Every finding on record at The Alverno Health Care Facility

Based on review of the Centers for Medicare & Medicaid Services Certification and Survey Provider Enhanced Report (CASPER), review of the facility Quality Assurance Performance Improvement (QAPI) plan, and staff interviews the facility failed to implement quality assurance practices to prevent the repeat of citations of deficient practices in the area of infection control and pharmacy services. The facility reported a census of 87 residents. \Findings include: Review of the CASPER revealed the facility had the following repeat deficient practices:F761 - Label/Store Drugs & Biologicals cited during a complaint survey ending on 8/7/25; and the current Recertification survey completed on 2/19/26.F880 - Infection Prevention & Control cited during the Recertification surveys that ended on 5/2/24, 2/6/25 and the most recent one completed on 2/19/26. During an interview on 2/19/26 at 1:30 PM, the Administrator stated the facility has been providing a lot of staff education regarding enhanced barrier precautions, performing staff audits on peri care, and providing one on one education on an as needed basis to staff members on infection control issues.Review of the facility's QAPI plan, dated November 2019, revealed a Statement of Purpose which declared The Mission Driven Quality Assurance and Improvement Plan (QAPI) at.is comprehensive and ongoing. It encompasses the full range of services and is founded in Clinical Care, Quality of Life and Resident Choice. The Mission Driven Quality Assurance and Performance plan section, directed, in part: The Mission Driven Performance Improvement Projects will be based upon input and data from CMS Nursing Home Compare, Resident and Family Satisfaction Surveys, [name of brand name decision making tool redacted], Family and Resident Councils, Annual Surveys, and Colleague feedback.

Based on observations, record review, staff interviews and facility policy review, The facility failed to ensure staff followed contact precautions for 1 of 1 residents (Resident #103) on contact precautions, failed to utilize Enhanced Barrier Precautions correctly effecting 2 of 2 residents (Resident #16 and Resident #52), failed to follow infection control practices to minimize the potential to spread COVID in the Memory Care unit, and failed to cover wet laundry during transport to an operational dryer. The facility reported a census of 87 residents.Findings include:1. Review of the Minimum Data Set (MDS) assessment for Resident #16, dated 12/2/25, revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated a severe cognitive impairment. The MDS listed a primary diagnosis of non-traumatic brain dysfunction (dementia). The MDS identified the resident dependent on staff to assist personal hygiene, toileting, showering, oral hygiene and bed mobility. The MDS indicated Resident #16 utilized a urinary catheter and has a pressure ulcer of the right heel. During an observation on 2/16/26 at 11:59 AM, an Enhanced Barrier Precautions sign noted to be posted on the wall by the entrance to the resident's room. During a continuous observation on 2/18/26 that stared at 8:03 AM, with the room to the door shut, Resident #16 heard yelling from his room. Staff D, Certified Nurse's Assistant (CNA) and Staff C, CNA, then exited the resident's room while they wore Personal Protective Equipment (PPE) which included a gown, eye covering an a N95 mask. During an immediate interview, Staff D, CNA stated she and Staff C, CNA had assisted Resident #16 to change an incontinence brief. She explained Resident #16 had fallen, and she and Staff C assisted the resident to get back into bed with a Hoyer lift. At 8:05 AM, without a change in PPE Staff D, CNA entered Resident #52's room. With the door partially left open, Staff D heard asking Resident #52 about their choice of clothing and then raised the resident's bed. At 8:07 AM during an interview, Staff C, CNA, confirmed that she and Staff D, CNA, did not change the PPE worn during personal cares to Resident #16 prior to entering Resident #52's. Staff C explained that Resident #16 did not have COVID, so they did not need to change their PPE. Staff C explained they currently had to wear PPE on the unit (memory care unit) at all times. During an interview at 8:10 AM, Staff D, CNA, reported she provided personal cares to Resident #52 including changing his incontinent brief and helping the resident to dress. During an interview on 2/18/26 at 8:56 AM, the Clinical Resource Manager reported staff should switch out their PPE including gown, mask and gloves before and after providing cares to a resident with EBP. The Clinical Resource Manager reported there was a risk of cross contamination between residents if staff did not change their PPE. 2. Review of the electronic health record (EHR) revealed Resident #103's admitted to the facility on [DATE] with diagnoses that included pneumonia, acute respiratory failure, stage 3 chronic kidney disease, and diarrhea. Review of a Treatment/Order Update/Change in Condition revealed a verbal order, dated 2/16/26, for Contact Precautions by Shift for possible C-DIFF (a bacterial infection which causes severe diarrhea). During an observation on 2/18/2026 at 12:35 PM, PPE supplies with a Contact Precaution signed noted to be present outside of Resident #103 door. A strong odor of bowel present upon entering room. Staff K, Certified Medication Assistant, and Staff L, CNA in room providing cares to Resident #103. Staff K and Staff L each wore gloves, with no other PPE. Staff L, CNA exited Resident #103 rom with a mop and bucket. Staff K, CMA, with a glove on her left hand exited the room while carrying a bag with soiled items. Staff K delivered the bag to the laundry, removed the glove and completed hand hygiene using alcohol-based hand rub. Review of the Treatment/Order Update/Change in Condition, updated 2/18/26, electronically signed by the provider at 10:06 PM revealed the order discontinued due a negative C-DIFF result. During an interview on 2/19/26 at 10:03 AM, the Infection Prevention Nurse stated a resident in contact precaution isolation for CDIFF required all staff entering and caring for the resident to wear the appropriate PPE, which included gown, gloves, and to complete hand hygiene with soap and water. 3. During an observation on 2/18/2026 at 12:22 PM, Staff E, Licensed Practical Nurse (LPN) exited the Memory Care Unit (MCU). Due to positive COVID residents on the MCU, Staff E wore a respirator mask, goggles and gown. Staff E then went to the mediation cart. While at the cart, Staff E obtained insulin pens, and made an entry into a computer. Staff E, without a change in PPE, entered another resident's room. During an observation on 2/19/26 at 11:25 AM, two signs noted to be placed at the entrance to the locked memory care unit. The signs included: a. Droplet Precautions, which directed. Everyone must: clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. b. A Notification the is experiencing a Covid/respiratory outbreak. And directed.All staff are to wear the proper PPE before entering the unit. Gown, N95 mask, and eye shield. A PPE Station present at the entrance of the unit. The Station included gowns, respirator masks, face shields, and hand sanitizer is provided. On the exit side of the door to the MCU another posted sign directed the how to remove PPE. The directions included: a. Except for respirator (mask), remove PPE at doorway. Remove respirator after leaving patient room and closing door. b. Performing hand hygiene between steps if hands become contaminated and immediately after removing all PPE. During an interview on 2/19/26 at 10:03 AM, the Infection Prevention Nurse stated, isolation for COVID positive residents in the locked memory unit is not ideal. She explained the facility's intervention for infection control is for all staff to wear PPE including a respirator mask, gown, gloves, and goggles at all times. The staff are expected to put on PPE when entering the memory unit and remove when exiting the unit. The Infection Prevention Nurse stated Staff E, LPN should have removed the PPE when exiting the memory unit and before assisting on the another. 4. During an observation on 2/16/26 that started at 12:04 PM, Staff F, Environmental Services Assistant Laundry, delivered residents' clean clothes in an uncovered shopping cart to residents residing on third floor North (memory care unit). A total of 20 residents resided on the unit. At 12:25 PM, Staff F observed on the third floor, with a cart full of uncovered wet blankets and toweling waiting outside the elevator. During an interview, Staff F reported the dryer was not working on the third floor, and she was taking the wet laundry down to the main laundry on the first floor to use the dryer. During an observation on 2/19/26 at 8:14 AM, Staff E, Environmental Services Assistant Laundry, at the second-floor elevator entrance with a laundry cart full of uncovered wet resident clothing and towels. During an interview, Staff E stated she was taking the laundry downstairs. Staff E explained each floor had their own laundry facilities, but there were extra dryers on the first floor. Review a policy manual for Infection Control, dated 11/12/2024 revealed the following: a. Enhanced Barrier Precautions: Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of targeted multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with targeted MDRO as well as those at increased risk of targeted MDRO acquisition (e.g., residents with chronic wounds or indwelling medical devices).Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. The use of gown and gloves for high-contact resident care activities may be indicated, when Contact Precautions do not otherwise apply, for nursing home residents with chronic wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with targeted MDRO infection or colonization according to CDC guidelines. In general, for residents with a targeted MDRO infection or colonization as well as a residents with chronic open wounds or indwelling medical devices (such as central lines, feeding tubes, catheters, tracheostomies, etc.) gown and gloves may be required for high contact care activities such as: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing b. Contact Precautions: 1. Hand Hygiene and Gloves: wearing gloves while providing care, when in direct contact with a resident who is infected, change gloves after contact with infective material, avoid contaminating other surfaces with gloved hands, and remove gloves before leaving the resident's room and immediately wash hands with an antimicrobial agent or use of waterless hand sanitizer. 2. Gown: wear gowns when clothing is anticipated to come in contact with the resident, environmental surfaces, or items contaminated with organism. Remove gown before leaving room and immediately perform hand hygiene. c. Droplet Precautions: 1. Gloves and Hand Hygiene: wear gloves during the course of providing resident care. Change gloves after contact with infective material and when moving form one body site to another or when going from dirty to clean tasks. Remove gloves before leaving the resident's room and immediately perform hand hygiene, using soap and water if hands are visibly soiled. 2. Mask: wear a mask when within three feet of the resident. Remove mask and immediately perform hand hygiene. Avoid touching front of mask during removal as it is considered contaminated. 3. Goggles: wear goggles if likelihood of exposure during care. Removing goggles and immediately perform hand hygiene. Avoid from touching goggles during removal as it is considered contaminated. d. Laundry Services: 1. Transport Clean and Soiled Linen Separately: Cover clean linen for protection from contamination during transport. Store clean linen in a protected area until distributed for resident use. Soiled linen barrels, linen carts, and covers are cleaned when visibly soiled.

