Every finding on record at North Lake Care Center and Rehab

Based on observation, interview, policy and record review, the facility failed to inform the physician of a significant weight loss for 1 of 3 sampled residents reviewed for nutrition, Resident #6.The findings included:Review of the facility's policy titled Change in a Resident's Condition or Status revised February 2021, revealed Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Review of the facility's policy titled Weight Assessment and Intervention revised March 2022 revealed 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. Record review revealed Resident #6 was initially admitted to the facility on [DATE] with diagnoses that included Heart Failure, Type 2 Diabetes Mellitus and Peripheral Vascular Disease.Review of the resident's quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 06/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. On 08/04/25, the resident was weighed, and the weight was documented as 237.5 pounds. On 09/02/25, the resident was weighed and documented as weighing 223 pounds. This indicated a 5.91% weight loss. The resident's re-weight was not in the electronic health record.An interview was conducted with Staff G, Registered Dietician / RD, on 09/10/25 at 11:49 AM who stated the resident takes Lasix (a diuretic) and it is expected the resident would have weight fluctuation with gradual weight loss. An interview was conducted with Staff F (RD) on 09/11/25 at 12:10 PM. She stated she comes to the facility once a week on a Thursday. She has been working in this facility for 3 months and has not yet met the resident. She stated Resident #6 was weighed on Tuesday 09/02/25 in the morning, she was aware of the weight the month prior, and she requested a re-weigh. They did the reweigh on the same day (09/04/25) but she had already left the facility. She stated that she should see the resident and do another assessment. Once she saw him, she would have a team meeting and proceed from there. She would see the resident and talk to him and see if the weight was desirable. She would notify the Physician after talking to the resident. She would look at the prior documentation and look at the weight trends. She agreed that it is a long time to wait a week to notify the physician.An interview was conducted with the Medical Director on 09/11/25 at 11:30 AM who stated that he would want to be informed of a resident's significant weight loss right away.An interview was conducted with the Nurse Practitioner on 09/11/25 at 1:05 PM who stated she would have liked to know as soon as the staff knew that the resident had a significant weight loss.

Based on interview and record review, the facility failed to report and resolve a grievance for 1 of 1 sampled resident reviewed for grievances, Resident #11. The findings included:Record review revealed Resident #11 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and required partial/moderate assistance with activities of daily living.Record review revealed Resident #11 was care planned on 04/23/25 for self-care deficit with dressing, grooming, and bathing as evidenced by needs set up to supervision with personal care tasks due to generalized weakness, and limited endurance. An intervention included to provide staff assistance with dressing, grooming, bathing as needed. An interview was conducted with Resident #11 on 09/08/25 at 11:30 AM. Resident #11 stated he had had concerns over the the care he receives on 2nd shift (3-11 PM). The resident stated they are slow to respond to his call light, and they are rude in responding. A subsequent interview was conducted with Resident #11 on 09/10/25 at 10:00 AM. Resident #11 asked if the surveyor had inquired about the lack of treatment and slow response to the call bell on 2nd shift. Resident #11 stated he had reported it multiple times to the guy that comes to his room almost every morning and he had not received a response or seen a change. An interview was conducted with the Director of Housekeeping on 09/10/25 at 10:30 AM. The Director stated he was assigned as the ambassador to Resident #11's room and communicates with the resident on a daily basis. The Director acknowledged that Resident #11 had expressed concerns with care and call light response time on the 2nd shift. The Director stated he brought it to the attention of the Director of Nursing (DON) and Administrator during morning meetings approximately a month ago, but could not give a definitive date. Review of the facility's grievance log did not indicate a grievance for Resident #11 regarding concerns with care and call light response time on the 2nd shift within the past 3 months review. An interview was conducted with the DON on 09/10/25 at 12:00 PM. The DON acknowledged awareness of Resident #11's concerns with 2nd shift's care and call light response time. The DON further stated she did not complete a grievance for Resident #11.

Based on record review and interview, the facility failed to obtain labs as ordered and failed to notify the physician of the missed labs for 1 of 1 sampled resident, Resident #54. The findings included:Record review revealed Resident #54 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and required partial/moderate assist with activities of daily living.Review of Resident #54's orders revealed an order dated 09/03/25 for, Urinalysis with reflex to culture, CBC (Complete Blood Count) with differential, BMP (Basic Metabolic Profile) in AM [morning]. Further review of Resident #54's record revealed the urine culture, CBC, and BMP were not conducted or obtained. Further review of Resident #54's record did not reveal any indication the physician was notified of the missed labs. An interview was conducted with the Director of Nursing (DON) on 09/10/23 at 12:00 PM. The DON acknowledged the above. The DON further stated it was missed.

Based on record review and interview, the facility failed to complete and have dialysis communication forms post treatment for 1 of 1 sampled resident reviewed for dialysis, Resident #3.The findings included:Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses included End Stage Renal Disease (ESRD). A comprehensive assessment dated [DATE] documented the resident had moderate cognitive deficit and required supervision for activities of daily living. The assessment further indicated the resident received dialysis. Review of Resident #3 care plan documented the resident was care planned on 08/11/25 for potential for complications related to hemodialysis for treatment of ESRD, receives dialysis on: Tuesday and Saturday. An intervention included to complete dialysis communicate tool on dialysis days and review upon return from dialysis. Review of Resident #3's Dialysis Communication Interchange forms revealed missing dialysis communication forms for 08/12/25, 08/30/25, and 09/02/25. Further review of the dialysis communication forms revealed the section labeled Facility Nurse Complete Below When Resident Returns From Dialysis (an assessment of the resident) was not completed for 08/16/25, 08/19/25, 08/23/25, and 08/26/25. An interview was conducted with Resident #3's nurse, Staff I, Registered Nurse, on 09/11/25 at 12:00 PM. Staff I acknowledged the above and stated the resident leaves the facility with the form to go to dialysis, and it is expected that the resident return with the form to review and complete the assessment post treatment.

Based on interview, record review and observation, the facility failed to appropriately reconcile controlled medications for 2 of 4 sampled residents reviewed for medication reconciliation, Resident #1 and Resident #16.The findings included:Review of the facility's policy titled Controlled Substances, publication date and revision date not supplied, under the heading of Policy Interpretation and Implementation, documented, in part: Under that section is the subsection with the heading Dispensing and Reconciling Controlled Substances. Item 1 documented: Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. Item 2 documented: The system of reconciling the receipt, dispensing, and disposition of controlled substances includes the following:Records or personnel access and usage. Medication administration records.Declining inventory records; andDestruction, waste, and return to pharmacy records. On 09/11/25 at 12:28 PM, an observation was made of the DIV 4 med cart [Division 4's medication cart] with Staff A, Licensed Practical Nurse (LPN). A review of the Controlled Substance Log was conducted for Resident #16. The medication identified on the Controlled Substance Log was Tramadol 100 mg (milligram) tablets. The instruction on the label stated: 1 tablet by mouth 3 times daily as needed. The pharmacy issue date was 06/15/25. The amount delivered to the facility was 30 tablets. The first dose was on 06/21/25 at 8:00 AM. The most recent dose recorded was on 08/20/25 at 2100 (9:00 PM). The medication dosing card had 21 tablets remaining. The count on the Controlled Substance Log had 21 tablets remaining. Review of the Medication Administration Record (MAR) for Resident #16 revealed a dose was administered on 09/04/25 at 2051 (8:51PM). This dose was not recorded on the Controlled Substance Log for Resident #16.On 09/11/25 at 1:35 PM, an observation was made of the DIV 1 med cart with Staff B, LPN. A review of the Controlled Substance Log was conducted for Resident #1. The medication identified on the Controlled Substance Log was Oxycodone IR 15 mg 1 Tab by mouth every 6 hours as needed for non-acute pain. The pharmacy issue date was 09/05/25. The amount delivered was 24 tablets. The first dose was on 09/05/25 at 10:05 PM. The medication dosing card had 9 tablets remaining. The count on the Controlled Substance Log had 9 tablets remaining. The most recent dose on the Controlled Substance Log was for 09/11/25 at 11:00 AM. Review of the MAR for Resident #1 revealed no entries for the 09/11/25 at 11:00 AM dose administered. The last MAR entry was for 09/10/25 at 2033 (8:33 PM).On 9/11/25 at approximately 2:30 PM, an interview was conducted with the Director of Nursing (DON). The DON agreed that there should not be discrepancies with Controlled Substance administration and documentation. The DON stated she would immediately begin in-service training with the nurses regarding reconciliation of Controlled Substances, and investigate the discrepancies identified by the surveyor.

