or yelling out .I believe I texted the nurse practitioner [NP H], we got an order for a stat x-ray .I believe the nurse practitioner was in the facility when that x-ray was done, anyway she saw it, and it was obviously something not right so we sent her [Resident #9] out [to the hospital]. LPN L was asked about her documentation that stated PRN medication provided see MAR for details and asked what medication was administered. LPN L stated, I honestly can't remember. LPN L was asked was the morning dose of Tylenol [Acetaminophen] administered. LPN L stated, I honestly can't remember. LPN L was asked did she tell NP H how badly Resident #9 was hurting. LPN L stated, I'm sure I did. I don't remember the exact conversation. LPN L was asked did she ask for something more for pain for Resident #9. LPN L stated, No, I think because we were sending her out pretty quick . LPN L was asked about her documentation of Acetaminophen on the MAR that listed a 6 which indicated the resident was hospitalized , and asked did that mean the medication was not administered. LPN L stated, I guess not. LPN L stated she could not remember if Resident #9 received anything for pain from 9:15 AM when she first began to exhibit pain until she transferred to the hospital. During a telephone interview on [DATE] at 4:46 PM, Resident #9's son stated, She [Resident #9] kept complaining about the pain and so they finally sent her to the hospital . Resident #9's son was asked did the facility staff tell him they were giving the Resident pain medication. Resident #9's son stated, No, she [the Resident] was in so much pain . Resident #9's son was asked did he meet her (Resident #9) at the emergency room and did she appear to be in pain. Resident #9's son stated, Oh yeah, she was really hurting, I thought there was something they could have given her to ease the pain .she would scream out in pain and holler out, 'No, don't do that. You're hurting me' .I really don't know when she got any kind of a pain shot or anything . During an interview on [DATE] at 2:20 PM, the MD was asked should Resident #9 have been given something for pain considering the pain was first documented on [DATE] at 9:15 AM, and per the medical record she did not receive anything for pain before transfer to the hospital. The MD stated, They should have called and gotten a prn [as needed] dose [of pain medication] or something . During an interview on [DATE] at 5:06 PM, the Regional Director of Clinical Operations (RDCO) confirmed the number 6 documented on the MAR meant Resident #9 was at the hospital. The RDCO was shown the MAR and asked according to this MAR did Resident #9 receive her morning dose of Acetaminophen. The RDCO stated, I don't know . An acceptable Removal Plan for F-697 was received on [DATE] and validated on-site on [DATE] through review of pain assessments conducted on [DATE] and [DATE] by the DON, MDS Nurse, and Unit Manager. Review of the facility-wide audit of all residents with pain medication orders included confirmation the ordered pain medication was available on-site. One resident was identified needing a re-fill of pain medication. The order request was sent to the pharmacy on [DATE], the resident received medication from the E-kit until the re-fill arrived the following day. Review of the Pain Assessment/Management In-service training records included review of the sign-in sheet and cross-referenced with the current nursing staff including agency nursing. All nurses currently working had received pain assessment and management in-service training. Multiple interviews were conducted with the nursing staff, during which the nursing staff were asked to describe the training received related to pain assessment, monitoring and management. The nursing staff verbalized training was conducted in person as well as electronically via the online training software. The acceptable Removal Plan included: On [DATE] Resident #17 was readmitted to the facility following surgery. Resident #17's readmission orders included Hydrocodone every six hours as needed. The facility failed to follow up on the Hydrocodone and why it did not arrive from the pharmacy in a timely manner. 1.Root Cause Analysis was completed on [DATE]. Root Cause Findings: The first root cause was that the hospital electronically prescribed the pain to the resident's community pharmacy and not the center's designated pharmacy. Second root cause is a knowledge deficit for the nurses due to not understanding the protocols for following up when a medication is not available. The third root cause is that the nurse practitioner did not reorder the pain medication [TRUNCATED]

Based on policy review, medical record review, facility investigation, and interview, the facility failed to implement effective interventions and supervision to prevent falls and incidents of elopement for 2 of 5 (Resident #17 and #5) sampled residents reviewed for accidents. Resident #17 had severe cognitive impairment and was dependent upon staff for assistance with all aspects of care. On [DATE] and [DATE], Resident #17 had undocumented new behaviors of attempting to climb out of the bed, then on [DATE], Resident #17 sustained an unwitnessed fall with a head injury which resulted in actual HARM. Resident #17 was transferred to the Emergency Department (ED), and a computed tomography scan (CT Scan - a detailed x-ray to diagnose conditions) of the brain revealed a subarachnoid hemorrhage (also referred to as subarachnoid bleed, is bleeding into the area between the innermost layer of the brain's protective membranes and the layers that surround the brain) and a left lateral periorbital fracture (broken bone in the side wall of the eye socket usually resulting from blunt force trauma). On [DATE], Resident #5, a resident with severe cognitive impairment, eloped from the facility through the front door of the facility. Resident #5 was gone from the facility for approximately 12 minutes and found at approximately 12:17 PM, in the pharmacy building directly in front of the facility. Resident #5 sustained no injuries during the elopement. The findings include: 1. Review of the policy titled, Free of Accident Hazards/Supervision/Devices dated [DATE], revealed .It is the policy of the facility to ensure it provides an environment that is free from accident hazards .provides supervision .to prevent avoidable accidents. This includes: Identifying hazard(s) and risk(s); and Monitoring for effectiveness and modifying interventions when necessary. Accidents refers to any unexpected or unintentional incident, which results or may result in injury .to a resident .Avoidable Accidents .means that accidents occurred because the facility failed to .Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or .Evaluate and analyze the hazards and risks and eliminate them, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible; and/or .Implement interventions, including adequate supervision, and assistive devices, consistent with a resident's needs, goals, care plan, and current professional standards of practice in order to eliminate the risk, if possible, and if not, reduce the risk of an accident; and/or .Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice .Fall refers to unintentionally coming to rest on the ground, floor, or other lower level .Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred .Supervision/Adequate Supervision .refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents . Review of the policy title, Fall Risk-Fall Prevention Assessment revised [DATE], revealed .It is the policy of the facility in conjunction with the Attending Physician, Consultant Pharmacist, Therapy Staff, Nursing Staff and others to seek to identify resident risk factors for falls .All residents .are screened for fall risk on admission, significant change of condition, quarterly, and annually. All residents .scored greater than 10 considered a high risk per fall screen will be referred to therapy and/or restorative nursing as deemed appropriate. All residents .that had a score of 10 on a fall screen will have a care plan to minimize injury from the fall .All falls, incidents, accidents will be reviewed in the Daily Clinical meeting, Monthly QAPI meeting, and Patient At Risk meetings . 2. Review of the medical record revealed Resident #17 was readmitted to the facility on [DATE], following a hospital discharge with diagnoses of Acquired absence of right leg below the knee (due to below the knee amputation on [DATE]), Dementia, and Peripheral Vascular disease. Review of the Occupational Therapy (OT) evaluation dated Saturday [DATE] at 3:05 PM, revealed Resident #17 experienced bilateral lower extremity pain at rest and with movement, described the pain as terrible and rated the pain as 10 on ,d+[DATE] scale (10 being highest pain level/severe). The OT pain evaluation revealed Resident #17 verbalized pain and indicated pain limited the resident's functional activities, the Resident experienced impaired sensation, and coordination and reported to the OT that she feels a burning sensation in her foot sometimes. The OT clinical impression revealed Resident #17 was non-weight bearing (NWB) of the right lower extremity due to a recent amputation, resulting in decreased functional mobility and coordination and was at risk for falls. Review of the Clinical Morning Meeting notes dated [DATE], revealed Resident #17 was listed as an Admission. There was no documentation in the Clinical Morning Meeting notes to address Resident #17's risk for falls or new onset of trying to climb out of the bed. Review of the Fall Risk assessment dated [DATE], revealed Resident #17 scored a 10 which indicated the Resident was at risk for falls. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #17 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment, which indicated Resident #17 had severe cognitive impairment. Resident #17 required assistance from staff for all aspects of care. Review of the Baseline Care Plan dated [DATE], revealed Resident #17 required assistance with Activities of Daily Living (ADL) and was at Risk for falls. Interventions included to encourage the Resident to the use the call light for assistance, ensure appropriate footwear was worn when out of bed (OOB), and to keep items within reach. The projected outcome for these interventions was Resident #17 .will not sustain serious injury . Review of the Physical Therapy (PT) evaluation dated [DATE], revealed Resident #17 exhibited significant pain in the left lower extremity during unsuccessful attempts to stand. The PT evaluation determined the resident was at risk for falls. Review of the Nursing Progress Note by Licensed Practical Nurse (LPN) B dated [DATE] at 2:20 PM, revealed .Called to [Resident #17]'s room by CNA [certified nursing assistant] .Patient [Resident #17] could not state what happened but did state that she hit her head. Patient did not have socks or shoes and patient has a new RBKA [right below the knee amputation] .Noted swelling by her left eye and a skin tear on her right hand .CNA and nurse assisted patient up and back into bed .Received new order to send patient to ER [emergency room /Emergency Department] for head CT [scan] . Review of the Hospital emergency department (ED) record dated [DATE] beginning at 4:02 PM, revealed Resident #17 arrived at the hospital by ambulance for evaluation and treatment after falling at the facility. During the ED exam, the Resident was disoriented and unable to follow simple commands. A Brain CT revealed a left lateral orbital fracture and subarachnoid hemorrhage. Review of the facility investigation dated [DATE], revealed Resident #17 was found on the floor in her room. The Resident was not wearing socks or shoes, was unable to recall what happened, and stated she hit her head when she fell . The facility investigation listed the Resident's injuries as a hematoma on the face and skin tear to right head. The mental status assessment indicated resident was alert and oriented. The facility investigation did not include documentation of Resident #17's new onset of trying to climb out of bed on [DATE] and [DATE]. There was no documentation in the progress notes regarding Resident #17 attempts to climb out of bed on [DATE] and [DATE]. During an interview on [DATE] at 10:29 AM, the Minimum Data Set (MDS) Nurse was asked what interventions were implemented to reduce the risk of falls with injury for Resident #17. The MDS nurse stated the baseline care plan interventions related to the Resident's risk for falls were to ensure appropriate footwear, keep items within reach of the Resident, and to encourage the Resident to use the call light. The MDS nurse was asked if encouraging a cognitively impaired Resident to use the call light was an appropriate intervention. The MDS nurse confirmed the Resident may not be able to retain instructions regarding use of the call light. During an interview on [DATE] at 12:12 PM, LPN G stated Resident #17 was placed in a chair at the nurses' station on Sunday [DATE], because the Resident was attempting to get out of bed. LPN G was asked if the plan of care was revised to address the Resident's attempt to get out of bed. LPN G stated, No. During an interview on [DATE] at 1:45 PM, the PT stated she conducted a physical therapy evaluation on Monday [DATE], prior to Resident #17's fall. The PT was asked to describe Resident #17's condition during the evaluation on [DATE]. The PT stated Resident #17 was very confused, in a lot of pain, and was at risk for falls. During an interview on [DATE] at 2:00 PM, CNA K stated she was assigned to Resident #17 on Saturday [DATE] and Sunday [DATE]. CNA K stated, [Resident #17] started trying to climb out of bed and seemed anxious. She wasn't like that before her leg was amputated. So, we got her up in a chair and put her at the nurses' station. During an interview on [DATE] at 2:20 PM, the Medical Director confirmed (Resident #17)'s uncontrolled pain and increased confusion were likely contributing factors to the new onset of the Resident climbing out of bed prior to falling on [DATE]. During an interview on [DATE] at 5:02 PM, Resident #17's family member stated Resident #17 was discharged home from the hospital with hospice care. Resident #17 expired on [DATE]. 3. Review of the facility policy titled, ELOPEMENT OF RESIDENT POLICY reviewed [DATE], revealed .It is the standard of this Health Care Center that appropriate procedures exist in the case of a missing resident. A missing resident is defined as a resident who has left the facility grounds without being signed out on pass . Review of the closed medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses of Urinary Tract Infection (UTI), Dementia, Hypertension, Dizziness and Giddiness, Adult Failure to Thrive, and Cognitive Communication Deficit. Review of the Clinical Admission documentation dated [DATE], revealed Resident #5 displayed short-term memory loss, spoke coherently, and exhibited no wandering behaviors on admission. Review of the Elopement Evaluation dated [DATE], revealed Resident #5 did not have a prior history of elopement or wandering behaviors and scored a 0.0 on the Elopement Evaluation, meaning the resident was not assessed to be at risk of elopement. Review of the admission MDS assessment dated [DATE], revealed Resident #5 scored a 5 on the BIMS assessment, which indicated Resident #5 had severe cognitive impairment, and exhibited wandering behaviors on 1 to 3 days of the lookback period. Resident #5 required supervision/touching assistance to partial/moderate assistance for most activities of daily living. Review of the Resident #5's admission care plan dated [DATE], revealed no documentation of interventions for elopement and wandering. Review of the facility investigation dated [DATE], revealed [DATE] around 12:22 [PM], Administrator was notified that resident [Resident #5] had exited the building and was located next door at the pharmacy .Staff stated resident was sitting at the nurse's station all morning, so when they saw she was not sitting they began to ask where she was, searched the building, called the code [code that a resident had eloped], asked the receptionist if she had seen her [Resident #5], they described the resident, she [Receptionist] stated she [Resident #5] left and stated she signed out when asked by the receptionist. Resident was located at [Named] Pharmacy .about 228 feet away. Administrator spoke with [Named Pharmacy] salesclerk, she stated the resident browsed and attempted to purchase a soda. She [the Pharmacy salesclerk] stated the resident was in there [in the Pharmacy] about 10 minutes before our staff [the facility] came in .Resident was determined to be out of the building from 12:05pm to 12:17pm . During an interview on [DATE] at 1:05 PM, CNA O stated Resident #5 was on her assigned hall and denied that Resident #5 exhibited any behaviors that indicated she was an elopement risk from the time she admitted on [DATE] until she eloped from the facility on [DATE]. CNA O was asked when was the last time she had seen Resident #5 before she was told the Resident was missing. CNA O stated, .In her room .11:00 or 11:30 [AM] .I believe the nurse that day .she .was looking for her [Resident #5] for medication I think, didn't find her in the room. We went around looking in every room .I looked in all the rooms, the restrooms, once we looked on C hall, B hall, and A hall we started looking outside. Once I got outside, I heard them [facility staff] yelling she [the Resident] was at [Named Pharmacy] .She [Resident #5] was very happy, seemed like she was trying to get her a drink. She didn't seem very confused .I believe we had a receptionist here, a newer lady, she said she let her out .believe she told us that when we come back in . CNA O stated they put a wander guard on Resident #5 that day. During an interview on [DATE] at 3:39 PM, the Administrator stated, I wasn't here. They called and said that she [Resident #5] had went out. The receptionist had asked [Resident #5] was she a visitor and she [the Resident] said yes, so she [the receptionist] let her out .she [the Resident] was not in the elopement book [the elopement book at the front door, in the Therapy department, and at each Nurse's Station] .she always sits at C Hall and [staff] always know where she is, noticed she was gone when they get [got] ready to pass trays, got to looking around the building .asked the receptionist, she said she let her out, she thought she was a visitor .she [the Resident] used to work here [as a CNA], she would always go to [Named Pharmacy] on break and buy a coke then bring it back and sit on the porch and drink it .asked her what she was doing [in the pharmacy] she said she was getting a Coke .brought her back, we did the wander guard, elopement assessment, put her in the book [the elopement book]. The Administrator stated, We implemented stickers [green visitor stickers] took the book [sign-in book] off of C Hall and brought it to one place .had everybody start coming in [at] one place [front door] .if they don't have the sticker they have to verify they are not a visitor before they [receptionist] let them out the door, seems to be working pretty good. The Administrator stated the pharmacy was measured to be approximately 228 feet from the facility and Resident #5 was gone 12 minutes. The Administrator stated she was able to identify the time Resident #5 eloped because she left at the same time the other visitors had left the facility. During a telephone interview on [DATE] at 9:40 AM, the Receptionist stated, Like I told the Manager [Administrator] she [Resident #5] had her purse, she wasn't in a wheelchair, she didn't have anything that could prove she was a resident. She told me she walked in and signed in on the C Hall. The Receptionist confirmed there was a sign-in sheet on the C Hall at that time. The Receptionist was asked how would you know which residents were an elopement risk. The Receptionist stated, Because they have a little binder [the elopement book] with pictures on them and I would look through it so I would recognize if they tried leaving .they didn't have a picture of her [in the binder] until the incident .they asked me to add a picture of her [[DATE]] .I was talking to this couple and they normally walk in through the main entrance and she just appeared and .was like do I have to sign out and I was like did you sign in at C Hall and she was like, yes .she was like I'm just going to get something from the store .since I didn't know all the residents at the time I didn't know some were able to walk like her . The Receptionist confirmed she had only worked in the facility 3 or 4 months at the time.