Based on clinical record review, review of facility policy, resident and staff interview, the facility failed to maintain clear, concise determination of a resident's advance directive choice related to receiving cardiopulmonary resuscitation for 1 of 1 residents sampled (Resident #33). The facility reported a census of 87 residents. Findings include:Review of the Minimum Data Set (MDS) assessment for Resident #33, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated a moderate cognitive impairment. The assessment identified diagnoses of renal failure, hip fracture, and chronic obstructive pulmonary disease. Review of the Care Plan for Resident #33, last revised [DATE], revealed , in part, a focus area of person centered care and a goal to promote quality of life. The care plan included an intervention for resident exert her individual rights by making her own independent choices, i.e. (for example) refusal of care, treatment and diet. On [DATE], review of the electronic health record (EHR) Advance Directives tab revealed the resident had chosen no CPR (do not resuscitate-DNR). Review of a form scanned into the EHR, titled Emergency Response Directive, dated [DATE], included documentation Resident #33 chose to receive CPR. The form included the resident's signature and physician's signature. Review of the Physician Order Sheet, dated [DATE], revealed an order, dated [DATE], for no CPR. On [DATE] at 12:02 PM, during an interview, Staff H, Certified Medication Aide (CMA), reported she would look in the EHR to determine a resident's code status. Staff H reported she would also look in a hardbacked binder located in the nurses office. Staff H confirmed the EHR identified Resident #33 was no CPR, and the binder located in the nurses office identified Resident #33 had chosen to receive CPR. Observation of the binder in the nurses station during the same interview with Staff H revealed a form, titled Emergency Response Directive, dated [DATE], which identified Resident #33 wanted to receive CPR. On [DATE] at 12:06 PM, during an interview, Staff G, Licensed Practical Nurse (LPN) reported that if she needed to know a resident's advance directive choices, she would look in the EHR, but if it was an emergency, she would go by the information kept in a binder in the nurses office. On [DATE] at 12:10 PM, during an interview with the MDS Nurse and the Clinical Resource Manager, they both reported they would grab the binder in the nurses office to determine the code status of a resident in an emergency situation. The MDS Nurse confirmed the EHR identified Resident #33 had chosen not to receive CPR. On [DATE] at 11:31 AM, during an interview, Resident #33 reported she did want staff to perform CPR on her in the event of an emergency. Review of the facility policy, titled Heartsaver Cardiopulmonary Resuscitation (CPR) and Automatic External Defibrillator (AED), last reviewed 2/2018, revealed, in part, the American Heart Association has established evidenced-based decision making guidelines for the initiation of CPR when cardiac arrest occurs. CPR is initiated unless one of the three following conditions is present: a. A valid DNR (do not resuscitate) order is in place;b. Initiating CPR would cause injury or peril to the rescuer; or,c. In the presence of signs of clinical death Be aware of residents' wishes including: DNR, advance directives, or limited treatment orders before proceeding.

Based on clinical record review, review of facility policy, resident and staff interview, the facility failed to determine if a resident was clinically appropriate to self-administer medications for 1 of 1 residents sampled (Resident #33). The facility reported a census of 87 residents. Findings include:Review of the Minimum Data Set (MDS) assessment for Resident #33, dated 12/26/25, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated a moderate cognitive impairment. The assessment identified diagnoses of renal failure, hip fracture, and chronic obstructive pulmonary disease. Review of the Care Plan for Resident #33, last revised 12/19/25, revealed, in part, a focus area of person centered care and a goal to promote quality of life. The care plan included an intervention for resident exert her individual rights by making her own independent choices, i.e. (for example) refusal of care, treatment and diet. The care plan did not address whether or not the resident had chosen to self-administer medication. Review of Physician Orders revealed an order, dated 12/19/25, for Albuterol inhaler 90 micrograms (mcg)/actuation 2 puffs every 6 hours PRN (as needed). On 2/16/26 at 2:38 PM, observation revealed Resident #33 had an Albuterol inhaler sitting on her bedside table. In an interview during the same observation, Resident #33 reported the Albuterol inhaler was her rescue inhaler and she had always kept this with her. On 2/18/26 at 7:55 AM, during an interview, Resident #33 reported she had the Albuterol inhaler in her pocket. On 2/18/26 at 8:56 AM, during an interview, the Clinical Resource Manager reported if a resident requested to self-administer a medication, nursing staff completed a Self-Administration Evaluation form, notified the physician and got an order approving the resident to self-administer the medication, and added the information to the resident's Care Plan. The Clinical Resource Manager confirmed staff had not completed a Self-Administration Evaluation form for Resident #33 to self administer her Albuterol inhaler. The Clinical Resource Manager reported an inability to find a physician order allowing the resident to self administer Albuterol and could not find information in the Care Plan that addressed the self-administration. On 2/18/26 at 9:13 AM, during an interview, Staff H, Certified Medication Aide (CMA), reported no residents were self medicating to her knowledge and denied any residents had medications in their room. Staff H confirmed Resident #33 was not approved to self-administer any of her medications.On 02/18/2026 12:10 PM, during an interview, the Clinical Resource Manager reported she did find the resident in possession of her Albuterol inhaler. The Clinical Resource Manager reported she had completed the Self-Administration Evaluation form with Resident #33, obtained a physician order and updated the resident's Care Plan. Review of the facility policy, titled Self Administration of Medications, dated 6/1/24, revealed, in part, the facility, in conjunction with the interdisciplinary team, should assess and determine, with respect to each resident, whether self-administration of medications is safe and clinically appropriate .the facility should ensure that orders for self administration list the specific medication(s) the resident may self-administer .the facility should document in the resident's care plan whether the resident or the facility is responsible for the storage of the resident's medications .