Based on interviews and record review, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that included, but are not limited to, time frames for the different steps in the process for 2 of 5 sampled residents sampled for unnecessary medications, Residents #2 and #5. The findings included:Review of the facility's policy titled, Tapering Medications and Gradual Drug Dose Reduction with a revised date of April 2025 included in part the following: Tapering/GDR (Gradual Dose Reduction) may be used as an approach to finding an optimal dose or determining if continued use of a medication will benefit the resident. In addition, the staff and practitioner consider GDR under certain circumstances including when: a) the resident's clinical condition has improved or stabilized, b) the underlying causes of the original target symptoms have resolved, c) non-pharmacological interventions, including behavioral interventions, have been effective in reducing symptoms; or d) a resident's condition has not responded to treatment or has declined despite treatment. Within the first year after a resident is admitted on a psychotropic medication or after the resident has been started on a psychotropic medication, the staff and practitioner will attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. Review of the facility's policy titled, Medication Regimen Reviews with a revised date of May 2019 included in part the following: The medication regiment review (MRR) involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities for example: c) duplicative therapies or omissions of ordered medication, h)other medication errors, including those related to documentation. If the Physician does not provide a timely or adequate response, or the Consultant Pharmacist identifies that no action has been taken, he/she contacts the Medical Director or (if the Medical Director is the physician of record) the Administrator. 1.) Record review revealed Resident #5 was originally admitted [DATE] with most recent readmission on [DATE] and diagnoses that included in part the following: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation and Major Depressive Disorder Recurrent Moderate. The Minimum Data Set (MDS) assessment dated [DATE] documented in Section C a Brief Interview of Mental Status score of 13 indicating an intact cognitive response.Review of the Physician's Orders for Resident #5 revealed in part the following:An order dated 02/21/25 for Trazodone HCl oral tablet 100mg give 1 tablet by mouth at bedtime and was discontinued on 06/22/25.An order dated 06/25/25 for Trazodone HCl oral tablet 100mg give 1 tablet by mouth at bedtime was discontinued on 07/20/25.An order dated 07/20/25 for Trazodone HCl oral tablet 100mg give 1.5 tablet by mouth at bedtime. Review of the Consultant Pharmacist Recommendation to the Physician for Resident #5 dated 05/06/25 documented, Federal guidelines stated that antidepressant drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with 1 month between attempts, then annually thereafter, when used to manage behavior, stabilize mood or treat psych disorder. This resident has been taking Trazadone 100mg every bedtime since 11/16/24 without a GDR. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? [Staff D] Advance Practice Registered Nurse (APRN) response dated 05/09/25 documented to decrease to 75mg tab oral every bedtime for depression. The order to attempt a GDR by decreasing the dosage of the Trazadone was never entered into the resident's chart. An interview was conducted on 09/10/25 at 4:15 PM with the Director of Nursing (DON) who was asked about the Consultant Pharmacist Recommendation to the Physician. She stated the recommendations are kept by herself, but she does not review them, but that the Physician/Nurse Practitioner are to put their own orders in the resident's chart. The DON stated the Consultant Pharmacist will review the residents' medications the following month. When asked about the Consultant Pharmacist Recommendation to Physician for Resident #5 dated 05/06/25 the DON stated as of 07/20/25 the Trazadone has been increased because patient symptoms have increased, so the order to decrease the Trazadone in May is null and void.2. Record review for Resident #2 revealed the resident was originally admitted to the facility 08/10/23 with a most recent readmission on [DATE] with diagnoses that included in part the following: Acute Chronic Diastolic (Congestive) Heart Failure, Type 2 Diabetes Mellitus, Generalized Anxiety Disorder and Major Depressive Disorder. The MDS assessment dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15 indicating an intact cognitive response. Review of the Physician's Orders for Resident #2 revealed in part the following:An order dated 02/19/25 for Pantoprazole Sodium oral tablet delayed release 40mg give 1 tablet by mouth at bedtime was discontinued on 08/19/25 (entered into the electronic medical record by Staff E, Advanced Practitioner Registered Nurse / APRN).An order dated 08/18/25 for Pantoprazole Sodium oral tablet delayed release 20mg give 1 tablet by mouth at bedtime (entered into the electronic medical record by Staff E). Review of the Consultant Pharmacist Documentation regarding Recommendations included in part the following:Review of the Consultant Pharmacist Recommendation to the Physician for Resident #2 dated 06/06/25 documented this resident has been taking Pantoprazole 40mg at bedtime since 02/19/25 without a dose reduction. Please consider a trial dose reduction to Pantoprazole 20mg at bedtime. Staff E, APRN, response dated 06/11/25 was to reduce dose of Pantoprazole to 20mg oral daily.Review of the Listing of residents 'Reviewed with No Recommendations' for recommendation created between 07/01/25 and 07/08/25 listed Resident #2.Review of the Consultant Pharmacist Recommendation to the Physician for Resident #2 dated 08/07/25 documented this resident has been taking Pantoprazole 40mg at bedtime since 02/19/25 without a dose reduction. Please consider a trial dose reduction to Pantoprazole 20mg at bedtime. Staff E Advanced Practice Registered Nurse (APRN) response dated 08/19/25 was to reduce dose of Pantoprazole to 20mg oral at bedtime.The order to reduce the dose of Pantoprazole from 40mg to 20mg at bedtime documented on 06/11/25 was never entered into Resident #2's chart. Additionally, it was not addressed in by the Consultant Pharmacist in the July 2025 report. An interview was conducted on 09/10/25 at 4:15 PM with the Director Of Nursing (DON) who was asked about the Consultant Pharmacist Recommendation to Physician in June 2025 for Resident #2,. The DON stated the ARNP who responded to the recommendation is supposed to enter their own orders. When asked if she reviews the responses to the recommendations, the DON said no she does not. An interview was conducted on 09/11/25 at 12:55 PM with Staff E, APRN, who was asked about the Consultant Pharmacist Recommendation to the Physician. Staff E stated they are given to me by the DON, I fill them out and give them back to the DON. It is my assumption she (the DON) puts the orders in (the resident's chart).

Based on observation, interview and record review, the facility failed to initiate behavior monitoring for 1 of 5 sampled residents reviewed for unnecessary medications, Resident #6. The findings included: Record review revealed Resident #6 was initially admitted to the facility on [DATE] with diagnoses that included Heart Failure, Type 2 Diabetes Mellitus and Peripheral Vascular Disease.Review of the resident's quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 06/25/25, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognitively intact. Review of the Physician order's revealed on 09/05/25 the resident was started on Quetiapine Fumarate 25 milligrams (mg) tablet to give 1 tablet by mouth two times a day for psychosis. On 09/10/25, Quetiapine Fumarate was increased to 50 mg at bedtime related to schizoaffective disorder. Review of the physician's orders revealed no behavior monitoring order for this medication since the start of the medication. AN interview was conducted with the Director of Nursing (DON) on 09/11/25 at 2:00 PM related to the no behavior monitoring being done for the antipsychotic medication. The DON acknowledged this. Behavior monitoring was added to Medication Administration Record (MAR) after surveyor intervention on 09/11/25.

Based on observations, interviews and record review, the facility failed to secure medications at all times for 1 of 21 sampled residents with medications observed at the bedside, Residents #42. The findings included:Review of the facility's policy titled, Storage of Medications with no date included in part the following: The facility stores all drugs and biologicals in a safe, secure and orderly manner.Review of the facility's policy titled, Self-Administer of Medications with no date included in part the following: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Record review for Resident #42 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Unspecified Adrenocortical Insufficiency, Anxiety Disorder and Unspecified Glaucoma. The Minimum Data Set (MDS) assessment dated [DATE] documented in Section C a Brief Interview of Mental Status (BIMS) score of 15 indicating an intact cognitive response. Review of Physician's Orders for Resident #42 revealed in part the following:An order dated 09/10/24 for Triamcinolone Acetonide external cream 0.5 % apply to affected areas topically every 12 hours as needed for eczema rash and apply to affected areas topically every day and night shift for eczema rash for 14 days.An order dated 08/22/24 for Hydrophilic External ointment apply to dry skin topically two times a day for Dry Skin.An order dated 07/25/25 for Aquaphor External ointment apply to dry skin areas topically every day and night shift for eczema. Review of the Self Administration of Medication assessment for Resident #42 dated 08/27/25 documented the resident did not express a desire to self-administer medication or treatments. Review of the Self Administration of Medication assessment for Resident #42 dated 09/10/25 documented the resident did not express desire to self-administer medication or treatments. On 09/08/25 at 10:30 AM, an observation was made of hydrocortisone cream 1% on the over bed table next to the resident sitting up in bed. An interview was conducted on 09/08/25 at 10:30 AM with Resident #42 who was asked about the hydrocortisone cream 1% on the over bed table. He stated that it is for his eczema. On 09/09/25 at 10:00 AM, a second observation with another surveyor was made of hydrocortisone cream 1% on the over bed table next to Resident #42 sitting up in bed. An interview was conducted on 09/10/25 at 1:00 PM with the Director of Nursing (DON) who was asked about residents having medications at the bedside. She stated the resident should be assessed for self-administration and if they are safe to do so, they could have the medications at the bedside but would need to keep the medications locked. The DON acknowledged they have a severely cognitively impaired resident with behaviors that included wandering into other resident's rooms and has taken various items from those resident's rooms and often attempting to eat inappropriate items.An interview was conducted on 09/10/25 at 1:45 PM with the DON who acknowledged Resident #42 had Hydrocortisone cream on his overbed table. She removed the cream and stated the resident had a different cream ordered for the same issue.