Based on facility policy review, personnel file review, medical record review, facility document review, Law Enforcement Investigation review, hospital order review, and interview, the facility failed to ensure the residents' rights to be free from misappropriation of residents' property for 13 of 13 (Resident #13, #14, #15, #18, #19, #20, #21, #22, #23, #25, #26, #28, and #30) sampled residents reviewed for misappropriation of resident property by means of diversion of resident medications including, but not limited to, controlled substances from [DATE] through [DATE]. On [DATE] facility Licensed Practical Nurse (LPN) M was arrested for drug diversion of the 13 residents' medications and controlled substances. The findings include: 1. Review of the facility policy titled, Abuse Prevention Policy with a facility review date of [DATE], revealed .The resident has the right to be free from .misappropriation of property .Facility has a zero-tolerance Abuse Standard regarding all proven allegations of .Misappropriation of Resident Property .means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent .Administrator will review investigational findings to determine appropriate corrective, remedial, or disciplinary actions to occur with accordance with applicable local, state or federal law. Administrator will review outcome in monthly continuous quality Improvement meeting. Department Manager(s) will be notified of investigation outcome for appropriate follow up and monitoring. Review of the facility policy titled, Controlled Substances revised ,d+[DATE], .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications .Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on premises .The charge nurse on duty maintains the keys to controlled substance containers. The director of nursing services maintains a set of back-up keys for all medication storage areas including keys to controlled substance containers .Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift .Upon disposition .Medications returned to the pharmacy are recorded and signed by the director of nursing (or designee) and the receiving pharmacy .Policies and procedures for monitoring controlled medication to prevent loss, diversion .are periodically reviewed and updated by the director of nursing services and the consultant pharmacist . 2. Review of LPN M's personnel file revealed she worked in the facility from [DATE] through [DATE]. 3. On [DATE], LPN M was arrested for drug diversion of residents' medications. Review of Law Enforcement's investigation revealed Investigator #1 initiated a traffic stop of LPN M on [DATE] due to a potential window tint violation. Investigator #1 observed miscellaneous pills on the driver's side floorboard. The vehicle was searched and different kinds of scheduled and non-scheduled prescription medication pill blister packs (cards of medication that the medication can be pushed through the back of the card to dispense to residents) containing names of different people were observed. LPN M informed Investigator #1 that she worked at (Named the facility). Investigator #1 discovered prescription blister packs that dated back to 2020. Investigator #1 also found a green cloth bag in the car that contained over 15 small plastic baggies containing non-scheduled and scheduled prescription drugs all packaged separately, and .the schedule drugs ranged from Schedule II from Morphine and Hydrocodone, Schedule IV Lorazepam to Xanax and Schedule V Gabapentin and Pregabalin . LPN M was taken into custody at that time and charged with Unlawful Window Tint, Unlawful Possession without Prescription, and Possess Controlled Substance with Intent to Manufacture, Deliver, or Sell Controlled Substance for Schedule II (3 counts), Schedule IV (4 counts), and Schedule V (3 counts) drugs. Continued review of Law Enforcement's investigation revealed on [DATE] a search warrant was executed at LPN M's home. Investigators located multiple different kinds of pill blister packs containing names of different people. The Schedule drugs ranged from Schedule II Morphine and Hydrocodone, Schedule IV Lorazepam and Xanax, and Schedule V Gabapentin and Pregabalin and other non-scheduled drugs in various locations in the home. LPN M was additionally charged with Unlawful Possession without Prescription, and Possess Controlled Substance with Intent to Manufacture, Deliver, or Sell Controlled Substance for Schedule II (2 counts), IV (4 counts), and V (3 counts) drugs. Review of the pictures from the Law Enforcement's investigation and search of LPN M's car and home revealed the LPN was in possession of the following Residents' medications: 3a. One (1) of Resident #13's empty muscle relaxer blister pill packs. Four (4) of Resident #14's empty controlled substance blister pill packs. Three (3) of Resident #15's empty controlled substance blister pill packs. One (1) of Resident #18's empty controlled substance blister pill packs. One (1) of Resident #19's empty controlled substance blister pill packs. Two (2) of Resident #20's empty controlled substance blister pill packs. One (1) of Resident #21's empty controlled substance blister pill packs. One (1) of Resident #22's empty controlled substance blister pill packs. One (1) of Resident #23's empty controlled substance blister pill packs. Three (3) of Resident #25's empty controlled substance blister pill packs. One (1) of Resident #26's empty controlled substance blister pill packs. One (1) of Resident #28's empty antibiotic blister pill pack and 1 of Resident #28's empty blister pill packs. One (1) of Resident #30's empty controlled substance blister pill packs. 3b. One (1) of Resident #14's 60-count blister pill pack of Gabapentin 100 milligrams (mg) with 39 capsules remaining. One (1) of Resident #15's 45-count blister pill pack of Gabapentin 100 mg with 45 remaining. One (1) of Resident #19's 12-count blister pill pack of Hydrocodone-Acetaminophen ,d+[DATE] mg with 5 tablets remaining. One (1) of Resident #20's 60-count blister pack of Gabapentin 600 mg with 50 tablets remaining. One (1) of Resident #25's 30-count blister pack of Gabapentin 300 mg with 2 capsules remaining. One (1) of Resident #28's 14-count blister pack of Doxycycline 500 mg with 9 capsules remaining. One (1) of Resident #28's 60-count blister pack of Tramadol 50 mg with 50 tablets remaining. On [DATE], the surveyor met with Investigator #1 at the Sheriff's Department, and he provided a flash drive with over 400 pictures from the Law Enforcement investigation and a folder which contained their investigation and pictures of pill blister packs of several residents, pictures of vials of medication, and Controlled Drug Record forms that were found in the possession of LPN M. The Law Enforcement investigation revealed the following items were found in the search of LPN M's car and home: a. Schedule II-67 pills and 6 bottles of liquid. b. Schedule IV-266 pills and 2 bottles of liquid. c. Schedule V-130 pills. d. There were 704.5 total pills found in LPN M's car. e. There were 1,225 total pills found in LPN M's home. f. The total number of pills seized by law enforcement was 1,929.5. 4. Review of the medical records revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dependence on Renal Dialysis, Hypothyroidism, Anxiety, Bipolar Disorder, and Insomnia. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 scored a 15 on the Brief Interview for Mental Status (BIMS), which indicated Resident #13 was cognitively intact, and received antipsychotic, antianxiety, antidepressant and opioid medications. Review of the physician orders for Resident #13 dated [DATE], revealed Tizanidine Hydrochloride (HCL) (a muscle relaxer, non-scheduled medication) 2 mg, give 1 tablet by mouth four times a day. Review of the Medication Administration Record (MAR) dated [DATE] through [DATE], for Resident #13 revealed Tizanidine HCL 2 mg four times a day was discontinued on [DATE]. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1611) of Resident #13's blister pill pack of Tizanidine HCL 2 mg with a date issued of [DATE]. There were zero (0) of 60 Tizanidine tablets remaining in the blister pack. Continued review revealed a printed picture in the investigation of Resident #13's blister pill pack for Tizanidine HCL 2 mg, card 2 of 4, date issued [DATE]. There were 7 of 60 Tizanidine tablets remaining in the blister pack. Review of the quarterly MDS assessment dated [DATE], revealed Resident #13 scored a 15 on the BIMS score, which indicated Resident #13 was cognitively intact, and received antipsychotic, antianxiety, antidepressant and opioid medications. Observation and interview on [DATE] at 9:20 AM, revealed Resident #13 laying in bed, oxygen was being administered at 3 liters per minute by nasal cannula, and a grab bar was present on the left side of the bed. Resident #13 confirmed that she received scheduled medications for pain. Resident #13 stated, I remember a time or two when [Named LPN M] didn ' t give me [my] night meds .she's no longer here .for stealing drugs .I saw it on the news .Resident #13 confirmed that she reported the incident to another staff nurse . 5. Review of the closed medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Dementia, Diabetes, Osteoporosis, Insomnia, and Anxiety. Review of the quarterly MDS assessment dated [DATE], revealed Resident #14 scored a 01 on the BIMS score, which indicated Resident #14 was severely cognitively impaired, and received antianxiety, antidepressant and opioid medications. Review of the physician orders for Resident #14 dated [DATE], revealed Ativan (Lorazepam - a medication for anxiety) 0.5 mg every 12 hours as needed (PRN) for anxiety and agitation. Review of the physician orders for Resident #14 dated [DATE], revealed Percocet (Oxycodone-Acetaminophen medication for pain) ,d+[DATE] mg give 1 tablet by mouth two times a day every 6 hours as needed for pain and give 1 tablet by mouth two times a day for pain. Review of the physician orders for Resident #14 dated [DATE], revealed Gabapentin (medication for seizures and nerve pain) 100 mg give 1 capsule by mouth two times a day for diabetic neuropathy. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed pictures (#1620 and #1705) of Resident #14's blister pill pack of Lorazepam 0.5 mg, a Schedule IV controlled substance with an issue date of [DATE]. There were 0 of 50 Lorazepam tablets remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1678) of Resident #14's blister pill pack of Oxycodone-Acetaminophen ,d+[DATE] mg, a Schedule II controlled substance, date issued [DATE]. There were 0 of 60 Percocet tablets remaining in the blister pack. Review of the Pharmacy Electronic Shipping Manifest dated [DATE] at 2:16 PM, revealed 120 Oxycodone ,d+[DATE] mg tablets were delivered to the facility for Resident #14. The Manifest is the list of medications delivered to the facility from the pharmacy. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1539) of Resident #14's blister pill pack of Oxycodone-Acetaminophen ,d+[DATE] mg a Schedule II controlled substance with a date issued of [DATE]. There were 0 of 60 Percocet tablets remaining in the blister pack. Review of the Pharmacy Electronic Shipping Manifest dated [DATE] at 7:26 PM, revealed 90 Oxycodone ,d+[DATE] mg were delivered to the facility for Resident #14. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1708) of Resident #14's blister pill pack of Gabapentin 100 mg, a Schedule V controlled substance, with an issued date of [DATE]. There were 39 of 60 Gabapentin capsules remaining in the blister pack. The facility was unable to provide the Pharmacy Electronic Shipping Manifest for Resident #14's Gabapentin dated [DATE] or a Controlled Drug Record form for the Lorazepam dated [DATE], the Percocet dated [DATE] and [DATE], and the Gabapentin dated [DATE]. Review of the Nurse's Note dated [DATE], revealed Resident #14 expired in the facility. 6. Review of the closed medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Bipolar Disease, Anxiety and Insomnia. Review of the physician orders for Resident #15 dated [DATE], revealed the following: (a). Gabapentin 100 mg, give 1 capsule by mouth three times a day for neuropathy (weakness, numbness, and pain from nerve damage and pain). (b). Diazepam 5 mg, give 1 tablet by mouth every 12 hours as needed for anxiety for 14 days. (c). Hydrocodone-Acetaminophen ,d+[DATE] mg, give 1 tablet by mouth every 6 hours as needed for pain for 14 days. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1623) of Resident #15's blister pill pack of Hydrocodone-Acetaminophen ,d+[DATE] mg, a Schedule II controlled substance, with an issued date of [DATE]. There were 0 of 12 Hydrocodone-Acetaminophen tablets remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1657) of Resident #15's blister pill pack of Diazepam 5 mg, a Schedule IV controlled substance, with an issued date of [DATE]. There were 0 of 12 Diazepam tablets remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1659) of Resident #15's blister pill pack of Gabapentin 100 mg, a Schedule V controlled substance, with an issued date of [DATE]. There were 45 of 45 Gabapentin capsules remaining in the blister pack. Review of the 5-day MDS assessment dated [DATE], revealed Resident #15 received antipsychotic and opioid medications. The facility was unable to provide a Pharmacy Electronic Shipping Manifest to show delivery of Resident #15's Gabapentin, Diazepam, and Hydrocodone-Acetaminophen dated [DATE], or a Controlled Drug Record for Gabapentin, Diazepam, and Hydrocodone-Acetaminophen. Review of the Nurses Note dated [DATE], revealed Resident #15 left the facility against medical advice. 7. Review of the closed medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including Diabetes, Chronic Pain Syndrome, and Anxiety. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1693) of Resident #18's blister pill pack of Alprazolam 0.25 mg, a Schedule IV controlled substance, with an issued date of [DATE]. There were 0 of 60 remaining in the blister pack. Review of the physician orders for Resident #18 dated [DATE], revealed Alprazolam (medication used to treat anxiety/depression) 0.5 mg, give 1 tablet by mouth three times a day. The facility was unable to provide a Pharmacy Electronic Shipping Manifest to show delivery of Resident #18's Alprazolam dated [DATE], or a Controlled Drug Record form for the Alprazolam. Review of the admission MDS assessment dated [DATE], revealed Resident #18 scored a 15 on the BIMS, which indicated the Resident was cognitively intact, and received antianxiety, antidepressant, and opioid medications. Review of the Nurse's Note dated [DATE], revealed Resident #18 was discharged home. 8. Review of the closed medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Prosthesis, Depression, Osteoarthritis, and Anxiety. Review of the physician orders from the Rehab Hospital for Resident #19 dated [DATE], revealed Norco 7XXX,d+[DATE] mg (Hydrocodone), give 1 tablet every 6 hours as needed for pain (pain scale ,d+[DATE]). Review of the Resident #1's admission MDS assessment dated [DATE], revealed the Resident scored a 15 on the BIMS, which indicated the Resident was cognitively intact, and received antianxiety, antidepressant, and opioid medications. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1391) of Resident #19' s blister pill pack of Hydrocodone-Acetaminophen 7XXX,d+[DATE] mg, a Schedule II controlled substance, date issued not visible. There were 4 of 12 Hydrocodone-Acetaminophen tablets remaining in the blister pack. The facility was unable to provide a Pharmacy Electronic Shipping Manifest to show delivery of Resident #19' s Hydrocodone-Acetaminophen or a Controlled Drug Record for the Hydrocodone-Acetaminophen. Review of the Nurse's Note dated [DATE], revealed Resident #19 was discharged home. 9. Review of the closed medical record revealed Resident #20 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Sepsis, Diabetes, Hypothyroidism, Anxiety, Insomnia. Review of the physician's order for Resident #20 dated [DATE], revealed Gabapentin 300 mg, give 2 capsules by mouth three times a day for neuropathy. Review of the physician's order for Resident #20 dated [DATE] revealed, Gabapentin 100 MG, give 1 capsule by mouth three times a day. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1655) of Resident #20's Gabapentin 600 mg, a Schedule V controlled substance, card 1 of 6, dated [DATE]. There were 0 of 30 Gabapentin capsules remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1719) of Resident #20 ' s Gabapentin 600 mg, a Schedule V controlled substance, card 2 of 6, dated [DATE]. 50 of 60 Gabapentin capsules remained in the blister pack. The facility was unable to provide a Pharmacy Electronic Shipping Manifest to show delivery of Resident #20's Gabapentin dated [DATE] or a Controlled Substance Record for the Gabapentin. Review of the admission MDS assessment dated [DATE], revealed Resident #20 scored a 15 on the BIMS, which indicated she was cognitively intact, and received antipsychotic, antianxiety, antidepressant and opioid medications. Review of the Nurse's Note dated [DATE], revealed Resident #20 was discharged home. 10. Review of the closed medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses including Anxiety, Chronic Obstructive, Depression and Muscle Weakness. Review of the admission MDS assessment dated [DATE], revealed Resident #21 had a BIMS score of 15, which indicated Resident #21 was cognitively intact, received anxiety, antidepressant and opioid medications. Review of the physician orders for Resident #21 dated [DATE], revealed Lorazepam 0.5 mg, give 1 tablet by mouth every 8 hours as needed for anxiety for 14 days. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1590) of Resident #21's blister pack for Lorazepam 0.5 mg, a Schedule IV controlled substance, issued [DATE]. There were 0 of 20 Lorazepam tablets remaining in the blister pack. The facility was unable to provide a Pharmacy Electronic Shipping Manifest to show delivery of Resident #21's Lorazepam dated [DATE] or a Controlled Drug Record form for the Lorazepam. Review of the Nurse's Note dated [DATE], revealed Resident #21 was transferred to the hospital, the resident did not return to the facility. 11. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dementia, Anxiety, and Chronic Kidney Disease Stage 4. Review of the physician orders for Resident #22 dated [DATE], revealed Clonazepam 0.5 mg, give 1 tablet by mouth every 24 hours for anxiety. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1625) of Resident #22's blister pack for Clonazepam 0.5 mg, a Schedule IV controlled substance, issued [DATE]. There were 0 of 14 Clonazepam tablets remaining in the blister pack. The facility was unable to provide a Pharmacy Electronic Shipping Manifest to show delivery of Resident #22's Clonazepam dated [DATE] or a Controlled Drug Record form for the Clonazepam. Review of the quarterly MDS assessment dated [DATE], revealed Resident #22 scored a 03 on the BIMS, which indicated Resident #22 was severely cognitively impaired, and received antidepressant and opioid medications. Observation in the resident's room on [DATE] 1:25 PM, revealed a sign for contact precautions on the hall wall to the right of the door, Resident #22 lay in bed on her back, her eyes were closed, and she appeared to be asleep. The call light was in reach and the bed in low position. 12. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Acquired Absence of Right Leg Above Knee (above the knee amputation), Anxiety, Personal History of Malignant Neoplasm of Uterus, and Diabetes. Review of the admission MDS assessment dated [DATE], revealed Resident #23 scored a 14 on the BIMS, which indicated Resident #23 was cognitively intact, and received opioids medications. Review of the physician orders dated [DATE], revealed Ativan (Lorazepam medication given for anxiety) 0.5 mg, give 1 tablet by mouth 3 times every week every Monday, Wednesday, and Friday for anxiety disorder. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1711) of Resident #23 ' s blister pack for Lorazepam 0.5 mg, a Schedule IV controlled substance, issued [DATE]. 0 of 12 Lorazepam tablets remained in the blister pack. The facility was unable to provide a Pharmacy Electronic Shipping Manifest to show delivery of Resident #23's Lorazepam dated [DATE] or a Controlled Drug Record form for the Lorazepam. 13. Review of the closed medical records revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Diabetes, Cirrhosis of Liver, Anxiety, Insomnia, and Gout. Review of the admission MDS assessment dated [DATE] revealed Resident #25 scored a 13 on the BIMS, which indicated Resident #25 was cognitively intact, and received antidepressant medications. Review of the physician orders for Resident #25 dated [DATE], revealed Gabapentin 300 mg, give 1 capsule by mouth two times a day for seizures. Review of the MAR dated [DATE]-[DATE], revealed Resident #25 received 20 doses of Gabapentin 300 mg. Review of the Law Enforcement investigation revealed a Controlled Drug Record for Resident #25's Gabapentin 300 mg that was seized in the search of LPN M's car and home. The form revealed there should have been 2 Gabapentin on the pill blister pack that LPN M diverted from the facility. Review of the Law Enforcement investigation for the drug diversion by LPN M, revealed a picture (#1694) of Resident #25's blister pack for Gabapentin 300 mg, a Schedule IV controlled substance, issued [DATE]. 2 of 30 Gabapentin capsules remained in the blister pack. Review of the Pharmacy Electronic Shipping Manifest dated [DATE], revealed 30 Gabapentin 300 mg and 28 Lorazepam 0.5 mg were delivered for Resident #25. Review of the Medication Administration Record (MAR) for Resident #25 dated [DATE]-[DATE], revealed Alprazolam 0.5 mg, give 1 tablet every 12 hours as needed for anxiety for 14 days, was ordered on [DATE]. Resident #25 received 1 dose of Alprazolam on [DATE] at 11:31 AM. On [DATE], the frequency of the order was changed to give 1 tablet of Alprazolam every 8 hours as needed for anxiety for 14 days. Resident #25 received 1 dose of Alprazolam on [DATE] at 9:00 PM. Review of the physician's order for Resident #25 dated [DATE], revealed Alprazolam 0.5 mg, give 1 tablet by mouth every 8 hours as needed for anxious behavior. Review of the Law Enforcement investigation revealed a Controlled Drug Record form for Resident #25's Alprazolam 0.5 mg dated [DATE], that was seized in the search of LPN M's car and home. The form revealed there should have been 8 of 28 Lorazepam 0.5 mg on the pill blister pack that LPN M diverted from the facility. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1645) of Resident #25's s blister pack for Alprazolam 0.5 mg, a Schedule IV controlled substance, issued [DATE]. 0 of 28 Lorazepam tablets remained in the blister pack. Continued review of the Law Enforcement investigation revealed a Controlled Drug Record form for Resident #25's Alprazolam 0.5 mg dated [DATE], that was seized in the search of LPN M ' s car and home. The form revealed there should have been 42 of 42 Lorazepam 0.5 mg in the pill blister pack that LPN M diverted from the facility. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1686) of Resident #25's blister pack for Alprazolam 0.5 mg, a Schedule IV controlled substance, issued [DATE]. 0 of 42 Lorazepam tablets remained in the blister pack. The facility was unable to provide a Controlled Drug Record form for Resident #25's Lorazepam dated [DATE] and [DATE]. Review of the Nurses' Note dated [DATE] revealed Resident #25 expired in the facility. 14. Review of the closed medical records revealed Resident #26 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Depression, Dementia, and Senile Degeneration of Brain. Review of the quarterly MDS assessment dated [DATE], revealed Resident had a BIMS score of 2, which indicated Resident #26 was severely cognitively impaired, and received antidepressant and opioid medications. Review of the physician's order For Resident #26 dated [DATE], revealed Lorazepam 0.5 mg, give 1 tablet by mouth four times a day for seizures. Review of the Pharmacy Electronic Shipping Manifest dated [DATE] at 8:43 PM, revealed 30 Lorazepam 0.5 mg tablets were delivered for Resident #26. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1519) of Resident #26's blister pack for Lorazepam 0.5 mg, a Schedule IV controlled substance, issued [DATE]. 0 of 30 Lorazepam tablets remained in the blister pack. The facility was unable to provide a Controlled Drug Record form for Resident #26 ' s Lorazepam dated [DATE]. Review of the Nurse's Note dated [DATE] at 7:13 PM, revealed Resident #26 expired in the facility. 15. Review of the medical records revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Diabetes, Cellulitis Right Lower Limb, and Cellulitis of Left Lower Limb. Resident #28 was discharged [DATE]. Review of the admission MDS assessment dated [DATE], revealed Resident scored a 13 on the BIMS, which indicated Resident # was cognitively intact, and received opioid medications. Review of the physician order for Resident #28 dated [DATE], revealed Tramadol (opioid medication given for pain) 50mg, give 1 tablet by mouth every 6 hours as needed for pain. Review of the Medication Administration Record (MAR) dated [DATE]-[DATE], revealed .DOXYCYCLINE MONO (monohydrate a non-scheduled medication given to treat bacterial infections)100 MG .Give .by mouth two times a day related to CELLULITIS OF RIGHT LOWER LIMB .CELLULITIS OF LEFT LOWER LIMB .for 3 days .Order dated XXX[DATE] . Continued review of the MAR revealed Resident #28 received 5 doses of Doxycycline. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1564) of Resident #28 ' s blister pack for Doxycycline 100mg, an antibiotic, date issued [DATE]. 9 of 14 Doxycycline remained in the blister pack. Review of the MAR for Resident #28 dated [DATE]-[DATE], revealed Resident #28 received 1 dose of Tramadol 50 mg. Review of the Pharmacy Electronic Shipping Manifest dated [DATE] at 8:25 PM, revealed 60 Tramadol Hydrochloride 50 mg tablets were delivered for Resident #28. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1561) of Resident #28's blister pack for Tramadol 50 mg, a Schedule IV controlled substance, date issued [DATE]. 50 of 60 Tramadol tablets remained in the blister pack. The facility was unable to provide a Controlled Drug Form for Resident #28's Tramadol dated [DATE]. Review of the Nurse's Note dated [DATE], revealed Resident #28 discharged home with family. 16. Review of the closed medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Fracture of Left Femur, Dementia, Anxiety, and Dementia. Review of the admission MDS assessment dated [DATE], revealed Resident scored a 03 on the BIMS, which indicated Resident #30 was severely cognitively impaired, and received anticoagulant and diuretic medications. Review of the physician's order for Resident #30 dated [DATE], revealed Lorazepam 0.5 mg, give 1 tablet by mouth every 12 hours as needed for agitation and anxious behavior for 2 days. Do not give within 2 hours of scheduled Oxycodone. Review of the Pharmacy Electronic Shipping Manifest dated [DATE] at 3:18 PM, revealed 4 Lorazepam 0.5 mg tablets were delivered for Resident #30. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1520) of Resident #30's blister pack for Lorazepam 0.5 mg, a Schedule IV controlled substance, date issued [DATE]. 0 of 4 Lorazepam tablets remained in the blister pack. The facility was unable to provide a Controlled Drug Record of Resident #30's Lorazepam dated [DATE]. Review of the Nurse's Note dated [DATE], revealed Resident #30 was discharged home with her daughter. 17. During an interview on [DATE] at 9:55 AM, the Director of Nursing (DON) stated, .when a card [pill blister pack] is emptied it is pulled from the cart as well as the narcotic sheet and put in a basket that comes to me .when a narcotic is discontinued and still some left on the [medication (med)] cart the nurses and I pull that, we log it on a sheet, the number of pills the resident's name, what it [medication] is and it's locked into this double locked cabinet until pharmacy comes and then pharmacy and I will destroy those narcs .I use Rx Destroyer, chemical based that you dump [medications to be destroyed] in there .so much of the diversion part we don't have because they [Law Enforcement] took it. The DON was asked were they able to substantiate the nurse [LPN M] took any medications. The DON stated, Our investigation was limited with having enough paperwork .I would have to say yeah she did [divert resident's medications] .they brought in some sheets and I reviewed them .they were all deceased residents .she [LPN M] was delegated with removing narcotics from the cart .they [residents] would expire, she took the narcotic sheet and the narcotic and I don't know how she was able to do it without getting caught .I was floored, devasted and angry .there was no hint, everybody was floored there [TRUNCATED]

Based on policy review, job description review, personnel record review, facility investigation review, in-service record review, medical record review, observation, and interview, the facility failed to provide sufficient nursing staff with appropriate competencies and skill sets to ensure residents attain or maintain the highest level of practicable physical well-being. The facility failed to ensure competent nursing staff (Certified Nursing Assistant (CNA) R) who immediately reported an allegation of abuse to Administration for 1 of 6 (Resident #1) sampled residents reviewed for allegations of abuse, failed to ensure competent nursing staff (Licensed Practical Nurse (LPN) B and LPN C) who documented controlled substances when administered for 14 of 57 (Resident #7, 8, 13, 22, 27, 29, 31, 32, 33, 34, 35, 36, 41, and 42) sampled residents reviewed for narcotic reconciliation, failed to ensure competent nursing staff (LPN L and LPN Q) who administered medications per the physician's order and as scheduled for 5 of 5 (Resident #6, 13, 16, 24, and 38) residents reviewed for administration of medications, and failed to ensure competent nursing staff (LPN D and LPN L) who appropriately assessed and implemented interventions to address pain and the new onset behavior of attempting to get up unassisted for cognitively impaired residents for 2 of 6 (Resident #17 and 9) sampled residents reviewed for pain assessments and implementation of pain management in cognitively impaired residents with non-verbal pain cues. The findings include: 1. Review of the policy titled, Staffing Guidelines, dated 8/22/2022, revealed It is the policy of the center [facility] to abide by the Federal and Sate staffing guidelines .The center adopts the Federal regulations from the Centers for Medicare and Medicaid Services (CMS) as well as the state regulations for which the center resides as our policies. The staffing and ratios outlined in the regulations will be followed by the Center. Review of the undated facility policy titled, Nursing Services, General, revealed .It is the policy of the facility to provide care and services related to Nursing Services in accordance to State and Federal regulation .This policy will include .Competent Nursing Staff . Review of the facility policy titled, Charting and Documentation, revised 7/2017, revealed .All services provided to the resident .or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .The following information is to be documented in the resident medical record .Medications administered .Treatment or services performed . Review of the facility policy titled, Charting Errors and Omissions, revised 12/2022, revealed .Accurate medical records shall be maintained by this facility .Late entries in the medical record shall be dated at the time of entry and noted as a late entry . Review of the facility policy titled, Administration of Drugs, dated 4/2022, revealed .Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director .Unless otherwise specified by the resident's attending physician, routine drugs should be administered as scheduled .The nurse administering the drug must record such information on the residents eMAR [electronic Medication Administration Record] .must electronically sign the resident's eMAR immediately after administration . Review of the undated facility policy titled, Pain Managment, revealed .The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice . 2. Review of the facility Job Description titled, Charge Nurse, revealed .The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility .to ensure that the highest degree of quality care is maintained at all times .delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Transcribe physician's orders to resident charts .medication cards .Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care .Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures .Prepare and administer medications as ordered by the physician .Ensure that an adequate supply of floor stock medications .is on hand to meet the nursing needs of the residents .Notify the Nurse Supervisor of all drugs and narcotic discrepancies noted on your shift .Review medication cards for completeness of information, accuracy in the transcription of the physician ' s order .Dispose of drugs and narcotics as required, and in accordance with established procedures .Notify the resident's attending physician .when there is a change in the resident's condition . 3. Review of the personnel record for Licensed Practical Nurse (LPN) B revealed the LPN Job Description was signed on 4/26/2016. Continued review revealed, .Provide direct nursing care to the residents and supervise the day-to-day nursing activities performed by nursing assistants .in accordance with Federal, State, and Local standards, guidelines and regulations .to maintain the highest degree of quality care at all times .Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures .Prepare and administer medication as ordered by the physician .Verify that narcotic records are accurate for your shift . Review of the personnel record for LPN C revealed the Charge Nurse Job Description was signed and dated on 6/1/2023. Review of the personnel record for LPN L revealed the Charge Nurse Job Description was signed and dated on 5/21/2024. Review of the Nurse Competency Assessment Form in LPN's personnel record dated 5/22/2024, revealed .Demonstrates ability to apply knowledge and skills in a healthcare setting .Demonstrates effective communication .Monitor, document and report all changes in condition appropriately .Understands specific facility client population .Demonstrates proper documentation of medication administration .Consistently, appropriately and correctly documents in EMR [Electronic Medical Record] . Review of the personnel record for LPN D revealed the Charge Nurse Job Description was signed and dated on 10/10/2024. Continued review of the Nurse Competency Assessment Form dated 10/24/2024, revealed .Demonstrates ability to apply knowledge and skills in a healthcare setting .Demonstrates effective communication .Monitor, document and report all changes in condition appropriately .Understands specific facility client population .Demonstrates proper documentation of medication administration .Consistently, appropriately and correctly documents in EMR . Review of the personnel record for Certified Nursing Assistant (CNA) R revealed the CNA Job Description was signed and dated 1/2/2025. Continued review revealed .Report all allegations of resident abuse . 4. The facility failed to ensure competent staff who immediately reported allegations of abuse. a. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Diabetes, Human Immunodeficiency Virus Disease, Depression, and Encephalopathy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14. Review of the progress notes dated 2/27/2025, revealed Resident #1 reported to RN A that a male staff member had sexually abused him by digital penetration of the rectum. RN A called the Administrator immediately and reported the allegation and Resident #1 was transported to the emergency room (ER). During an interview on 3/4/2025 at 3:29 PM, Certified Nursing Assistant (CNA) R stated she was told by Resident #1 on 2/26/2025 that a male staff member raped him. CNA R stated .the new nurse .was [NAME] [missing in action] .he was nowhere to be found .I had an Uber waiting on me . CNA R stated she reported the allegation of abuse to facility staff the following day (2/27/2025). CNA R stated, .I'm sorry .I know you have to tell right away .now I know to tell any nurse in charge. I feel bad . b. CNA R had previously attended an Abuse inservice on 2/5/2025, but did not report the abuse on 2/26/2025, when the resident reported the allegation. 5. The facility failed to ensure competent nursing staff documented controlled substances when administered: a. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Review of the Medication Administration Audit Report for Resident #7 dated 3/4/2025 at 9:07 AM, revealed Lacosamide (medication to control seizures) 50 mg tablet was administered to Resident #7. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, with LPN C, revealed a discrepancy of Resident #7's Lacosamide 50 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 6 Lacosamide tablets and the Controlled Drug Record documented there should be 7 Lacosamide tablets presents. LPN C confirmed the discrepancy. b. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Review of Resident #8's physician's orders dated 2/6/2025, revealed an order for Percocet (Oxycodone-Acetaminophen) 5-325 mg one time a day. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #8's Oxycodone-Acetaminophen 5-325 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 28 Oxycodone-Acetaminophen tablets. and the Controlled Drug Record documented there should be 29 Oxycodone-Acetaminophen tablets present. LPN C confirmed the discrepancy. c. Review of the medical records revealed Resident #13 was admitted to the facility on [DATE]. Review of Resident #13's physician's orders dated 3/6/2025, revealed Norco (Hydrocodone-Acetaminophen) 7.5-325 mg 4 times a day. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #13's Hydrocodone-Acetaminophen 7.5-325 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 9 Hydrocodone-Acetaminophen tablets, and the Controlled Drug Record documented 10 Hydrocodone-Acetaminophen tablets should be present. LPN C confirmed the discrepancy. d. Review of the medical records revealed Resident #22 was admitted to the facility on [DATE]. Review of Resident #22's physician's orders dated 2/6/2025, revealed an order for Lorazepam 0.5 mg twice a day for anxiety. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #22's Lorazepam tablets between the medication card and the Controlled Drug Record. The medication card contained 17 Lorazepam tablets, and the Controlled Drug Record documented there should be 18. LPN C confirmed the discrepancy. e. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Review of Resident #27's physician's orders dated 2/14/2025, revealed an order for Hydrocodone-Acetaminophen 5-325 mg every 6 hours as needed (PRN) for pain. Observation and interview at the C Hall Medication Cart with LPN B on 3/4/2025 beginning at 11:23 AM, revealed a discrepancy of Resident #27's Hydrocodone-Acetaminophen 5-325 milligrams (mg) tablets between the medication card and the Controlled Drug Record. The medication card contained 39 Hydrocodone-Acetaminophen tablets, and the Controlled Drug Record documented there should be 40 Hydrocodone-Acetaminophen tablets present. LPN B acknowledged she administered the Hydrocodone-Acetaminophen and failed to sign it out when it was administered. f. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Review of Resident #29's physician's orders dated 2/6/2025, revealed an order for Tramadol Hydrochloride (HCL) 50 mg two times a day for pain and every 6 hours PRN for pain. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #29's Tramadol HCL 50 mg tablets between the medication card and the Controlled Drug Record. The medication card contained no Tramadol tablets, and the Controlled Drug Record documented there should be 1 tablet present. LPN C confirmed the discrepancy. g. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #31's physician ' s orders dated 2/6/2025, revealed an order for Xanax (Alprazolam) 0.25 mg two times a day. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #31's Alprazolam 0.25 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 32 Alprazolam tablets, and the Controlled Drug Record documented there should be 33 Alprazolam tablets present. LPN C confirmed the discrepancy. h. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Review of Resident #32's physician's orders dated 2/6/2025, revealed an order for Lacosamide 150 mg two times a day for seizures. Observation and interview at the B Hall medication cart with LPN C beginning at 11:31 AM, revealed a discrepancy of Resident #32's Lacosamide 150 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 8 Lacosamide tablets and the Controlled Drug Record documented there should be 9 Lacosamide tablets present. LPN C confirmed the discrepancy. i. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #33's physician's orders dated 2/6/2025, revealed an order for Pregabalin 75 mg, 2 capsules one time a day related to Chronic Pain Syndrome and give 1 capsule one time a day for Chronic Pain Syndrome. 2 capsules were scheduled to be administered at bedtime and 1 capsule in the morning. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident 33's Pregabalin 75 mg capsules between the medication card and the Controlled Drug Record. The medication card contained 25 Pregabalin capsules and the Controlled Drug Record documented there should be 26 Pregabalin present. LPN C confirmed the discrepancy. j. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE]. Review of Resident #34's physician's orders dated 2/21/2025, revealed an order Alprazolam 0.25 mg three times a day related to Anxiety Disorder. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #34's Alprazolam 0.25 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 18 Alprazolam tablets and the Controlled Drug Rcord documented there should be 19 Alprazolam tablets present. k. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. Review of Resident #35's physician's orders dated 2/6/2025, revealed Xanax 0.25 mg four times a day for Anxiety Disorder. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #35's Alprazolam (Xanax) 0.25 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 20 Alprazolam tablets, and the Controlled drug Record documented there should be 21 Alprazolam tablets present. During an interview on 3/4/2025 at 11:45 AM, LPN C acknowledged the facility's policy was to sign off the controlled substances when they were administered and stated, .but you caught us on a busy day. During an interview on 3/5/2025 at 9:55 AM, the DON stated controlled substances should be signed out on the Controlled Drug Record when they were pulled from the medication cart. l. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Review of Resident #36's physician's orders dated 2/13/2025, revealed Hydrocodone-Acetaminophen 5-325 mg three times daily. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #36's Hydrocodone-Acetaminophen 5-325 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 26 Hydrocodone-Acetaminophen tablets and the Controlled Drug Record documented there should be 27 Hydrocodone-Acetaminophen tablets present. LPN C confirmed the discrepancy. m. Review of the medical records revealed Resident #41 was admitted to the facility on [DATE]. Review of Resident #41's physician's order dated 2/6/2025, revealed an order for Alprazolam 0.5 mg two times a day for anxiety and Norco 7.5-325 mg (Hydrocodone-Acetaminophen) 4 times a day for Phantom Limb Pain. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #41's Alprazolam 0.5 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 28 Alprazolam tablets, and the Controlled Drug Record documented there should be 29 Alprazolam tablets present. Continued observation revealed a discrepancy of Resident #41's Hydrocodone-Acetaminophen 7.5-325 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 31 Hydrocodone-Acetaminophen tablets, and the Controlled Drug Record documented there should be 32 Hydrocodone-Acetaminophen tablets present. LPN C confirmed the discrepancy. n. Review of the medical records revealed Resident #42 was admitted to the facility on [DATE]. Review of Resident #42's physician's orders dated 2/6/2025, revealed an order for Gabapentin 400 mg two times a day for diabetes with polyneuropathy. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #42's Gabapentin 400 mg capsules between the medication card and the Controlled Drug Record. The medication card contained 33 Gabapentin capsules, and the Controlled Drug Record documented there should be 34 Gabapentin capsules present. LPN C confirmed the discrepancy. 6. The facility failed to ensure competent nursing staff who administered medications per the physician's order and as scheduled: Review of the undated facility document titled, MED [Medication] PASS TIME FRAMES, revealed .One time a day = [equals .7-10a [7:00-10:00 AM] or 7-10p [7:00-10:00 PM] .TID [three times a day] .enter 0500 [5:00 AM], 1300 [1:00 PM], 2100 [9:00 PM] .QID [four times a day] & [and] q6 [every 6 hours] .enter 0500 [5:00 AM], 1100 [11:00 AM], 1700 [5:00 PM], 23:00 [11:00 PM . a. Review of the medical record revealed Resident #6 was readmitted on [DATE], with diagnoses of Parkinson's Disease, Contracture of ankle, and muscle spasms. Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #6 was cognitively intact and required use of a wheelchair for mobility. Review of the physician's orders dated 1/2/2025 for Resident #6 revealed Carbidopa Levodopa ER (extended release) oral tablet 25-100 milligram (mg) give 1 tablet by mouth every three hours for Parkinson's Disease, Entacapone 200 mg give 1 tablet by mouth every 3 hours for Parkinson's Disease, Ropinirole Hydrochloride (HCL) 0.5 mg give 1 tablet by mouth 3 times a day for Parkinson's, Tizanidine HCI 4mg give 1 tablet by mouth 3 times a day for Contracture, and Gabapentin 800 mg give 1 tablet by mouth 3 times a day for Parkinson's Disease. Review of the physician's orders dated 2/18/2025, Resident #6 Carvidopa 50-200 mg give 1 tablet by mouth four times a day for Parkinson's Disease, Diazepam 2mg give 1 tablet by mouth three times a day for Anxiety disorder and muscle spasms. Review of the Medication Admin (Administration) Audit Report, which indicated the actual time medications were documented as being administered, dated 3/14/2025 revealed the following medications were not documented as being administered accurately: The Ropinirole HCl 0.5 mg scheduled for 5:00 AM was documented as administered at 9:24 AM. The Tizanidine HCI 4 mg scheduled for 5:00 AM was documented as administered at 9:24 AM. The Gabapentin 800 mg scheduled for 6:00 AM was documented as administered at 9:24 AM. The Entacapone 200 mg give 1 tablet scheduled for 6:00 AM was documented as administered at 9:24 AM. The Carbidopa- Levodopa 25-100 mg dose scheduled for 6:00 AM was documented as administered at 9:24 AM. The Diazepam 2 mg scheduled for 6:00 AM was documented as administered at 9:24 AM. The Ropinirole HCI 0.5 mg scheduled for 9:00 PM was documented as administered at 11:34 PM. The Tizanidine HCI 4 mg scheduled for 9:00 PM was documented as administered at 11:33 PM. The Entacapone 200 mg scheduled for 9:00 PM was documented as administered at 11:33 PM. The Carbidopa-Levodopa 25-100 mg was scheduled for 9:00 PM was documented as administered at 11:33 PM. During an interview on 3/18/2025 at 2:26 PM, Resident #6 stated on 3/14/2025, the night nurse did not administer his medicine as scheduled. Resident #6 stated, this problem comes and goes, depending on the number of agency nurses working. During interview on 3/20/25 12:05 PM, the DON acknowledged the medication administration audit form revealed Resident #6's medication was not administered as scheduled per the physician order and the medication administration was not documented timely and accurately. b. Review of the medical records revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dependence on Renal Dialysis, Hypothyroidism, Anxiety, Bipolar Disorder, and Insomnia. Review of Resident #13's physician's orders dated 2/6/2025, revealed the following: Insulin Lispro (fast-acting insulin to lower blood glucose) 100 Unit/ML inject per sliding scale before meals: for a blood glucose of 71-150 mg/dL give 0 units, for a blood glucose of 151 - 200 mg/dL give 2 units, for a blood glucose of 201-250 mg/dL give 4 units, for a blood glucose of 251-300 mg/dL give 6 units, for a blood glucose of 301-350 mg/dL give 8 units, for a blood glucose of 351-400 mg/dL give 10 units, and for a blood glucose of 401 mg/dL or higher give 10 units and recheck in one hour, if blood sugar (glucose) has not gone down, notify the Nurse Practitioner (NP). Norco (Hydrocodone-Acetaminophen) 7.5-325 mg, give 1 tablet by mouth four times a day for pain. Buspirone Hydrochloride (HCL) 10 mg, give 1 tablet by mouth two times a day for depression. Montelukast Sodium 10 mg, give 1 tablet by mouth one time a day for allergies. Ezetimibe 10 mg, give 1 tablet by mouth one time a day for Hyperlipidemia. Fluticasone Propionate Nasal Suspension 50 micrograms/actuation (mcg/act), 1 spray alternating nostrils two times a day for Allergic Rhinitis. Sennosides-Docusate (Senna-S) 8.6-50 mg, give 2 tablets by mouth one time a say for Constipation. Review of the MAR for Resident #13 dated 2/1/2025-2/28/2025, revealed Resident #13's blood glucose was 233 mg/dl on 2/26/2025 at 7:30 AM and 4 units of Lispro Insulin was administered. Continued review revealed Resident #13's blood glucose was 264 mg/dL on 2/26/2025 at 12:00 PM and 6 units of Lispro Insulin were administered. Review of the Medication Admin (Administration) Audit Report (report which indicated the actual time medications were documented as given) for Resident #13 dated 2/25/2025-2/27/2025, revealed the following: Lispro Insulin scheduled to be administered per sliding scale on 2/26/2025 at 7:30 AM, before breakfast, was documented as administered at 2:20 PM, 6 hours and 50 minutes late. Lispro Insulin scheduled to be administered per sliding scale on 2/26/2025 at 12:00 PM, before lunch, was documented as administered at 2:21 PM, 2 hours and 21 minutes late. Resident #13's 7:30 AM dose of Insulin and her 12:00 PM dose of Insulin were documented as administered 1 minute apart. Norco scheduled to be administered on 2/26/2025 at 11:00 AM, was documented as administered at 2:20 PM, 3 hours and 20 minutes late. Buspirone 10 mg tablet scheduled for 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:51 AM, 3 hours and 51 minutes late. Montelukast Sodium 10 mg tablet scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:51 AM, 3 hours and 51 minutes late. Ezetimibe 10 mg tablet scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:52 AM, 3 hours and 52 minutes late. Fluticasone Propionate Nasal spray scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:52 AM, 3 hours and 52 minutes late. Senna-S 8.6-50 mg scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:53 AM, 3 hours and 53 minutes late. Review of the working schedule dated 2/27/2025, revealed LPN Q worked the B Hall where Resident #13 resided on 2/27/2025. Observation and interview in the Resident's room on 3/13/2025 at 9:20 AM, revealed Resident #13 lay in bed, oxygen was administered by nasal cannula at 3 liters per minute. Resident #13 confirmed she had been in the facility about 4 years. Resident #13 stated, One day .they had a nurse in, I didn't get my night medicine I asked him about it and he said no I gave it to you, you were asleep, come to find out the next morning there was a lot of people that didn't get their medication so he's not coming back .[Named LPN Q] . During an interview on 3/26/2025 at 12:46 PM, LPN L reviewed Resident #13's Medication Admin Audit Report. LPN L stated Resident #13 was not even in the facility at 2:20 PM and 2:21 PM on 2/26/2025 (2/26/2025 was a dialysis day for Resident #13 and she left the facility at approximately 11:00 AM). LPN L stated the 7:30 Lispro Insulin was given before breakfast and the 11:00 AM dose of Norco and the 12:00 PM dose of Lispro and were given right before the resident left for dialysis. LPN L stated, That ' s probably just when I was able to chart it [Lispro Insulin and Norco] . c. Review of the medical records revealed Resident #16 was admitted to the facility on [DATE]. Review of Resident #16's physician's orders dated 3/6/2025, revealed Levothyroxine Sodium 137 micrograms [MCG], give 1 tablet by mouth one time a day related to Hypothyroidism (where the thyroid gland does not produce enough thyroid hormone) and Furosemide 20 mg, give 1 tablet by mouth one time a day for edema. Review of the Medication Admin Audit Report for Resident #16 dated 3/14/2025, revealed the Levothyroxine Sodium 137 MCG [micrograms] scheduled at 4:00 AM, was documented as administered at 1:06 PM, 9 hours late. Continued review revealed the Furosemide 20 mg scheduled at 5:00 AM, was documented as administered at 1:06 PM, 8 hours late. d. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Review of Resident #24 physician's order dated 3/6/2025, revealed Simethicone 125 mg by mouth before meals and at bedtime for heartburn and indigestion; Tamsulosin Hydrochloride (HCL) 0.4 mg, 2 capsules at bedtime for an enlarged prostate; Risperdal 1 mg at bedtime related to Schizophrenia; Gabapentin 600 mg, give 1 tablet three times a day for polyarthritis (arthritis in five or more joints simultaneously); Clonazepam 1 mg, 1.5 tablets at bedtime related to Generalized Anxiety Disorder; and Mesalamine Rectal Suppository, 1000 mg at bedtime related to Constipation. Review of the Medication Admin Audit Report for Resident #24 dated 3/14/2025-3/16/2025, revealed the following medications were scheduled for 3/14/2025 at 9:00 PM, and were documented as administered on 3/15/2025 at 12:01 AM, 3 hours late: Simethicone 125 mg Tamsulosin HCL 0.4 mg Risperdal 1 mg Gabapentin 600 mg, Clonazepam 1 mg Mesalamine Rectal Suppository 1000 mg. e. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses including Dementia, Diabetes, Bipolar Disorder, Schizophrenia, Insomnia, Osteoarthritis, and Depression. Review of the Resident #38's physician's orders dated 3/6/2025, revealed Acetaminophen 650 mg, 2 tablets by mouth three times a day; Gabapentin 800 mg, three times a day; Ziprasidone (medication to treat psychosis) 20 mg at bedtime; Ziprasidone 80 MG at bedtime; Lamictal (a medication to treat seizures and bipolar disorder) 100 MG at bedtime. Review of the Medication Admin Audit Report for Resident #38 dated 3/15/2025, revealed the following: Acetaminophen 650 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 1:44 AM, 3 hours and 44 minutes late. Lamictal 200 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:13 AM, 4 hours and 13 minutes hours late. Gabapentin 800 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:14 AM, 4 hours and 14 minutes hours late. Ziprasidone 20 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:16 AM, 4 hours and 16 minutes hours late Ziprasidone 80 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:16 AM, 4 hours and 16 minutes hours late. Observation and interview on 3/17/2025 at 12:20 PM, revealed Resident #38 sitting in her wheelchair in her room and the Resident stated, .didn ' t get our meds last night till 2:30 the next morning .agency nurse she didn't know what she was doing . During an interview on 3/26/2025 at 3:38 PM, the DON acknowledged the facility was having issues with medications being administered as ordered. The DON stated, .it's [medication administration] being spotty and we ' re trying to get every agency person in here for additional training .the ones who are not performing, I'm not letting them come back. The DON was asked would you say staff are following the instructions and the in-services provided following the drug diversion (in October 2024) and signing out narcotics when administered. The DON stated, No. I went as far as demonstrating when you pull your pills, I walked them through each step of administration . The DON was asked would you say this is not an education issue because the staff were educated, but rather this is a staff performance issue. The DON stated, Yes, ma'am and I walk around and say be sure you're signing as soon as it [medication] pops out of that cart. The DON was asked would you say that would be the same issue with the staff member who did not report an allegation of sexual abuse until the following day. The DON stated, Yes, they were not following directions . 7. The [TRUNCATED]