Based on observation, clinical record review and staff interview the facility failed ensure the secure location of the keys to the double locked compartment to ensure the safety of narcotic medications as required by law to prevent potential loss and/or diversion. The facility reported a census of 87 residents. Review of the facility investigation for the 11/10/25 reported incident regarding a medication discrepancy found on 11/9/25 revealed Staff R, Registered Nurse (RN) was scheduled on first floor. Staff R delivered medications from the pharmacy to the second floor. After delivering medications Staff R, RN proceeded to enter the second floor medication room and was witnessed by at least 3 other employees to be in the medication cart, the nurses office and medication room that she was not assigned to. Staff R, RN reported that she was in the nurse's office and noticed that Staff P, Licensed Practical Nurse (LPN) had left her keys in the narcotic box behind the locked medication room door.During an observation on 02/17/2026 at 1:14 PM, the medication cart on 2 South unit noted to be locked locked. Staff N, Licensed Practical Nurse (LPN) and Staff O, Registered Nurse (RN) completed narcotic count. The keys to the narcotics secured and passed from Staff N to Staff O after the count completed. During an interview on 02/18/2026 at 8:57 AM, Staff P, LPN stated on 11/09/25 while on the 2 South unit she left the narcotic box open with the keys left in it. She explained the keys were in the narcotic box and she had left them in the box because she was running back and forth between the two sides of second floor. Staff P stated at that time a resident had fallen and another had a drop in their oxygen levels and she had forgotten to take the key out of the narcotic box. She stated she had never done that before left narcotic box wide open and the door was not shut on it. She stated she knew to keep the narcotic box locked and was a new nurse and had been overwhelmed. During an observation on 02/19/2026 at 10:11 AM, Staff O, RN dispensed locked medication from cart and relocked the narcotic box and then locked the medication cart During an interview on 02/19/2026 at 10:23 AM Staff O, RN stated the narcotic keys should always be kept on the nurse assigned them and never left in the narcotic box, or the box left open. During an observation on 02/19/2026 at 10:34 AM, the two medication carts on the lower level skilled floor locked with no issues noted. During an interview on 02/19/2026 at 10:36 AM Staff Q, RN stated once the narcotic keys are in your possession they should stay with you. She stated you should never leave the narcotic box open and medication cart should always be locked. During an interview on 02/19/2026 at 11:06 AM, the Administrator explained on 11/09/25 Staff P, LPN worked on the second floor and left the keys in the narcotic box and left it unlocked. The medication room was locked and the narcotic box left inside of it was left open. She stated she would expect the nurses to keep the keys on themselves and the narcotic box should be kept locked. On 02/19/2026 at 1:42 PM, the Administrator revealed the facility did not have a policy on the narcotic keys for the nurses. She stated after the last deficiency their plan of correction included staff education and she had provided individual education to staff.

Based on observation, clinical record review, pharmacy record review, facility policy review and staff interviews, the facility failed to prevent unauthorized access to the keys to Schedule II narcotic medications stored in a double locked compartment as required by law to prevent potential loss and/or diversion for 1 of 9 residents (Resident #4) reviewed for controlled medication storage and access. The facility reported a census of 85 residents.Findings include: The Minimum Data Set (MDS) Assessment tool dated 6/7/25 revealed Resident #4 had diagnoses that included arthritis, anxiety and an unstageable pressure ulcer of the sacral region (lower back/upper buttocks area). In the 5 days that preceded the assessment the resident received analgesics (pain medication) on both a scheduled and as needed basis, non-pharmacological pain management interventions, and the resident reported occasional moderate pain that rarely interfered with his ability to sleep, participate in day to day activities or Therapy activities.Review of the hospital discharge orders, dated 6/10/25 and the June 2025 Medication Administration Record (MAR) revealed and order for Oxycontin (a pain medication, classified as a Schedule II narcotic) 30 mg (milligrams) tablet, extended release (30 mg) TABLET, EXTENDED RELEASE 12 HR (hour) oral Every Twelve Hours Starting 6/10/25. The MAR scheduled times listed as 7:00 am and 7:00 pm. The June 2025 MAR included DISCONTINUED 6/11/25. The June 2025 MAR documented an order Oxycontin 30 mg tablet, extended release .EXTENDED RELEASE 12 HR Oral Every Eight Hours Starting 6/11/25. The MAR schedule times listed as 6:00 am, 2:00 pm, 10:00 pm. Review of [pharmacy name redacted] Proof of Delivery Shipment Summary revealed on 6/10/25 two lines with the following information repeated: Resident: [name redacted - Resident #4].Item Description: OXYCONTIN 20 MG ER (extended release) TABLET QUANTITY 30 Date Filled 6/10/25 x 2 shipped to facility. Received by: See paper signature [paper signature not included].Review of a Controlled Substance Proof of Use form revealed an order for Resident #4 for Oxycontin 30 mg ER Tablet. Amt. (amount) Rec. (received) 60; Date Rec 6/11; Nurse Signature [name redacted - Staff G, Licensed Practice Nurse (LPN)]. The form documented a total of 60 tablets administered with the first dose of administered on 6/11/25 at 0600 (6:00 am) and the last dose administered on 7/1/25 at 1310 (1:10 pm). Review of Proof of Delivery - Shipment Detail Shipment Summary, Date Shipped: 6/11/25, Date Received: 6/12/25 revealed three lines of the following information repeated: Shipment Orders[Name redacted - Resident #4].Item description OXYCONTIN 30 MG ER TABLET QTY (quantity) 30 Date Filled: 6/11/2025. The Proof of Delivery signed by Staff C, Registered Nurse (RN). The facility could not provide a Controlled Substance Proof of Use form for the 90 Oxycontin 30 mg ER tablets delivered on 6/12/25. Review of the June and July 2025 MAR for Resident #4 revealed:a. On 6/10/25, the 7:00 pm dose administered from the Resident #4 home supply as medication had yet to be delivered form the pharmacy per statement by Staff E, RN Clinical Resources Manager. b. From 6/11/25 at 6:00 am through 10:00 pm on 6/30/25, Resident #4 received all scheduled doses of Oxycontin as ordered. A total of 58 doses in June 2025 from pharmacy delivered supply.c. From 7/1/25 at 6:00 am through 6:00 am on 7/4/25, Resident #4 received all scheduled doses of Oxycontin 30 mg ER as ordered. A total of 10 doses in July 2025 form the pharmacy delivered supply. For June 2025 and July 2025, the MAR documented a total of 68 doses of oxycontin administered form the pharmacy delivered supply. Review of the clinical record revealed a Fax Transmittal Form to [physician name redacted} from the facility regarding Resident #4's a planned discharge (on 7/4/25) upon the 7/3/25 discontinuation of skilled services. The orders signed by the physician on 7/3/25. The orders included, in part to send facility supply of medications home with the resident, which included Oxycontin 30 mg ER tablets. Review of a facility reported incident, Submission Date: 7/05/25, Date/Time Occurred: 7/04/2025, Resident Name: [name redacted - Resident #4] revealed an Incident Summary: [name redacted - Staff A, RN0 reported to DON (Director of Nursing [name redacted] that they could not find 86 tabs of 30 mg Oxycontin for discharging skilled patient, [name redacted - Resident #4]. The Oxycontin was last administered at 0600 by [name redacted, Staff C, RN]. [Name redacted - Staff C, RN] was contacted to come to work. It was determined at 12:45 PM that the Oxycontin could be located, and a search commenced to determine if it had been misplaced. The Oxycontin was not found, and a call was placed to the [city name redacted] Police Department at 2:33 pm to report the incident. A call was then placed to DIA [State Agency] to self-report at 2:40 pm. [Name redacted] arrived to take a statement from [name redacted - DON] and gathered the facts as they are currently known. Corrective Action Description: Effective immediately a second set of keys must be the nurse or in the locked box in the medication room. The nurse on duty must keep their keys on them and locked unclaimed keys in the lock box, in the medication room. No unauthorized staff should be in the medication room. Supplies are to be retrieved form the stockroom, not the skilled med room. Additionally, all controlled counts are to be 2 nurses verified and signed off. We will be adding a extra check point for verification of controlled medications. During an interview on 8/5/25 at 10:09 am, the DON stated she was in the facility on 7/4/25 and on duty when Staff A, RN reported she could not locate the resident's [Resident #4] Oxycontin. The DON explained Staff A reported she counted narcotics with Staff C, RN, the off-going nurse that morning, in anticipation of the resident's planned discharge as the physician ordered the medications go home with the resident. The DON stated Staff A reported after the count she moved all his controlled narcotic medications and the associated narcotic inventory control sheets to the bottom shelf within the double locked narcotic storage compartment in the