Based on record review, interview, and policy review, the facility failed to have an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 sampled resident reviewed for infection, Resident #54. The findings included: Record review revealed Resident #54 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and required partial/moderate assist with activities of daily living. Resident #54 had diagnoses including Dysuria (difficulty urinating) and Benign Prostatic Hyperplasia (BPH, enlarged prostate). Record review revealed Resident #54 was care planned for alteration in elimination as evidence by frequent incontinence of bladder and bowel, impaired mobility, and difficulty with urine stream due to diagnosis of BPH, at risk for UTI (Urinary Tract Infection). Interventions included; administer medications as ordered, observe for effectiveness and for side effects, observe for signs and symptoms of UTI, report to physician if noted, and labs as ordered, report results to physician. Resident #54 was observed and communicated with by surveyor on 09/08/25, 09/09/25, and 09/10/25 without concerns. An interview was conducted with Resident #54 on 09/10/25 at 9:30 AM. The resident was observed in bed with a new intravenous (IV) line on the right arm. The surveyor inquired about the IV line, and Resident #54 stated the line was paced this morning for some kind of an infection. Review of Resident #54's physician orders revealed an order dated 09/03/25 for Urinalysis with reflex to culture, CBC (Complete Blood Count) with differential, BMP (Basic Metabolic Profile) in am. There was also an order for Ciprofloxacin [antibiotic] 250 milligrams every 12 hours for UTI for 5 days (start date 09/04/25).Further review of Resident #54's record revealed the urine culture, CBC, and BMP were not conducted or obtained on 09/04/25 as ordered Further review of Resident #54's physician orders revealed orders dated 09/09/25 to place a mid-line (IV) and to start IV antibiotics every 24 hours for 7 days UTI / pyelonephritis (kidney infection) for 7 Days. There was also an order for a urinalysis with culture, CBC, and BMP.Further review of Resident #54's chart did not reveal any indications of the resident having pain or difficulty urinating, or increased temperature. An interview was conducted with the Nurse Practitioner (NP) on 09/10/25 at 11:00 AM. The NP stated Resident #54 had completed antibiotic therapy on 09/09/25, and continued to be symptomatic. The NP acknowledged that the initial urine culture ordered 09/03/25 was not completed, and the ordered CBC and BMP were not completed, which would have helped to determine if the resident had an infection, and which antibiotic, if needed, would be effective. The NP stated she examined Resident #54 on 09/09/25, and he presented with flank pain. An interview was conducted with Staff H, Registered Nurse/RN, on 09/10/25 at 2:00 PM. Staff I stated Resident #54 had not complained of any pain. Staff I further stated if the resident had pain, it would be documented in the resident's progress notes, and the resident had Tylenol prescribed for pain, which Staff I confirmed the resident had not received any pain medication. An interview was conducted with the Medical Director on 09/10/25 at 1:00 PM. The Medical Director stated based on the information he received from the NP, the treatment was appropriate. An interview was conducted with the Director of Nursing (DON) and the Infection Control Preventionist (ICP) on 09/10/25 at 2:00 PM. The DON and ICP stated Resident #54 did not meet the criteria for antibiotic stewardship. They stated the NP ordered it, so it was given. They acknowledged if there was a concern with antibiotic use, they should notify the physician / Medical Director. Review of a progress note dated 09/10/25 at 4:34 PM by the NP documented: Urinalysis (UA) and Labs reviewed with physician. UA results not consistent with UTI at this time post Cipro (antibiotic completion). Few bacteria are noted and culture is pending. He remains afebrile. Resident received x 1 dose of Rocephin (antibiotic) IV secondary to suspicion for pyelonephritis / persistent UTI. Recommendations to stop Rocephin at this time. NP notified physician also that midline infiltrated RUE [right upper extremity/arm] and has been removed by nursing staff. Initially orders were given to reinsert however orders have been given to discontinue orders for reinsertion. He denies any pain at this time in RUE or left flank.

Based on observations, interviews and record reviews, the facility failed to provide appropriate supervision to 1 of 3 sampled residents assessed as at risk for elopement. The deficient practice allowed Resident #1 to exit the facility on 10/12/24 at approximately 8:50 PM, through an unsecured door on the second floor. The findings included: The facility's policy, titled, Wandering and Elopements, with a revision date of March 2019, documented, in part: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified as at risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Record review revealed Resident #1, a resident with severe cognitive impairment, eloped from the facility on 10/12/24 at approximately 8:40 PM. The record revealed Resident #1 was observed by an individual from the community walking west on Silver Beach Road, a two-lane road with one lane traveling in each direction from east and west with a 30 miles per hour speed limit and no lighting. Resident #1 was found in an industrial area approximately 0.3 miles west of the facility. It was determined by the facility's investigation, that Resident #1 left her room and went through the Dining/Activities room to a staircase with two landings and 2 turns. Resident #1 then went through an area that consisted of the Human Resources office, Activities desk, and Staff Development office. At that time, there were no staff in this area as it was after hours and on a Saturday evening. Resident #1 then exited an unlocked door to an outside staircase that led to an unsecured area on the east side of the building with uneven terrain and then traveled west on Silver Beach Road and across Old Dixie Highway, a 4-lane road with two lanes traveling in each direction north and south. Resident #1 had to cross a set of two active railroad tracks used by Brightline, with trains that travel more than 80 miles per hour, as well as other transportation and freight interests/companies. Record review revealed Resident #1 was admitted to the facility on [DATE] and discharged to an Assisted Living Facility with a secure unit on 10/16/24. According to an Admission/Medicare 5-[NAME] MDS, dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00, indicating that the resident had severe cognitive impairment. The assessment documented Resident #1 did not exhibit wandering or exit seeking behaviors. The assessment documented that the resident required minimal assistance for bed mobility and transfer. Resident #1's diagnoses at the time of the assessment included Arthritis, Alzheimer's Disease, Dementia, Parkinson's Disease, Psychotic Disorder, History of falling and Sarcopenia. An Elopement Risk Evaluation, dated 10/07/24, concluded that the resident was an elopement risk based on: Cognitive status: Resident alert and continuous confusion. History of elopement/wandering: wanders, but has never eloped. Mobility: Ambulates independently with no device. Adjustment to facility placement: content with placement. Resident #1's care plan for elopement, initiated on 10/08/24, documented: Resident has a potential for elopement due to: has cognitive impairment, BIMS score is , has periods of increased confusion, is exit seeking, is (I) ambulatory, wanders the unit & wanders near exit doors 10/12/24 exited facility and redirected back to the facility. The goal of the care plan was documented as: Resident will remain safe and will refrain from leaving facility unsupervised thru the next review date. Interventions in the care plan included: - Discharge planning to a more appropriate level of care. - Facility has secured exit doors on the first floor. - Perform frequent observations of resident's whereabouts every shift. - Provide redirection when observed going towards exit doors. - Encourage resident to participate in activities of choice; provide 1:1s as needed. - Include resident in Elopement Book. - Update physician and responsible party if resident elopes. A Nurse's Progress note, dated 10/12/24 at 20:30, documented by Staff A, Licensed Practical Nurse (LPN), revealed, Note Text: At approximately 8:30p, this writer could not locate resident for her scheduled HS [hour of sleep] medication administration. A thorough search of the premises was initiated immediately. The resident was last seen in bed reading her bible. Facility protocols initiated. Staff conducted a head count and confirmed that resident was not on site. Following facility protocol resident was located outside of facility grounds by staff member. Resident appeared to be in stable condition, laughing, smiling, calm with bible in hand. Resident was assessed upon return to facility. Vital signs taken B/P 99/54, P 97, T 97.1, R 18, and O2 at 96% on room air. No visible trauma noted. Resident denies any pain or discomfort. No complaints voiced. Resident skin assessment completed. Resident skin is intact. 1:1 initiated and continued throughout shift. MD, DON, administrator, and resident primary contact [NAME] Colon made aware. Resident noted resting comfortably in bed at this time. During an interview with the Administrator and the Director of Nursing (DON), on 10/21/24 at 12:10 PM, when asked how Resident #1, a resident with severe cognitive impairment based on a BIMS score of 00, exited the facility, the DON replied, We figured out that she had come up the stairs and exited a door from the second floor. Then we went through an elopement drill and saw that the door was open. This isn't a resident area, and we had all of the doors secured with magnetic box, it was not done up here because it is not a residential area. Her coming up here showed us that residents could get up here. There has never been another resident up here, there is no elevator. Since then, we corrected that. The DON stated that Resident #1 was seen on camera at 8:36 PM around the dining room and then went upstairs. At 8:40 PM, an alarm sounded from the door that the resident exited from. At the time, there was no one in the dining room that would have heard the alarm and no staff in the area upstairs. The Administrator stated that there were no video cameras in the outside area where Resident #1 exited the facility and that the video was not saved. The Administrator stated that they were unable to determine the exact time that the resident exited the facility. When asked where the resident was going, the DON replied, She did not say, she was confused. When I interviewed her, she said that she was in the mountains in Puerto Rico. It was nighttime and she thought she was in the mountains of Puerto Rico. The DON stated that the resident was found approximately 0.3 miles west of the facility in an industrial area west of the facility on Silver Beach Road. The Administrator provided documentation of a Root Cause Analysis that documented: 1. Cognitively impaired and confused Resident exited facility from second floor by HR [Human Resources]. 2. high risk for elopement based on elopement assessment done by nurses scored as a 15. 3. Screamer on the second floor was not audible. 4. During the time, we locked the facility's doors and did not consider the second floor needed to be locked or secured. 5. The second floor was not identified as a risk area due it is not considered a resident common area. 6. Door not secured in a way that was consistent with the other doors. During an interview, on 10/21/24 at 3:30 PM with Staff C, Certified Nursing Assistant (CNA), when asked about Resident #1's elopement, Staff C stated that she was told there was a resident outside, by someone from the community and that she and Staff B, CNA, went outside and found the resident. She stated she was on the street when they found her and she stated the resident was giggling. She stated the resident was not injured. She stated she did not hear any alarms go off in the building when the resident left. During an interview, on 10/22/24 at 12:28 PM, with the Administrator and the DON, when asked about the member of the community coming in and informing the staff about Resident #1 being seen on Silver Beach Road, the DON replied, They heard a code green and then they started searching the areas. They were doing the code green, that was when the gentleman came in. while the two CNAs (referring to Staff B, CNA and Staff C, CNA) went with the individual, the rest of the staff were checking their own patients. One person, Staff A, saw that the door upstairs was open and understood that was where she most likely exited the building from. Once they saw that the patient was out of the building, that was when they called code green. When the Administrator and the DON were asked about the resident being observed on the second floor the previous evening, they stated that they were not aware of the observation. During an interview, on 10/22/24 at 4:49 PM, Staff D, CNA, stated that the resident was seen in the upstairs area the evening prior and redirected. On 10/22/24 at 5:03 PM, the Administrator and the DON were presented with an Immediate Jeopardy (IJ) template by the survey team, and informed that the Agency had determined that the deficient practice was determined to be Immediate Jeopardy. The facility's removal plan and corrective actions for the IJ included: On 10/12/2024, an Ad hoc QAPI (Quality Assurance and Performance Improvement) with Root Cause Analysis was performed with the IDT (Interdisciplinary Team) team, including: the Administrator, the Regional Director of Operations, the Regional Clinical Director, the Regional Maintenance Director. QAPI meetings were scheduled for the last Thursday of each month with the next scheduled meeting on 10/24/24. On 10/13/2024, all current residents' Elopement Assessment were reviewed and updated by nursing. There were no newly identified residents at high risk of elopement. On 10/13/2024, staff education was initiated to include Abuse and Neglect policy and procedure, Elopement policy and procedure, and new processes of closing the dining room door when the room is not in use. The Survey team confirmed via interviews and record reviews that 100% of all staff were provided the training. Elopement drills were conducted daily up to every shift daily to continue on for 14 days, then weekly for 4 weeks, then monthly thereafter. The Survey team confirmed via interviews and record review that 100% of staff participated in multiple elopement drills on all shifts. On 10/14/2024, the Senior Safety and Technology company installed Maglock (mag) on the second-floor exit door next to HR department office and the door between the unit and the Activities/Dining room for added security. The Survey team confirmed that all doors, mag locks and alarms were in working order and that the alarms were audible from a distance. On 10/15/24, education on the Identifying residents with behavioral symptoms that put the residents at risk for elopement was initiated. The Survey team confirmed via interviews and record review that 100% of all staff were provided the training. On 10/13/24, daily audits of the doors and alarms were initiated and the results reported to QAPI/QA Committee of the findings. The Survey team confirmed via observations, interviews and record review of the daily audits of the doors and alarms being audited for lock function and alarm sounding.