Based on policy review, Pharmacy Services Agreement, Law Enforcement Investigation, facility investigation, medication reconciliation document review, medical record review, facility document review, observation, and interview, the facility failed to have a system of recording, accurate reconciliation, and accounting for all controlled medication, failed to promptly identify diversion of controlled substances, failed to provide medications according to physician orders and per facility policy, and failed to ensure controlled substances were in date and no discrepancies were identified for 31 of 57 (Residents #6, 7, 8, 9, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 38, 41, and 42) sampled residents reviewed for controlled substance reconciliation, drug diversion, and medication administration. The findings include: 1. Review of the Pharmacy Services Overview Policy, revised [DATE], revealed, .the facility shall accurately and safely provide or obtain pharmacological services, including the provision of routine and emergency medications .Policy interpretation and implementation .Pharmaceutical services consist of .a. the process of receiving and interpreting prescribers' orders; acquiring, receiving, storing, controlling, reconciling, compounding, dispensing, packaging, labeling, distributing, administering, monitoring responses to, using and or disposing of all medications .b. the provision of medication- related information to health care professionals and residents .c. the process of identifying, evaluating and addressing medication - related issues including the prevention and reporting of medication errors .d. The provision, monitoring and/or the use of medication-related devices .Pharmacy services are available to residents 24 hours a day, seven days a week .Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner .Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting pharmacy if a resident's medication is not available for administration .Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice .The consultant pharmacist, in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services including (but not limited to) .acquisition and availability of medications .receipt, labeling and storage of medications .reconciliation of medications from the pharmacy .control of medications from point of receipt to secured storage areas .facility staff roles and responsibilities during the receipt and storage of medication .administration of medications, disposition of medications . Review of the facility policy titled, Medication Ordering and Receiving From Pharmacy Provider Emergency .Emergency Kits (E-Kits), dated ,d+[DATE], revealed .Emergency pharmaceutical service is available on a 24-hour basis. Emergency needs for medication are met by using the nursing care center ' s approved emergency medication supply or by special order from the provider pharmacy. Emergency medications and supplies are provided by the pharmacy in compliance with applicable state and federal regulations .The provider pharmacy supplies emergency or stat [immediate or urgent] medications/items according to the provider pharmacy agreement. Emergency medications and supplies are .checked periodically for integrity and dating and stored in accordance with .federal regulations .When an emergency or stat medication is needed, the nurse first verifies and reviews the prescriber's orders for appropriateness, checks the resident ' s allergies, and removes the required non-controlled medication from the emergency kit .Upon removal of any medication or supply item from the emergency kit, the nurse documents the medication .used on an emergency kit log .One copy of this information should be immediately faxed to the pharmacy or placed within the resealed emergency kit until it is scheduled for exchange .Items to be documented on the log include .Resident's name .Medication name, strength and quantity .Date and time of medication removal .Prescriber's name .Date and time pharmacy notified .Signature of nurse removing and administering dose .The nursing staff, consultant pharmacist and provider pharmacy designee checks the emergency kits regularly for expiration dating of the contents. The date of expiration is noted on the outside of the kit .If hard copy Prescriber signed prescription is available .Nurse will contact pharmacist to communicate need to access E-kit .Nurse will fax hard copy prescription to pharmacist .Once the pharmacist confirms receipt of a valid prescription, the pharmacist will contact facility nurse to communicate .Authorization to access emergency kit .Specific prescription details .Number of authorized entries to E-kit .Number of doses per entry to E-kit . Review of the facility policy titled, Controlled Substances, revised ,d+[DATE], revealed .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications . Review of the facility policy titled, Pharmacy Services, reviewed ,d+[DATE], DISCARDING AND DESTROYING MEDICATIONS .medications will be disposed of in accordance with federal, state and local regulations governing management of .controlled substances .All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of .Schedule V (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines .Schedule II .and IV (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines .If a resident is transferred to another facility, or dies while he or she is in lawful possession of controlled substance(s) by depositing in the authorized on-site collection receptacle .must take place immediately (no longer than three days after discontinuation of use by the resident .Completed medication disposal records shall be kept on file in the facility for at least two (2) years, or as mandated by state law governing the retention and storage of such records . Review of the facility policy titled, Administration of Drugs, dated ,d+[DATE], revealed .Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's [facility's] Medical Director .Drugs may not be set up in advance and must be administered within one (1) hour before or after their prescribed time .Unless otherwise specified by the resident's attending physician, routine drugs should be administered as scheduled .The nurse administering the drug must record such information on the residents eMAR [electronic Medication Administration Record] .The nurse administering the drugs must electronically sign the resident's eMAR immediately after administration . Review of the facility policy titled, Person-Centered Medication Administration Schedule, revised [DATE], revealed .Medications shall be administered according to established durations to allow for a more relaxed, person-centered schedule . Review of the PHARMACY SERVICES AGREEMENT, dated and signed on [DATE], revealed Pharmacy Services Agreement .is made between Pharmacy Corporation of America .and [Named Facility Management Company] .The parties agree as follows .Pharmacy shall provide services set forth in this Agreement to Client and persons in care of the Customer (the Residents .) in accordance with terms and conditions of this Agreement, and any Schedules .or policies and procedures of the Manual .which are incorporated into this agreement .3. OBLIGATIONS OF THE PHARMACY .Pharmacy shall provide to Client and deliver to the Customer prescription and non-prescription drugs, biologicals .and Services as set forth in this Agreement, in accordance with the orders of the Residents ' licensed prescribers as provided to the Pharmacy by Customer, and the Customer ' s own orders .B. Pharmacy shall provide, maintain and replenish emergency drug supply kits (the Emergency Kits) as permitted by Applicable Law .F. The parties anticipate that Customer shall use best efforts to provide Medications to Resident at time of discharge or return Products to Pharmacy. Pharmacy shall manage Product returns in accordance with its then current return policy as specified in the Manual .4. Obligations of the Client [facility] .Comply with .Drug Enforcement Agency (DEA) requirements relating to the submission of prescriptions for controlled substances, including, but not limited to, promptly providing Pharmacy with copies of prescriptions for Medications .properly execute physician prescription for all controlled substance Medication orders .Document usage of Emergency Kits .H. Store and handle all medications in accordance with Applicable Law .Nurse Consulting Services .[Named Pharmacy Company] employs a Nurse Consulting Services organization intended to satisfy specific service needs of the Customer .employs qualified pharmacy technicians and nurses who upon request can be called upon to perform the following .Perform medication cart audits .check of all Medications for .date opened and expiration dates .removal of all discontinued Medications .Perform a Narcotics Review with documentation review for the protection of facility staff and residents .Perform a Root Cause Analysis to determine process gaps and provide written solutions for both Pharmacy and Client Issues . 2. Review of the Law Enforcement investigation dated [DATE], revealed Investigator #1 conducted a traffic stop of Licensed Practical Nurse (LPN) M for a window tint violation on [DATE]. LPN M was found with miscellaneous pills in the floorboard of her car and a probable cause search warrant was conducted of the vehicle. Investigators found multiple pill blister packs (a card of medication with the pills showing in clear windows on the front and the ability to pop the pills out on the back of the card) of non-scheduled and scheduled prescription medications containing names of different people. [Named LPN M] advised on scene that the prescription pill blister packets were from deceased patients that she had worked with .advised that she worked with patients at a long term care facility. Some of the prescription pill blister packets dated back to the year 2020. Also located inside of [Named LPN M] vehicle was a green cloth bag that contained over 15 small plastic baggies containing non scheduled prescription drugs and scheduled prescription drugs all packaged separately for resale, the schedule drugs ranged from Schedule II Morphine and Hydrocodone, Schedule IV Lorazepam to Xanax and Schedule V Gabapentin and Pregabalinand [Pregabalin] . Continued review of the Law Enforcement Investigation revealed LPN M ' s home was also searched and Investigators found a total of 704.5 pills in her car and 1,225 pills in her home for a total of 1,929.5 pills seized by authorities. LPN M was taken into custody and formally charged with Unlawful Window Tint, Unlawful Possession without Prescription, and Possess Controlled Substance with Intent to Manufacture, Deliver, or Sell Controlled Substance for Schedule II (3 counts), Schedule IV (4 counts), and Schedule V (3 counts) drugs. 3. Review of the facility investigation revealed the facility was provided a list of 109 residents' names affected by the drug diversion of LPN M on [DATE]. Review of a typewritten statement by the Administrator dated [DATE], revealed she was notified on [DATE] that (LPN M) was detained on drug charges. On [DATE], the Drug Enforcement Agency (DEA) served the facility with a search warrant on the drug diversion. The residents identified were discharged , deceased , or the medications were expired .No adverse effects have been identified .I [Administrator] had no prior knowledge of any incidents regarding the missing medications .The investigation concluded that (LPN M) removed various types of medications from the facility .The employee was termed on [DATE], due to employee failing to return to work .The root cause is the drug destruction process was not followed properly by the nurse . Review of the typewritten statement by the Director of Nursing (DON) signed and dated [DATE], revealed the DON was notified on [DATE] by the day shift nurse on A Hall that the Unit Manager (LPN M) would be late because of a traffic stop. After an hour had passed LPN M had still not arrived at work. The DON made multiple attempts through the night to reach LPN M by phone without success. The DON and the Administrator met with 2 investigators from the District Attorney's Office of Drug Enforcement in the facility lobby on [DATE] and were notified that LPN M was in custody for drug related charges, she had narcotics (controlled substances) from the facility and narcotic tracking sheets with residents' information, in addition to miscellaneous (non-scheduled) medications. The DON and the Administrator met with DA Drug Enforcement, DEA, and the [Named City where facility was located] Police Department at different times.Because all evidence is in the possession of law Enforcement I [DON] was unable to perform a thorough investigation. However, I do know I delegated to [Named LPN M] to assist with pulling of narcotics from the medication carts for destruction. She was part of a trusted management team. I am unaware exactly how she accomplished this without my knowledge. Upon becoming aware of the situation narcotic audits were completed, reviewed policies and procedures with nursing staff and conducted interviews. The Narcotic audits did not find any discrepancies . 4a. Review of the medical records revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dependence on Renal Dialysis, Hypothyroidism, Anxiety, Bipolar Disorder, and Insomnia. Review of the physician orders for Resident #13 dated [DATE], revealed Tizanidine Hydrochloride (HCL) (a muscle relaxer, non-scheduled medication) 2 mg was ordered four times a day. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #13's pill blister pack of Tizanidine HCL 2 mg, card 1 of 4, dated [DATE] was found in LPN M's possession. There were zero (0) of 60 Tizanidine tablets remaining in the blister pack. Continued review revealed Resident #13's blister pill pack for Tizanidine HCL 2 mg, card 2 of 4, dated [DATE] was found in LPN M's possession. There were 7 of 60 Tizanidine tablets remaining in the blister pack. b. Review of the closed medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dependence on Renal Dialysis, Hypothyroidism, Anxiety, Bipolar Disorder, and Insomnia. Review of the physician orders for Resident #14 dated [DATE], revealed Ativan (Lorazepam - a medication for anxiety) 0.5 mg was ordered every 12 hours as needed (PRN) for anxiety and agitation and Percocet (medication for pain) ,d+[DATE] mg was ordered mouth two times a day every 6 hours as needed for pain and two times a day for pain. Review of the physician orders for Resident #14 dated [DATE], revealed Gabapentin (medication for seizures and nerve pain) 100 mg was ordered two times a day for diabetic neuropathy. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #14's blister pill pack of Lorazepam 0.5 mg, a Schedule IV controlled substance dated [DATE] was found in LPN M's possession. There were 0 of 50 Lorazepam tablets remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #14's blister pill pack of Percocet (Oxycodone-Acetaminophen) ,d+[DATE] mg, a Schedule II controlled substance, dated [DATE] was found in LPN M's possession. There were 0 of 60 Percocet tablets remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #14's blister pill pack of Percocet ,d+[DATE] mg a Schedule II controlled substance dated [DATE] was found in LPN M's possession. There were 0 of 60 Percocet tablets remaining in the blister pack. c. Review of the closed medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Bipolar Disease, Anxiety and Insomnia Review of the physician's orders for Resident #15 dated [DATE], revealed Gabapentin 100 mg was ordered three times a day for neuropathy (weakness, numbness, and pain from nerve damage and pain), Diazepam 5 mg was ordered every 12 hours as needed for anxiety for 14 days, and Hydrocodone-Acetaminophen ,d+[DATE] mg was ordered every 6 hours as needed for pain for 14 days. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #15's blister pill pack of Hydrocodone-Acetaminophen ,d+[DATE] mg, a Schedule II controlled substance, dated [DATE] was found in LPN M's possession. There were 0 of 12 Hydrocodone-Acetaminophen tablets remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #15's blister pill pack of Diazepam 5 mg, a Schedule IV controlled substance, dated [DATE] was found in LPN M's possession. There were 0 of 12 Diazepam tablets remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #15's blister pill pack of Gabapentin 100 mg, a Schedule V controlled substance, dated [DATE] was found in LPN M's possession. There were 45 of 45 Gabapentin capsules remaining in the blister pack. d. Review of the closed medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including Diabetes, Chronic Pain Syndrome, and Anxiety. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #18's blister pill pack of Alprazolam 0.25 mg, a Schedule IV controlled substance, dated [DATE] was found in LPN M's possession. There were 0 of 60 remaining in the blister pack. Review of the physician orders for Resident #18 dated [DATE], revealed Alprazolam (medication used to treat anxiety/depression) 0.5 mg was ordered by mouth three times a day. e. Review of the closed medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Prosthesis, Depression, Osteoarthritis, and Anxiety. Review of the physician orders from a Rehab Hospital for Resident #19 dated [DATE], revealed Norco 7XXX,d+[DATE] mg (Hydrocodone) was ordered every 6 hours as needed for pain (pain scale ,d+[DATE]). Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #19's blister pill pack of Hydrocodone-Acetaminophen 7XXX,d+[DATE] mg, a Schedule II controlled substance, with date not visible, was found in LPN M's possession. There were 4 of 12 Hydrocodone-Acetaminophen tablets remaining in the blister pack. f. Review of the closed medical record revealed Resident #20 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Sepsis, Diabetes, Hypothyroidism, Anxiety, Insomnia. Review of the physician's order for Resident #20 dated [DATE], revealed two capsules of Gabapentin 300 mg (for a total of 600 mg) were ordered three times a day for neuropathy. The order was discontinued [DATE]. Review of the physician's order for Resident #20 dated [DATE], revealed Gabapentin 100 MG three times a day. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #20's Gabapentin 600 mg, a Schedule V controlled substance, card 1 of 6, dated [DATE], was found in LPN M's possession. There were 0 of 30 Gabapentin capsules remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #20 ' s Gabapentin 600 mg, a Schedule V controlled substance, card 2 of 6, dated [DATE], was found in LPN M's possession. 50 of 60 Gabapentin capsules remained in the blister pack. g. Review of the closed medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses including Anxiety, Chronic Obstructive, Depression and Muscle Weakness. Review of the physician orders for Resident #21 dated [DATE], revealed Lorazepam 0.5 mg was ordered every 8 hours as needed for anxiety for 14 days. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #21's blister pack for Lorazepam 0.5 mg, a Schedule IV controlled substance, dated [DATE], was found in LPN M's possession. There were 0 of 20 Lorazepam tablets remaining in the blister pack. h. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dementia, Anxiety, and Chronic Kidney Disease Stage 4. Review of the physician orders for Resident #22 dated [DATE], revealed Clonazepam 0.5 mg was ordered every 24 hours for anxiety. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #22's blister pack for Clonazepam 0.5 mg, a Schedule IV controlled substance, dated [DATE], was found in LPN M's possession. There were 0 of 14 Clonazepam tablets remaining in the blister pack. i. Review of the closed medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Acquired Absence of Right Leg Above Knee (above the knee amputation), Anxiety, Personal History of Malignant Neoplasm of Uterus, and Diabetes. Review of the physician's orders dated [DATE], revealed Ativan (Lorazepam medication given for anxiety) 0.5 mg was ordered 3 times every week on Monday, Wednesday, and Friday for anxiety disorder. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #23' s blister pack for Lorazepam 0.5 mg, a Schedule IV controlled substance, dated [DATE], was found in LPN M's possession. 0 of 12 Lorazepam tablets remained in the blister pack. j. Review of the closed medical records revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Diabetes, Cirrhosis of Liver, Anxiety, Insomnia, and Gout. Review of the physician orders for Resident #25 dated [DATE], revealed Gabapentin 300 mg was ordered two times a day for seizures. Review of the Law Enforcement investigation of the drug diversion by LPN M, revealed Resident #25's blister pack for Gabapentin 300 mg, a Schedule IV controlled substance, dated [DATE], was found in LPN M's possession. 2 of 30 Gabapentin capsules remained in the blister pack. Review of the physician s order for Resident #25 dated [DATE], revealed Alprazolam 0.5 mg was ordered every 8 hours as needed for anxious behavior. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #25's blister pack for Alprazolam 0.5 mg, a Schedule IV controlled substance, dated [DATE], was found in LPN M's possession. 0 of 28 Lorazepam tablets remained in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #25's blister pack for Alprazolam 0.5 mg, a Schedule IV controlled substance, dated [DATE], was found in LPN M's possession. 0 of 42 Lorazepam tablets remained in the blister pack. k. Review of the closed medical records revealed Resident #26 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Depression, Dementia, and Senile Degeneration of Brain. Review of the physician's order for Resident #26 dated [DATE], revealed Lorazepam 0.5 mg was ordered four times a day for seizures. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #26's blister pack for Lorazepam 0.5 mg, a Schedule IV controlled substance, dated [DATE], was found in LPN M's possession. 0 of 30 Lorazepam tablets remained in the blister pack. l. Review of the medical records revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Diabetes, Cellulitis Right Lower Limb, and Cellulitis of Left Lower Limb. Review of the physician's order for Resident #28 dated [DATE], revealed Tramadol (opioid medication given for pain) 50 mg was ordered every 6 hours PRN for pain. Review of the Medication Administration Record (MAR) dated [DATE]-[DATE], revealed Resident #28 received five doses of Doxycycline (a medication given to treat bacterial infections) 100 mg. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #28's blister pack for Doxycycline 100 mg, dated [DATE], was found in LPN M ' s possession. 9 of 14 Doxycycline remained in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #28's blister pack for Tramadol 50 mg, a Schedule IV controlled substance, date [DATE], was found in LPN M's possession. 50 of 60 Tramadol tablets remained in the blister pack. m. Review of the closed medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Fracture of Left Femur, Dementia, Anxiety, and Dementia. Review of the physician's order for Resident #30 dated [DATE], revealed Lorazepam 0.5 mg was ordered every 12 hours as needed for agitation and anxious behavior for 2 days. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #30's blister pack for Lorazepam 0.5 mg, a Schedule IV controlled substance, dated [DATE], was found in LPN M's possession. 0 of 4 Lorazepam tablets remained in the blister pack. 5. During an interview on [DATE] at 9:55 AM, the Director of Nursing (DON) stated, Our investigation was limited with having enough paperwork .I would have to say, yeah, she [LPN M] did [divert residents' medications] .they brought in some sheets and I reviewed them .they were all deceased residents .she [LPN M] was delegated with removing narcotics from the cart .they [residents] would expire, she took the narcotic sheet and the narcotic and I don ' t know how she was able to do it without getting caught .I was floored, devasted and angry .there was no hint of anything. The DON stated, .I delegated to a criminal unknowingly. During an observation and interview at the [Named County] Sheriff's Department on [DATE] 9:30 AM, Investigator #1 provided the Law Enforcement investigation of the drug diversion by LPN M. Investigator #1 stated that while he was talking to (Named LPN M) she told him she was on her way to work at the facility where she was a charge nurse, he observed loose pills in the floorboard of the LPN's car and initiated a search warrant, which revealed Scheduled and non-scheduled pill blister packs, some bottles of liquid medication with resident's names on them, and the Controlled Drug (substance) Record form for several residents during the search. Continued interview revealed investigators also found a bluish-green handbag inside her (LPN M's) purse with several little baggies which contained various medications, that appeared to be ready for resale. LPN M was arrested and taken into custody at that time. Investigator #1 stated a search of LPN M's home was initiated, which also revealed many more Scheduled and non-scheduled medications with names of residents from the facility. 6a. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-dominant side, Vascular Dementia, Epilepsy, Depressive Disorder, Anxiety Disorder, Mood Disorder, Pseudobulbar Effect, and Psychotic Disorder with Delusions. Review of the Medication Administration Audit Report for Resident #7 dated [DATE], revealed Lacosamide (medication to control seizures) Oral Tablet 50 mg was administered to Resident #7 at 9:07 AM. Observation and interview at the B Hall medication cart on [DATE] beginning at 11:31 AM, with LPN C, revealed the CONTROLLED DRUG RECORD for Resident #7 dated 21/ (the date was not correctly filled out), revealed 7 tablets of Lacosamide were present. Review of the Lacosamide medication card for Resident #7 revealed 6 Lacosamide tablets were present, a discrepancy of 1 tablet. LPN C confirmed the discrepancy. Review of the Alprazolam medication card for Resident #7 revealed 32 Alprazolam tablets were present, a discrepancy of 1 tablet. LPN C confirmed the discrepancy. b. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Nondisplaced Intertrochanteric Fracture of Right Femur, Osteoporosis, Falls, Dementia, and Anxiety Disorder. Review of a physician's order dated [DATE], revealed an order for Percocet (Oxycodone-Acetaminophen) ,d+[DATE] mg, give 1 tablet by mouth one time a day. Observation and interview at the B Hall medication cart on [DATE] beginning at 11:31 AM, with LPN C, revealed the CONTROLLED DRUG RECORD for Resident #8 dated [DATE], revealed 29 tablets of Oxycodone-Acetaminophen ,d+[DATE] mg were present. Review of the medication card for Resident #8's Oxycodone-Acetaminophen, revealed 28 Oxycodone-Acetaminophen tablets were present, a discrepancy of 1 tablet. LPN C confirmed the discrepancy. c. Review of the medical records revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dependence on Renal Dialysis, Hypothyroidism, Anxiety, Bipolar Disorder, and Insomnia. Review of the physician s order for Resident #13 dated [DATE], revealed Norco (Hydrocodone-Acetaminophen) 7XXX,d+[DATE] mg, give 1 tablet by mouth 4 times a day. Observation and interview at the B Hall medication cart on [DATE] beginning at 11:31 AM, with LPN C, revealed the CONTROLLED DRUG RECORD for Resident #13 dated [DATE], revealed 10 Hydrocodone-Acetaminophen 7XXX,d+[DATE] mg tablets were present. Review of the Hydrocodone-Acetaminophen medication card for Resident #13 revealed 9 Hydrocodone-Acetaminophen tablets were present, a discrepancy of 1 tablet. LPN C confirmed the discrepancy. d. Review of the medical records revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dementia, Anxiety, and Chronic Kidney Disease Stage 4. Review of the physician's order for Resident #22 dated [DATE], revealed Lorazepam 0.5 mg, give 1 tablet by mouth two times a day for anxiety. Observation and interview at the B Hall medication cart on [DATE] beginning at 11:31 AM, with LPN C, revealed the CONTROLLED DRUG RECORD for Resident #22 dated [DATE], revealed 18 Lorazepam 0.5 mg tablets were present. Review of the Lorazepam medication card for Resident #22 revealed 17 Lorazepam tablets were present, a discrepancy of 1 tablet. LPN C confirmed the discrepancy. e. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Traumatic Spinal Cord Dysfunction, Quadriplegia, Anxiety, and Depression. Review of the physician's order for Resident #27 dated [DATE], revealed an order for Hydrocodone-Acetaminophen ,d+[DATE] mg by mouth every 6 hours as needed for pain. Observation and interview at the C Hall medication cart on [DATE] beginning at 11:23 AM, revealed Licensed Practical Nurse (LPN) B was asked to review Resident #27's controlled substance