Medication Room. The DON stated Staff A reported the medications and the inventory control sheet were not in the storage compartment when she went to get them to give the resident at his discharge. The DON stated she contacted Staff C, RN who reported the medication was in the narcotic compartment during the morning narcotic count with Staff A, and had no other information. The DON stated in their search for the medication they found a 2nd set of keys to the double locked medication compartment in the top drawer of a desk in the nurse's office. The DON stated the drawer and the nurse's office were unlocked and that potentially anybody working on that floor or within the facility had access to the keys and the medication room and the double locked narcotic compartment. The DON explained there are two sets of keys so if there are two nurses on duty they each have a set. However, if there is only one nurse on duty the spare set of keys should be secured. The DON explained on 7/4/25, there was only one nurse assigned to that floor, the 2nd set of keys should have been secured, but were not. The DON stated since the incident they have reduced the number of keys and color-coded the keys and the nurse(s) are the only staff that have a key and access to the Medication Rooms.During an interview on 8/5/25 at 3:12 pm, Staff A, RN, stated on the morning of 7/4/25, she counted narcotics with Staff C, RN. She stated were no discrepancies with the count. Staff A explained she moved Resident #4 narcotics from the middle shelf within the compartment to the bottom shelf with the narcotic inventory control sheets and locked the storage compartment. Staff A stated after she completed a medication pass around 9:30 am she went to get Resident #4's medications to get ready for his discharge. She stated she could not find the Oxycontin. Staff A stated she had completed the count that morning and knew there were three cards of Oxycontin and a narcotic inventory control sheet. Staff A stated she panicked, contacted Staff B, RN, the nurse assigned to 2nd floor that morning. Staff A explained Staff B came and they both looked throughout the area and could not find the missing Oxycontin. She stated she then notified the DON who was on duty and came to assist. Staff A stated they discovered a 2nd set of keys in an unlocked desk drawer in the Nurses office, which had not been locked. Staff A stated the 2nd set of keys would have unlocked the medication Room and the narcotic storage compartment. Staff A stated this had never happened to her before and she was still upset about it.During an interview on 8/5/25 at 2:50 pm, Staff B, RN, identified as the 1st floor manager, stated when she got to work on 7/4/25 they had low census on 1st floor so she went to work on 2nd floor as assigned. Staff B explained Staff A, RN called her that morning very upset because she couldn't find Resident #4's Oxycontin and it was present when she counted narcotics that morning. Staff B stated she went to 1st floor to help look for the medication. Staff B stated the medication was not found, but they did find a 2nd set of keys in an unlocked drawer of the desk. Staff B stated the drawer the keys were found in was not the usual drawer where the keys were kept. Staff B explained the keys were not locked up as they should have been, and potentially anyone had access to them and could have went into the Medication Room and taken the Oxycontin from the narcotic compartment. Staff B stated they notified the DON right away who also helped look for the medication. During an interview on 8/5/25 at 6:43 am, Staff C, RN, stated on the morning of 7/4/25, she administered the resident's morning Oxycontin before she left, and had counted narcotics by herself before Staff A, RN got there and everything was in order. She stated she completed a count with Staff A when she arrived. Staff C stated she thought there were 83 or 84 Oxycontin tablets left at that time, and the medication was in the double locked narcotic compartment when she counted with Staff A. Staff C stated later she was called in and talked to the DON. Staff C stated the DON spoke to both her and Staff A, RN. Staff C recalled Staff A stated the count was right, and Resident #4 was supposed to discharge so she [Staff A] put the narcotic inventory control sheets around the associated narcotic card and placed them on the bottom shelf of the narcotic compartment, double locked. Staff C continued, retelling when Staff A was ready to discharge Resident #4 she went to get his medications and found the Oxycontin wasn't there. Staff C stated the Oxycontin was in the locked narcotic compartment when they counted that morning and she gave the keys to Staff A at that time.During an interview on 8/6/25 at 1:28 pm, Staff E, the Clinical Resource Manager stated they did not get the 6/10/25 dose of Oxycontin from their emergency medication supply, the resident used his own home medications until they got their delivery from the pharmacy later that night.Review of the facility's Inventory of Controlled Medications policy, effective 6/30/2008, last revised 8/1/2018, directed staff, in part:a. The community should maintain separate individual controlled medication records on all Schedule II medications and any drug with a potential for abuse or diversion in the form of a declining inventory, using the Controlled Substances Declining Inventory Record.b. The community should ensure the incoming and outgoing nurse or designee counts all Schedule II medications at least once daily or per community policy and document on the Controlled Drug Count Verification/Shift Count Sheet.c. The community should ensure its staff immediately report suspected theft or loss of controlled medications to their executive director for appropriate documentation, investigation and timely follow-up in accordance with community policy and applicable law.d. The community should routinely reconcile:1) The current and discontinued inventory of controlled medications with log used in the community's-controlled drug inventory system.2) The current inventory with the controlled medication declining inventory record and the resident's MAR's.3) Any unused controlled medications held in storage awaiting destruction with the declining inventory record.

Based on observation, clinical record review, pharmacy record review, pharmacy consultant interview, and staff interview, the facility failed to have safeguards and systems in place to control, account for, and periodically reconcile controlled medication in order to prevent potential loss and/or diversion for 1 of 4 residents (Resident #8) reviewed for controlled substance reconciliation. The facility reported a census of 85 residents.Findings include: Review of the Minimum Data Set (MDS) Assessment tool dated 2/4/25 revealed Resident #8 had medical diagnoses that included, in part, hypertension (high blood pressure), anxiety, non-Alzheimer's dementia and age-related debility. The MDS indicated in the 5 days that preceded the assessment the resident received analgesics (medication type used to treat pain) on both a scheduled and as needed basis, non-pharmacological pain management interventions, and the resident denied that he experienced pain symptoms.Review of the Care Plan Report, effective date 11/12/24 - Present revealed a Problem area to address At Risk for Pain generalized, left hip with a goal of ­_4_ R/T (related to) CHF exacerbation (chronic heart failure), hypoxia (low oxygen levels), hx (history) of left hip contusion. Interventions included, in part:a. Administer pain medication as ordered and evaluate for effectiveness and adverse effects. Notify the physician if ineffective or if adverse effects present. Status: Active (Current).b. Evaluate for pain at least daily by using a pain rating scale (numeric or descriptive). Notify physician of uncontrolled pain and obtain orders as needed. Modify Care Plan accordingly. Status: Active (Current). Review of Physician Order Sheet April 2025 revealed Resident #8 had the following orders for pain medications:a. Tramadol 50 mg (milligram) tablet (50 mg) TABLET oral three times daily, starting 11/13/2024b. Morphine concentrate 20 mg/ml (milliliter) oral syringe (FOR ORAL USE ONLY) (0.5 ml) Syringe (ML) oral As needed every four hours, starting 11/13/24c. Tylenol Arthritis Pain 650 mg tablet, extended release (650 mg) TABLET, EXTENDED RELEASE Oral Every Eight Hours, starting 11/13/24. Review of a facility reported incident, Submission Date: 4/25/25 revealed an Incident Summary: During a routine medication pass, a full cart of Tramadol 50 mg was found missing. Corrective Action Description: All other narcotics were accounted and accurate in the facility. Police were notified at 2pm on 4/25/25. Review of a Proof of Delivery - Shipment Detail sent by the consulting pharmacy, dated 4/3/25 revealed three lines with the following information repeated: Shipment Orders[Name redacted - Resident #8].Item description TRAMODOL 50 MG HCL TABLET QTY (quantity) 30 Date Filled: 4/3/2025 Review of the April 2025 Medication Administration Record (MAR) revealed staff initialed Tramadol 50 mg, three times daily administered as ordered April 1, 2025 through April 24, 2025. On April 25, 2025 the symbol = documented, which per the MAR legend indicated previously scheduled. Staff initialed Tramadol 50 mg, three times daily administered as ordered April 26, 2025 through April 30, 2025. Review of the April 2025 Treatment Administration Record (TAR) revealed an order for Pain assessment q (every) shift assessment. Starting 11/12/24. Review of the APRIL 2025 