Based on observations, and interviews, the facility failed to provide housekeeping and maintenance services in order to maintain a clean, comfortable, sanitary and home like environment in 9 of 30 rooms and the Community Shower Room. The findings included: On 05/16/24 at approximately 2:00 PM, an environmental tour was conducted with the Director of Maintenance. The following was observed: a. In room [ROOM NUMBER], the hand washing sink in the bathroom was clogged in a manner that the basin was slow to drain. b. In room [ROOM NUMBER], the toilet was clogged and the faucet at the hand washing sink was not secured to the sink. c. In room [ROOM NUMBER], there was no drain plug in the tub to allow the tub to hold water, and there was duct tape covering a screen on the sides of the window mounted air conditioning unit. d. In room [ROOM NUMBER], the basin and faucets of the tub and the were dirty and there were urinals in need of being changed. e. In room [ROOM NUMBER], the surface of the over bed table for the door bed was worn to a point that the particle board underneath was exposed. f. In room [ROOM NUMBER], there was no overbed table provided to the resident in the door bed. g. In room [ROOM NUMBER], there was duct tape covering screens on the sides of the window mounted air conditioning unit. h. In room [ROOM NUMBER], the rails that were attached to the seat of the toilet were loose to a point that they were not sturdy and the residents would not be able to rely on the rails for support while toileting. i. In room [ROOM NUMBER], there was an accumulation of debris on the floor under the bed. j. In the Community Shower Room, there was an odor similar to smell of sewage from the shower and sinks. At the conclusion of the tour, the Director of Maintenance acknowledged understanding of the findings.

Based on observation and interview, the facility failed to follow facility-wide policies and procedures for 17 of 18 residents on Enhanced Barrier Precautions (EBP), including Residents #9, #1, #29, #236, #18, #13, #45, #54, #48 and #53, as evidenced by no gowns at or outside of the residents' doors; and failed to maintain an appropriately clean environment in the facility's laundry rooms to prevent cross contamination of the laundry with various forms of debris. The census at the time of survey was 83 residents. The findings included: 1. Review of the policy, titled, Enhanced Barrier Precautions, not dated, provided by the Director of Nurses (DON) on 05/16/24 at 1:45 PM revealed the following, in part: .EBPs are utilized to prevent the spread of multi-resistant organisms (MDROs) for residents . Under 11. PPE [Personal Protective Equipment]is available outside of the resident rooms . Review of the Center for Disease Control (CDC) guidelines, as the website provided by the DON, documented, in part, that for residents on EBPs that PPE (gowns and gloves) are to be located at the residents' doors. The CDC website is: CDC_Implementation_Of_Personal_Protective_Equipment_(PPE)_Use_In_Nursing_Homes_To_Prevent_Spread_Of_Multidrug-resistant_Organisims_(MDROs). Observation and review of the posted sign on residents' doors on 05/1624 at approximately 1:20 PM, for Residents #9, #1, #29, #236, #18, #13, #45, #54, #48 and #53, who were designated as being on EBP, noted instructions for staff to wear gowns and gloves when providing care. On 05/16/24 at 1:20 PM to 1:40 PM, observation revealed the following 18 rooms had EBP signs posted on their doors, and there were no gowns at or outside the residents' doors: Division 1 had 7 rooms with an EBP sign posted on the door that stated gowns and gloves were required for care. Division 2 had 2 rooms designated the same as Division 1. Division 3 had 3 rooms designated the same as Division 1. room [ROOM NUMBER], at this time, had a yellow PPE over-the-door holder or caddy with several slots in it. The holder was empty of PPE. Division 4 had 6 rooms designated the same as Division 1. On 05/16/24 at approximately 1:45 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they have a policy they follow for Enhanced Barrier Precautions (EBP) and they follow the CDC guidelines. The DON stated for residents on EBP, the door should have a sign posted on it. She stated PPE gowns are located on 3 Blue linen carts, one for Division 4, one for Division 3, and one shared with Divisions 1 and 2. She stated that extra gowns and gloves were located in the central supply room. She stated gloves were also located in each of the residents' rooms. She stated if needed, masks are available in the central supply room. Observation with the DON on 05/16/24 at approximately 1:50 PM of the units revealed the following: Division 1 and 2: One Blue Cart utilized for both units with a packet of 10 PPE gowns. Division 3: no Blue linen cart, and 2 packets of 10 PPE gowns located in the linen closet. Division 4: no Blue linen cart; and 1 and 1/2 packets of 10 PPE gowns located in the linen closet. There were no PPE gowns located at or near the residents' doors, except for room [ROOM NUMBER]. 39142 2. On 05/16/24 at approximately 1:00 PM, a tour of the facility's laundry room was conducted with the Director of Housekeeping and the Director of Nursing (DON) present. The following observations were noted: a. In the dirty laundry room, the floor was noted to have peeling paint with large, loose paint edges on a large area of the floor. Peeling paint with loose edges can break off and with activity and airflow have the potential to get into the sorting bin used to prepare the laundry for washing. b. The sorting bin in the dirty laundry area had a false bottom, which is a suspended platform that is mounted inside the cart with four springs that are cloth covered. The false bottom is removable. Beneath the false bottom, it was noted that there was an accumulation of dirt and refuse. This foreign matter has the potential to become entangled with the laundry and continue through to the clean laundry processing. A second bin was brought into the dirty laundry area by the Housekeeping Director from the clean laundry room. The Housekeeping director indicated that the second bin was used to transport the wet, clean laundry to the dryer and folding room. The second bin also had a false bottom where it was noted that there was debris under the false bottom. c. An observation of the clean laundry folding area was conducted. There were two housekeeping staff folding laundry from a bin with a false bottom. At that time, there was dirt and debris identified by the surveyor under the false bottom. The Housekeeping Director instructed one of the workers to lift the false bottom so he could see the debris. When the worker did this, she saw two washcloths at the bottom of the bin, which she then removed and tossed onto the clean surface of the folding table. One of the cloths struck an item that the second worker was folding. The second worker tossed one of the cloths into a clean rag bin even though the Housekeeping Director requested the items be given to him. d. The dryer tumblers in both Industrial dryers were noted to have foreign matter that was blue in appearance adhering to the drum surface. The blue matter matched in color to the disposable gloves used in the resident care area by staff. The drum in Dryer #1, closest to the door as approaching the dryers, had a dark rough spot with rust colored staining. There is potential for debris from the drum to flake off into the clean clothes/linens just washed. e. The floor in the clean laundry area also had a large areas of peeling paint that could break off and contaminate the clean laundry as people and equipment move throughout the area. Photographic Evidence Obtained.