Based on policy review, document review, medical record review, Law Enforcement Investigation review, observation, and interview, the Administration failed to assure the provision of appropriate fiscal resources and personnel to meet the needs of the residents. Administration failed to ensure residents' medications were timely and accurately reconciled and free of misappropriation, failed to ensure competent nursing staff documented controlled substances when administered and administered medications per the physician's order and the facility's medication schedule; and failed to ensure available medications weren't expired. The findings include: 1. Review of the undated policy titled, Administration revealed, .It is the policy of the facility to provide care and services related to Administration in accordance to state and Federal regulation .The Administration of the facility will ensure the following .1. Administration 2. License/Comply with Fed [Federal] /State/Local Law/Professional Standards .5. Staff Qualifications 6. Use of Outside Resources .Resident Records- Identifiable Information . Review of the facility policy titled, Abuse Prevention Policy, reviewed [DATE], revealed .The resident has the right to be free from .misappropriation of property .Misappropriation of Resident Property .means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent .Administrator will review investigational findings to determine appropriate corrective, remedial, or disciplinary actions to occur with accordance with applicable local, state or federal law. Administrator will review outcome in monthly continuous quality Improvement meeting .appropriate follow up and monitoring. Review of the facility policy titled, Controlled Substances revised ,d+[DATE], .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications .Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on premises .The director of nursing services maintains a set of back-up keys for all medication storage areas including keys to controlled substance containers .Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift .Upon disposition .Medications returned to the pharmacy are recorded and signed by the director of nursing (or designee) and the receiving pharmacy .Policies and procedures for monitoring controlled medication to prevent loss, diversion .are periodically reviewed and updated by the director of nursing services and the consultant pharmacist . Review of the undated facility policy titled, Nursing Services, General, revealed .It is the policy of the facility to provide care and services related to Nursing Services in accordance to State and Federal regulation .This policy will include .Competent Nursing Staff . Review of the facility policy titled, Administration of Drugs, dated ,d+[DATE], revealed .Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director .Unless otherwise specified by the resident's attending physician, routine drugs should be administered as scheduled . Review of the facility policy titled, Pharmacy Services DISCARDING AND DESTROYING MEDICATIONS, reviewed ,d+[DATE], revealed .Medication will be disposed of in accordance with federal, state and local regulations governing management of .controlled substances . Review of the facility policy titled, Charting Errors and Omissions, revised ,d+[DATE], revealed .Accurate medical records shall be maintained by this facility . 2. Review of the undated job description titled, Administrator, revealed .The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality of care can be provided to our residents at all times .Duties and Responsibilities .Plan, develop, organize, implement, evaluate and direct the facility's programs and activities in accordance with guidelines issued by the governing board. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility .Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed .Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services .Ensure that an adequate number of appropriately trained licensed professional and non-licensed personnel are on duty at all times to meet the needs of the residents .Review and check competence of work force and make necessary adjustments/corrections as required or that may become necessary . Review of the undated job description titled Director of Nursing Services, revealed .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that govern our facility .to ensure that the highest degree of quality care is maintained at all times As Director of Nursing Services, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Develop, implement, and maintain an ongoing quality assurance program for the nursing service's department .Assist the Quality Assessment & Assurance committee in developing and implementing appropriate plans of action to correct identified deficiencies .Assist the Pharmaceutical Services Committee in developing, maintaining, implementing, and periodically updating written policies and procedures for the administration, storage, and control of medications and supplies .Delegate to nursing service supervisory personnel the administrative authority, responsibility, and accountability necessary to perform their assigned duties . Make daily rounds of the nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Monitor medication passes and treatment schedules to ensure that medications are being administered as ordered and that treatments are provided as scheduled .Ensure that residents who are unable to call for help are checked frequently .Assist the Safety officer in developing safety standards for the nursing service department Ensure that a stock level of medications .is maintained on premises at all times to adequately meet the needs of the resident . Assist in the development of preliminary and comprehensive assessments of the nursing needs of each resident. Develop a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished, and which professional services is responsible for each element of care . Report suspected or known incidence of fraud .Report and investigate all allegations of resident abuse and/or misappropriation of resident property . 3. The facility Administration failed to ensure Residents #13, #14, #15, #18, #19, #20, #21, #22, #23, #25, #26, #28, and #30 were free from misappropriation of resident property when Licensed Practical Nurse (LPN) M, diverted resident medications from [DATE] through [DATE]. The facility Administration failed to identify the misappropriation until notified by Law Enforcement Officials on [DATE]. During an interview on [DATE] at 10:17 AM, the DON was asked how the facility was made aware of the allegation of the drug diversion by LPN M. The DON stated, When they came, I think the first to come in was the District Attorney's office of drug enforcement, they came in that morning [[DATE]]and that's how I was made aware. The DON confirmed the facility did not identify the residents' medications were missing prior to notification by the authorities. The DON was asked did you identify that the controlled drug record sheet was missing on any of the residents or medications prior to being notified by the authorities. The DON stated, No. The DON was asked who provided oversight to ensure drugs were not diverted. The DON stated, Me, I have to take responsibility . During an interview on [DATE] at 3:15 PM, the Medical Director (MD) confirmed he was made aware of the allegation of drug diversion by LPN M when the District Attorney came to the building, and they asked to speak to him. The MD was asked as the Medical Director, did he expect the facility to have systems and processes in place to track and reconcile controlled substances. The MD stated, Yes. Refer to F602 4. The facility Administration facility failed to ensure staff provided appropriate pain management consistent with professional standards of practice for Resident #9 and #17 and a safe environment to prevent accidents for Resident #17. a. Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Dementia, Anxiety, Periprosthetic Fracture Around Internal Prosthetic Hip Joint, and Pain in Right Knee. Resident #9's Minimum Data Set (MDS) assessment dated [DATE], revealed the Resident was rarely understood, exhibited short-term and long-term memory problems, and was assessed by staff with severe cognitive impairment. On [DATE] at 1:15 AM, Resident #9 sustained an unwitnessed fall, and later at 9:15 AM, Resident #9 began to exhibit verbal complaints and nonverbal cues of intense pain, hollering out when her right leg was moved, grimacing, and guarding her right hip and femur (thigh bone). The practitioner was not immediately notified of Resident #9's pain and the Resident did not receive pain medication. An x-ray was ordered at 11:31 AM and was obtained approximately 2 hours later at 1:32 PM. The x-ray revealed Resident #9 suffered a periprosthetic fracture (fracture that occurs around or near an orthopedic implant). Resident #9 was transferred to the hospital at approximately 3:40 PM. Resident #9 did not receive pain medication to address her pain prior to leaving the facility. b. Review of the medical record revealed Resident #17 was readmitted to the facility on [DATE], following hospital discharge with diagnoses that included a right below the knee amputation on [DATE]. On [DATE], Resident #17's physician orders included Hydrocodone every 6 hours as needed for a moderate pain level of ,d+[DATE] and Ibuprofen 800 milligrams (mg) every 8 hours as needed for a mild pain level of ,d+[DATE]. Review of the admission assessment dated [DATE] at 6:30 PM, revealed Resident #17 was experiencing pain rated as 5, which frequently caused difficulty sleeping and led to limitations of day-to-day activities. Resident #17 was severely cognitively impaired and dependent upon staff for assistance with all aspects of care. Resident #17 was experiencing uncontrolled pain as evidenced by the Resident's restlessness and trembling of the extremity. Resident #17 developed a new behavior of climbing out of bed on [DATE] and on [DATE]. Resident #17 sustained an unwitnessed fall with head injury, was transferred to the hospital and diagnosed with subarachnoid hemorrhage and a periorbital fracture. The facility failed to have a system in place to assess pain of residents with cognitive impairment and appropriately address the pain. c. During an interview on [DATE] at 9:41 AM, the DON confirmed Resident #17 did not receive Hydrocodone as ordered by the physician for pain rated 4 or greater. During an interview on [DATE] at 3:43 PM, the DON reviewed the orders from the hospital for Resident #17 that documented to pick up the ordered Hydrocodone at a local pharmacy in front of the facility. The DON stated, I would have said, whoa, I could have the family go get it and use it .she [LPN D] could have called me, and I could have given her direction .something would have happened, even if I called a Nurse Practitioner .she could have put in something [for pain]. They call me for a million things .night and day, but they didn't call me for this. The DON stated, I found out Monday when she went out. During an interview on [DATE] at 5:20 PM, when the Immediate Jeopardy template for Pain Management was presented to the Administrator and DON, the Administrator was asked was she aware of the issue with Resident #17 not receiving Hydrocodone for pain from [DATE]-[DATE]. The Administrator stated she had just been made aware when she returned from her trip (was not in the facility during the survey from [DATE] through [DATE] due to a pre-planned trip). During an interview on [DATE] at 1:33 PM, the DON confirmed Resident #9 experienced a fall with periprosthetic femur fracture, did not receive pain medication on [DATE], and the nursing staff should have called the Nurse Practitioner (NP) to get an order for pain medication. Refer to F689 and F697 5. The facility Administration failed to ensure the facility had a system of recording, accurate reconciliation, and accounting for all controlled medications, failed to promptly identify diversion of controlled substances, failed to provide medications according to physician orders and the facility's medication schedule, and failed to ensure controlled substances were in date and no discrepancies were identified for Residents #8, #9, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27,# 28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #41, and #42 reviewed for drug diversion, controlled substance reconciliation, and administration of medications. During a telephone interview on [DATE] at 12:15 PM, the Administrator was asked how the facility reconciled controlled substances prior to [DATE], to ensure that all medications delivered to the facility were handled properly and accounted for. The Administrator was unable to answer the question and stated, That would be a DON [Director of Nursing] question . The Administrator was asked if she was aware that LPN M had unlimited access to controlled substances without having to have a second nurse to sign with her. The Administrator stated, .No, I was not .I thought it was always two nurses . The Administrator was asked if, as the Administrator, she expected that someone was tracking the controlled substances. The Administrator stated, .Yes, I just expect that to be the DON's responsibility to make sure those [controlled] substances are safe . During an interview on [DATE] at 3:43 PM, the DON was asked when the narcotic E-kit should be reconciled if a medication is taken out of it. The DON stated, When it's taken out. The DON confirmed she identified the narcotic E-kit on the C Hall Medication Cart was expired on [DATE] when she audited the cart at the time of the drug diversion by Licensed Practical Nurse (LPN) M. The DON stated, .I have since it expired been trying to get it in here . During an interview on [DATE] at 3:38 PM, the DON acknowledged the facility was having issues with medications being administered as ordered. The DON stated medication administration was being spotty, and they were trying to conduct additional training for agency staff. The DON acknowledged nursing staff failed to follow the education and training related to controlled substance documentation that was provided after the drug diversion was identified in [DATE], when the controlled substances were not signed out when administered on [DATE]. The DON acknowledged this was a staff performance issue, rather than an education issue. Refer to F726 and F755

Based on policy review, medical record review, and interview, the facility failed to maintain accurate medical records related to medication administration for 6 of 6 (Resident #6, 9, 13, 16, 24, and 38) sampled residents reviewed for medication administration. The findings included: 1. Review of the facility policy titled, Charting and Documentation, revised 7/2017, revealed .All services provided to the resident .or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .The following information is to be documented in the resident medical record .Medications administered . Review of the facility policy titled, Administration of Drugs, dated 4/2022, revealed .Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director .Unless otherwise specified by the resident's attending physician, routine drugs should be administered as scheduled .The nurse administering the drug must record such information on the residents eMAR [electronic Medication Administration Record] .must electronically sign the resident's eMAR immediately after administration . Review of the facility policy titled, Charting Errors and Omissions, revised 12/2022, revealed .Accurate medical records shall be maintained by this facility .Late entries in the medical record shall be dated at the time of entry and noted as a late entry . 2. Review of the medical record revealed Resident #6 was readmitted on [DATE], with diagnoses of Parkinson's Disease, Contracture of ankle, and muscle spasms. Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #6 was cognitively intact and required use of a wheelchair for mobility. Review of the physician's orders dated 1/2/2025 for Resident #6 revealed Carbidopa Levodopa ER (extended release) oral tablet 25-100 milligram (mg) give 1 tablet by mouth every three hours for Parkinson's Disease, Entacapone 200 mg give 1 tablet by mouth every 3 hours for Parkinson's Disease, Ropinirole Hydrochloride (HCL) 0.5 mg give 1 tablet by mouth 3 times a day for Parkinson's, Tizanidine HCI 4mg give 1 tablet by mouth 3 times a day for Contracture, and Gabapentin 800 mg give 1 tablet by mouth 3 times a day for Parkinson's Disease. Review of the physician's orders dated 2/18/2025, Resident #6 Carvidopa 50-200 mg give 1 tablet by mouth four times a day for Parkinson's Disease, Diazepam 2mg give 1 tablet by mouth three times a day for Anxiety disorder and muscle spasms. Review of the Medication Admin (Administration) Audit Report, which indicated the actual time medications were documented as being administered, dated 3/14/2025 revealed the following medications were not documented as being administered accurately: The Ropinirole HCl 0.5 mg scheduled for 5:00 AM was documented as administered at 9:24 AM. The Tizanidine HCI 4 mg scheduled for 5:00 AM was documented as administered at 9:24 AM. The Gabapentin 800 mg scheduled for 6:00 AM was documented as administered at 9:24 AM. The Entacapone 200 mg give 1 tablet scheduled for 6:00 AM was documented as administered at 9:24 AM. The Carbidopa- Levodopa 25-100 mg dose scheduled for 6:00 AM was documented as administered at 9:24 AM. The Diazepam 2 mg scheduled for 6:00 AM was documented as administered at 9:24 AM. The Ropinirole HCI 0.5 mg scheduled for 9:00 PM was documented as administered at 11:34 PM. The Tizanidine HCI 4 mg scheduled for 9:00 PM was documented as administered at 11:33 PM. The Entacapone 200 mg scheduled for 9:00 PM was documented as administered at 11:33 PM. The Carbidopa-Levodopa 25-100 mg scheduled for 9:00 PM was documented as administered at 11:33 PM. During an interview on 3/18/2025 at 2:26 PM, Resident #6 stated on Friday night 3/14/2025, the nurse did not give him his Parkinson's medicine as scheduled. Resident #6 stated, This problem comes and goes, depending on the number of agency nurses working. During interview on 3/20/25 12:05 PM, the Director of Nursing (DON) confirmed the medication administration audit revealed Resident #6's medication was not administered as scheduled per the physician order and/or the medication administration was not documented timely and accurately. 3. Review of the medical records revealed Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Dementia, Diabetes, Anxiety, Periprosthetic Fracture Around Internal Prosthetic Hip Joint, and Pain in Right Knee. Review of a physician's order for Resident #9 dated 2/6/2025, revealed an order for Acetaminophen (for minor aches and pains) 325 mg, give 3 tablets by mouth two times a day. Review of the fall Incident Report dated 2/21/2025 at 1:15 AM, revealed Resident #9 sustained an unwitnessed fall. Review of the undated facility document titled MED (Medication) PASS TIME FRAMES revealed medications ordered two times a day should be administered from 7:00 AM-10:00 AM for the morning dose and 7:00 PM-10:00 PM for the evening dose. Review of the Medication Admin Record (MAR) for Resident #9 dated 2/21/2025, revealed a 6 (indicated the resident was hospitalized ) was documented in the box where the 7:00 AM to 10:00 AM dose of Acetaminophen should have been documented. Resident #9 was not transferred to the hospital until approximately 3:41 PM. Continued review revealed the MAR did not reflect documentation that Resident #9 received the Acetaminophen. Review of the E-INTERACT FORM dated 2/21/2025, revealed Resident #9 was transferred to the hospital at 3:41 PM. During a telephone interview on 3/27/2025 beginning at 2:10 PM, Licensed Praqctical Nurse (LPN) was asked about her documentation of Acetaminophen on the Medication Administration Record (MAR) that documented a 6 which indicated the resident was hospitalized , and asked did that mean the medication was not administered. LPN L stated, I guess not. LPN L stated she did not remember what time Resident #9 was transferred to the hospital. 4. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Diabetes, Dependence on Renal Dialysis, Hypothyroidism, Anxiety, Bipolar Disorder, and Insomnia. a. Review of the physician's order for Resident #13 dated 2/6/2025, revealed the following: Insulin Lispro (fast-acting insulin to lower blood glucose) 100 Units/ML, inject per sliding scale before meals for blood sugar (glucose) levels of: 71 - 150 mg/dL = 0 units 151 - 200 mg/dL = 2 units 201 - 250 mg/dL = 4 units 251 - 300 mg/dL = 6 units 301 - 350 mg/dL = 8 units 351 - 400 mg/dL= 10 units 401 mg/dL or above = 10 units recheck in one hour if blood sugar (glucose) has not gone down, notify the Nurse Practitioner (NP). Continued review revealed Norco (Hydrocodone-Acetaminophen) 7.5-325 mg, give 1 tablet by mouth four times a day for pain, Montelukast Sodium 10 mg, give 1 tablet by mouth one time a day for allergies, Ezetimibe 10 mg, give 1 tablet by mouth one time a day for Hyperlipidemia, Fluticasone Propionate Nasal Suspension 50 micrograms/actuation (mcg/act), 1 spray alternating nostrils two times a day for Allergic Rhinitis, and Sennosides-Docusate (Senna-S) 8.6-50 mg, give 2 tablets by mouth one time a say for Constipation. b. Review of the MAR for Resident #13 dated 2/1/2025-2/28/2025, revealed the following medications were documented as being administered timely: On 2/26/2025 at 7:30 AM, Resident #13's blood glucose (sugar) was 233 milligrams per deciliter (mg/dL) and LPN L documented she administered 4 units of Lispro Insulin at 7:30 AM. On 2/26/2025 at 12:00 PM, Resident #13's blood glucose was 264 mg/dL and LPN L documented she administered 6 units of Lispro Insulin at 12:00 PM. On 2/26/2025 at 11:00 AM, LPN L documented that she administered Resident #13's Norco. Review of the Medication Admin Audit Report, which indicated the actual time medications were documented as being administered, dated 2/25/2025-2/27/2025 revealed the following medications were not documented as being administered accurately: The Lispro Insulin scheduled on 2/26/2025 at 7:30 AM was documented as administered at 2:20 PM. The Norco 7.5-325 mg scheduled on 2/26/2025 at 11:00 AM was documented as administered at 2:20 PM. The Lispro Insulin scheduled on 2/26/2025 at 12:00 PM was documented as administered at 2:21 PM. The Buspirone 10 mg scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:51 AM. The Montelukast Sodium 10 mg scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:51 AM. The Ezetimibe 10 mg scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:52 AM. The Fluticasone Propionate Nasal Spray scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:52 AM. The Senna-S 8.6-50 mg scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:53 AM. Review of the MAR revealed the medications were administered timely, but review of the Medication Admin Audit Report revealed the medications were actually not accurately documented as administered timely. Observation and interview in the Resident's room on 3/13/2025 at 9:20 AM, revealed Resident #13 was in bed and wearing oxygen. Resident #13 stated a night nurse (Named LPN Q) said he gave her medications while she was asleep, but she told him she couldn't take medications while she slept. Resident #13 stated, .come to find out the next morning there was a lot of people that didn't get their medication so he's not coming back . During an interview on 3/26/2025 at 12:46 PM, LPN L stated medication should be administered within an hour before and an hour after the time it was scheduled. LPN L reviewed the Medication Admin Audit Report and stated she gave Resident #13's 7:30 AM dose of Lispro Insulin before breakfast. LPN L stated, I know because that's when I go down the hall and administer .sometimes there's just so much going on with that many patients it's hard to get it signed out. LPN L stated she administered Resident #13's 12:00 PM Lispro and Norco right before the Resident left for Dialysis which was around 11:00 AM. When asked about the documentation that showed Resident #13 received her 7:30 AM at 2:20 PM and 12:00 PM dose of Lispro Insulin at 2:21 PM, LPN L stated, That's probably just when I was able to chart it [Lispro Insulin and Norco] . 5. Review of the medical records revealed Resident #16 was admitted to the facility on [DATE], with diagnoses including Diabetes, Hypothyroidism, Gout and Cellulitis of Right Lower Limb. Review of the physician's orders for Resident #16 dated 3/6/2025 revealed Levothyroxine Sodium Tablet 137 micrograms (MCG) Give 1 tablet by mouth one time a day for Hypothyroidism and Furosemide Tablet 20 mg Give 1 tablet by mouth one time a day for edema. Review of the quarterly MDS assessment dated [DATE] revealed resident had a BIMS score of 15, which indicated Resident #16 was cognitively intact. Review of the Medication Admin Audit Report, which indicated the actual time medications were documented as being administered, dated 3/14/2025 revealed the following medications were not documented as being administered accurately: The Levothyroxine Sodium 137 MCG Give 1 tablet scheduled at 4:00 AM was documented as administered at 1:06 PM. The Furosemide 20 mg Give 1 tablet scheduled at 5:00 AM was documented as administered on 3/14/2025 at 1:06 PM. Observation and interview in the Resident's room on 3/13/2025 at 9:34 AM, revealed Resident #16 was in bed. Resident #16 stated there were times she did not receive her medications as scheduled especially on the night shift and she would get the medications when the day shift nurse arrived. During an interview on 3/26/2025 at 3:38 PM, the DON confirmed Resident #16's Levothyroxine that was due at 4:00 AM and the Furosemide that was due at 5:00 AM were documented as administered at 1:06 PM. The DON stated, [Named LPN C] comes at 7 [7:00] AM and gave the meds that were due at 4 [4:00] and 5 [5:00] am because they were not administered by either Agency [an agency nurse] or [Named LPN Q], a prn nurse. The DON stated, .it's [medication administration] being spotty and we're trying to get every agency person in here for additional training and the ones who are not performing I'm not letting them come back. 6. Review of the medical records revealed Resident #24 was admitted to the facility on [DATE], with diagnoses including Diabetes, Paraplegia, Schizophrenia, Narcolepsy, Insomnia, and Anxiety. Review of the quarterly MDS assessment dated [DATE], revealed resident had a BIMS score of 15, which indicated Resident #24 was cognitively intact. Review of the physician's orders for Resident #24 dated 3/6/2025, revealed Simethicone 125 mg give 1 tablet by mouth before meals and at bedtime for heartburn, Tamsulosin HCL 0.4 mg give 2 capsules by mouth at bedtime for enlarged prostate, Risperdal 1 mg give one tablet by mouth at bedtime for Schizophrenia, Gabapentin 600 mg give 1 tablet by mouth three times a day for Polyarthritis, Clonazepam 1 mg give 1.5 tablets by mouth at bedtime for Anxiety, and Mesalamine Rectal Suppository 1000 mg, insert 1 suppository rectally at bedtime for Constipation. Review of the Medication Admin Audit Report, which indicated the actual time medications were documented as being administered, dated 3/14/2025-3/16/2025 revealed the following medications were not documented as being administered accurately: The Simethicone 125 mg scheduled at 9:00 PM was documented as administered on 3/15/2025 at 12:01 AM. The Tamsulosin HCL 0.4 mg scheduled at 9:00 PM was documented as administered on 3/15/2025 at 12:01 AM. The Risperdal 1 mg scheduled at 9:00 PM was documented as administered on 3/15/2025 at 12:01 AM. The Gabapentin 600 mg scheduled at 9:00 PM was documented as administered on 3/15/2025 at 12:01 AM. The Clonazepam 1 mg scheduled at 9:00 PM was documented as administered on 3/15/2025 at 12:01 AM. The Mesalamine Suppository 1000 mg scheduled for 3/14/2025 at 9:00 PM, was documented as administered on 3/15/2025 at 12:01 AM. 7. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including Dementia, Diabetes, Bipolar Disorder, Schizophrenia, Osteoarthritis, and Depression. Review of the annual MDS assessment dated [DATE] revealed Resident #38 was cognitively intact. Review of the physician's orders for Resident 38 dated 3/6/2025, revealed Acetaminophen 650 MG give 2 tablets by mouth three times a day, Gabapentin (to treat seizures and nerve pain) 800 MG give 1 tablet by mouth three times a day, Ziprasidone (to treat Schizophrenia) 20 MG give 1 capsule by mouth at bedtime, Ziprasidone 80 MG, give 1 capsule by mouth at bedtime, and Lamictal (to treat seizures and bipolar disorder) 200 MG give one tablet by mouth at bedtime. Review of the Medication Admin Audit Report, which indicated the actual time medications were documented as being administered, dated 3/15/2025 revealed the following medications were not documented as being administered accurately: The Acetaminophen 650 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 1:44 AM. The Lamictal 200 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:13 AM. The Gabapentin 800 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:14 AM. The Ziprasidone 20 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:16 AM. The Ziprasidone 80 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:16 AM. Observation and interview on 3/17/2025 at 12:20 PM, revealed Resident #38 sitting in her wheelchair in her room and the Resident stated, .didn't get our meds last night till 2:30 the next morning .agency nurse she didn't know what she was doing .