NON-PRN TREATMENT NOTES revealed on Resident #8 reported a Pain Level of 0 (zero) on April 23, 2025, April 24, 2025 and April 25, 2025 at each Day and Night assessment. Review of a document titled Clinical Notes Report revealed a Clinical Note entered on 4/25/25 at 12:34 PM by Staff J, Licensed Practical Nurse (LPN) which documented Resident has no Tramadol left, Call placed to [name of pharmacy redacted] and scrip is not available for fill until 4/27/25. [Pharmacy name redacted] stated 90 tabs were sent on 4/3, resident ran out of tabs 4/23, takes his med TID (three times a day). [Name redacted] CCC notified. [Name redacted - Staff E, Clinical Resources Director] has given this nurse request for [pharmacy name redacted] to fill, send and charge facility. During an observation on 8/5/25 at 7:36 am, Staff C, Registered Nurse (RN) and the Director of Nursing (DON) completed a shift to shift narcotic count in the 1st floor Medication Room. Resident #8 Tramadol medication stored in a double locked compartment, with individual narcotic inventory control records that demonstrated a declining drug inventory. The count accurately reconciled during this observation.During an interview on 8/5/25 at 7:20 am the Administrator stated on the morning of 4/25/25 the nurse mentioned there was a missing card of Tramadol [Resident #8] and she notified Staff E, RN immediately. The facility initiated their investigation at that time.During an interview on 7/22/25 at 10:51 am, Staff E, current Clinical Resource Manager and interim Director of Nursing (DON) at the time of the incident [April 2025] stated Tramadol medication that was ordered on a scheduled basis was stored in Medication Carts under single lock prior to the 4/25/25 discovery of missing Tramadol. Staff E explained the facility implemented the use of individual narcotic inventory control records for all Schedule III through V medications at that time. She stated the facility had always utilized the narcotic inventory control records for Schedule III through V controlled medications that were ordered on an as needed (PRN) basis. Staff E stated staff completed an exhaustive search of the facility on 4/25/25 and the missing card of 30 Tramadol could not be located. She stated the physician was notified immediately, and staff obtained appropriate orders for a new Tramadol prescription. Staff E stated the facility paid for the resident's new prescription delivered on 4/26/25. Staff E stated in the several years that she has worked there they had never had missing scheduled Tramadol from the Medication Carts, and their consultant Pharmacist had not directed the facility that Iowa Board of Pharmacy required periodic reconciliation of Schedule III through V controlled medications when declining inventory documentation methods or perpetual inventory documentation methods were not utilized that insured reconciliation. During an interview on 8/5/25 at 8:31 am, Staff D, Licensed Practical Nurse (LPN) stated when she worked on 4/24/25, she contacted the pharmacy to say they needed some Tramadol for the resident and the pharmacy said it was too soon to send more. She had administered the resident's Tramadol on other days when she worked. Staff D explained there were 3 cards each with 30 tablets of Tramadol stored in the Medication Cart. Staff D stated the Tramadol was not under double lock, and they were not counted with narcotics when they were ordered as scheduled. She stated when she worked on 4/25/25, they still didn't have the resident's scheduled Tramadol and she called the nursing supervisor right away that morning. She looked for the Tramadol the day before, continued to look on 4/25/25 and they could not locate the missing medication. Staff D explained, after that all Tramadol are now stored under double lock, with individual narcotic inventory control sheets for them and were counted in the shift to shift narcotic count by nurses.During an interview on 8/6/25 at 9:36 am Staff F, consultant Pharmacist stated the facility had not asked him for direction on appropriate procedures for periodic reconciliation of Schedule III through V controlled medications when an inventory control method was not utilized. He completed monthly medication storage audits at the facility, rotated what Medication Carts were reviewed for quality control purposes and had not identified concerns for medication storage.Review of the facility's Inventory of Controlled Medications policy, effective 6/30/2008, last revised 8/1/2018, directed staff, in part:a. The community should maintain separate individual controlled medication records on all Schedule II medications and any drug with a potential for abuse or diversion in the form of a declining inventory, using the Controlled Substances Declining Inventory Record.b. With respect to Schedule III - V controlled medications, the community may require staff count all such medications in accordance with community policy and applicable law.c. The community should ensure its staff immediately report suspected theft or loss of controlled medications to their executive director for appropriate documentation, investigation and timely follow-up in accordance with community policy and applicable law.d. The community should routinely reconcile:1) The current and discontinued inventory of controlled medications with log used in the community's-controlled drug inventory system.2) The current inventory with the controlled medication declining inventory record and the resident's MAR's.3) Any unused controlled medications held in storage awaiting destruction with the declining inventory record.

Based on clinical record review, policy review, and staff interviews, the facility failed to complete a root-cause analysis for three falls in a 4 day period, that started within 48 hours of a resident's admission to the facility, for 1 of 3 residents reviewed for resident safety/nursing supervision (Resident #5). The facility reported a census of 85 residents.Findings include:The facility's initial incomplete Comprehensive Nursing assessment dated [DATE] revealed the resident scored 7 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated severe cognitive impairment, able to make herself understood and understood others, had vision impairment that required corrective lenses, some hearing difficulty in certain environments without hearing aids used, and required 1 staff assist/limited assist for ambulation, toileting, dressing and moderate staff assist for bathing/hygiene. The current Care Plan included the following problem: Potential for injury associated with falls R/T (related to) history of falls, fall with subdural hematoma and generalized weakness. The goal with goal date of 7/25/25 revealed, Resident's risks for injury related to falls will be minimized through next review, and directed staff to complete fall risk assessment and modify care plan as needed, and to keep call light within reach.Fall Incident Reports revealed:a. On 4/27/25 at 2:15 p.m. the resident found on the floor after self-transfer off the toilet that occurred as the resident backed up to the recliner chair in her room, the fall unwitnessed. The resident required 1 to 1 staff assist at the time with assistive device. No injuries were identified. The resident was last toileted at 12:30 p.m., the call light not activated, staff recommended and implemented signs posted in her room to remind the resident to use the call light for assistance. b. On 4/30/25 at 12:35 a.m. resident found on the floor in front of the recliner in her room, unwitnessed, the resident denied hitting her head, had minor skin tears surrounded by bruising to her neck and bruising of the left hip. The resident reported falling forward into her walker, hit her neck against the walker, then landed on her left hip. The resident required 1 staff assist for transfer, had an unsteady gait with history of falls, was barefoot, reported she was looking for my men when she fell and last toileted at 11:45 p.m. The resident disoriented and got up without assistance or use of the call light. Staff recommended and implemented leaving the light on in the bathroom at night to help with orientation and updated her care plan. c. On 5/1/25 at 1:35 a.m. resident found on the floor in front of the recliner in her room, unwitnessed, denied hitting her head and no injuries identified. The resident required 1 to 1 staff assistance for transfer, was confused and disoriented, and had not activated the call light. Upon assessment the resident's blood pressure was 192/95, pulse 103, respirations 29 per minute. The resident was last toileted at 12:30 a.m., had gripper socks on, the resident stated she got up from the chair and fell over on my butt. Staff recommended completing visual checks of the resident every 30 minutes and updated the care plan. On 8/7/25 at 2:05 p.m., the Administrator stated they had not completed a Root-Cause Analysis of the resident's falls to determine if there was a common factor related to her falls.The facility's Falls Management policy, dated last revised August, 2021 revealed, Falls and fall risk would be managed through the process of assessment, planning, implementation and evaluation . Communities will evaluate resident falls and determine appropriate interventions to prevent future falls. The facility's Falls Management policy, dated last revised August, 2021 revealed, Falls and fall risk would be managed through the process of assessment, planning, implementation and evaluation . Communities will evaluate resident falls and determine appropriate interventions to prevent future falls.