Based on interview and record review, the facility failed to ensure showers as per resident preference and facility schedule for 1 of 4 sampled residents, Resident #19, reviewed for choices. The findings included: Review of the record revealed Resident #19 was admitted to the facility on [DATE]. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Further review of this MDS revealed the resident needed set-up assistance of staff for bathing and showering. Review of the comprehensive Admission MDS dated [DATE] documented it was very important for Resident #19 to choose between a bath and a shower. During an interview on 05/13/24 at 2:57 PM, when asked if she received baths and / or showers as she would like, Resident #19 stated staff never offer her a shower and she rarely gets them. When asked how often she would like a shower, Resident #19 stated at least weekly. Review of the Certified Nursing Assistant (CNA) documentation revealed the resident's bathing and/or showering schedule was Monday and Thursday on the 3 PM to 11 PM shifts. Further review of this documentation revealed staff documented the completion of the Bathing/Shower task for Resident #19, but the documentation did not reveal if the resident received a bath or a shower. During an interview on 05/15/24 at 2:45 PM, Staff F, CNA, explained they had a shower book that documented the shower schedule for each resident, and then the completion was documented in the electronic medical record (EMR). When asked what happened if the resident refused a shower, the CNA stated she would speak with the nurse first then document the refusal in the EMR, if the nurse could not convince the resident to shower. During a side-by-side record review and interview on 05/16/24 at 1:18 PM, Staff E, Licensed Practical Nurse (LPN)/Unit Manager confirmed the CNAs documented the provision of showers in the EMR. When shown the documentation for Resident #19, Staff E agreed it did not differentiate between a bath and a shower.

Based on interview, record review and observation, the facility failed to maintain residents' fingernails for 2 of 6 sampled residents identified with long fingernails, Resident #45 and Resident #48. The findings included: The facility's policy, titled, Fingernails/Toenails Care, from MED-PASS, Inc, (Revised February 2018), under General Guidelines, item 3 documented in part, Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. a. On 05/13/24 at 3:28 PM, an interview was conducted with Resident #45. At that time, it was noted that Resident #45 had fingernails that extended past his fingertips by about 1/2 inch, on both hands. When asked about the length of the fingernails, Resident #45 stated he would like to have his nails trimmed. On 05/15/24 at 10:02 AM, a second observation was made, and it was noted that Resident #45 still had untrimmed fingernails. On 05/16/24 at 2:30 PM, Resident #45 showed the surveyor that his fingernails had now been trimmed. The resident stated that the staff had trimmed his nails, and he was satisfied with the result. b. On 05/13/24 at 1:06 PM, an interview was conducted with Resident #48. At that time, it was noted that the resident had fingernails at least 1/2 inch beyond his fingertips. When asked if he was okay with the length of the fingernails, the resident stated he was not. When asked if he wanted them trimmed the resident stated yes, but they won't do it here (in the facility). The resident stated he has paid for someone to do it in the past. On 05/15/24 at 3:00 PM, an interview was conducted with Resident #48 who expressed that his nails were still not trimmed but he was going to ask the staff for it later. 05/16/24at 2:59 PM, an interview was conducted with Resident #48 regarding his fingernails. The resident revealed his fingernails were now trimmed and the resident was satisfied with the result. On 05/16/24 at 09:19 AM, an interview was conducted with Staff C, Certified Nursing assistant (CNA), who stated the Activities staff does the fingernail trimming but the responsibility for ensuring it is done falls to the nurses and CNAs. Staff C also stated the residents can ask for the nails to be trimmed themselves if they are capable, but the CNAs and nurses are responsible for noting when the nails need to be trimmed. The CNA stated she believed they were not allowed to trim the fingernails for Diabetic residents. She stated they were not allowed to trim toenails for Diabetics but she thought the same was true for fingernails.

Based on observations, interviews and record reviews, the facility failed to ensure the safe transfer for 1 of 27 sampled residents, Resident #18, resulting in skin damage to the resident; and failed provide devices to ensure the safety of the resident while smoking for 1 of 2 sampled residents reviewed for smoking, Resident #80. The findings included: 1. Resident #18 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, an Annual Minimum Data Set (MDS), dated [DATE] documented Resident #18 was not assessed for cognition due to 'resident is rarely/never understood'. The MDS documented Resident #18 was dependent upon staff for all Activities of Daily Living (ADLs) and was 'always incontinent' of urine and bowel. Resident #18's diagnoses at the time of the assessment included: Anemia, Atrial fibrillation, Hypertension, Orthostatic hypotension, Peripheral Vascular Disease (PVD), Gastro-esophageal reflux disease (GERD), Obstructive uropathy, Hyperkalemia, Aphasia, Cerebral Vascular Accident (CVA), Quadriplegia, Seizure disorder, Traumatic brain injury, Anxiety disorder, Depression, Cataracts, Encephalopathy, Anoxic brain damage, Idiopathic Peripheral Autonomic Neuropathy, Dysphagia, Contracture of muscle, Pain, open wound to right foot, Personal history of Methicillin Resistant Staph Aureus (MRSA). An interview was conducted with Resident 18's sister, 05/13/24 at 1:35 PM, who stated, on 04/24/24, I came in and he had a scrape on his arm. I was told that his shirt was wet from his feeding tube and they had to change his shirt and that was when she [referring to a Certified Nursing Assistant (CNA)] noticed a 4-inch cut that went to the white meat. I went to the Director of Nursing [DON] she told me that it was pressure (left elbow). I was fine until they told me that it was pressure, there is no pressure on his elbow [Left]. I called the police and he made a report that I am not privy to. They are unable to give me an accurate description of what happened and how he got the big tear on his arm. I called [another agency] for the tube feeding incident and the skin tear. Review of the record documented physician orders that included: 05/06/24 - Cleanse Left Elbow with Normal Saline, pat dry, apply Silverdene Cream I% to affected area, cover with dry protective dressing three times a week until resolved - every day shift every Mon, Wed, Fri [Monday, Wednesday, Friday] for Skin Abrasion. Review of the Nurse note, dated 04/26/24 at 19:31 [7:31 PM], documented, Note Text: All medication and treatment provided to patient on day shift by writer and CNA. Dressing to Left elbow was completed, feedings done and tolerated well. Resident placed in bed and in comfortable position, safety measures are in place, call light within reach. Patients mother and sister came to visit resident on day shift all questions and concerns addressed. Will continue to monitor resident. Review of the Nurse note, dated 04/26/24 at 16:00 [4:00 PM], documented, Note Text: in geri-chair at this time. Sister in room visiting states that she removed dressing to resident's left elbow. On assess shearing noted to left elbow. Treatment in place and consult for Wound care eval [evaluation] with [name of group] wound care group. Dressing reapplied. No grimacing noted. Review of the Nurse note, dated 04/24/24 at 14:40 [2:40 PM], documented, Note Text: This writer called to room by aide to observe open area to resident left elbow. Upon further assessment resident has bilateral hand and forearm contracture. Open area located on the under surface of left elbow. Resident mother present at bedside and verbally notified. This writer cleansed area with normal saline and covered with dry protective dressing. Demonstrates no evidence of pain at this time. MD notified and treatment orders received and initiated. An interview was conducted on 05/16/24 at 12:32 PM with the Director Of Nursing (DON). When asked about the open area to Resident #18's left arm, the DON replied, the CNA was in the room transferring the resident via hoyer with the assistance of his mother. He got some shearing on his elbow from the hoyer lift pad. I asked the aide and she said that his mother was helping. I asked her why the mother was helping and why staff was not and she could not answer me. I called in the staff that worked 3-11 [PM] and 11-7 [PM, AM] and they all said that they did not see anything. The shift that reported was the 7-3 [AM, PM] shift. She said that the mother was in the room, so she asked for help. We don't have a policy for 2 persons hoyer lift. Safety wise, they should use 2 people on the hoyer lift - staff members. We don't have a policy on the hoyer lift. An interview was conducted on 05/16/24 at 3:42 PM with the Social Services Director [SSD] and the Administrator. When asked about staff transferring Resident #18 via the hoyer lift, the SSD replied, Staff H, CNA, was giving care and transferred him from the bed to the chair. During our investigation, it was found out that she did it alone, this is the first I am hearing of the resident's mother helping. I was told that the mom was present. When she was doing the transfer, she noticed the opening. We are assuming that the sling went up and caused the abrasion. There was no other opportunity for it to happen. She [CNA] felt like she was comfortable to do it alone and while the mom was there. She didn't want to wait for anyone to come and help. The DON reported to me [SSD]that she felt that she could do it herself. Staff D was not available for interview due to being out of the country. 2. The facility's policy, titled, Smoking Policy - Residents, most recently revised on 10/05/22, documented, in part: The center will establish and maintain a safe designated smoking area and safe smoking practices for the residents .The center will have safety equipment available in designated smoking areas including: a fire blanket, smoking aprons, smoking aprons, a fire extinguisher, and non-combustible self-closing ashtrays. Record review documented Resident #80 was admitted to the facility on [DATE]. Review of the resident's most recent full assessment, an Admission MDS, dated [DATE], documented Resident #80 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Resident #80's diagnoses at the time of the assessment included Heart Failure, Hypertension, PVD, GERD, DM, Anxiety disorder, Depression, Post-Traumatic Stress Disorder (PTSD), Chronic lung disease, Acute Respiratory Failure with hypoxia, Pain in thoracic spine, Hereditary and idiopathic neuropathy, Nicotine dependence, Morbid Obesity due to excess calories, Disorder of adrenal gland, Absence of left leg below the knee, Achalasia of Cardia, Chronic pain syndrome, Impingement syndrome of right shoulder. Review of the Smoking evaluation, dated 04/18/24, documented: Resident Smokes safely - Yes. Resident must wear smoking apron at all times. Resident #80's care plan for smoking, initiated on 04/26/24, documented, Resident desires to smoke. Resident has been assessed as able to smoke: with supervision; Resident has been informed of the facility smoking policy. The goal of the care plan was documented as, Resident will demonstrate safe smoking practices through the next review date 04/26/24 with a target date of 07/25/24. Interventions to the care plan included: Apply/remove smoking apron. On 05/13/24 at 10:45 AM, six residents were observed in the designated smoking area with the Activities Director, including Resident #80. It was noted that none of the residents were provided with a smoking apron. On 05/15/24 at 9:04 AM, five residents were observed on the smoking patio, including Resident #80 with supervision provided by Staff D, CNA. It was noted that none of the residents were provided a smoking apron. An interview was conducted on 05/15/24 at 1:48 PM with Resident #80, who when asked stated she has never been offered apron and was not aware of the benefits, Resident #80 further stated, Sometimes I get distracted by watching on my phone and I drop ashes. An interview was conducted on 05/15/24 at 3:36 PM with the Activities Director, who when asked about the smoking aprons, stated, we keep them (aprons) in the Activities closet. We bring them for the residents who need them. We leave them on Division 2 when we leave. An interview was conducted on 05/15/24 at 3:43 PM with the Staffing Coordinator, who when asked, was unable to locate smoking aprons at nurse's station. An interview was conducted on 05/15/24 at 3:53 PM, with Staff E, Licensed Practical Nurse / Nursing Supervisor, who when asked about the residents using smoking aprons, Staff E stated, We have 2 patients that need them, Resident #53 and Resident #80. When Activities leave, they bring the aprons and cigarettes to the nurses' station for the evening nursing staff.