Based on policy review, medical record review, facility investigation, observation, and interview, facility staff failed to ensure an allegation of abuse was reported to Administration immediately for 1 of 6 (Resident #1) sampled residents reviewed for allegations of abuse and neglect. The findings include: 1. Review of the facility's policy titled, ABUSE PREVENTION POLICY, revised on 3/1/2018 revealed .resident has the right to be free from verbal, sexual, physical and mental abuse .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but no later than 2 hours after the allegation is made . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Diabetes, Human Immunodeficiency Virus Disease, Depression, and Encephalopathy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #1 was cognitively intact. Review of the progress notes dated 2/27/2025, revealed .This nurse and another nurse were walking down the A hall when this [Resident #1] motioned for us to come here. We entered his room and asked if he needed something he stated that someone stuck their finger in his butt last night. I asked what she looked like. [Named Resident #1] stated it was a he. I asked him if he could describe him, and he stated that he was tall and had curly hair. I asked him if he was his CNA [Certified Nursing Assistant]. He stated I guess so, I don't know. I Called the administrator immediately and reported what [Named Resident #1] had told me. Called for ambulance transport to .ER [emergency room ] . During an observation and interview on 3/11/2025 at 8:59 AM, revealed Resident #1 lying in the bed with the head of the bed up approximately 45 degrees, a coffee cup on the overbed table, Quarter (1/4) side tails x 2. Resident #1 was asked are you receiving good care. Resident #1 stated, .assume they are . Resident #1 was asked if he had had ever been abused or touched inappropriately here in the facility. Resident #1 stated, Touched inappropriately. Resident #1 was very difficult to understand and communicate with. During an interview on 3/4/2025 at 3:29 PM, Certified Nursing Assistant (CNA) R was asked about the alleged incident with Resident #1. CNA R stated, .short staffed .one of our CNAs had left early on C hall, can't work it by yourself .skilled people .that needs helps, too much for one person. This night [2/26/2025] our unit manager called and asked if I could help .on C hall .asked if anyone on my hall needed help. I told her I had .[Named Resident #1] .could [Named accused CNA F] help me with my people .as we were coming out [referring to another resident's room] [Named accused CNA F] said hey [Named Resident #1] is done, he [Resident #1] was cursing 'black son of a b**** [expletive],' he [Resident #1] was like ' .he raped me.' I was like that quick [happened that quick] and he was like yeah. I said give me a second .the new nurse .was [NAME] [missing in action] .he was nowhere to be found and so I told [what Named Resident #1 had reported] the next day .I had an Uber waiting on me, so I told the next day .I'm sorry .I know you have to tell right away .now I know to tell any nurse in charge. I feel bad I tried to tell my nurse, and he wasn't there [CNA R could not find him] .on my mind the whole night . During an interview on 3/5/2025 at 1:51 PM, Registered Nurse (RN) A stated, . he [Named Resident #1] sometimes will motion to me [to come in his room], so I didn't think anything about it until he told me that [the allegation of abuse]. He's with it. He said this is hard to talk about .Me and [Named RN P] were walking down the hall from medical records. We walked by and I said, hey, I waved, he waved and he [motioned with his hand] motioned me to come in .I said what's wrong because something was off .he said, Stuck his finger in my butt and tried to screw me with it. I said who, what does she look like. He said, It wasn't a she, it was a he .tall and curly hair. We only have 1 male CNA in the building .I said okay [Named Resident #1] he stuck his finger in he said 'yes' I said I've got to go report this .reported it then started calling the Nurse Practitioner .She said send him to the hospital . RN A was asked do your recall what day he told you. RN A stated, Thursday .2/27/2025 . RN A was asked did he tell you he had told anyone else. RN A stated, No .when she [Administrator] told me to start investigating and that's when I run up on [Named CNA R] and of course [Named accused CNA F] .I did skin checks on everybody in his [CNA F] section, and I didn ' t find anything. RN A confirmed she had talked to CNA [R] and stated, .got her to write her statement and of course I did an in-service afterwards .take it serious even if they ' re [the resident] confused, just go ahead and call [Named Administrator] . RN A was asked is that when you found out he (Resident #1) reported the same thing to CNA R the night before. RN A stated, Yeah she [CNA R] was in the room next [to Named Resident #1] and heard him yelling . During an interview on 3/20/2025 at 8:59 AM, the Chief Nursing Officer confirmed when an allegation of abuse is made it should be reported immediately and stated, .we have 2 hours to report it . During a telephone interview on 3/21/2025 at 12:13 PM, the Administrator stated, .He [Resident #1] reported to nurse supervisor that a staff member tried to put his finger in his rectum .we looked at the schedule .I think he described him to us .when we did the investigation suspended him [CNA F] .when we interviewed the male CNA [F] he denied it .[Named Resident #1] said he [CNA F] didn't do it .just tried to .we sent him [Resident #1] to the ER . The Administrator confirmed when an allegation of abuse is made it should be reported immediately.

Based on policy review, American Heart Association website: www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure, medical record review, and interview, the facility failed to ensure residents were free of significant medication errors for 1 of 5 (Resident #13) sampled residents reviewed for medication administration. The findings include: 1. Review of the Administration of Drugs, policy dated April 2022, revealed . Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Directo .Drugs must be administered in accordance with the written orders of the attending physicia . 2. Review of the American Heart Association website: www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure revealed the following Blood Pressure Categories: a. Normal systolic (upper number) is less than 120 millimeters of mercury (mm Hg) and normal diastolic (lower number) is less than 80 mm Hg. b. Elevated blood pressure is 120-129 mm Hg systolic and elevated diastolic is less than 80 mm Hg. c. High Blood Pressure (Stage 1) is 130-139 mm Hg systolic or 80-89 mm Hg diastolic. d. High Blood Pressure (Stage 2) is 140 mm Hg or higher systolic or 90 mm Hg or higher diastolic. c. Hypertensive Crisis is higher than 180 mm Hg systolic and/or higher than 120 mm Hg diastolic. 3. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dependence on Renal Dialysis, Hypothyroidism, Anxiety, Bipolar Disorder, and Insomnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #13 was cognitively intact. Review of the Nurse's Note dated 1/29/2025 at 5:03 PM, revealed Resident #13 returned from dialysis with a prescription for Midodrine (Medication used to raise blood pressure) 5 mg by mouth on Monday, Wednesday, and Friday, 30 minutes before dialysis. Review of the physician's order for Resident #13 dated 1/29/2025, revealed an order for Midodrine Hydrochloride Oral Tablet 5 milligram (MG) by mouth every Monday, Wednesday, and Friday related to Dependence on Renal Dialysis, give 30 minutes prior to dialysis on Monday, Wednesday, and Friday. Review of the Black Box Warning for Midodrine revealed, midodrine can cause marked elevation of supine (lying down position) blood pressure . Review of the February 2025 Medication Administration Record (MAR) revealed Midodrine was administered two times a day on Monday, Wednesday, and Friday, instead of the ordered one time a day on Monday, Wednesday, and Friday. Review of the March 2025 Medication Administration Record (MAR) revealed Midodrine was administered two times a day on Monday, Wednesday, and Friday from 3/3/2025 through 3/24/2025. Review of the Vital Signs Summary on Friday, 3/7/2025 at 7:33 PM, revealed Resident #13's blood pressure was elevated at 177/95. There was no documentation to show the elevated blood pressure was re-checked. Review of the Medication Admin (Administration) Audit Report dated 3/7/2025, revealed Midodrine 5 mg was administered at 8:25 PM, less than an hour after Resident #13's blood pressure was 177/95. During an interview on 3/26/2025 at 3:32 PM, the Director of Nursing (DON) was asked to review Resident #13's medical record. The DON was asked when Midodrine should be administered. The DON stated 30 minutes prior to dialysis. The DON was asked if Midodrine should be administered twice a day on dialysis days. The DON stated, No. The DON confirmed the order for Midodrine was transcribed incorrectly and scheduled in error for two times a day instead of one time a day on dialysis days. During an interview on 3/27/2025 at 1:52 PM, Nurse Practitioner (NP) H confirmed she instructed Licensed Practical Nurse (LPN L) to enter an order for Midodrine but did not notice the order was entered incorrectly (twice a day on dialysis days). NP H stated, .I will take all the blame . NP H was asked if she would expect a blood pressure of 177/95 to be re-checked. NP H stated, I would.

Based on policy review, observations, and interview, the facility failed to ensure food was handled, prepared, and served under sanitary conditions when 2 of 6 dietary staff (Dietary Aide #1 and Dietary Aide #3) failed to remove their gloves and perform hand hygiene after leaving the dirty side of the dishwasher and before removing clean dishes from the clean side of the dishwasher, when 1 of 6 dietary staff (Dietary Aide #2) failed to cover food when transporting food through the hallway, and when the facility failed to test the sanitizing solution level of the low temperature dishwasher daily. The facility had a census of 66 with 63 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility's undated policy titled, Policy: Cleaning of Dish Machine, revealed All flatware, servicing dishes, and cookware will be washed, rinsed, and sanitized after each use. Dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitation .The person loading dirty dishes should not handle the clean dishes unless they change their apron and wash their hands thoroughly before moving from dirty to clean dishes FOLLOW MANUFACTURES SPECIFICATIONS .Low Temperature Dishwasher Spray Type Dish Machines Using Chemicals to Sanitize .Wash Temperature 120 [degrees Fahrenheit] 50 PPM [Parts per Million] Hypochlorite . Review of the facility's undated policy titled GENERAL FOOD PREPARATION AND HANDLING, revealed .Prepared food will be transported to other areas in covered containers . 2. Observation in the Dining Room on [DATE] from 11:20 AM to 11:30 AM, revealed Dietary Aide #2 transported uncovered metal pans of Salisbury Fried Steak, Puree Meat, and Puree Vegetables the dining room steam table to the kitchen to reheat. 3. Observation in the Dishwashing Area on [DATE] at 1:03 PM, revealed Dietary Aide #1 failed to remove his gloves and perform hand hygiene after working on the dirty side of the dishwasher, then walked to the clean side of the dishwasher and removed clean dishes, picked up and stacked clean dishes while wearing the same dirty gloves. Observation in the Dishwashing Area on [DATE] at 8:51 AM to 9:19 AM, revealed Dietary Aide #1 failed to remove his gloves and perform hand hygiene after dumping food from dirty dishes, and stacking dirty dishes from the dirty side of the dishwasher then he went to the clean side of the dishwasher, removed, and stacked clean dishes from the clean side of the dishwasher with the same dirty gloves. Observation in the Dishwashing Area on [DATE] at 10:04 AM, Dietary Aide #1 failed to remove his gloves and perform hand hygiene after working on the dirty side of the dishwasher, then walked to the clean side of the dishwasher and removed clean dishes and stacked clean dishes, wearing the same dirty gloves. Observation in the Dishwashing Room on [DATE] at 1:28 PM, revealed Dietary Aide #3 failed to remove his gloves and perform hand hygiene after working on the dirty side of the dishwasher, then walked to the clean side of the dishwasher and removed clean dishes and stacked clean dishes, wearing the same dirty gloves. 4. Review of the facility's Dish Machine Log dated ,d+[DATE] and ,d+[DATE], revealed there were no sanitizing chemical levels documented on the log. The facility failed to perform a daily test of the low temperature dishwasher's sanitizing chemical level. During an interview on [DATE] at 9:41 AM, Dietary Aide #1 confirmed there is no documentation of the sanitizing solution level for the low temperature dishwashing machine. During an interview on [DATE] at 11:36 AM, the Certified Dietary Manager (CDM) confirmed the facility's dishwasher is a low temperature dishwasher and the level of the sanitizing chemical for the low temperature dishwasher should be tested daily and documented on a log (a sheet of paper with results of findings). The CDM was asked to explain the process when the same person moves from working on the dirty side of the dishwasher to the clean side of the dishwasher. The CDM stated, .gloves off, wash hands, and new gloves to catch the clean plates or whatever it is .always change gloves once changing a task and always wash hands before putting on gloves . The CDM was asked to explain the process when transporting food from one area of the building to another area. The CDM stated, .all food has to be covered .debris floating in the air and hallway is unsanitized bacteria in the air can't see it [bacteria] but they [bacteria] are there or something could fall in it [food]. It [food] has to be wrapped . The CDM confirmed the facility had no documented test results of the sanitizing solution for the low temperature dishwasher. During an interview and observation on [DATE] at 11:37 AM, revealed one bottle of chlorine sanitizing test strips were expired dated ,d+[DATE] and two bottles were dated ,d+[DATE]. The CDM confirmed the chlorine sanitizing test strip were expired. During an interview on [DATE] at 2:09 PM, the Service Representative from (Named Company) and the CDM was asked, per manufacturers recommendation, how often should the sanitizing solution for the low temperature dishwasher be tested to make sure it is at the correct range. The CDM stated, It [manufacturer recommendation] is on the dishwasher to test the sanitizing solution every day. The Service Representative stated, .Always want to make sure the sanitizer level is at correct level with a low temp dishwasher .It [sanitizing solution] is what sanitizes the dishes. During an interview on [DATE] at 5:13 PM, the CDM confirmed there was no documentation of the sanitizer level for the dishwasher and it should have been on the Dish Machine Log sheet. The facility failed to ensure staff removed gloves and performed hand hygiene after working from the dirty side of the dishwasher and proceeded to the clean side of the dishwasher to work, failed to ensure food was covered during transport from one area of the facility to another area, and failed to ensure staff tested the dishwasher's sanitizing solution level daily.

Based on policy review, medical record review, and interview, the facility failed to implement a comprehensive care plan for 2 of 18 (Resident #21 and #70) sampled residents reviewed for care planning. The findings include: 1. Review of the facility's policy titled, CARE PLAN POLICY ., dated 10/25/2022, revealed .Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .facility must provide the resident .a written summary of the baseline care plan by the completion of the comprehensive care plan .summary must include .summary of the resident's medications . 2. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses of Hemiplegia and Hemiparesis, Cerebrovascular Disease, Gastrostomy, Pneumonia, Diabetes, End Stage Renal Disease, and Dysphagia. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Resident #21 required moderate assistance for activities of daily living (ADLs), received dialysis [process that removes waste products and excess fluid from the blood], received antiplatelets [used to treat and prevent blood clots], and insulin [medication to lower blood glucose]. Review of the Medication Administration Record (MAR) dated 2/1/2024- 2/29/2024, revealed Heparin Sodium [blood thinner] .5000 UNIT/0.5 ML [milliliter] .Inject 5000 unit subcutaneously two times a day . The MAR revealed the Heparin was administered on 2/26/2024 through 2/29/2024. Review of the Care Plan dated 2/20/2024, revealed the medications, including Heparin, used for a blood thinner, were not included in the care plan. 3. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE], with diagnoses of Multiple Fractures of Ribs, Right Tibia, and Compression Fracture of T11-T12 Vertebra, Anxiety, and Urinary Retention. Review of the admission MDS dated [DATE], revealed Resident #70 had a BIMS score of 15, which indicated she was cognitively intact. Medications received included antianxiety, antidepressant, anticoagulant, and opioid. Review of the Physician Order dated 2/15/2024 revealed DULoxetine HCl [antidepressant medication] Oral Capsule Delayed Release Particles 60 MG [milligram] [Duloxetine] .Give 1 capsule by mouth one time a day related to ANXIETY DISORDER . Review of the Physician Order dated 2/1/2024 revealed oxyCODONE HCl [pain medication] Oral Tablet 5 MG [Oxycodone] *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for Pain. Review of the Physician Order dated 2/15/2024 revealed busPIRone HCl [medication to treat anxiety] Oral Tablet 5 MG [Buspirone HCl] Give 1 tablet by mouth two times a day related to ANXIETY DISORDER . Rivaroxaban [medication to prevent blood clots] Oral Tablet 10 MG [Rivaroxaban] Give 1 tablet by mouth one time a day related to OTHER PRIMARY THROMBOPHILIA . Review of the Care Plan dated 2/26/2024, revealed the medications of Duloxetine, Oxycodone, Buspirone, and Rivaroxaban were not included in the care plan. During an interview on 3/7/2024 at 10:01 AM, the MDS Coordinator was asked should the comprehensive care plan include the current medications. The MDS Coordinator stated, Yes, they should . The MDS Coordinator was asked, do you see the medications on the care plan for Resident #70. MDS Coordinator stated, I don't . During an interview on 3/7/2024 at 11:15 AM, the Director of Nursing (DON) was asked should Heparin be documented on the care plan. The DON stated, Yes .

Based on policy review, Nursing Home Licensure Checklist review, work schedules, and interview, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day 7 days a week. The findings include: Review of the facility's policy titled Payroll Based Journaling dated October 25, 2022 revealed, .Facility shall use the services of a Registered Professional nurse for at least 8 consecutive hours a day, 7 days a week .Facility shall permit the CCO [Chief Clinical Operations]/DON [Director of Nursing] to serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents . Review of the Nursing Home Licensure Checklist dated 2/11/2023 through 2/24/2023 revealed there were not 8 consecutive hours of RN services on the following dates and the average daily censuse was 66 residents: a. 2/14/2023 b. 2/21/2023 c. 2/24/2023 Review of the working schedule for February 2023 revealed there was not 8 consecutive hours of RN services on the following dates: a. 2/7/2023 b. 2/14/2023 c. 2/21/2023 d. 2/24/2023 During an interview on 2/28/2023 at 12:51 PM, the DON confirmed there was no Registered Nurse (RN) coverage for the dates listed above. The DON stated, I didn't have an RN on those days .Didn't have anyone that would fill the position. I'm supposed to have an RN for 8 consecutive hours a day; on those days I didn't . During an interview on 3/2/2023 at 1:20 PM, when asked if the facility provided 8 hours of RN coverage 7 days a week, the [NAME] President of Clinical Operations stated, I'm aware the RN coverage was not filled. We are aware an RN should provide coverage 8 consecutive hours and the DON hours do not count for the hours of coverage .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance related to nail care was provided for 1 of 3 sampled residents (Resident #1) reviewed for ADL care. The findings included: Review of the facility's policy titled, A.M. [morning] CARE dated 5/2018, with a review date of 11/2022, revealed .A.M. Care will be given to all residents daily .Assist to allowed position of comfort .Provide nail care . Review of the facility's policy titled, ADMISSION OF THE RESIDENT -LICENSED NURSE dated 11/28/2017, with a review date of 12/2022, revealed .When a resident is admitted to the facility all required information will be obtained to complete a comprehensive assessment and baseline of the resident .Establish lines of communication between the facility, the resident .Reconcile Physician Orders . Review of the facility's policy titled, NAIL CARE (FINGER AND TOE) dated 4/25/2018, with a review date of 11/15/2022, revealed .The purpose is to clean the nail bed, prevent infection and comfort the resident .Nail care includes daily cleaning and regular trimming. Stop and report any evidence of .infection, pain, or if nails are too hard or thick to cut .Wash hands .Explain .to the resident .Soak hands, Scrub nails gently .Trim nails .Report the condition of the resident's nails .Complaints or problems with hands .Pain .Any difficulty or complaints made by the resident related to the procedure . Review of the facility's policy titled, NOTIFICATION OF RESIDENT'S CHANGE OF CONDITION dated 9/1/2018, with a review date of 10/19/2021, revealed .This facility will promptly notify the resident .Physician and Responsible Party of changes .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician when there has been .Refusal of treatment or medications ( .(2) or more consecutive times [without breaks or gaps]) .the Nurse Supervisor/Charge Nurse will inform the resident, family, or responsible party of any changes in .medical care or nursing treatments . Review of the facility's policy titled, REQUESTING, REFUSING AND/OR DISCONTINUING CARE OF TREATMENT POLICY dated 11/28/2017, revealed .Residents have the right to request, refuse and/or discontinue treatment prescribed .as well as care routines outlined on the resident's assessment and plan of care .If a resident .refuses care or treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will meet with the resident to a. determine why .try to address the resident's concerns and discuss alternative options .discuss the potential .consequences .of the resident's decision .Detailed information relating to the .refusal .of care or treatment will be documented in the resident's medical record .shall include .date and time .treatment was attempted .type of treatment .reason for .refusal .That the resident was informed .purpose of .and potential outcome of not receiving .The resident's condition .date and time the practitioner was notified .response . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, Liver Disease (Cirrhosis of the Liver), Depression, Cerebral Infarction, Osteoarthritis, and Hypertension. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15 and required extensive assistance from staff for personal hygiene. Review of the quarterly MDS dated [DATE], revealed Resident #1 had moderately impaired cognition as indicated by a BIMS score of 8 and required limited assistance for personal hygiene. Review of the Care Plan dated 6/15/2021, and reviewed 11/29/2022, revealed .has an ADL Self Care Performance Deficit .Check nail length and clean on bath day and as necessary. Report any changes or necessity for trimming to the nurse . Review of the Physician's orders dated 5/5/2022, and discontinued on 12/20/2022, revealed .Dilute 1/4 [one fourth] cup of white vinegar with 4 cups of water and have patient soak both hands for 15 minutes every Monday and Thursday. Nails are to be trimmed and /or filed every Thursday. Instruments are to be sanitized after each use .PLEASE DOCUMENT IF PATIENT REFUSES . Review of signed Physician orders dated 12/08/2022, revealed .All orders initiated between recerts [recertification] will continue until the next recert unless otherwise indicated .Next Review Date: 01/08/2023 . Review of the Medication Administration Record (MAR) dated 10/2022, revealed Resident #1 did not receive the ordered nail care 2 out of 9 scheduled days. The MAR was blank on 10/3/2022 and 10/27/2022. Review of the MAR dated 11/2022 revealed Resident #1 did not receive the ordered nailcare 8 out of 8 scheduled days on 11/3/2022, 11/7/2022, 11/10/2022, 11/14/2022, 11/17/2022, 11/21/2022, 11/24/2022, and 11/28/2022. Review of the MAR dated 12/2022, revealed Resident #1 did not receive the ordered nailcare 6 scheduled days on 12/1/2022, 12/5/2022, 12/8/2022, 12/12/2022, 12/15/2022, and 12/19/2022. Observation in Resident #1's room on 12/28/2022 at 11:48 PM, revealed Resident #1 had long, curved fingernails on both hands. Observation in resident's room on 12/29/2022 at 5:21 PM, revealed Resident #1 had long, curved fingernails with a thick tan-colored buildup underneath them. During an interview on 12/29/2022 at 6:17 PM, the Director of Nursing (DON) confirmed Resident #1 had long, curved fingernails on both hands with a buildup underneath them. The DON confirmed Resident #1's nails should be short and clean. During an interview on 12/29/2022 at 4:36 PM, the Administrator confirmed all residents' nails should be clean and trimmed; and if nurses cannot clean and trim a resident's fingernails, they should document in the resident's progress notes and notify the provider to see if the resident needs to be sent to a specialist. During an interview on 12/29/2022 at 5:26 PM, the DON confirmed the physician's order for Resident #1's fingernails to be soaked in vinegar and water two times per week and trimmed and/or filed once a week was not reconciled after Resident #1's return from the hospital on 12/23/2022, and that the order should have continued after Resident #1's return from a 4 day stay at the hospital. The DON confirmed she had spoken with the provider, and the order should have continued. The DON confirmed it was the floor nurses' responsibility to follow the order to soak and cut Resident #1's nails on Mondays and Thursdays, any unsuccessful attempts should have been documented, and the provider should have been notified. The DON confirmed, If it is not documented it is not done. During a telephone Interview on 1/3/2023 at 12:23 PM, Licensed Practical Nurse (LPN #2) confirmed she provided care to Resident #1 from 12/25/2022 to 12/29/2022. LPN #2 confirmed she did not soak and trim Resident #1's fingernails from 12/25/2022 to 12/29/2022.