Based on clinical record review, policy review, and staff and physician interviews, the facility failed to assess a resident's vital signs and neurological status at regular intervals after an unwitnessed fall for 1 of 3 resident records reviewed for post fall assessments (Resident #5). The resident was found unresponsive to painful stimulus 6 hours after the fall that required transfer and assessment at the hospital. The facility reported a census of 85 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had a fall in the month prior to last admission, entry, or reentry and also had a fall in the last 2-6 months prior to admission, entry, or reentry. The facility's Comprehensive Nursing assessment dated [DATE] revealed the resident scored 7 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated severe cognitive impairment. The resident was able to make herself understood and understood others, had vision impairment that required corrective lenses, had some hearing difficulty in certain environments without hearing aids used, and required one staff assist/limited assist for toileting, bed mobility, and transfer. The resident had fall history during the month before entry, in the last six months before entry, and had fracture from fall in the last six months before entry to the facilityThe current Care Plan included the following problem: Potential for injury associated with falls R/T (related to) history of falls, fall with subdural hematoma and generalized weakness. The goal with goal date of 7/25/25 revealed, Resident's risks for injury related to falls will be minimized through next review, and directed staff to complete fall risk assessment and modify care plan as needed, and to keep call light within reach.Another problem listed on the current Care Plan revealed, I am receiving anticoagulation therapy for diagnosis of DVT (deep vein thrombosis) prophylaxis and am at risk for bleeding and related complications. The goal with goal date of 7/25/25 revealed, Anticoagulation therapy will be administered in a safe and effective manner to achieve therapeutic levels determined by physician as evidenced by therapeutic effects of medication and rapid identification of bleeding or related complications through review date. Current interventions directed staff to monitor for any unusual bleeding: blood in stools or urine, bruising, excessive nose or gum bleeding, persistent oozing from superficial injuries, to track and monitor therapeutic levels and order changes as needed, and to notify physician of any abnormal assessment findings or lab values and obtain orders as needed.A third problem on the current Care Plan revealed, I have recently undergone significant health declines and appears to have limited strength and endurance, and cognitive functioning. The Care Plan Resident Summary document directed staff to transfer the resident with assist of one with gait belt and walker. The Hospital Discharge form dated 4/25/25 (date of Resident #5's admission) revealed resident #5 had diagnoses that included hypertension, atrial fibrillation, T11 (thoracic spine) compression fracture and right sided subdural hematoma from a fall on 4/21/25.The resident's 4/25/25 facility admission orders directed the resident to receive therapy services as indicated for strengthening.Physician orders directed staff to administer medications that included, in part, the following Heparin orders: The order dated 4/25/25 and discontinued 4/26/25 revealed Heparin (a strong anticoagulant medication that requires frequent monitoring by laboratory analysis due to potentially life-threatening complications from hemorrhage) 5000 units ordered via intramuscular injection (IM) every 12 hours. Then, Heparin 5000 units to be administered subcutaneously (injection into the fatty tissue under the skin) from 4/26/25 and discontinued 4/27/25. Heparin 5000 units then ordered from 4/27/25, discontinued on 4/30/25, to be administered via subcutaneous injection every 12 hours for 7 days. Also, Aspirin 81 milligrams (mg) (a medication used for blood thinning properties) administered oral daily starting on 4/26/25.Fall Incident Reports and Skin Assessments revealed:a. On 4/27/25 at 2:15 p.m. the resident found on the floor after self-transfer off the toilet that occurred as the resident backed up to the recliner chair in her room, the fall unwitnessed. The resident required 1 to 1 staff assist at the time with assistive device. No injuries were identified. The resident was last toileted at 12:30 p.m., the call light not activated, staff recommended and implemented signs posted in her room to remind the resident to use the call light for assistance. Staff initiated post fall ,vital sign and neurological assessments for 72 hours.b. On 4/30/25 at 12:35 a.m. resident found on the floor in front of the recliner in her room, unwitnessed, the resident denied hitting her head, had minor skin tears surrounded by bruising to her neck and bruising of the left hip. The resident reported falling forward into her walker, hit her neck against the walker, then landed on her left hip. The resident required 1 staff assist for transfer, had an unsteady gait with history of falls, was barefoot, reported she was looking for my men when she fell and last toileted at 11:45 p.m. The resident disoriented and got up without assistance or use of the call light. Staff recommended and implemented leaving the light on in the bathroom at night to help with orientation and updated her care plan. Skin assessments completed 4/30/25 after the fall at 12:30 a.m. revealed a 14 centimeter (cm) by 5 cm red/purple bruise located on the left hip that was tender to touch, skin tears on the right side of the neck, surrounded by bruising, 1 measured 1 cm by 1.5 cm, the other measured 0.2 cm by 1.2 cm, both required closure with steri-strips, and a red to purple bruise forming on the right side of the neck that measured 3 cm by 0.5 cm.Vital sign or neurological assessments were not observed to be completed after the initial assessment at the time of the fall, and the physician/provider lacked notification of the fall until 8:20 a.m. on 4/30/25.c. On 5/1/25 at 1:35 a.m. resident found on the floor in front of the recliner in her room, unwitnessed, denied hitting her head and no injuries identified. The resident required 1 to 1 staff assistance for transfer, was confused and disoriented, and had not activated the call light. Upon assessment the resident's blood pressure was 192/95, pulse 103, respirations 29 per minute. The resident was last toileted at 12:30 a.m., had gripper socks on, the resident stated she got up from the chair and fell over on my butt. Vital signs or neurological assessments were not observed to be completed after the initial post fall assessment, as well as physician notification of the fall at the time. Staff recommended completing visual checks of the resident every 30 minutes and updated the care plan.The Post Fall 72-Hour Monitoring Report directed staff to complete the assessment at the following intervals for follow up for all falls. A fall that is unwitnessed, or in which the head is struck requires neurological checks. Any change in resident condition requires a phone call to the primary care physician. The form directed after the initial fall assessment, assessments be completed every 15 minutes x 4, every 30 minutes x 2, every hour x 2 then every shift for 72 hours.The facility's self-reported incident described the resident had an unwitnessed fall on 5/1/25 at 1:25 a.m., resident was found on the floor in front of the recliner chair, denied hitting her head, and stated she was getting up from her chair and fell on her butt. No injuries were identified, range of motion and neurological checks were within normal limits, and the resident assisted from the floor to her bed. The resident remained awake until sometime around 4 a.m. When the staff checked on her at 5 a.m. she was asleep in her bed snoring. The resident remained asleep in her bed until 7:30 a.m. when staff could not wake the resident, resident unresponsive to painful stimulus, and a physician in the facility at the time directed the resident's transfer and assessment at the local hospital. The resident left the facility at 8:10 a.m. The resident returned to the facility later that morning with physician orders for comfort care. On 7/24/25 at 9:49 a.m., Staff A, Registered Nurse (RN) stated on the morning of 5/1/25, the night nurse Staff H, RN reported the resident had fallen but not hit her head, and denied hitting her head. She had not assessed the resident that morning until the Certified Nursing Assistants (CNA's) came to her around 7:30 a.m. and said they couldn't wake her (resident). She assessed her immediately, she (resident) was non-responsive to painful stimulus, and Staff A tried to contact the provider and couldn't reach her. At that time their Medical Director was in the facility and summoned to assess the resident. The physician ordered the resident's immediate transfer to the hospital for assessment. Prior to the fall on 5/1/25, the resident was very independent and wanted to transfer herself, and had 3 or 4 falls at the facility from her self-transfers without staff assist. There were signs in resident's room to remind her to use the call light for assistance, but she didn't use the call light. When a resident falls there were 2 different protocols post fall. If the resident didn't hit their head and no injuries, they were assessed twice a day for 72 hours. If the fall was unwitnessed or the resident hit their head, they were supposed to check vital signs and neuro assessments every 15 minutes 4 times, then every 30 minutes 2 times, then every hour 2 times, then every shift for 72 hours. The resident was on Heparin and she was concerned due to the number of falls she had, requested the order to discontinue it and that was approved by the provider.On 8/4/25 at 6:22 p.m., Staff I, CNA, stated she remembered on the night of 5/1/25, she heard a crash from the resident's room. Staff I went in and found the resident sitting on the floor in front of her recliner and the radiator. The nurse heard it and got there right after her, and Staff I was pretty sure the resident said yes when the nurse asked if she hit her head. They did have the light on by the doorway of her room, the door to the hall was open, and a light was on in her bathroom with the door partially closed. Staff I wasn't sure/couldn't recall what happened after that as the resident was not on her assignment.On 8/5/25 at 2:50 p.m., Staff B, RN, Nurse Manager stated if a resident fell, the nurse should complete a head to toe assessment, assess neuros if the fall was unwitnessed or if the resident hit their head, and start the post fall assessments of every 15 minutes times 4, every 30 minutes times 2, every hour times 2 then every shift for 72 hours. Per Staff B, the nurse should call the provider if the resident was injured, could fax the provider to notify of the fall if there was no injury, and would call the physician if there was any change in condition and request orders.On 8/5/25 at 10:09 a.m., the Director of Nursing (DON) stated if a resident had an unwitnessed fall and they were not alert/reliable to say whether or not they hit their head, the nurse should assess the resident for injuries, and complete vital signs and neuro checks per the protocol, even when injuries were not identified at the time. Staff should notify the physician timely by phone if there were injuries of concern with the fall or questions for follow up. If there were no injuries with the fall and no need for a change of orders the staff could notify the provider by facsimile (fax).On 8/4/25 at 6:17 p.m. Staff H, RN, stated she was the nurse on duty on 4/30/25 and 5/1/25 when the resident fell. The resident didn't want to be alone, she wanted to get up but didn't know where she wanted to go. On the 4/30/25 fall, the resident stated as she leaned forward to stand up she hit her neck on the walker that was positioned in front of her, but denied hitting her head. She assessed her and there was no change in her range of motion, or signs of injury beyond the skin tears on her neck with bruising and the bruising on her hip. She thought having more light in her room would help the resident's orientation, on 5/1/25 the light by her door was on, and her door was open to the hallway so there was a lot of light in her room. When she assessed her after the 5/1/25 fall, initially the resident denied hitting her head, she didn't identify any injuries on her assessment, her neuros were normal and no change in range of motion. Then later that night the resident said her head hurt and she must have bumped her head. Staff H stated she did not initiate the post fall neuro checks for an unwitnessed fall, the resident was awake for a while and visited with staff, did fall asleep after they got her to bed, the resident had very little sleep the first 3 days that she had been there and thought she was tired from that and the physical therapy program. The resident's room was located where staff could have frequent observations of her when they went past her room. Staff H stated she did not notify the provider of the falls on 4/30/25 or 5/1/25, but would call the provider during the night if the resident had significant injuries or if they needed to send the resident to the hospital. On 8/6/25 at 3:31 p.m., the facility's Medical Director was asked if staff should assess neuros (neurological assessments) after an unwitnessed fall and stated staff should assess neuros post fall when there was the potential for hitting their head. The Medical Director further explained this was how they could detect a change in condition from a head injury. On 8/7/25 at 11:40 a.m., the Administrator stated they did not have a post fall assessment policy. On 8/7/25 at 2:05 p.m., Staff E, Clinical Resource Manager stated the Post Fall 72 Hour Monitoring Report was not a facility form or policy of the facility.The facility's Falls Management policy, dated last revised August, 2021, revealed the following: Falls and fall risk would be managed through the process of assessment, planning, implementation and evaluation, fall assessments should be completed on admission, quarterly, and with any significant change in condition, and residents who are at risk for falls will have an individualized care plan developed which identifies interventions to reduce fall risk.