Based on observations interviews and record reviews, the facility failed to assess a resident for the risks associated with the use of bed rails, obtain physician's orders for the use of bed rails, and initiate a care plan for the use of bed rails for 1 of 2 sampled residents reviewed for the use of bed rails, Resident #134. The findings included: The facility's policy, titled, Bed Safety and Bed Rails, revised August 2022, documented, in part: Use of Bed Rails 5. If attempted alternatives do no adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes: a. An evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs. b. the resident's risk associated with the use of bed rails. c. input from the resident and/or responsible party. d. consultation with the attending physician. 7. The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following: a. Accident hazards: (2) The resident or part of his/her body could be caught between rails, the openings, or between the bed rails and mattress. Record review documented Resident #134 was admitted on [DATE]. Review of the resident's most recent full assessment, an Admission Minimum Data Set (MDS), dated [DATE], documented Resident #134 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS documented the resident was dependent on staff for transfer and bed mobility, was frequently incontinent of urine and was always incontinent of bowel. Resident #134's diagnoses at the time of the assessment included: Anemia, Hypertension, Gastro Esophageal Reflux Disease, Hyperlipidemia, Malnutrition, Chronic Lung Disease, Dependence on Renal Dialysis, Thrombosis due to Vascular Prosthetic, Kidney Transplant Rejection, Toxic Nephropathy, Vitamin D deficiency, and Hypocalcemia. Review of Resident #134's care plan for Activities of Daily Living (ADLs), initiated on 04/26/24, documented, Resident has a selfcare deficit with dressing, grooming, bathing as evidenced by needs assistance with personal care tasks mobility and transfer skills. The goal of the care plan was documented as, Resident will have clean, neat appearance daily thru the next review date; date of 04/26/24 with a target date of 05/28/24. An intervention to the care plan included: May use 1/4 side rails X2 as an enabler for bed mobility. On 05/14/24 at 9:48 AM, Resident #134 was observed in bed with half side rails on the bed. During an interview with the resident and the spouse, when asked about the use of the bed rails, Resident #134 replied, they keep me from falling out of the bed. Resident #134 further stated the bed rails were provided per his request. Review of Resident #134's medical record revealed the resident had not had the bed assessed for the risks associated with the use of the rails. There was no care plan and there were no physician orders for the use of the rails.