Based on policy review, review of a facility incident report, medical record review, observation and interview, the facility failed to ensure a resident was free from neglect when the facility staff neglected to provide adequate supervision for a vulnerable resident (Resident #3) who exited the facility unsupervised and without staff knowledge. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #3, a cognitively impaired resident at risk for wandering/elopement, exited the facility without staff knowledge, was missing for an undetermined amount of time when she walked approximately 218 feet from the facility, and was found at a nearby pharmacy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON), were notified of the Immediate Jeopardy (IJ) for F-600 on 12/13/2022 at 4:40 PM, in the Alpha Room. The facility was cited Immediate Jeopardy at F-600 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 11/4/2022 through 12/15/2022. An acceptable Removal Plan for F-600, which removed the immediacy of the Jeopardy, was received on 12/15/2022 at 11:01 AM. The corrective actions were validated onsite by the surveyors on 12/15/2022 through observations, review of education records, and staff interviews conducted on all shifts. The findings include: 1. Review of the facility's policy titled, ABUSE PREVENTION, revised 11/1/2021, revealed .Abuse Prohibition .The resident has the right to be free from .neglect .neglect .means failure to provide goods and services necessary to avoid physical harm .when abuse is suspected .obtain witness statements following incident policies .it is the responsibility of all staff to provide a safe environment for the resident. Resident care and treatment shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse .Care will be monitored so that the resident's care plan is followed . Review of the facility's undated policy titled, MISSING RESIDENT, revealed .If the search of the immediate area (building) is unsuccessful, the Nursing Shift Supervisor/Charge Nurse will immediately contact .Local Police Department . Review of the facility's policy titled, Use of Alarms Policy, revised October 2021, revealed .Wander/Elopement Alarm .include devices such as bracelet .worn on the resident clothes .sensors in resident shoes, or building/unit exit sensor worn or attached to the resident that alert the staff when the resident nears or exits an area or building . 2. Medical record review revealed Resident #3 was admitted on [DATE] with a diagnosis of Alzheimer's Disease, Hypertension, and Anxiety Disorder. Review of an Elopement Evaluation dated 10/21/2022, revealed Resident #3 had a history of elopement while at home, and attempted elopement while at home, attempted to leave the facility without informing staff, wandering, and verbally expressed a desire to go home. Review of Psychosocial /Social Service Note dated 10/25/2022, revealed .Resident stated that she just wants to go home because she doesn't belong here. Resident asked if I would contact her daughter and tell her to come get her . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, had wandering behavior, and had a wander/elopement alarm that was used daily. Review of a Nurses Noted dated 11/2/2022, revealed .Resident wandering this shift, frequently approaching back door, and holding onto door handle despite door alarm sounding. This nurse and B hall nurse redirected resident back to her room multiple times . Review of an Elopement Evaluation dated 11/4/2022, revealed Resident #3 had a history of elopement and attempted elopement while at home, attempted to leave the facility without informing staff, wandering, and had a personal safety alarm device. Review of the Incident Report dated 11/4/2022, revealed .Around 3:50 pm nurse notified by CNA [Certified Nursing Assistant] that the resident was missing. Code Search initiated. Staff members searched the facility as well as outside. Staff searched out to the road, at the bank next door, the plaza near the facility and around [Named Facility] building. Resident was found at [Named Pharmacy] and was escorted back to the facility . Review of the Maintenance Log of the front door checks revealed the front door was not checked prior to October 2022. The doors were not checked the weeks of 10/23/2022 -10/30/2022 and 10/31/2022 - 11/6/2022. During an interview on 12/9/2022 at 10:51 AM, Unit Manager #1 was asked what she was doing when Resident #3 eloped from the facility. The Unit Manager #1 stated .I was in my office .she was in the common area .the nurse came and said [Named Resident #3] is miss .I jump up .told [Unit Manager #2] to alert the staff .I did not call any code .had come to the front desk to announce it .when we got up there .they were bringing her back into the facility . Unit Manager #1 confirmed the Front Desk staff did not realize she was a resident, and she walked out the front door with another visitor. Unit Manager #1 confirmed she did not call or alert the police. During an interview on 12/9/2022 at 11:27 AM, Register Nurse (RN) #1 was asked if she was aware Resident #3 exited the facility. RN #1 stated .the last time I saw her was after the CNA directed her back to her room .[Named CNA #6] went to check on her again .she [Resident #3] was agitated and wandering .she went to her room .did not find her .we started looking throughout the facility .did not find her in the building .we began to look outside the facility .she was at [Named Pharmacy] they went inside the store and found her sitting in a chair with one of the staff members who worked there . RN #1 confirmed she did not take Resident #3 to the front door to check the function of her wanderguard the day she eloped from the facility on 11/4/2022. RN #1 confirmed she was told it worked when she was on the C hall and did not check it. During a telephone interview on 12/9/2022 at 12:00 PM, the Front Desk Staff Member was asked how Resident #3 got out of the facility. The Front Desk staff member stated .she was a new resident .I had seen her one time when she was admitted .she walked out behind another lady .I opened the door .both ladies went out .I just assumed they were together .that is how she got out .one of the nurses came up to the front desk .asked me if I had seen [Named Resident #3]. I said no, don't know who she is .asked what did she have on .she said .a blue shirt and white pants .I said 'oh my gosh she just went outside' .we immediately went outside to look for her .I walked to the bank, there was people in line at the bank in their vehicles .then I went to [Named Pharmacy] I was going in the pharmacy .there was a police officer behind me .she had a wanderguard on her ankle . The Front Desk Staff Member confirmed Resident #3 was found inside the pharmacy. During an interview on 12/9/2022 at 2:05 PM, the Pharmacy Manager for the pharmacy where Resident #3 was found confirmed Resident #3 was in the pharmacy holding a package of urinary incontinence briefs labeled with her name on them, became upset, and was retrieved by the nursing home staff members after approximately 10 minutes. The Pharmacy Manager relayed that he did not see Resident #3 enter the pharmacy, and she could have been there more than 10 minutes. The Pharmacy Manager confirmed he called the police, who arrived at the same time the nursing home staff arrived to retrieve the resident. During interviews on 12/12/2022 at 8:15 AM and at 10:52 AM, the Maintenance Director was asked if he checked the front door weekly. The Maintenance Director stated .I don't check them .I did not know what a wanderguard was until now . The Maintenance Director confirmed he did not start checking the front door until October 2022, and had no other documentation the front doors were checked weekly. The Maintenance Director confirmed he conducted an elopement drill once a year on one shift, and the last elopement drill was in July 2021 on the first shift. The Maintenance Director confirmed he did not check the front door correctly, and did not know the door was malfunctioning until the door technician alerted him. During a telephone interview on 12/12/2022 at 11:21 AM, the Door Technician was asked what repairs he made to the front door and alarm system. The Door Technician stated .I rewired the antenna on the door, only one had come disconnected on the back, and I pulled it all off to make sure it was secure .a door contact was completely broken .had to replace it on the top left side of the door .it was not working .it allowed the resident to just walk through the door and not alarm .if you approach the door it should turn red .if the resident walked through the door the alarm should have sounded .that was not happening when I was there . The Door Technician was asked how the door functioned. The Door Technician stated .when the resident walk to the door with the wanderguard on .the panel senses the wanderguard .it will lock the door down immediately .if the door is open it senses the wanderguard .it will alarm because it can't lock down the door .when the resident went out the door .the door should have alarmed .the antenna was not working .there are 2 antennas on the door .the one on the right side of the door .was not working .it was disconnected . During an interview on 12/12/2022 at 12:43 PM, the Treatment Nurse was asked if she knew Resident #3 eloped from the facility. The Treatment Nurse stated .I was in my office .the next thing I knew people were running up and down the hallway .we checked all the rooms and the bathroom .could not find her .we moved to the outside of the building .I went out the back door and around the back of the building all the way around to the Assisted Living Facility .there were 2 ladies sitting back there .I asked if they had seen a lady .they said no .they said someone has come by already .we did not see her .by the time I made it around the side of the building .I saw 2 nurses with her coming from the pharmacy .they said that is where they found her .it had not been very long .less than 30 minutes . The Treatment Nurse was asked how long did they search inside the building. The Treatment Nurse stated .about 10-15 minutes we searched inside the building .then searched and went outside .it was about 20-30 minutes before she was found . During a telephone interview on 12/12/2022 at 2:06 PM, the Confidential Dispatch Operator stated the call was at 1543 [3:43 PM] and was cleared at 1552 [3:52 PM] .9 minutes . During a telephone interview on 12/14/2022 at 10:05 AM, the Social Worker was asked what she was doing when Resident #3 exited the facility. The Social Worker stated .I was there .I did not know it had happened until everyone was looking for her .I was in my office .my office is right beside the front door .I went to the C hall .asked 2 people there if she was gone they said just heard about it .most people were in the process of looking in the room then .I walked back to my office .they were back into the building .2 people [Named Front desk Staff Member] .one of the nurses .it was at the end of the day .I know it was before 4:30 PM .a few department heads had gone home .I did not hear the alarm go off at the door .I never heard them call a code .they usually call a code . The Social Worker confirmed Resident #3 wanted to go home, wanted the Social Worker to call her daughter, and did not understand why she was in the facility. During an interview on 12/14/2022 at 3:50 PM, LPN #4 was asked if she knew Resident #3 had wandered away from home. LPN #4 stated .when I completed the elopement evaluation .I talked to the daughter .she [Resident #3] would get out of the house . LPN #4 confirmed Resident #3 went to the fire door and the alarm went off and startled her when she was pushing on the bar. LPN #4 confirmed she assumed the wanderguard was working and did not check the function of the wanderguard. During an interview on 12/15/2022 at 11:35 AM, the Medical Director confirmed the staff members should be aware of residents who are at risk for wandering and elopement. The Medical Director confirmed a resident should not be allowed to leave the facility unsupervised. Refer to F-610, and F-689. The surveyors verified the removal plan through observations, review of education records, and staff interviews conducted on all shifts. 1. On December 14, 2022, the [NAME] President of Clinical Operation (VPCO) re-educated the Administrator, Chief Director of Clinical Operations (CDCO), on Abuse and Neglect Prevention and Elopement Policy. This was confirmed by surveyors through interviews. 2. A total of 67 out of 108 staff were in-serviced on Abuse & Neglect Prevention and Elopement Policy on 11/4/2022 by the CDON and Clinical Unit Managers. This was confirmed by surveyors through interviews and medical record review. 3. On December 13, 2022, all remaining staff and contract staff will receive education regarding Abuse & Neglect Prevention, and the Elopement Policy. This was confirmed by surveyors through interview. 4. Employees will not be able to work an assignment until the in-services are completed. New hires and employees on LOA (leave of absence) will not be placed on the schedule and will not be allowed to return to work until in-services are completed. This was confirmed by surveyors through interviews. 5. An Elopement Drill was completed by maintenance for 7-3, 3-11, and 11-7 shifts 12/13/22. A total of 57 out of 108 employees participated in the Elopement Drills conducted on all shifts. At present 55% employees have participated. Elopement Drills will continue until 100% participation of staff and contract staff is achieved. Staff will be allowed to work while drills are being completed. This was confirmed by surveyors through interviews, medical record review, and observations. 6. Beginning December 13, 2022, Licensed Nurses will be in-serviced on signing the electronic medical record (eMAR) for wanderguard for function and placement by the Chief Clinical Director of Operations. Licensed Nurses will not be able to work an assignment until the in-services are completed. New hires and Licensed Nurses on LOA will not be allowed to return to work until in-services are completed. This was confirmed by surveyors through interviews and record reviews. 7. The Corporate Director of Nursing (CDON) or designee will audit the Medication Administration Records (MAR) 7a-7p/7 days a week after a Wanderguard is placed on a Resident. Monitoring will continue 7 days a week for 4 weeks then weekly for times 2 months. The DON/designee will report findings in Quality Analysis Process Improvement (QAPI) meetings monthly for 3 months or until a period of compliance is achieved. This was confirmed by surveyors through interviews. 8. The Maintenance Director will monitor the front entry door with a wanderguard and all other doors weekly for proper function as part of preventative maintenance program. Technician inspected and repaired wanderguard door and maintenance checked other doors with technician 11/8/22, no other door had wanderguard. All other doors functioned properly. Maintenance/designee will report finding to QAPI monthly for 3 months. If the front entry door with the wanderguard locking function is discovered not to be working properly the Administrator will be notified and the service vendor will be called to come to the facility for an assessment if trouble shooting efforts have not restored proper alarming or locking function. This shall be reported to the QAPI committee, and documented in the preventative software computer program. This was confirmed by surveyors through interviews and observations. The facility's noncompliance of F-600 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure incidents of neglect/elopement were thoroughly investigated for 1 of 5 sampled residents (Resident #3) reviewed for wandering/elopement behaviors. The facility's failure to thoroughly investigate incidents of elopement resulted in Immediate Jeopardy when Resident #3, a cognitively impaired resident at risk for wandering/elopement, exited the facility without staff knowledge, was missing for an undetermined amount of time and was later found at a nearby pharmacy approximately 218 feet from the facility. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON), were notified of the Immediate Jeopardy (IJ) for F-610 on 12/13/2022 at 4:40 PM, in the Alpha Room. The facility was cited Immediate Jeopardy at F-610 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 11/4/2022 through 12/15/2022. An acceptable Removal Plan for F-610, which removed the immediacy of the Jeopardy, was received on 12/15/2022 at 11:01 AM. The corrective actions were validated onsite by the surveyors on 12/15/2022 through observations, review of education records, and staff interviews conducted on all shifts. The findings include: 1. Review of the facility's policy titled, INCIDENT REPORT-DOCUMENTATION, INVESTIGATING, AND REPORTING, revised September 20, 2021, revealed .The Nursing Supervisor/Charge Nurse and /or the department director or supervisor shall promptly initiate and document investigation of the accident or incident and the notifying of the Director of Nursing and Administrator .The Administrator/director of Nursing should obtain signed and dated written statements from all witness with knowledge of the event. The Administrator/Director of Nursing should review these statements with respective staff, document findings, re-view the potentially refined report with the staff member and the staff member should sign off with the Administrator/Director of Nursing that they concur .The supervisor designee is to document the investigation of the event and the intervention put into place. They will ensure that the care plan is updated, that the medial records contains documentation of the event . Review of the facility's undated policy titled, MISSING RESIDENT, revealed .If the search of the immediate area (building) is unsuccessful, the Nursing Shift Supervisor/Charge Nurse will immediately contact .Local Police Department . Review of the facility's policy titled, Use of Alarms Policy, revised October 2021, revealed .Wander/Elopement Alarm .include devices such as bracelet .worn on the resident clothes .sensors in resident shoes, or building/unit exit sensor worn or attached to the resident that alert the staff when the resident nears or exits an area or building . 2. Review of the facility's undated Director of Nursing (DON) Job Description, revealed .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines and regulation that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times .Assist the Quality assessment & [and] assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies .Review complaints .made or filed by department personnel .Participate in the interviewing and selection of resident for admission to the facility .Report and investigate all allegations of resident abuse . 3. Closed medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Hypertension, and Anxiety Disorder. Review of an Elopement Evaluation dated 10/21/2022, revealed Resident #3 had a history of elopement/attempted elopement while at home, and attempted leaving the facility without staff knowledge, wandering, and verbally expressed a desire to go home. Review of an Elopement Evaluation dated 11/4/2022, revealed Resident #3 had a history of elopement/attempted elopement while at home, attempted leaving the facility without staff knowledge, wandering, and application of a personal safety alarm device. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, had wandering behavior, and had a wander/elopement alarm that was used daily. Review of the Incident Report dated 11/4/2022, revealed .Around 3:50 pm nurse notified by CNA [Certified Nursing Assistant] that the resident was missing. Code Search initiated. Staff members searched the facility as well as outside. Staff searched out to the road, at the bank next door, the plaza near the facility and around [Named Facility] building. Resident was found at [Named Pharmacy] and was escorted back to the facility . The Incident Report did not specify what time Resident #3 was located and returned to the facility. Review of a Psychosocial/Social Service Note dated 10/25/2022, revealed .Resident denied wanting to harm herself. Resident visibly upset, putting hands over her ears saying, 'I don't want to listen to you.' Resident stated that she just wants to go home because she doesn't belong here. Resident asked if I would contact her daughter and tell her to come get her . Review of a Nurses Note dated 11/2/2022, revealed .Resident wandering this shift, frequently approaching back door, and holding onto door handle despite door alarm sounding. This nurse and B hall nurse redirected resident back to her room multiple times. Resident forgets where her room is at, has difficulty finding her belongings in the room as well . Review of the Maintenance Log of the front door checks revealed the front door was not checked prior to October 2022. The doors were not checked the week of 10/23/2022 -10/30/2022 or the week of 10/31/202 - 11/6/2022. During an interview on 12/9/2022 at 10:51 AM, Unit Manager #1 confirmed Resident #3 eloped from the facility unsupervised when the Front Desk Staff member failed to recognize her as a resident. Resident #3 walked out the front door with a visitor. Unit Manager #1 confirmed she did not notify the police. During an interview on 12/9/2022 at 11:27 AM, Registered Nurse (RN) #1 was asked if she was aware Resident #3 got outside the facility. RN #1 stated .the last time I saw her was after the CNA directed her back to her room .[Named CNA #6] .the CNA went to check on her again .she [Resident #3] was agitated and wandering .she went to her room .did not find her .we started looking throughout the facility .did not find her in the building .we began to look outside the facility .she was at [Named Pharmacy] they went inside the store and found her sitting in a chair with one of the staff members who worked there . RN #1 confirmed she did not take Resident #3 to the front door to check the function of her wanderguard the day she eloped from the facility on 11/4/2022. RN #1 confirmed she was told it worked when she was on the C hall and did not check it. During a telephone interview on 12/9/2022 at 12:00 PM, the Front Desk staff member was asked how Resident #3 got out of the facility. The Front Desk staff member stated .she was a new resident .I had seen her one time when she was admitted .she walked out behind another lady .I opened the door .both ladies went out .I just assumed they were together .that is how she got out . The Front Desk Staff member confirmed Resident #3 was found at a nearby pharmacy with her wanderguard intact. During an interview on 12/9/2022 at 2:05 PM, the Pharmacy Manager for the pharmacy where Resident #3 was found confirmed Resident #3 was in the pharmacy holding a package of urinary incontinence briefs labeled with her name on them, became upset, and was retrieved by the nursing home staff members after approximately 10 minutes. The Pharmacy Manager relayed that he did not see Resident #3 enter the pharmacy, and she could have been there more than 10 minutes. The Pharmacy Manager confirmed he called the police, who arrived at the same time the nursing home staff arrived to retrieve the resident. During interviews on 12/12/2022 at 8:15 AM and on 12/12/2022 at 10:52 AM, the Maintenance Director was asked if he checked the front door weekly. The Maintenance Director stated .I don't check them .I did not know what a wanderguard was until now . The Maintenance Director confirmed he did not start checking the front door until October 2022. The facility was unable to provide documentation that the front doors were checked weekly. The Maintenance Director confirmed he conducted elopement drills once a year on one shift, with the last elopement drill being conducted in July 2021 on the first shift. The Maintenance Director confirmed he did not check the front door correctly and did not know the door was malfunctioning until the door technician alerted him. During a telephone interview on 12/12/2022 at 11:21 AM, the Door Technician confirmed the front door should have alarmed, but was in disrepair on 11/4/2022, when Resident #3 eloped from the facility. The Door Technician confirmed repairs were made to the front door by reconnection of an antenna. During an interview on 12/12/2022 at 12:43 PM, the Treatment Nurse confirmed resident #3 was unaccounted for approximately 20-30 minutes before she was found on 11/4/2022. During an interview on 12/13/2022 at 4:10 PM, the DON confirmed the facility staff should have called the code, completed a head count, and notified the police department. The DON confirmed the facility did not complete a thorough investigation after Resident #3 eloped from the facility on 11/4/2022. During a telephone interview on 12/14/2022 at 10:05 AM, the Social Worker confirmed her office was beside the front door where Resident #3 exited the facility on 11/4/2022, and the Social Worker stated she did not hear the door alarm nor hear a missing person code called. During an interview on 12/14/2022 at 3:50 PM, LPN #4 was asked if she knew Resident #3 wandered away from home. LPN #4 stated .when I completed the elopement evaluation .I talked to the daughter .she [Resident #3] .would get out of the house . LPN #4 confirmed Resident #3 had been observed pushing on the door handle until it alarmed. LPN #4 confirmed she assumed Resident #3's wanderguard was working and did not check the function of the wanderguard. During an interview on 12/15/2022 at 11:35 AM, the Medical Director confirmed the staff members should be aware of the residents who are at risk for wandering and elopement. The Medical Director confirmed a resident should not be allowed to leave the facility unsupervised. Review of the facility's investigation revealed the facility failed to obtain written statements or interviews with all staff member on the shift prior to and during Resident #3's elopement on 11/4/2022. The facility failed to obtain statements from Treatment Nurse, RN #1 and #2, Licensed Practical Nurse (LPN) #1, Agency CNA #1 and #2, CNA #4, #7 and Dietary Staff Member #2. The facility failed to interview staff on the 7AM-3 PM shift on 11/4/2022. Elopement drills were not conducted post elopement. The last elopement drill was held was on 7/28/2021 with 30 of the 83 staff members. Review of the in-services conducted on 11/4/2022, revealed education was provided for 67 of the 81 staff members related to the elopement and abuse policies. The facility failed to complete elopement assessments to identify other residents at risk for elopement and wandering. The facility failed to update Resident #3's care plan to reflect her risk for wandering and elopement. Staff members failed to check the function of the wanderguard at the front door. Refer to F-600 and F-689. The surveyors verified the removal plan through observations, review of education records, and staff interviews conducted on all shifts: 1. A Root Cause Analysis was initiated on 11/7/2022 and completed on December 13, 2022. Root Cause Findings: Unit Manager statement stated 5 people were involved in the elopement response: Administrator determined the 5 people from current statements and conversations with Unit manager. Administrator was able to determine based on root cause, medical review and interviews events occurred and based on her decision was able to implement appropriate interventions. This was confirmed by surveyors through interviews and review of the facility's investigation. 2. On December 14, 2022, VP (Vice President) of Clinical Operations re-educated the Administrator, Chief Director of Clinical Operations (CDCO), Assistant Chief Director of Clinical Operations Incident Report-Documentation, Investigating and Reporting. MDS Coordinator will be in-serviced on properly updating care plans after incidents 12/14/2022, by CDON. This was confirmed by surveyors through interviews and medical record reviews. 3. Beginning December 13, 2022, all staff and contract staff not educated since 11/04/2022, were in-serviced on Abuse & Neglect Prevention and Elopement Policy by Human Resources/Nursing Administration, both are deemed competent to complete in-services. Employees will not be able to work an assignment until the in-services are completed. New hires and employees on LOA (Leave of Absence) will not be placed on the schedule and/or will not be allowed to return to work until in-services are completed. Initial elopement assessment conducted by clinical team began on 11/4/2022, and concluded on 12/13/2022. Based on assessments in the electronic medical record; (4) residents are at risk of elopement behavior. Care Plans have been reviewed and updated by the interdisciplinary team as needed. This was confirmed by surveyors through interviews and review of medical records. 4. Chief Director of Clinical Operations (CDCO)/Unit Manager will monitor resident identified as at risk for elopement or unsafe wandering in clinical meeting 5 times per week by reviewing the Elopement assessment completed by clinical staff and the 24-hour shift reports for documented behaviors for elopement or unsupervised exiting attempts. This was confirmed by surveyors through interviews. 5. Elopement Assessments will be completed on newly admitted residents, quarterly or with significant changes. Results of elopement assessments will be reviewed by the interdisciplinary team and resident centered interventions will be implemented. This was confirmed by surveyors through interviews and medical record reviews. 6. Nursing Home Administrator (NHA)/ Chief Director of Clinical Operations (CDCO) will monitor and audit all reports of alleged abuse and missing residents are investigated thoroughly. Regional Director of Clinical Operations (RDCO)/designee will review alleged abuse and elopement investigations after completion by NHA per occurrence. RDCO/designee will monitor weekly times (x) 8 weeks then monthly x 3 months. DON/designee will monitor care-plan updates during clinical meeting for 8 weeks and weekly thereafter during PAR (Patient at risk meeting) for four weeks. NHA/designee will report findings in QAPI monthly x 3 months or until a period of compliance is achieved. This was confirmed by surveyors through interviews and medical record reviews. The facility's noncompliance of F-610 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, facility investigation review, medical record review, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent elopement for 1 of 5 sampled residents (Resident #3) reviewed for elopement/wandering behaviors. The facility's failure to ensure residents at risk for wandering/elopement behaviors were adequately supervised resulted in Immediate Jeopardy when Resident #3, who had severe cognition impairment and was at risk for wandering, exited the facility without staff knowledge through the front door, walked approximately 218 feet and was found by staff in a nearby pharmacy after an undetermined amount of time. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON), were notified of the Immediate Jeopardy (IJ) for F-610 on 12/13/2022 at 4:40 PM, in the Alpha Room. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 11/4/2022 through 12/15/2022. An acceptable Removal Plan for F-689, which removed the immediacy of the Jeopardy, was received on 12/15/2022 at 11:01 AM. The corrective actions were validated onsite by the surveyors on 12/15/2022 through observations, review of education records, and staff interviews conducted on all shifts. The findings include: 1. Review of the facility's policy titled, ELOPEMENT OF RESIDENT, reviewed November 30, 2021 revealed .It is the standard of this Health Care Center that appropriate procedures exist in the case of and missing resident .Make a thorough search of the building(s) and premises .Notify law enforcement officials .The Supervisor/Charge Nurse will alert other personnel by paging Dr. [doctor] wander and location (including unit, floor and room number .Verification tags will be placed on the front of the door once a room is searched .Determine time and location when last seen .Provide description of resident and photos .The Administrator and Director of Nursing Services report to the facility immediately upon notification of a missing resident .Assess the resident thoroughly to assure their health and well-being .The Supervisor/Charge Nurse will alert all other personnel by all-paging Dr. Wander All Clear and give location . Review of the facility's policy titled, UNSAFE WANDERING-ELOPEMENT RISK POLICY, reviewed November 30, 2021, revealed .All residents will be assessed for elopement using an elopement assessment upon admission and review and updated quarterly and as necessary .The resident's care plan will be modified to indicate the resident is at risk for elopement. Facility staff will be informed of the modification to the resident's care plan .Interventions will be entered on the resident's care plan and medical record .The resident will have a picture taken and placed in the elopement book. The book will be located on each unit and at the front desk .Should an elopement episode occurs, an incident report will be completed providing explanation of how the event occurred and contributing factors .If an elopement episode occurs, a monitoring schedule will be implemented to ensure resident safety. Resident's monitoring schedule will be determined by the interdisciplinary team. The resident care plan will be updated as to the implementation of the monitoring schedule . Review of the facility's policy titled, ELOPEMENT OF RESIDENT, reviewed November 21, 2021, revealed .Were the alarms system working properly .were all internal and external doors visually checked .Randomly test door and personal alarm system .Stage quarterly mock drills . Review of the facility's undated policy titled, MISSING RESIDENT, revealed .if the search of the immediate area (building) is unsuccessful, the Nursing Shift Supervisor/Charge Nurse will immediately contact .Local Police Department . 2. Closed medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Hypertension, and Anxiety Disorder. Review of an Elopement Evaluation dated 10/21/2022, revealed Resident #3 had a history of elopement/attempted elopement while at home, attempted leaving the facility without staff knowledge, wandered, and verbally expressed a desire to go home. Review of an Elopement Evaluation dated 11/4/2022, revealed Resident #3 had a history of elopement/attempted elopement while at home, attempted leaving the facility without staff knowledge, wandered, and used a personal safety alarm device. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, had wandering behavior, and had a wander/elopement alarm that was used daily. Review of the Physician's Orders dated 10/22/2022, revealed .Wanderguard-Check every shift for placement and active . Review of the Medication Administration Record (MAR), dated 11/1/2022-11/30/2022 revealed the wanderguard was not checked on 11/4/2022 on the 7:00 AM - 7:00 PM shift. Review of Psychosocial /Social Service Note dated 10/25/2022, revealed .Spoke with resident .Resident denied wanting to harm herself. Resident visibly upset, putting hands over her ears saying, I don't want to listen to you. Resident stated that she just wants to go home because she doesn't belong here. Resident asked if I would contact her daughter and tell her to come get her . Review of a Nurses Note dated 11/2/2022, revealed .Resident wandering this shift, frequently approaching back door, and holding onto door handle despite door alarm sounding. This nurse and B hall nurse redirected resident back to her room multiple times. Resident forgets where her room is at, has difficulty finding her belongings in the room as well . Review of Nurse Note dated 11/4/2022 at 15:50 (4:50 PM), revealed .Was notified by CNA [Certified Nursing Assistant] that the resident was missing. Staff members searched the facility as well as outside. Staff searched out to the road, at the bank next door, the plaza near the facility and around [Named Towers] building. Resident was found at [Named Pharmacy] and was escorted back to the facility . Review of the Incident Report dated 11/4/2022, revealed .Around 3:50 pm nurse notified by CNA that the resident was missing. Code Search initiated. Staff members searched the facility as well as outside. Staff searched out to the road, at the bank next door, the plaza near the facility and around [Named Facility] building. Resident was found at [Named Pharmacy] and was escorted back to the facility .Other info [information] .Resident was sitting in common area on A/B hall and at 3:50 [3:50 PM] noted she had left her chair .visitor reached the front desk she told reception she needed to go out and move her car. The door was unlocked by the receptionist and the visitor and the resident both exited the door at the same time .resident .returned to the facility by staff by 3:55 pm .lack of resident identification when opening doorway . Review of the Maintenance Log of the front door checks dated October and November 2022, revealed the front door was not checked prior to October 2022. The doors were not checked the weeks of 10/23/2022 -10/30/2022 and 10/31/202 - 11/6/2022. Review of the Facility Assessment reviewed and updated 10/22/2022-10/22/2023, revealed 11 residents at high risk for wandering. Review of the Assessment Scoring Report dated 11/4/2022, revealed the facility had 6 residents at risk for elopement and wandering. Review of the undated Wanderguard Book on 12/9/2022, revealed 3 residents identified with wanderguards (Resident #3, #10 and Resident #11). Resident #11 was discharged on [DATE], and Resident #3 was discharged on [DATE]. The facility failed to update the wanderguard book to reflect the residents identified for wandering and elopement according to the Facility Assessment. Review of the QAPI (Quality Assurance Performance Improvement) Root Cause Analysis (RCA) WORKSHEET, revealed .Elopement from facility of Resident on 11-4-22 between 3:50 [3:50 PM] to 3:55 [3:55 PM] .Difficulty in identification of resident when ambulatory and appears to be visitor . The facility did not reassess the residents at risk for wandering or update the care plans after the incident of elopement on 11/4/2022. During an interview on 12/9/2022 at 10:51 AM, Unit Manager #1 confirmed Resident #3 eloped from the facility unsupervised when the Front Desk Staff Member failed to recognize her as a resident. Resident #3 walked out the front door with a visitor. Unit Manager #1 confirmed she did not notify the police. During an interview on 12/9/2022 at 11:27 AM, Registered Nurse (RN) #1 was asked if she was aware Resident #3 got outside the facility. RN #1 stated .the last time I saw her was after the CNA directed her back to her room .[Named CNA #6] went to check on her again .she [Resident #3] was agitated and wandering .she went to her room .did not find her .we started looking throughout the facility .did not find her in the building .we began to look outside the facility .she was at [Named Pharmacy] they went inside the store and found her sitting in a chair with one of the staff members who worked there . RN #1 confirmed she did not take Resident #3 to the front door to check the function of her wanderguard the day she eloped from the facility on 11/4/2022. RN #1 confirmed she was told it worked when she was on the C hall and did not check it. During a telephone interview on 12/9/2022 at 12:00 PM, the Front Desk staff member was asked how Resident #3 got out of the facility. The Front Desk staff member stated .she was a new resident .I had seen her one time when she was admitted .she walked out behind another lady .I opened the door .both ladies went out .I just assumed they were together .that is how she got out . The Front Desk Staff member confirmed Resident #3 was found at a nearby pharmacy with her wanderguard intact. During an interview on 12/9/2022 at 2:05 PM, the Pharmacy Manager for the pharmacy where Resident #3 was found confirmed Resident #3 was in the pharmacy holding a package of urinary incontinence briefs labeled with her name on them, became upset, and was retrieved by the nursing home staff members after approximately 10 minutes. The Pharmacy Manager relayed that he did not see Resident #3 enter the pharmacy, and she could have been there more than 10 minutes. The Pharmacy Manager confirmed he called the police, who arrived at the same time the nursing home staff arrived to take the resident back to the nursing facility. During interviews on 12/12/2022 at 8:15 AM and on 12/12/2022 at 10:52 AM, the Maintenance Director was asked if he checked the front door weekly. The Maintenance Director stated .I don't check them .I did not know what a wanderguard was until now . The Maintenance Director confirmed he did not start checking the front door until October 2022. The facility was unable to provide documentation that the front doors were checked weekly. The Maintenance Director confirmed he conducted elopement drills once a year on one shift, with the last elopement drill being conducted in July 2021 on the first shift. The Maintenance Director confirmed he did not check the front door correctly and did not know the door was malfunctioning until the door technician alerted him. During a telephone interview on 12/12/2022 at 11:21 AM, the Door Technician confirmed the front door should have alarmed, but was in disrepair on 11/4/2022, when Resident #3 eloped from the facility. The Door Technician confirmed repairs were made to the front door by reconnection of an antenna. During an interview on 12/12/2022 at 12:43 PM, the Treatment Nurse confirmed resident #3 was unaccounted for approximately 20-30 minutes before she was found on 11/4/2022. During a telephone interview on 12/12/2022 at 2:06 PM, the Confidential Dispatch Operator stated The call was at 1543 [3:43 PM] and was cleared at 1552 [3:52 PM] .9 minutes . During an interview on 12/13/2022 at 4:10 PM, the DON confirmed the facility staff should have called the missing person code, completed a head count, and notified the police department. The DON confirmed the facility did not complete a thorough investigation after Resident #3 eloped from the facility on 11/4/2022. During a telephone interview on 12/14/2022 at 10:05 AM, the Social Worker confirmed her office was beside the front door where Resident #3 exited the facility on 11/4/2022, and the Social Worker stated she did not hear the door alarm nor hear a missing person code called. During an interview on 12/14/2022 at 3:50 PM, Licensed Practical Nurse [LPN] #4 was asked if she knew Resident #3 wandered away from home. LPN #4 stated .when I completed the elopement evaluation .I talked to the daughter .she [Resident #3] .would get out of the house . LPN #4 confirmed Resident #3 had been observed pushing on the door handle until it alarmed. LPN #4 confirmed she assumed Resident #3's wanderguard was working and did not check the function of the wanderguard. During a telephone interview on 12/14/20222 at 7:24 PM, LPN #2 confirmed she did not take Resident #3 to the front door to check the function of the wanderguard. LPN #2 confirmed Resident #3 would wake up in the early mornings, wander down the B Hall and come back to the A Hall, and once she went to the back door on the B Hall, which was the smoke break door that leads out to the sheds. During an interview on 12/15/2022 at 11:35 AM, the Medical Director confirmed the staff members should be aware of the residents who are at risk for wandering and elopement. The Medical Director confirmed a resident should not be allowed to leave the facility unsupervised. During an interview on 12/15/2022 at 5:36 PM, LPN #6 confirmed Resident #3 would wander off the C Hall to the B Hall, and was returned by other staff members. LPN #6 confirmed she never took Resident #3 to the front door to check the function of her wanderguard. LPN #6 confirmed she received in report that Resident #3 tried to go out the back door on the Covid hall. LPN #6 confirmed she was not aware of the wanderguard book. Refer to F-600 and F-610. The surveyors verified the removal plan by: 1. On December 14, 2022, [NAME] President of Clinical Operation (VPCO) re-educated the Administrator, Chief Director of Clinical Operations (CDCO), on Abuse and Neglect Prevention and Elopement Policy and Accident and Incident Investigation Procedures. This was confirmed by interviews and record review. 2. Beginning December 13, 2022, all staff and contract staff not educated since 11/04/2022, were in-serviced on Abuse & Neglect Prevention and Elopement Policy, by Human Resources/Nursing Administration. Total staff including contract is 102, of which 97 have completed the required in-services. Employees will not be able to work an assignment until the in-services are completed. New hires and employees on LOA (leave of absence) will not be placed on the schedule and/or will not be allowed to return to work until in-services are completed. This was confirmed by interviews and record review. 3. An Elopement Drill completed by maintenance for 7-3, 3-11, and 11-7 shifts 12/13/22. A total of 57 out of 102 employees participated in the Elopement Drills conducted on all shifts. At present 55% employees have participated. Elopement Drills will continue until 100% staff and contract staff participation, staff will be allowed to work while drills are completed. This was confirmed by observation, interviews, and record review. 4. Beginning December 13, 2022, in addition, Licensed Nurses were in-serviced on signing the electronic medical record eMAR (electronic medication administration record) for wanderguard for function and placement. Licensed Nurses will not be able to work an assignment until the in-services are completed. New hires and Licensed Nurses on LOA will not be placed on the schedule and/or will not be allowed to return to work until in-services are completed. As of 12/14/22, (22) out of (23) have completed the in-service. This was confirmed by interviews and record review. 5. CDON/designee will audit MARS (medication administration records) 7a-7p for 7 days a week after wanderguard is placed is placed on resident. Monitoring will continue 7 times a week for 4 weeks then weekly for times 2 months. CDON/designee will report findings in QAPI (quality assurance performance improvement) monthly times 3 months or until a period of compliance is achieved. This was confirmed by interviews and record review. 6. Maintenance will check wanderguard and all other doors weekly for proper function as part of preventative maintenance program. Technician inspected and repaired wanderguard door and maintenance checked other doors with technician 11/8/22, no other door had wanderguard. All other doors functioned properly, and the doors will be checked weekly for proper function as part of preventative maintenance program. Maintenance/designee will report finding to QAPI monthly times 3 months. If an exit door with the wander guard locking function is discovered not to be working properly the Administrator will be notified and the service vendor will be summonses for an assessment if trouble shooting efforts have not restored proper alarming or locking function. This shall be reported to the QAPI committee and documented in the preventative software computer program - maintenance care. This was confirmed by interviews and record review. The facility's noncompliance of F-689 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to follow the facility policy for monitoring weights and failed to follow the Registered Dietician's (RD) recommendations to provide nutritional interventions for 1 of 8 sampled residents (Resident #54) reviewed for nutrition and the facility failed to follow the RD recommendations timely and obtain reweight assessments for a weight change for 1 of 8 sampled residents (Resident #24) reviewed for nutrition. The facility's failure to monitor weights and follow the RD recommendations for nutritional interventions resulted in Actual Harm when Resident #54 had a severe weight loss. The findings include: Review of the facility's WEIGHT ASSESSMENT AND INTERVENTION POLICY, revised 4/2022, revealed .The multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents .The nursing staff will measure resident weights on admission and weekly for (4) four weeks thereafter .Any weight change of 5% [percent] or more since the last weight assessment will be retaken the next day for confirmation .Negative trends will be evaluated by the treatment team whether or not the criteria for 'significant' weight change has been met .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month - 5% weight loss is significant; greater than 5% is severe .Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made .The Physician and the multidisciplinary team will identify conditions and medications that may cause anorexia, weight loss .Interventions for undesirable weight loss shall be based on careful consideration .Nutrition and hydration needs of the resident .The use of supplementation . Review of the medical record, revealed Resident #54 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #54 had a Brief Interview for Mental Status (BIMS) of 9, which indicated he was moderately cognitively impaired, required assistance of staff for all activities of daily living (ADLs), and weighed 203 pounds. Review of Resident #54's weights revealed the following: a. 3/22/2022 202.4 pounds (lbs). b. 3/23/2022 202.6 lbs. c. 4/14/2022 173.8 lbs., which was a loss of 28.8 pounds or a severe weight loss of 14.2 % from 3/23/2022 to 4/14/2022. d. On 4/26/2022, Resident #54 weighed 155.6 pounds, a total loss of 47 pounds or a severe weight loss of 23.2% from 3/23/2022-4/26/2022. Review of the Care Plan revised on 4/14/2022, revealed .The resident has nutritional problem .receives a mechanically altered diet .4/14/22 [2022]: -14.2% x [times] 1 month .Monitor/record/report to MD [Medical Doctor] PRN [as needed] s/sx [signs and symptoms] of malnutrition: Emaciation [abnormally thin or weak] (Cachexia) [marked weight and muscle loss], muscle wasting, significant weight loss: 3 lbs in 1 week, >[greater than] 5% in 1 month,>7.5% in 3 months, >10% in 6 months .Provide and serve supplements as ordered .RD to evaluate and make diet change recommendations PRN [as needed] . Review of Resident #54's Dietary Note dated 4/14/2022, revealed .-14.2% x 1 month .3/23 [2022] weight accuracy? [question] .Rec [recommend] Ensure plus [nutritional supplement] one daily x 4 weeks, fortified cereal with breakfast x 3 weeks r/t [related to] weight loss. weekly weights X4. reweigh for accuracy . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Ensure Plus one time a day for Nutritional Supplementation for 4 weeks . This recommendation was implemented on 4/19/2022, 5 days after the Dietary Note was made by the Dietician. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was unable to provide documentation of Resident #54's re-weights and weekly weights. Observation of Resident #54's weight recheck on 4/26/2022 at 1:56 PM, revealed Licensed Practical Nurse (LPN) #2 weighed Resident #54 in her wheelchair with an oxygen tank. The resident's weight was 205 pounds. Resident #54 was assisted back to bed and her wheelchair with the oxygen tank was weighed. The wheelchair weighed 49.4 lbs and revealed the resident weighed 155.6 lbs. This was a weight loss of 18.2 lbs. since 4/14/2022 and the dietary recommendations were not started until 4/19/2022 (5 days after the recommendations on 4/14/2022). During an interview on 4/26/2022 at 10:49 AM, the RD confirmed Resident #54 was not on weekly weights. The RD confirmed Resident #54 had been evaluated on 4/14/2022 and had a weight loss of 14% in one month and confirmed his recommendation for a re-weight and the weekly weights had not been implemented. The RD confirmed he sent an email on 4/14/2022 with his recommendations to the Administrator, Director of Nursing (DON), Dietary Manager, and Unit Managers. During an interview on 4/26/2022 at 3:57 PM, the DON confirmed Resident #54 should have been reweighed, on weekly weights, and the recommendations should have been implemented at the time of the RD recommendation. The facility's failure to monitor weights and follow RD recommendations for nutritional interventions resulted in Actual Harm when Resident #54 had a severe weight loss. Review of the medical record, revealed Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS assessment dated [DATE], revealed Resident #24 had a BIMS score of 8, which indicated she was moderately cognitively impaired, required supervision for meals, and weighed 162 pounds. Review of Resident #24's weights revealed the following: a. 1/18/2022 -161.4 lbs. b. 2/8/2022 - 162.4 lbs. c. 3/11/2022 -163.2 lbs. d. 4/14/2022 -154.2 lbs. e. 4/19/2022 -153.2 lbs. On 3/11/2022, Resident #24 weighed 163.2 lbs. On 4/14/2022, Resident #24 weighed 154.2 pounds which is a loss of 9 pounds or a 5.5% weight loss in 30 days. Review of the Care Plan revised on 4/14/2022, revealed .resident [Resident #24] has nutritional problem or potential nutritional problem r/t .[CONDITION(S)], dementia .receives a mechanically altered diet 4/14/22 [2022]: -5.5% x 1 month .Interventions .Monitor/Document for side effects and effectiveness .muscle wasting, significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months .Provide and serve diet as ordered .Provide and serve supplements as ordered . Review of the Registered Dietician's Note dated 4/14/2022, revealed .Weight Review .3/11[2022] .163.2 .154.2 lb (4/14)[2022] .-5.5% x 1 month .Resident receives regular, dysphagia advanced texture diet with PO [by mouth] intake 0 - 100% q [every] meal .appetite varies .resident tends to like snacks sometimes .No issues chewing or swallowing noted no [CONDITION(S)] noted feeds self .Rec weekly weights x 4 . offer afternoon/HS [hour of sleep] snack r/t weight loss, fortified cereal with breakfast x 2 weeks . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This recommendation was implemented 5 days after the RD's recommendation. During an interview on 4/26/2022 at 10:17 AM, LPN #2 confirmed Resident #24 wasn't re-weighed the next day after her 9-pound weight loss on 4/14/2022 per facility policy. LPN #2 confirmed the RD's 4/14/2022 recommendation to re-weigh Resident #24 and offer afternoon and a bedtime snacks should have been entered in the resident's electronic record that evening or the next day. During an interview on 4/26/2022 at 10:50 AM, the RD confirmed Resident #24 was not re-weighed the next day following her 9 lb. weight loss on 4/14/2022 per facility policy. The RD was asked what had been recommended on 4/14/2022 for the weight loss. The RD stated, .weekly weights .added snack in the afternoon and evening .to make sure she gets that .she does tend to snack trying to increase her po [by mouth intake] . The RD confirmed he sent an email on 4/14/2022 with his recommendations to the Administrator, DON, Dietary Manager, and Unit Managers. The RD was asked when the recommendation should have been added. The RD stated, .I think this recommendation should be implemented as soon as possible .time is vital . The RD confirmed he would expect the staff to follow the facility policy and his recommendation. During an interview on 4/26/2022 at 3:57 PM, the DON confirmed Resident #24 was not re-weighed the next day per facility policy after a 9 lb. weight loss. The DON confirmed Resident #24 was not weighed per facility policy and the RD's recommendation were not implemented until 4/19/2022, five days after the RD's recommendation.