Based on observation, food storage guidelines, and staff interviews the facility failed to label food, indicate the opened/prepared date of an item, and dispose of food kept beyond the expiration date in an effort to prevent prevent food borne illness. The facility reported a census of 91 residents. Findings include: During the initial kitchen tour on [DATE] at 9:45 AM, the following food items found in a refrigerator with either no label and or date opened, and kept beyond the expiration date: a. Large bag of lettuce in saran wrap, no open date indicated. b. Bag of french fries, no open date indicated. c. Melted butter, no prepared date indicated d. Corned beef, dated [DATE]. e. Zip lock bag with unknown contents, no date indicated. f. Dish of oatmeal, no prepared date indicated. g. Bread crumbs, no open date indicated. h. [NAME] beans with bacon, no prepared date indicated i. Cranberry salsa, dated [DATE] j. Three - 1 pound blocks of butter, no open date indicated. k. Bag of fried chicken, no open or prepared date indicated. l. Thawed chicken, no open or thraw date indicated. m. Pork roast, no open or prepared date indicated. n. Scrambled eggs, dated [DATE]. o. Chopped onions, dated [DATE]. The walk in refrigerator had the following items with expired dates on them: a. Sliced ham, dated [DATE]. b. Home made ranch dressing, dated [DATE]. During an interview on [DATE] at 1:00 PM Staff F, Sous Chef stated the kitchen uses the waste not program to dispose of outdated food. He explained it is a tracking program of food in refrigerator. Staff F explained food has various shelf life and we use first in first out method. He stated he, and the cooks are responsible for disposing of outdated foods. Staff F stated everything should be labeled with name, date opened and what it is. He stated the discard date should also be on the item. Staff F stated they have paperwork in the kitchen that tells you how long the food is good for once it has been opened. During an interview on [DATE] at 1:27 PM the Dietary Manager stated the expectation of staff for labeling food items, and it is actually on the cleaning list to check the refrigerators it is usually on 3 times per week. The Dietary Manager stated it would have been done on Friday and Monday and then again it should have gotten done. The Dietary Manager stated they would have expected those things to be labeled and dated. We usually have someone do a walk through on Sunday night. All items should be labeled and dated. The facility provided a document titled Refrigerated Storage Life of Foods dated [DATE] which directed: Use manufacturer's expiration date for products before they are opened. If there is no expiration date on the package, add the time listed here to the date the food is received. Add the time in the opened column to the date when the food is prepared or opened. Label when product is opened. The time listed is added to today's date. The document listed all types of foods and the amount of days to be added, for example: butter/margarine + 3 days, homemade salad dressings +7 days, and deli meat +3 days.

Based on clinical record review, facility policy review and staff interview the facility failed to follow up on pharmacy recommendations for the monitoring of medications and gradual dose reduction for 4 out of 5 residents reviewed. (Residents #2, #20, #45, and #60) The facility identified a census of 91 residents. Findings include: 1. Review of the Minimum Data Set (MDS), dated [DATE] revealed Resident #20 scored 13 out of 15 on the Brief Interview for Mental Status, which indicated intact cognition. Per the assessment the resident took antidepressant, hypnotic, diuretic, opioid, and antiplatelet medications A review of Physician Orders revealed an order, dated 4/21/23 for duloxetine (an antidepressant) 30 mg (milligrams) 1 tab daily The Consultation report dated 11/25/24 revealed [Resident #20] has received duloxetine (Cymbalta) daily since 4/20/23. Recommendation: Please attempt a gradual dose reduction (GDR) of duloxetine to 20 mg daily. Review of Resident #20 Progress Notes revealed a lack of documentation about a GDR for duloxetine. A review of the February Medication Administration Record (MAR) revealed Resident #20 received the duloxetine 30 mg from 2/1/25 through 2/6/25. 2. A review of Physician Orders revealed an order for Resident #2 for lorazepam (antianxiety) 0.5 mg twice daily, state date 11/8/23. The Consultation Report dated 10/23/24 revealed [Resident #2] has received lorazepam 0.5 mg twice daily since 11/8/23. Recommendation: Please attempt a GDR of lorazepam 0.5 mg at bedtime. Review Resident #2 Progress Notes revealed a lack of documentation about a GDR for lorazepam. Review of the February 2025 MAR for Resident #2 revealed lorazepam 0.5 mg was administered 2/1/25 to 2/6/25. 45338 3. Review of the MDS dated [DATE] revealed Resident #45 scored 2 out of 15 on a BIMS exam, which indicated severely impaired cognition. Per this assessment, the resident took antidepressant, antianxiety, antipsychotic, opioid, antiplatelet, hypoglycemic, and anticonvulsant medication. The Physician Order dated 9/26/24 revealed the resident ordered fluoxetine 40 mg one time daily. The Consultation Report dated 7/23/24 revealed, [Resident #45] has received fluoxetine (Prozac) 40 mg (milligrams) daily since 9/21/22. Recommendation: Please attempt a gradual dose reduction (GDR) of fluoxetine to 30 mg daily. An option per the Physician Response section was left blank, and the Consultation Report was unsigned. Review of Resident #45's Progress Notes from 7/23/24 to 2/4/24 lacked documentation about a gradual dose reduction (GDR) for fluoxetine. Review of the Medication Administration Record (MAR) dated February 2025 revealed the resident received fluoxetine 40 mg from 2/1/25 though 2/6/25. 34821 4. The MDS assessment dated [DATE] revealed Resident #60 scored 13 out of 15 on the BIMS, which indicated intact cognition. The MDS list of diagnoses included depression. The Care Plan for Resident #60 dated 11/27/24, identified diagnoses of anxiety and depression, and the resident prescribed buspirone and venlafaxine (antidepressants). The Physician's Orders dated 2/6/25 listed medication orders that included: a. buspirone 5 milligrams (mg) two times daily started on 4/5/2024 (anxiety medication). b. venlafaxine extended release ER 150 mg (take with the 75 mg) started on 4/5/2024 (antidepressant medication). c. venlafaxine extended release ER 75 mg one time a day started on 4/5/2024. The Pharmacist Consultation Report dated 8/28/24, listed the names of 2 diuretic medication, furosemide 80 mg daily and Spironolactone 25 mg daily. He questioned to the Primary Care Provider (PCP) to complete a basic metabolic panel (BMP) blood draw on the next laboratory (lab) day and then every 6 months. The Pharmacist Consultation Report dated 10/24/24, reflected a question to the Primary Care Provider (PCP) to attempt a GDR of the buspirone 5 mg two times a day to 2.5 mg two times a day. The Pharmacist Consultation Report dated 12/20/24, identified Resident#60 took Spironolactone 25 mg daily, and potassium chloride 20 milliequivalent (mEq) daily. The Pharmacist explained the risks of the medication and requested laboratory monitoring. He asked the PCP to schedule a BMP on the next lab. The Pharmacist Consultation Report dated 1/20/25, questioned to the PCP to attempt a GDR of the buspirone 5 mg two times a day to 2.5 mg two times a day. The Clinical Notes for Resident #60 dated 8/28/24 through 2/6/25 failed to include documentation the Pharmacist recommendations were addressed. During an interview on 2/06/25 at 9:40 AM, the Director of Nursing (DON) reported she took the DON job in May 2024. She revealed as the DON she received the emails form the Pharmacist and put them in a folder. She stated she failed to review the information and send the request to the PCP. Review of the facility policy, titled Medication Regimen Review, last revised on 6/1/24 revealed Procedures which included, in part: #8. The consultant pharmacist will provide the resident ' s MRRs (Medication Regimen Review) to facility identified personnel who will ensure that the attending physician, medical director, director of nursing and other necessary facility staff receive the recommendations. #13. The attending physician/prescriber should address the consultant pharmacist ' s recommendation no later than their next scheduled visit to the facility to assess the resident per facility policy, or applicable state and federal regulations.