Based on record review, interview, and policy review, the facility failed to follow physician's orders related to the timing for administration of medication for 3 of 6 sampled residents, Residents #19, #63 and #68, as evidence by: Resident #19 was receiving two medications with a potential drug to drug interaction, in which nursing staff failed to administer at the ordered time; and Residents #63 and #68 complained medications were not provided timely. The findings included: Review of the policy, titled, Administering Medications, revised April 2019 documented, in part, . 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 1. Review of the record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses to include major depression and anxiety disorders. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #19 was receiving both an antianxiety medication and an antidepressant. Review of the current orders revealed Resident #19 was receiving the antidepressant medication mirtazapine 15 milligrams (mg) which was ordered at bedtime, and scheduled for 9:00 PM. Resident #19 was also receiving the antianxiety medication alprazolam 0.25 mg which was ordered for the evening at 6:00 PM. The order for the alprazolam specifically documented, Please do not administer with mirtazapine. Review of the corresponding Medication Administration Record (MAR) documented Resident #19 was receiving both medications at 9:00 PM. During a side-by-side record review and interview on 05/16/24 at 1:18 PM, when asked about the timing of the mirtazapine and alprazolam, Staff E, Licensed Practical Nurse (LPN)/Unit Manager, agreed with the concern and identified the staff who entered the alprazolam order scheduled it for 9:00 PM, instead of 6:00 PM, upon admission on 01/09/24. 2. Review of the record revealed Resident #63 was admitted to the facility on [DATE]. Review of the current Admission MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. During an interview on 05/13/24 at 11:38 AM, Resident #63 stated he was not getting his night medications at bedtime, but was getting them whenever staff wanted. The resident stated his bedtime medications were given anywhere from 6:30 PM to after midnight. Review of the current orders revealed Resident #63 had the following medications ordered for bedtime, which was scheduled for 9:00 PM: a) Trazodone 25 mg, an antidepressant ordered to help with sleep. b) Flonase Allergy Relief nasal spray. c) Risperidone 1 mg, an antipsychotic medication. Review of the May 2024 Medication Administration Record (MAR) documented these three medications were documented as ordered, as evidenced by a checkmark at the 9 PM time-slot, and with the nurse's computer identification. Review of the Administration Detail for these three medications revealed the timestamp as to when the medication was documented as administered and was as follows: 05/02/24 at 10:59 PM, 05/04/24 at 12:44 AM, 05/06/24 at 3:12 AM, 05/07/24 at 12:06 AM, 05/08/24 at 12:42 AM, 05/09/24 at 2:58 AM, 05/10/24 at 12:09 AM, 05/11/24 at 11:17 PM and 12:15 AM, 05/14/24 at 2:26 AM, and 05/15/24 at 2:38 AM. Upon receipt of the Administration Detail from the Consultant Nurse on 05/16/24, she agreed with the findings. 41837 3. Record review for Resident #68 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Generalized Anxiety Disorder Major Depressive Disorder, Insomnia, and Attention Deficit Hyperactivity Disorder (ADHD) Predominately Hyperactive Type. Review of the Minimum Data Set (MDS) for Resident #6 dated 02/23/24 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition was intact. Review of the Physician's Orders for Resident #68 revealed an order dated 05/25/23 for Dextroamphetamine Sulfate 10 MG give 2 tablet by mouth three times a day (6:00 AM, 12:00 PM, and 4:00 PM) for ADHD. Review of the Physician's Orders for Resident #68 revealed an order dated 03/28/23 for Bupropion HCl Extended Release 24 Hour 150 MG give 3 tablet by mouth one time a day for depression. Review of the Physician's Orders for Resident #68 revealed an order dated 05/03/24 Lunesta Oral Tablet 3 MG give 3 mg by mouth at bedtime for Insomnia. Further review of the Physician's Orders for Resident #68 revealed an order dated 05/06/24 Xanax Oral Tablet 1 MG give 1 tablet by mouth every 8 hours as needed for Anxiety for 14 Days. Further review of the Physician's Orders for Resident #68 revealed an order dated 04/07/23 for Outcome codes: Improved=[+], Unchanged=[0], worsened=[W] every day and night shift for monitoring. Review of the Physician's Orders for Resident #68 revealed an order dated 04/07/23 for Intervention Codes: 0= None/ no behaviors noted 1= Redirect 2= 1:1 3= Ambulate/ Exercise 4= Diversion Activity [CP] 5= Give food/ fluids 6= Toileting 7= Repositioned 9= Removed stimulus 10= Psych. Eval 11= Re-approach 12= Other every day and night shift for Monitor. Review of the Physician's Orders for Resident #68 revealed an order dated 04/07/23 for Medication Management: Diagnosis (Dx) Anxiety 0= no behavior 1= Combativeness 2= Verbally inappropriate 3= Sexually inappropriate 4= Disrobing 5= Crying excessively 6= Calling out constantly 7= Screaming excessively 8= Auditory Hallucinations 9= Delusional 10= Resists Care 11= Socially inappropriate 12= Extreme Pacing 13= Restlessness 14= Other every day and night shift for Monitor. Review of the Physician's Orders for Resident #68 revealed an order dated 04/07/23 for side effects related to psychoactive medication: 0= None 1= movement side effects 2= non-movement side effects every day and night shift for Monitoring. Review of the Medication Administration Record (MAR) for Resident #68 for the month of May revealed the Dextroamphetamine Sulfate was administered three times (6:00 AM, 12:00 PM, and 4:00 PM) as ordered. Review of the Medication Actual Administrated times for Resident #68 for Dextroamphetamine Sulfate for the month of May 2024 documented the following: for 9 times out of 45 opportunities the medication was given more than 1 hour late. This included on 05/09/24 when the medication was scheduled for 6:00 AM and was given at 8:02 AM, indicating over 2 hours late. An interview was conducted on 05/13/24 at 9:50 AM with Resident #68 who stated they do not give her the ADHD medications like they are supposed to be given as they are often late and she needs the medication on time or it interferes with her sleep. An interview was conducted on 05/15/24 at 11:35 AM with the Director of Nursing who was asked about medication administration. She said medications are administered as prescribed. When asked what is an acceptable time to give scheduled medications, she said generally it is within an hour to the medication scheduled time. During an interview conducted on 05/16/24 at 9:30 AM with the Director of Nursing and the Regional Clinical Consultant who were asked about Resident #68 and the medication Dextroamphetamine Sulfate when shown the actual medication administration documented time, they acknowledged the medication was given several times outside of the hour before or after the scheduled times. On 05/16/24 at 12:45 PM, an interview was conducted with the Licensed Practical Nurse / LPN who stated she works a 12-hour shift at the facility. When asked if she documents behaviors for the residents who are on any psychotic medications, she said yes, every shift we document behaviors, even if they have no behaviors, we document that as well. When asked where this is documented, she said on the behavior monitoring flowsheet in the Medication Administration Record. When asked about medication administration, she said we have an hour before and an hour after the medication scheduled time to give the medication. On 05/16/24 at 1:00 PM, an interview was conducted with the Registered Nurse / RM who stated she works a 12-hour shift at the facility. She was asked if she documents behaviors for residents who are on any psychotic medications, she said she documents behaviors every shift. When asked where this is documented, she said it is on the MAR (Medication Administration Record). When asked about medication administration, she said we give the medications when they are scheduled. When asked if she did not administer a medication at the exact time, what was acceptable to be considered administered on time, she said it can be an hour before or after the scheduled time. An interview was conducted on 05/16/24 at 1:50 PM with the Consultant Pharmacist who was asked about the medication Dextroamphetamine Sulfate. He stated the medication is a stimulant and he would expect it to not be given later than 6:00 PM or it may interfere with sleep. When asked about Resident #68 having the medication ordered 3 times per day with last dose scheduled for 4:00 PM and given as late as 8:00 PM, he acknowledged it would most likely interfere with this resident's sleep.

Based on record review and interview, the pharmacist failed to identify a timing issue with a possible drug to drug interaction for 1 of 5 sampled residents, Resident #19. The findings included: Review of the record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses to include major depression and anxiety disorders. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #19 was receiving both an antianxiety medication and an antidepressant. Review of the current orders revealed Resident #19 was receiving the antidepressant medication mirtazapine 15 milligrams (mg) which was ordered at bedtime, and scheduled for 9:00 PM. Resident #19 was also receiving the antianxiety medication alprazolam 0.25 mg which was ordered for the evening at 6:00 PM. The order for the alprazolam specifically documented, Please do not administer with mirtazapine. Review of the corresponding Medication Administration Record (MAR) documented Resident #19 was receiving both medications at 9:00 PM. During a side-by-side record review and interview on 05/16/24 at 1:18 PM, when asked about the timing of the mirtazapine and alprazolam, Staff E, Licensed Practical Nurse (LPN)/Unit Manager, agreed with the concern and identified the staff who entered the alprazolam order and scheduled it for 9:00 PM, instead of 6:00 PM, upon admission on 01/09/24. Pharmacy reviews from January 2024 through April 2024 lacked any recommendations for Resident #19. During a phone interview on 05/16/24 at 3:32 PM, when asked if he identified that both mirtazapine and alprazolam where being administered at the same time, despite the fact that the order documented not to do so, the Consultant Pharmacist stated it was overlooked. When asked why the medications were not to be administered at the same time, the Consultant Pharmacist explained given together may cause added sedative affects, CNS (Central Nervous System) depression, and respiratory depression.