Based on policy review, hospital medical record review, medical record review, observation and interview, the facility failed to ensure care plan interventions were implemented for 2 of 7 (Resident #1 and #2) sampled residents reviewed for accidents. The facility failed to implement the intervention to supervise Resident #1, who was assessed with [REDACTED]. This resulted in actual harm and Immediate Jeopardy when Resident #1 was not supervised by facility staff during transport to an outside appointment and fell sustaining lacerations and a fractured nose. The facility failed to implement the safe mechanical lift (assistive transfer device) transfer intervention utilizing 2 staff members to transfer Resident #2. Resident #2 was assessed with [REDACTED]. This resulted in actual harm and Immediate Jeopardy when Resident #2 was transferred via mechanical lift by 1 staff member and was found with a discoloration on the cheek on 11/7/18. On 12/12/18 Resident #2 developed bruising and swelling of the face and sustained a fractured mandible (jaw). Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 1/27/19 at 9:00 AM in the conference room. The facility was cited an Immediate Jeopardy at F656-J. The Immediate Jeopardy is ongoing. An extended survey was conducted on 1/26/19 and 1/27/19. The findings include: 1. Review of the facility Care Plan policy revised on 12/12/17 documented, .Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 2. Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed a score of 10 out of 15 which indicated the resident had moderately impaired cognition. A Fall Risk assessment dated [DATE] and 12/19/18 revealed a score of 14 and was .at high risk for potential falls. Resident #1's Care Plan initiated on 11/19/18 documented, The resident has an ADL (activity of daily living) Self Care Performance Deficit .Interventions .The resident requires staff participation with transfers. A Care Plan initiated on 11/28/18 documented The resident has impaired cognitive function r/t (related to) dementia . Interventions .supervise . Resident #1's Care Plan initiated on 11/28/18 documented The resident has impaired cognitive function r/t (related to) dementia .Interventions .supervise . Resident' #1's Nurses note by the DON dated 12/19/18 at 2:45 PM documented, .Patient with dental apt (appointment) today .Patient noted to have left the front door for dentist apt with (Named Transport Company) transport x1 (1 transport employee). A few mins (minutes) later entered the facility with (Named Transport Company) transport .Patient was sitting up in WC (wheelchair) with blood noted on face .911 called for transport . Interview with the DON on 1/15/19 at 1:00 PM in the conference room, the DON was asked if anyone accompanied Resident #1 to the dental appointment and the DON stated, No staff accompanied (Named Resident #1) . The DON was asked the cognitive status of Resident #1 and stated, .his cognition does come and go .he didn't remember anything after the fall .he has had previous falls . The DON was asked what was expected during transportation if a resident was cognitively impaired and stated, If a resident is cognitively impaired then either a family member or a CNA (certified nursing assistant) goes with them . Interview with Transportation Employee #1 on 1/16/19 at 1:00 PM via telephone, Transportation Employee #1 was asked if anyone accompanied him and Transportation Employee #1 stated, .I went to the desk .I was told his daughter was going to meet us at the doctor's clinic . Interview with Resident #1 on 1/16/19 at 1:40 PM in his room, Resident #1 was asked to describe the events on the day he fell in the parking lot and stated, .1 transport guy came to (my) room .(I) got in wheelchair .the transport guy took me out the front doors and down the ramp, at the bottom he stopped but I didn't, I slid out (of the wheelchair) in the driveway and landed on my knees, hands and hit my face .He took me out forward and took me down that ramp forward . Observations during this interview revealed Resident #1 had a healed scar area across the bridge of his nose and healed scars on both knees. The facility failed to ensure the care plan intervention of supervision was implemented for Resident #1, a cognitively impaired resident with a history of falls and mobility deficits resulting in actual harm and Immediate Jeopardy when Resident #1 was transported out of the building unaccompanied, unsupervised by facility staff, and not assessed to travel independently. Resident #1 was taken from the facility to the transport van by a transport company employee. The resident fell and sustained lacerations and a fractured nose. 3. Review of the facility Lift Management Program policy dated (MONTH) (YEAR) documented, .Our Lift Management Program is designed to meet the following goals: .To protect .residents from injury .Each co-worker is expected to support this program 100% (percent) .This procedure is always done with 2 people . 4. Medical record review for Resident #2 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. An Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was assessed with [REDACTED]. Resident #2's Care Plan initiated on 4/4/18 revealed, The resident has an ADL (activities of daily living) Self Care Performance (deficit) .r/t (related to) stroke .dementia .[MEDICAL CONDITION] .Interventions .Hoyer (mechanical) lift with assist of 2 for transfers . An incident report dated 11/7/18 at 1:30 AM revealed Resident #2 was found with a discoloration on her left cheek. An Incident Report dated 12/12/18 at 10:06 AM documented, .Witnesses Statement 12/12/18 Phone interview with (named Certified Nursing Assistant (CNA) #1) states she believes she did not have adequate assist with Hoyer (mechanical) lift. She said it was possible the lift arm tapped (named Resident #2) cheek . Review of Resident #2's hospital medical record revealed a History and Physical (H&P) dated 12/15/18 that documented, .She (Resident #2) presented from a nursing home with worsening altered mental status and facial bruising .Significant bruising on the left side of her jaw .CT maxillofacial: Subtle (high energy trauma) nondisplaced [MEDICAL CONDITION] body of the right mandible (jaw) . Interview with CNA #1 on 12/28/18 at 12:57 PM via telephone, CNA #1 was asked how she transferred Resident #2 and she stated, .I get her up in the morning, 1 person .since I've been there, I've always transferred by myself . Interview with the DON on 1/15/19 at 1:00 PM in the conference room, the DON was asked what she expected staff to do during lift transfers and she stated, .2 people are to transfer with lifts. The facility failed to ensure staff implemented the care plan interventions, appropriately and safely transferred Resident #2 via mechanical lift which resulted in actual harm and Immediate Jeopardy when Resident #2 was found with a discoloration on her left cheek 11/7/18 and on 12/12/18 developed significant facial bruising, swelling, deterioration of swallowing status and was found with a fractured right mandible (jaw) after 1 staff member independently transferred the resident by mechanical lift.

Based on Invacare Reliant 450 (mechanical) Lift (assistive transfer device) manufacturer recommendation review, Oxford University Hospitals Occupational Therapy manual review, Lippincott Manual of Nursing Practice 10th Edition review, Mobility Advisor Wheelchair Ramps review, policy review, medical record review, and interview, the facility failed to ensure staff provided care according to acceptable standards of clinical practice to prevent accidents for 2 of 7 (Resident #1 and #2) sampled residents reviewed for accidents. The facility failed to ensure safe transport was provided for Resident #1 who was transported without staff supervision by a transport company employee, fell out of the wheelchair, sustained facial injuries and a fractured nose which resulted in Immediate Jeopardy. The facility failed to ensure staff appropriately and safely transferred Resident #2 via mechanical lift . On 11/7/18 Resident #2 sustained cheek discoloration. On 12/12/18 after a staff member transferred Resident #2 using a mechanical lift without assistance of another staff member, Resident #2 sustained extensive facial bruising, swelling, swallowing difficulties and had a fractured mandible (jaw) which resulted in actual harm and Immediate Jeopardy. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 1/27/19 in the conference room. The facility was cited an Immediate Jeopardy at F658-J. The Immediate Jeopardy is ongoing. An extended survey was conducted on 1/26/19 and 1/27/19. The findings include: 1. Review of the Oxford University Hospitals Occupational Therapy A Guide to Using Your Manual Wheelchair Safely manual dated (MONTH) (YEAR) documented, .Going down a steep slope .It is safer if the wheelchair can be guided down a steep slope backwards by a carer (caregiver) . Review of the Lippincott Manual of Nursing Practice 10th Edition documented, .Ensuring Safety .assess safety .Assess for the patient's personal safety issues-sensory deficits .The nursing process is a deliberate, problem-solving approach to meeting the health care and nursing needs of patients. It involves assessment (data collection), nursing diagnosis, planning, implementation, and evaluation, with subsequent modifications . Review of the Mobility-Advisor. com ADA (Americans with Disabilities Act) Wheelchair Ramps undated article documented, .When the front wheels hit the landing, the wheelchair can come to a sudden stop, causing the wheelchair user to fly forward . Review of the Coordination of Transportation policy dated (MONTH) (YEAR) documented, .The facility will assist in making appointments and safe transport arrangements for the resident .The facility will consider all clinical, physical, mental and financial conditions related to the transportation arrangements . Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed a score of 10 out of 15 which indicated the resident had moderately impaired cognition. A Fall Risk assessment dated [DATE] and 12/19/18 revealed a score of 14 and was .at high risk for potential falls. Resident #1's Care Plan initiated on 11/19/18 documented, The resident has an ADL (activity of daily living) Self Care Performance Deficit .Interventions .The resident requires staff participation with transfers. Resident #1's Care Plan initiated on 11/28/18 documented, The resident has impaired cognitive function r/t (related to) Dementia .Interventions .supervise . Resident #1's Nurses note dated 12/19/18 at 2:45 PM documented Patient with dental apt (appointment) today .Patient noted to have left the front door for dentist apt with (Named Transport Company) transport x1 (1 transport employee). A few mins (minutes) later entered the facility with (Named Transport Company) transport .Patient was sitting up in WC (wheelchair) with blood noted on face . Review of a statement completed by Licensed Practical Nurse (LPN #1) on 12/19/18 documented, Transportation personnel stated .we were going down the ramp, he fell forward out of chair . Interview with the DON on 1/15/19 at 1:00 PM in the conference room, the DON was asked if anyone accompanied Resident #1 to the dental appointment. The DON stated, No staff accompanied (Named Resident #1) . The DON was asked the cognitive status of Resident #1 and she stated, .his cognition does come and go .he didn't remember anything after the fall .he has had previous falls . The DON was asked what was expected during transportation if a resident was cognitively impaired and she stated, If a resident is cognitively impaired then either a family member or a CNA (certified nursing assistant) goes with them .There were 2 van transport employees that day 1 stayed in the van . Review of a statement by Transportation Employee #1 and verified on 1/16/19 at 1:00 PM documented, .I went to the desk and got his (Resident #1) face sheet then we continue to leave we went down the ramp to get in the van as we started going toward the van he failed (fell ) forward out of the wheelchair .the driver got out the van help (helped) me pick him up. Interview with Transportation Employee #1 on 1/16/19 at 1:00 PM via telephone, Transportation Employee #1 was asked about the incident and he stated, I helped him (Resident #1) into the wheelchair .I backed him out the front door and down the ramp .turned him and started toward the van and he just fell forward out of the wheelchair like he couldn't hold himself up .we picked him up and got him inside. Interview with Transportation Employee #2 on 1/16/19 at 1:10 PM via telephone, Transportation Employee #2 stated, .I was in the van .I was looking down at phone dialing and then talking to dispatch. I didn't see them come out of the building, go down the ramp or fall. I just happened to look up and see him (Resident #1) on the ground . An Administrator's note dated 12/20/18 documented, .(Named Resident #1) .was asked if he could recall any events from the incident .He( Resident #1) did not know specifically if he was turned forward or not but recalled that the wheelchair stopped .He remembered the wheelchair stopping but he kept coming out of the wheelchair .Resident recalled hitting his face on the cement .he believes that his weight shifted . Interview with Resident #1 on 1/16/19 at 1:40 PM in his room, Resident #1 was asked to describe the events on the day he fell in the parking lot and he stated, .1 transport guy came to room .the transport guy took me out the front doors and down the ramp, at the bottom he stopped but I didn't, I slid out (of the wheelchair) in the driveway and landed on my knees, hands and hit my face .He took me out forward and took me down that ramp forward . Interview with Facility Staff #1 on 1/16/19 at 2:25 PM in the conference room, Facility Staff #1 stated, .I saw the transport guy push (Named Resident #1) forward through the front exit doors .he was not pulling him through the doors backwards, he pushed him forward out the front doors . The failure of the facility to ensure acceptable standards of practice were provided to Resident #1, a cognitively impaired resident with a history of falls and mobility deficits, resulted in actual harm and Immediate Jeopardy when Resident #1 was transported out of the facility by a transport company employee, was unaccompanied and unsupervised by facility staff. Resident #1 fell out of the wheelchair, sustained lacerations and a fractured nose. 2. Review of the Invacare Reliant 450 Lift manufacturer recommendation (undated) revealed, .Invacare recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures . Review of the facility Lift Management Program policy dated (MONTH) (YEAR) documented, .Our Lift Management Program is designed to meet the following goals: .To protect .residents from injury .Each co-worker is expected to support this program 100% (percent) .This procedure is always done with 2 people . Medical record review for Resident #2 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. An Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was assessed with [REDACTED]. Resident #2's Care Plan initiated on 4/4/18 documented, The resident has an ADL (activities of daily living) Self Care Performance (deficit) .r/t (related to) stroke .dementia .[MEDICAL CONDITION] .Interventions .Hoyer (mechanical) lift with assist of 2 for transfers . Interview with the DON on 1/26/19 at 11:10 AM in the conference room, the DON was asked why Resident #2 was to have mechanical lift transfers by 2 people and the DON stated, We determined to use the lift and 2 people because of her size and debility. She was a large lady and completely out (paralyzed) except for a slight amount of movement in 1 arm and head. She'd had a stroke and was total care . Interview with the DON on 1/26/19 at 1:15 PM in the conference room, the DON was asked what was determined to be the cause of the discolored area (found on Resident #2's left cheek) and she stated, (Named Certified Nursing Assistant #1) had gotten her up via lift around 5:30 (AM) that morning .the sling brushing her face was the only thing we could come up with that caused the area (discoloration to cheek on 11/7/18) . An Incident Report dated 12/12/18 at 10:06 AM documented, .Witnesses Statement 12/12/18 Phone interview with (Named CNA #1) states she believes she did not have adequate assist with Hoyer lift . Interview with CNA #1 on 12/28/18 at 12:57 PM via telephone, CNA #1 was asked how she transferred Resident #2 and she stated, .I get her up in the morning, 1 person .since I've been there, I've always transferred by myself . Interview with the DON on 1/15/19 at 1:00 PM in the conference room, the DON was asked what she expected staff to do during lift transfers and the DON stated, .2 people are to transfer with lifts. The facility failed to ensure staff followed the facility policy and acceptable standards of practice for an appropriate and safe transfer of Resident #2 via mechanical lift. Resident #2 was assessed to require 2 people transfers via mechanical lift. Resident #2 was found on 11/7/18 with a discoloration on her left cheek determined to have been caused during lift transfer. During a second incident on 12/12/18 Resident #2 developed significant facial bruising, swelling, deterioration of swallowing status and was found to have a fractured right mandible (jaw) on 12/12/18 after being transferred by 1 staff member via mechanical lift. This resulted in actual harm and Immediate Jeopardy to Resident #2.

Based on Invacare Reliant 450 Lift (mechanical assistive transfer device) manufacturer recommendation review, policy review, hospital medical record review, medical record review, observation and interview, the facility failed to provide 2 of 7 (Resident #1 and #2) sampled residents appropriate and adequate supervision and assistance that ensured an environment free of accident hazards. The facility failed to provide adequate staff supervision for Resident #1 during transportation to an outside appointment. Resident #1 had been assessed at high risk for falls, had a history of [REDACTED]. Resident #1 was placed in a wheelchair, pushed out the doors of the facility and down a ramp by an outside transportation employee, unaccompanied, unsupervised by facility staff, and had not been assessed for safe independent transport. Resident #1 fell face forward out of the wheelchair onto the parking lot, sustained lacerations to his face and a fractured nose which resulted in actual harm and Immediate Jeopardy. The facility failed to ensure appropriate and safe lift transfers were provided to Resident #2 who was paralyzed on the left side from a [MEDICAL CONDITION] (stroke), was assessed as cognitively impaired and required total assistance of 2 staff with mechanical lift transfers. Resident #2 was transferred via lift by 1 staff member and was found with a discoloration on the left cheek on 11/7/18 and sustained a facial injury of extensive bruising and swelling, swallowing difficulties and was diagnosed with [REDACTED].#2. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 1/27/19 at 9:00 AM in the conference room. The facility was cited an Immediate Jeopardy at F689-J which is Substandard Quality of Care. The Immediate Jeopardy is ongoing. An extended survey was conducted on 1/26/19 and 1/27/19. The findings include: 1. Review of the Coordination of Transportation policy dated (MONTH) (YEAR) documented, .The facility will assist in making appointments and safe transport arrangements for the resident .The facility will consider all clinical, physical, mental and financial conditions related to the transportation arrangements . Review of the facility Care Plan policy revised on 12/12/17 documented, .Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of the facility Fall Prevention Protocol policy dated 9/21/17 documented, .All residents/patients that had a score of > (greater than 10 was at high risk) 10 on a fall screen will have a care plan to minimize injury . Medical record review for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. An Admission Minimum Data Set ((MDS) dated [DATE] documented the resident required extensive assistance with transfers and locomotion on and off the unit. A Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed a score of 10 out of 15 which indicated the resident had moderately impaired cognition. A Fall Risk assessment dated [DATE] and 12/19/18 revealed a score of 14 and was .at high risk for potential falls. Resident #1's Care Plan initiated on 11/19/18 documented, .The resident has an ADL (activity of daily living) Self Care Performance Deficit .Interventions .The resident requires staff participation with transfers. A Care Plan initiated on 11/28/18 documented, The resident has impaired cognitive function r/t (related to) Dementia .Interventions .supervise . Resident #1's Care Plan initiated on 11/28/18 documented The resident has impaired cognitive function r/t (related to) dementia .Interventions .supervise . Resident #1's Nurses note dated 12/19/18 at 2:45 PM documented .Patient with dental apt (appointment) today .Patient noted to have left the front door for dentist apt with (Named Transport Company) transport x1 (1 transport employee). A few mins (minutes) later entered the facility with (Named Transport Company) transport .Patient was sitting up in WC (wheelchair) with blood noted on face .911 called for transport . Review of a statement completed by Licensed Practical Nurse (LPN) #1 dated 12/19/18 documented, .I observed (Named Resident #1) sitting upright in WC moderate bleeding to bridge of nose, brow ridge, and inside mouth, but unable to find cause of bleeding in mouth. Transportation personnel stated, .'we were going down the ramp, he fell forward out of chair .'I attempted to evaluate resident's cognition. 'Resident alert but unable to respond verbally, resident was able to follow my finger to the left but unable to follow to the right, resident did not respond verbally . Resident #1's Nurses note dated 12/21/18 at 9:49 AM documented, Fall on 12/19/18 in parking lot with escort services .Nasal FX. (fracture) and lacerations noted . Review of a statement completed by Registered Nurse (RN) #1 and verified on 12/27/18 at 10:50 AM documented, .I observed (Named Resident #1) sitting in a WC w/blood (with blood) on his face and hands .(Named Resident #1) had 2 gashes between his eyes, one gash mid nose, a large hematoma/clot in his bottom lip & (and) blood coming out of his mouth. He also had two bruises-one on each knee & one abrasion on each knee . Interview with LPN #1 on 1/15/19 at 10:25 AM in the conference room, LPN #1 stated, .I assisted .after his fall. He (Resident #1) was awake .but not responsive verbally . Interview with the DON on 1/15/19 at 1:00 PM in the conference room, the DON was asked if anyone accompanied Resident #1 to the dental appointment. The DON stated, No staff accompanied (Named Resident #1) . The DON was asked the cognitive status of Resident #1 and the DON stated, .his cognition does come and go .he didn't remember anything after the fall .he has had previous falls . The DON was asked what was expected during transportation if a resident was cognitively impaired and she stated, If a resident is cognitively impaired then either a family member or a CNA (Certified Nursing Assistant) goes with them .There were 2 van transport employees that day 1 stayed in the van . Interview with the Administrator on 1/15/19 at 10:20 AM in the conference room, the Administrator was asked for the transportation contract and policy and he stated, We do not have a transportation policy, staff just get them up and ready and the transport company picks them up .don't have a copy of the contract . Interview with the DON 1/15/19 at 1:10 PM in the conference room, the DON was asked how resident safety was ensured during transportation and she stated, We do not do a safety assessment for transportation. Review of a statement verified on 1/16/19 at 1:00 PM by Transportation Employee #1 documented, .I went to the desk and got his (Resident #1) face sheet then we continue (continued) to leave we went down the ramp to get in the van as we started going toward the van he failed (fell ) forward out of the wheelchair .the driver got out the van help me pick him up. Interview with Transportation Employee #1 on 1/16/19 at 1:00 PM via telephone, Transportation Employee #1 was asked about the incident and he stated, I helped him (Resident #1) into the wheelchair, went to the desk and got his face sheet and asked if anyone was going with him. I was told his daughter was going to meet us at the doctor's clinic . (Named Resident #1) never said anything to me just nodded .I backed him out the front door and down the ramp .turned him and started toward the van and he just fell forward out of the wheelchair like he couldn't hold himself up .we picked him up and got him inside. Interview with Transportation Employee #2 on 1/16/19 at 1:10 PM via telephone, Transportation Employee #2 stated, .I was in the van .I was looking down at phone dialing and then talking to dispatch. I didn't see them come out of the building, go down the ramp or fall. I just happened to look up and see him on the ground . An Administrator's note dated 12/20/18 documented, .(Named Resident #1) .was asked if he could recall any events from the incident .He ( Resident #1) did not know specifically if he was turned forward or not but recalled that the wheelchair stopped .He remembered the wheelchair stopping but he kept coming out of the wheelchair .Resident recalled hitting his face on the cement .he believes that his weight shifted . Interview with Resident #1 on 1/16/19 at 1:40 PM in his room, Resident #1 was asked to describe the events on the day he fell in the parking lot and he stated, .1 transport guy came to room .got in wheelchair .the transport guy took me out the front doors and down the ramp, at the bottom he stopped but I didn't, I slid out (of the wheelchair) in the driveway and landed on my knees, hands and hit my face .He took me out forward and took me down that ramp forward . Observations during this interview revealed Resident #1 had a healed scar across the bridge of his nose and healed scars on both knees. The resident's wheelchair was at the bedside and noted to have a pressure cushion with a slick covering on it. Interview with the Social Worker on 1/16/19 at 2:10 PM in the conference room, the Social Worker was asked how the facility assured the residents are transported safely and the Social Worker stated, .Not aware of any type of safety assessment for transports, I don't do one . Interview with Facility Staff #1 on 1/16/19 at 2:25 PM in the conference room, Facility Staff #1 stated, .I saw the transport guy push (Named Resident #1) forward through the front exit doors .he was not pulling him through the doors backwards, he pushed him forward out the front doors . Review of Resident #1's hospital computerized tomography (CT) Maxillofacial (forehead, face, and dental) area scan dated 12/19/18 revealed, .Pt (patient) came by EMS (emergency medical services) for AMS (altered mental status) after being pushed down ramp in wheelchair .and fell forward, Pt with LAC (laceration) to nose, 2 lacerations to forehead .There is left-sided nasal plates fracture (fractured nose) . The failure of the facility to adequately supervise Resident #1, a cognitively impaired resident with a history of falls and mobility deficits, resulted in actual harm and Immediate Jeopardy when Resident #1 was transported out of the facility by a transport company employee, unaccompanied, unsupervised by facility staff and not assessed by facility staff for safe transport independently. Resident #1 fell out of the wheelchair and sustained lacerations and a fractured nose. 2. Review of the Invacare Reliant 450 (mechanical) Lift manufacturer recommendation (undated) documented, .Invacare recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures . Review of the facility Lift Management Program policy dated (MONTH) (YEAR) documented, .Our Lift Management Program is designed to meet the following goals: .To protect .residents from injury .Each co-worker is expected to support this program 100% (percent) .This procedure is always done with 2 people . Medical record review for Resident #2 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. An Annual MDS dated [DATE] revealed Resident #2 was assessed with [REDACTED]. Resident #2's Care Plan initiated on 4/4/18 documented, .The resident has an ADL (activities of daily living) Self Care Performance .r/t (related to) stroke .dementia .[MEDICAL CONDITION] .Interventions .Hoyer (transfer assistive device) lift with assist of 2 (persons) for transfers . Interview with the DON on 1/26/19 at 11:10 AM in the conference room, the DON was asked why Resident #2 required mechanical lift transfers by 2 people and she stated, We determined to use the lift and 2 people because of her size and debility. She was a large lady and completely out (paralyzed) except for a slight amount of movement in 1 arm and her head. She'd had a stroke and was total care . An Incident Report dated 11/7/18 at 1:30 AM revealed Resident #2 was found with a discoloration on her left cheek. An Incident Report dated 12/12/18 at 10:06 AM documented, .Witnesses Statement 12/12/18 Phone interview with (named CNA #1) states she believes she did not have adequate assist with Hoyer (mechanical) lift. She said it was possible the lift arm tapped (named Resident #2) cheek . Resident #2's Nurses note dated 11/7/18 at 10:58 AM documented, .Discoloration the left cheek area that appears as fabric burn .Resident requires a mechanical lift and sling for all transfers. Investigation finds that lift pad grazed Left cheek during transfer . Interview with CNA #1 on 12/28/18 at 12:57 PM via telephone, CNA #1 was asked how she transferred Resident #2 and she stated, .I get her up in the morning, 1 person .since I've been there, I've always transferred by myself . Interview with the DON on 1/26/19 at 1:15 PM in the conference room, the DON was asked what caused this discolored area on Resident #2's cheek and she stated, (Named CNA #1) had gotten her up via lift around 5:30 (AM) that morning, .the sling brushing her face was the only thing we could come up with that caused the (discolored) area . An Incident Report dated 12/12/18 at 10:06 AM revealed Resident #2 was found with, .Green bruising/discoloration to L (left) cheek extending up to L eye, swelling, and redness noted. Half dollar sized dark green bruise to R (right) side of chin. Dried red blood observed to L nostril .Witnesses Statement 12/12/18 Phone interview with (named CNA #1) states she believes she did not have adequate assist with Hoyer (mechanical) lift. She said it was possible the lift arm tapped (named Resident #2) cheek . A situation, background, assessment, recommendation (SBAR) Communication Form dated 12/15/18 documented Resident #2 with deterioration, . Significant decline in food and fluid intake in resident with marginal hydration and nutritional status .Discoloration .L side of face starting at L eye extending down the face to the jaw line. Bruising is noted to bilateral (both) jaw lines. Resident having difficulty swallowing, liquids upgraded to nectar thick liquids, increase in drooling noted .Send to ER (emergency room ) for eval (evaluation) and treatment . Review of Resident #2's hospital medical record revealed a History and Physical (H&P) dated 12/15/18 that documented, .She (Resident #2) presented from a nursing home with worsening altered mental status and facial bruising .Significant bruising on the left side of her jaw .CT maxillofacial: Subtle (high energy trauma) nondisplaced [MEDICAL CONDITION] body of the right mandible (jaw) . Interview with CNA #1 on 12/28/18 at 12:57 PM via telephone, CNA #1 was asked how she transferred Resident #2 and she stated, .I get her up in the morning, 1 person ., since I've been there, I've always transferred by myself . Interview with LPN #2 on 1/22/19 at 5:42 AM via telephone, LPN #2 stated, .There for a little bit (Named CNA #1) didn't ask for help (when transferring residents with a mechanical lift) . Interview with the DON on 1/15/19 at 1:00 PM in the conference room, the DON was asked what she expected staff to do during lift transfers and she stated, .2 people are to transfer with lifts. The failure of the facility to ensure staff appropriately and safely transferred Resident #2 via mechanical lift resulted in actual harm and Immediate Jeopardy when Resident #2 was found with discoloration to the left cheek on 11/7/18. A second incident occurred on 12/12/18 and Resident #2 developed significant facial bruising, facial swelling, deterioration of swallowing status and had a fractured right mandible (jaw) after the resident had been transferred by 1 staff member via mechanical lift.

Based on job description review, policy review, Invacare Reliant 450 manufacturer recommendation, hospital medical record review, medical record review, observation and interview, Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of the residents when they failed to ensure a safe environment free of accident hazards, failed to ensure staff implemented care plan interventions, failed to ensure acceptable standards of practice were followed, and failed to ensure the facility maintained an effective Quality Assurance program that identified and addressed concerns for 2 of 7 (Resident #1 and #2) sampled residents that had accidents resulting in actual harm and Immediate Jeopardy. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 1/27/19 at 9:00 AM in the conference room. The facility was cited an Immediate Jeopardy at F835-J. The Immediate Jeopardy is ongoing. An extended survey was conducted on 1/26/19 and 1/27/19. The findings include: 1. Review of the Administrator job description documented, .Administrative Functions .Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility .Interpret the facility's policies and procedures to employees, residents, family members, visitors, government agencies .Ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Review and check competence of work force and make necessary adjustments/corrections as required or that may become necessary .Ensure that all facility personnel, residents, visitors .follow established safety regulations .Monitor to determine the effectiveness of the facility's risk management program . Review of the Director of Nursing job description documented, .Administrative Functions .Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assessment & (and) Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies .Make daily rounds of the nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Assist the Safety Officer in developing safety standards for the nursing service department .Ensure that the department's policy and procedure manuals identify safety precautions and equipment to use when performing tasks that could result in bodily injury .Monitor nursing service personnel to ensure that they are following established safety regulations in the use of equipment and supplies .Ensure that all personnel operate nursing service equipment in a safe manner .Ensure that all personnel involved in providing care to the resident are aware of the resident's care plan .that nursing personnel refer to the resident's care plan .determine if the care plan is being followed 2. Review of the Coordination of Transportation policy dated (MONTH) (YEAR) documented, .The facility will assist in making appointments and safe transport arrangements for the resident .The facility will consider all clinical, physical, mental and financial conditions related to the transportation arrangements . Review of the facility Care Plan Policy with a revised date of 12/12/17 documented, .Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of the facility Fall Prevention Protocol policy dated 9/21/17 documented, .All residents/patients that had a score of > (greater than 10 was at high risk for falls) 10 on a fall screen will have a care plan to minimize injury . Review of the Invacare Reliant 450 Lift (mechanical assistive transfer device) manufacturer recommendation (undated) documented, .Invacare recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures . Review of facility Lift Management Program policy dated (MONTH) (YEAR) documented, .Our Lift Management Program is designed to meet the following goals: .To protect .residents from injury .Each co-worker is expected to support this program 100% (percent) .This procedure is always done with 2 people . 3. Administration failed to ensure the care plan intervention of supervision was implemented for Resident #1, who was assessed as cognitively impaired and had a history of [REDACTED].#1 was injured when he was unsupervised by facility staff and fell during transportation to a dental appointment. He sustained lacerations and a fractured nose which resulted in Immediate Jeopardy. Administration failed to ensure the care plan intervention of mechanical (assistive transfer device) lift transfers by 2 staff members for Resident #2 was followed. Resident #2 was transferred via mechanical lift by 1 staff member and was found with a discoloration on the cheek on 11/7/18. On 12/12/18 Resident #2 developed significant bruising, swelling, swallowing difficulties and was diagnosed with [REDACTED]. Refer F656. 4. Administration failed to ensure staff followed acceptable standards of practice for safe transport to outside appointments which resulted in Immediate Jeopardy to Resident #1 when he fell forward out of a wheelchair onto the parking lot while being transported by an outside transport company, unsupervised by facility staff. Administration failed to ensure staff followed acceptable standards of practice for safe mechanical lift transfers which resulted in Immediate Jeopardy to Resident #2 when she was found to have a discoloration on her cheek on 11/7/18. On 12/12/18 Resident #2 developed swelling, bruising, swallowing difficulties, and a fractured mandible (jaw) after 1 staff member transferred her via mechanical lift without assistance of another staff member. Refer to F658. 5. Administration failed to ensure a safe accident hazard free environment for Resident #1 who fell during an unsupervised transport and sustained lacerations and a fractured nose resulting in Immediate Jeopardy. Administration failed to ensure a safe and accident hazard free environment for Resident #2 who was found with a discoloration on her cheek on 11/7/18 and on 12/12/18 developed swelling, bruising, swallowing difficulties and a fractured mandible after being transferred via mechanical lift by 1 staff member which resulted in Immediate Jeopardy. Refer to F689. 6. Administration failed to ensure the facility had an effective Quality Assurance program that thoroughly investigated, identified and addressed concerns with safe transportation for the residents. The Administrator failed to assure the transport staff were trained for safe transport of residents. The Administrator stated he .left word with (Named transport service) to request their drivers be in-serviced on safety transport and .obtain a copy of the in-service . Interview with the Administrator on 1/15/19 at 10:20 AM in the conference room, the Administrator was asked to provide a transportation policy and the contract with the transportation company. The Administrator stated, We do not have a transportation policy, staff just get them up and ready and the transport company picks them up .I have no contract copy but we do have a contract with them . Interview with the DON on 1/15/19 at 1:10 PM in the conference room, the DON was asked how resident safety was ensured during transportation out of the building and she stated, We do not do a safety assessment for transportation. Interview with the Administrator on 1/26/19 at 10:15 AM in the conference room, the Administrator stated, .I have made multiple requests for (Named Transportation Company) contract and staff inservices and have received no response, don't have them . Interview with the Administrator on 1/26/19 at 3:10 PM in the conference room, the Administrator was asked if the pressure cushion cover Resident #1 had in the wheelchair had been considered in the root cause for Resident #1 sliding out of the wheelchair and the Administrator stated, I looked at the cushion, he was sitting on it. The Administrator was asked if lack of staff supervision had been considered during the root cause of Resident #1's fall during transport and he stated, .the nurses monitor transport exits . Refer to F865-J

Based on job description review, policy review, Invacare Reliant 450 lift (assistive transfer device) manufacturer recommendation, hospital medical record review, medical record review, observation and interview, the facility failed to ensure an effective Quality Assurance (QA) program recognized potential accident hazards by identifying the root cause, failed to ensure systems and processes were developed and implemented to address potential accident hazards and resident safety. The QA committee failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently. The QA committee failed to ensure staff provided care according to resident care plans and acceptable standards of practice. The failure of the QA committee to recognize, identify, develop and implement corrective systems to ensure appropriate care and safety were provided resulted in actual harm and Immediate Jeopardy to Resident #1 and #2. Resident #1 was transported by a contract transport employee unsupervised by facility staff, fell out of the wheelchair and sustained facial lacerations and a fractured nose. Resident #2 was transferred via mechanical lift (assistive transfer device) by 1 staff member and was found with discoloration on the cheek on 11/7/18. On 12/12/18 Resident #2 sustained extensive facial bruising, swelling, swallowing difficulties and a fractured mandible (jaw). Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 1/27/19 at 9:00 AM in the conference room. The facility was cited an Immediate Jeopardy at F865-J. The Immediate Jeopardy is ongoing. An extended survey was conducted on 1/26/19 and 1/27/19. The findings include: 1. Review of the Administrator job description documented, .Administrative Functions Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Monitor to determine the effectiveness of the facility's risk management program . Review of the Director of Nursing job description revealed, .Administrative Functions .Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assessment & (and) Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies . 2. Review of the Quality Assurance Performance Improvement Plan undated policy documented, .It is the intent of this facility to conduct an on-going quality assurance/performance improvement program designed to systematically monitor and evaluate the quality and appropriateness of resident care, pursue opportunities to improve resident care, resolve identified problems and identify opportunities for improvement . 3. The QA committee failed to thoroughly investigate and identify the root cause of the incidents, failed to develop and implement corrective actions to address all potential accident hazards which resulted in actual harm and Immediate Jeopardy to Resident #1 and #2. Refer to F689-J. 4. The QA committee failed to identify staff were not providing care according to resident care plans which resulted in actual harm and Immediate Jeopardy to Resident #1 and #2. Refer to F656-J. 5. The QA committee failed to ensure staff provided care according to acceptable standards of practice which resulted in actual harm and Immediate Jeopardy to Resident #1 and #2. Refer to F658-J. 6. The QA committee failed to ensure the facility was administered in a manner that its resources were effectively and efficiently used which resulted in actual harm and Immediate Jeopardy to Resident #1 and #2. Interview with the DON on 1/15/19 at 1:10 PM in the conference room, the DON was asked how resident safety was ensured during transportation and stated, We do not do a safety assessment for transportation. Interview with the Administrator on 1/26/19 at 10:15 AM in the conference room, the Administrator stated, .I have made multiple requests for (Named Transportation Company) contract and staff inservices and have received no response, don't have them (inservices or contract) . Interview with the Administrator on 1/26/19 at 3:10 PM in the conference room, the Administrator was asked if the pressure cushion cover Resident #1 had in the wheelchair had been considered in the root cause for Resident #1 sliding out of the wheelchair and he stated, I looked at the cushion, he was sitting on it. The Administrator was asked if lack of staff supervision had been considered during the root cause of Resident #1's fall during transport and he stated, .the nurses monitor transport exits . Refer to F835-J. The Administrator was unable to provide information that the QA process had identified processes to prevent further occurrences during outside transportation and safe mechanical lift transfers.