5. Record review revealed Resident #19 was admitted to the facility on [DATE]. Review of the current orders revealed the resident was currently taking an antidepressant and an antianxiety medication. Further review of the orders revealed as of 01/08/24 nursing staff was to monitor for resident behaviors twice daily on day and night shifts, and document any intervention provided and outcomes, and monitor for side effects of these medications. Review of the current May 2024 Behavior Monitoring Flow sheet revealed a lack of monitoring on the 05/01/24 day shift, 05/06/24 day shift, 05/07/24 day shift, 05/08/24 day shift, 05/13/24 night shift, and the 05/14/24 night shift. This resulted in a failure to monitor behaviors on 6 of 29 shifts. Review of the April 2024 Behavior Monitoring Flow Sheet revealed a lack of monitoring on the folowing shifts: 04/02/24 day shift, 04/03/24 night shift, 04/07/24 day shift, 04/08/24 both shifts, 04/09/24 both shifts, 04/10/24 day shift, 04/13/24 day shift, 04/14/24 night shift, 04/16/24 day shift, 04/17/24 night shift, 04/22/24 both shifts, 04/23/24 day shift, 04/24/24 both shifts, 04/26/24 day shift, 04/26/24 day shift, 04/29/24 day shift, and 04/30/24 day shift. This resulted in a failure to monitor behaviors on 20 of 60 shifts. 41837 Based on interviews and record reviews the facility failed to monitor behaviors as ordered by physician related to psychotropic medications for 5 of 6 sampled residents reviewed for medications, (Residents #35, #64, #68, #236, and #19). The findings included: Review of the facility's policy, titled, Behavioral Assessment, Intervention and Monitoring, dated March 2019, included, in part, the following: Behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment. 1. Record review for Resident #35 revealed the resident was originally admitted to the facility on [DATE] with a most recent readmission on 09/06/23, with diagnoses that included Lymphedema, Major Depressive Disorder, and Anxiety Disorder. Review of the Minimum Data Set (MDS) for Resident #35 dated 02/16/24 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition is intact. Review of the Physician's Orders for Resident #35 revealed an order dated 09/06/23 for Medication Management: Dx. Anxiety 0= no behavior 1= Combativeness 2= Verbally inappropriate 3= Sexually inappropriate 4= Disrobing 5= Crying excessively 6= Calling out constantly 7= Screaming excessively 8= Auditory Hallucinations 9= Delusional 10= Resists Care 11= Socially inappropriate 12= Extreme Pacing 13= Restlessness 14= Other. Review of the Physician's Orders for Resident #35 revealed an order dated 09/06/23 for Outcome codes: Improved=[+], Unchanged=[0], worsened=[W] every day and night shift for monitoring. Review of the Behavior Monitoring Flow Sheet for Resident #35 for the month of May 2024 revealed the interventions, the medication management, and side effects were not documented for 8 of 30 opportunities. 2. Record review for Resident #68 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Generalized Anxiety Disorder Major Depressive Disorder, Insomnia, and Attention Deficit Hyperactivity Disorder (ADHD) Predominately Hyperactive Type. Review of the MDS assessment for Resident #68 dated 02/23/24 revealed, in Section C, a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #68 revealed an order dated 04/07/23 for Medication Management: Dx Anxiety 0= no behavior 1= Combativeness 2= Verbally inappropriate 3= Sexually inappropriate 4= Disrobing 5= Crying excessively 6= Calling out constantly 7= Screaming excessively 8= Auditory Hallucinations 9= Delusional 10= Resists Care 11= Socially inappropriate 12= Extreme Pacing 13= Restlessness 14= Other every shift for Monitor. Review of the Behavior Monitoring Flow Sheet for Resident #68 for the month of May 2024 revealed the interventions, the medication management, and side effects were not documented 15 of 30 opportunities. 3. Record review for Resident #64 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Anxiety Disorder, Unspecified Mood Disorder, and Unspecified Psychosis. Review of the MDS assessment for Resident #64 dated 04/18/24 revealed, in Section C, a BIMS score of 5 indicating severe cognitive impairment. Review of the Physician's Orders for Resident #64 revealed an order dated 01/13/23 for Medication Management: Dx. Mood Disorder/Anxiety 0= no behavior 1= Combativeness 2= Verbally inappropriate 3= Sexually inappropriate 4= Disrobing 5= Crying excessively 6= Calling out constantly 7= Screaming excessively 8= Auditory Hallucinations 9= Delusional 10= Resists Care 11= Socially inappropriate 12= Extreme Pacing 13= Restlessness 14= Other every shift for Monitor. Review of the Physician's Orders for Resident #64 revealed an order dated 01/10/23 for Intervention Codes: 0= None/ no behaviors noted 1= Redirect 2= 1:1 3= Ambulate/ Exercise 4= Diversion Activity [CP] 5= Give food/ fluids 6= Toileting 7= Repositioned 9= Removed stimulus 10= Psych. Eval 11= Re-approach 12= Other every shift for Monitor Review of the Behavior Monitoring Flow Sheet for Resident #64 for the month of May 2024 revealed the interventions, the medication management, and side effects were not documented 20 out of 45 opportunities. 4. Record review for Resident #236 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Dementia, Major Depressive Disorder, and Unspecified Psychosis. Review of the MDS for Resident #236 dated 05/13/24 revealed in Section C, a BIMS score of 0 indicating severe cognitive impairment. Review of the Physician's Orders for Resident #236 revealed an order dated 05/14/24 for Medication Management: Dx. Mood Disorder/Anxiety 0= no behavior 1= Combativeness 2= Verbally inappropriate 3= Sexually inappropriate 4= Disrobing 5= Crying excessively 6= Calling out constantly 7= Screaming excessively 8= Auditory Hallucinations 9= Delusional 10= Resists Care 11= Socially inappropriate 12= Extreme Pacing 13= Restlessness 14= Other every shift for Monitor. Review of the Physician's Orders for Resident #236 revealed an order dated 05/14/24 for Intervention Codes: 0= None/ no behaviors noted 1= Redirect 2= 1:1 3= Ambulate/ Exercise 4= Diversion Activity [CP] 5= Give food/ fluids 6= Toileting 7= Repositioned 9= Removed stimulus 10= Psych. Eval 11= Re-approach 12= Other every shift for Monitor Review of the Behavior Monitoring Flow Sheet for Resident #236 for the month of May 2024 revealed the interventions, the medication management, and side effects were not documented 2 out of 3 opportunities. An interview was conducted on 05/16/24 at 12:00 PM with the Director of Nursing and Regional Clinical Conslutant, who acknowledged the behavior monitoring for Residents #35, #64, #68, #236 were not documented as ordered.

Based on interview and record review, the facility failed to ensure accuracy of records for 1 of 3 sampled residents, reviewed as closed records, Resident #83, as evidenced by failure to ensure accurate documenation in the residnet's record that reflected the resident's discharge. The findings included: Record review for Resident #83 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Anxiety Disorder, Alcohol Abuse, and Nicotine Dependence of Cigarettes. Review of the Minimum Data Set (MDS) assessment for Resident #83 dated 01/29/24 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 15, indicating an intact cognitive response. Review of the MDS for Resident #83 dated 02/29/24 titled and documented that Discharge Return Anticipated. Review of the MDS for Resident #83, dated 02/29/24, titled and documented that 'Discharge Return Not Anticipated (Modification).' Review of the Nurses Note for Resident #83 dated 03/02/24 documented: 'Report received that patient signed out on 2/29 (02/29/24) and has not returned since.' Review of the Nurses Note for Resident #83 dated 02/29/24 documented: 'Resident alert and oriented x3 verbally responsive left facility ambulated with walker, sign out book.' During an interview conducted on 05/14/24 at 2:30 PM with Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM), she stated she has worked at the facility since the 3rd week in February of 2024. When asked about Resident #83 leaving the facility, she stated on 02/29/24 the resident left the facility after signing himself out. The resident often signed himself out and would return the same day with several bags from various stores. On 02/29/24, the resident told his nurse Staff A, LPN, he would not be back until the following Monday. Staff E stated she believes Staff A told the Administrator and the Administrator called her to go see what was happening. Staff E spoke to Staff A and was informed the resident 'was not planning to return to the facility until Monday, Saturday at the earliest.' Staff E further stated she was able to get in touch with the resident by phone on 02/29/24 and the resident told her he was not planning to return to the facility until Monday. After her conversation with the resident, she notified the Administrator of what had happened, and he instructed her to call the resident back to inform him he would need to return to the facility tonight before midnight or he would be discharged . Staff E attempted to call the resident, but he would not answer his phone. She called the resident's family member who stated she was out of town. Within 5 minutes, the resident called Staff E back and she instructed the resident he needed to return to the facility by midnight, and he said, 'the Administrator messed screwed up his Medicaid, now he will screw him back.' Staff E said that on Monday 03/04/24 when she returned to work at the facility, she was made aware by Staff A that the resident had not returned to the facility. Staff E spoke to the Administrator and Staff E notified the police to request a wellness check. She informed the police they did not have an address for the resident, only a phone number. The police said they would follow up. Staff E said the physician was notified on 02/29/24 that the resident had informed the staff he was not coming back to the facility, and the resident seemed to have slurred speech when she spoke to him on the phone on 02/29/24. Staff E stated she considered the resident gone and left against medical advice (AMA) when he did not return on Monday 03/04/24. When asked about when a resident leaves AMA what the facility does, Staff E LPN/UM said they notify the doctor, notify family, also for safety do a wellness visit (done by police) and document this in the resident's chart. Staff E LPN/UM said if the resident is found, they try to see if the resident will come back and advise them, they have rights to make their own decision. She stated that another agency [name provided] is notified if the resident lacks mental capacity or if suspect manipulation from an outsider. When asked about documentation of the incident with Resident #83, she said she thought she had documented it in the resident's EMR. When it was brought to her attention on 05/14/24 that there was no documentation from her in the resident's chart, she hand wrote a statement to what happened and signed it with the date of 05/14/24. She acknowledged that there was no documentation of the incident or any phone calls in the resident's chart until 05/14/24. During an interview conducted on 05/14/24 at 3:07 PM with Administrator who was asked about Resident #83, the Administrator said the resident left AMA. When asked what the process was for a resident who leaves AMA, he said they call another agency [name provided]. When asked if a resident leaves AMA, do they code the Minimum Data Set (MDS) as discharge return anticipated, he said no. When asked who spoke to the resident or attempted to reach the resident after leaving, the Administrator said it was a combination of nursing and admissions. The Administrator acknowledged there was no documentation in the resident's chart about the resident leaving AMA or any conversation that the resident did not wish to return to the facility. During an interview conducted on 05/16/24 at 9:30 AM with the Administrator who was asked about the process they follow when a resident leaves AMA, such as Resident #83, he stated it is the Director of Nursing's (DON's) responsibility to ensure documentation is in the resident's chart so that the resident can be discharged out of the system. During an interview conducted on 05/16/24 at 1:00 PM with MDS Director who was asked about the coding of the discharge for Resident #83, she stated on 02/29/24 she coded it as discharge return anticipated. When asked when she uses the code discharge return not anticipated, she said she does not document a discharge that way until she sees some supporting documentation that the resident is not returning, this could be in a progress note, or a physician's order. She stated that once she saw the order on 05/14/24 to discharge the resident, she then entered a discharge for the resident that identified the resident as discharged return not anticipated. The MDS Director acknowledged the Discharge Return Not Anticipated was not entered into the resident's chart until 05/14/24.