Based on observations, clinical record review, nurse competency checklist and staff interviews, the facility failed to perform the infection control practices of hand hygiene and cleaning the hub of an insulin pen prior to the attachment of the needle for 2 of 2 residents reviewed for insulin administration (Resident #11 and Resident #45). The facility reported a census of 91 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 12/17/24, revealed Resident #11 had diagnosis of Type 2 Diabetes Mellitus and received insulin injections on a daily basis. A review of the February 2025 Medication Administration Record (MAR), revealed an order, initiated 7/18/24, for Insulin Lispro 100 units per milliliter (mL) subcutaneous pen with instructions to administer sliding scale insulin three times a day as follows:For blood sugars between 70 and 150, give 0 units; 151-200, give 2 units; 201-250, give 4 units; 251-300, give 6 units; 301-350, give 8 units; and 351-400, give 10 units. The MAR, dated February 2025, revealed an order, initiated 2/04/25, for Lantus Solostar Insulin 100 units/mL subcutaneous pen with instructions to inject 50 units every morning and 48 units every evening. During an observation on 2/06/25 at 8:20 AM, Staff H, Licensed Practical Nurse (LPN), prepared Resident #11's Insulin Lispro pen and Insulin Lantus pen at the medication cart. Staff H opened the insulin pen needles, packaged separately from the pen, and without cleaning the hub directly screwed the needle to the pens. Staff H then entered the residents room to administer the medication. Without donning gloves, Staff H cleaned the residents right upper inner thigh with an alcohol wipe and injected both Insulin Lispro and Insulin Lantus. Staff H applied hand sanitizer and exited resident room, insulin needles placed into sharps container kept on medication cart. During an interview on 2/06/25 at 08:30 AM, Staff H denied cleaning the hub of the insulin pens prior to needle attachment and stated she probably should have. Staff H denied wearing gloves to administer Resident #11's insulin and stated she would normally wear gloves when administering insulin injection. 2. The MDS assessment, dated 10/03/24, revealed Resident #45 had diagnosis of Diabetes Mellitus and received insulin injections on a daily basis. A review of the February 2025 MAR revealed an order, initiated 9/26/24, for Insulin Lispro 100 units per milliliter (mL) subcutaneous pen with instructions to administer sliding scale insulin three times a day as follows: For blood sugars between 70 and 150, give 0 units; 151-200, give 2 units; 201-250, give 4 units; 251-300, give 6 units; 301-350, give 8 units; 351-400, give 10 units; and 401-450, give 12 units. During an observation on 1/06/25 at 8:55 AM, Staff A, LPN, prepared Resident #45's Insulin Lispro pen at the medication cart. The insulin pen needles, packaged separately from pen, were opened and without cleaning the hub Staff A screwed the needle onto the insulin pen. During an interview on 2/06/25 at 1:35 PM, Staff I, Infection Preventionist stated the expectation is for the nurse to clean the hub of insulin pens prior to attaching needle. She added nursing staff are to wear gloves during administration of a resident's insulin injection in efforts to prevent infections. During an interview on 2/06/25 at 2:47 PM, the Director of Nursing stated she would expect the nursing staff to clean the hub of insulin pens with alcohol wipe prior to attaching the needle. She stated the staff should also perform hand hygiene and apply gloves before administering injections. A review of the document titled Licensed Nurse Skill Competency Checklist, dated 11/14/23, revealed competencies under the Glucometer section included, in part: Demonstrate how to prepare and give insulin injection and to demonstrate how to apply a needle to an insulin pen. A review of document titled Medication Pass Review, dated 10/01 under the Infection Control section revealed a competency related to Where universal precautions adhered to, including syringe disposal?

Based on observations, clinical record review, and staff interviews, the facility failed to ensure an insulin pens was primed and the medication administered prior to the expiration date for 1 of 2 residents reviewed for insulin administration (Resident #45). The facility reported a census of 91 residents. Findings include: The Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #45 had diagnosis of Diabetes Mellitus and received insulin injections on a daily basis. A review of the February 2025 MAR revealed an order, initiated [DATE], for Insulin Lispro 100 units per milliliter (mL) subcutaneous pen with instructions to administer sliding scale insulin three times a day as follows: For blood sugars between 70 and 150, give 0 units; ,d+[DATE], give 2 units; ,d+[DATE], give 4 units; ,d+[DATE], give 6 units; ,d+[DATE], give 8 units; ,d+[DATE], give 10 units; and ,d+[DATE], give 12 units. During an observation on [DATE] at 8:55 AM, Staff A, Licensed Practical Nurse (LPN), prepared Resident #45's Insulin Lispro pen at the medication cart. Staff A did not prime the insulin pen prior to the administration of 2 units for a blood sugar of 168. The Insulin Lispro pen observed to have a hand written open date of [DATE] on the storage bag and the pharmacy label. When queried, Staff A stated Resident #45's insulin Lispro pen did not need to be primed prior to administration. Staff A unable to identify how long the Lispro pen is good for after it is opened, and if or when the the insulin pen expired. During an interview on [DATE] at 2:47 PM, the Director of Nursing (DON), stated the insulin pen needed to be primed with 2 units prior to administration to prevent air from remaining in needle. The DON stated nursing staff needed to the check expiration date on insulin pens prior administration and if expired, they need to obtain a new insulin pen. During an interview on [DATE] at 3:27 PM, the DON confirmed Resident #45's Insulin Lispro pen had an opened date of [DATE] and stated that according to manufacturer's recommendations, the insulin pen expired 28 days after opened and should have been removed from medication cart on [DATE]. The DON reported Resident #45 Lispro insulin pen had been discarded. The facility provided a document titled Licensed Nurse Skill Competency Checklist, dated [DATE]. The checklist included a competency for licensed nursing staff to demonstrate how to prepare and give insulin injection and to demonstrate how to apply a needle to an insulin pen, dial and perform a two unit air shot, dial the insulin dose, and administer with an insulin pen. The checklist did not address the need to check the expiration date of an insulin pen.

Based on observation, interview, and record review the facility failed to ensure a resident's transfer from chair to bed was completed in a safe manner for 1 of 3 residents observed for transfers (Resident #12). The facility reported a census of 91 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 1/28/25 revealed the resident scored 99 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident was unable to complete the interview. Per this assessment, the resident was dependent for the following: to roll left to right, sit to lying, lying to sitting on the side of the bed, sit to stand, and chair/bed-to-chair transfer, and weighed 89 pounds. Review of the Care Plan dated 12/18/17 revealed, I have a self care deficit associated with need for assistance with ADLs (activities of daily living) R/T (related to) (advanced age and alzheimers dementia. The Care Plan did not specify the level of transfer assistance required for Resident #12. The Intervention Dated 12/18/17 revealed, Provide assistance as described on the resident summary to complete ADL tasks. Allow resident to complete as much as possible for self and then complete task to standard. Review of the Resident Summary modified 10/17/24 revealed, I am a two assist with transfers and ambulation. I use a Broda chair for mobility with staff assisting me. Please keep my foot pedals up when I am stationary. I may use a positioning bear as needed for repositioning to promote my independence. On 2/5/25 at 2:32 PM, Staff A, Licensed Practical Nurse (LPN) and Staff B, Certified Nursing Assistant (CNA) present in Resident #12's room. Resident #12 observed in a broda chair positioned next to the resident's bed, with broda chair next to the foot of the resident's bed and Resident #12 in the chair, which was facing the head of the bed. Staff removed a pillow, the resident's broda chair observed to not be locked, and the chair moved when Staff A and Staff B two person lifted the resident from the broda chair into bed. A gait belt not observed to be used for Resident #12's transfer. When providing cares, staff said usually had two people in as the resident was so contracted. On 2/6/25 at 10:56 AM, the Therapy Director explained the resident's transfer status would have been in the resident summary. When queried about two person assist, as seen in the resident's summary, the Therapy Director explained there would be two staff assisting, one on each side, especially for Resident #12 as not real active. Per the Therapy Director, they'd put a gait belt on [Resident #12], person on each side, and would give her a lift. When queried if staff should use a gait belt, the Therapy Director responded, absolutely. When queried if moving from broda chair to bed if the broda chair should be locked, the Therapy Director responded, absolutely. On 2/6/25 at 11:03 AM, Staff C, CNA queried about transfer status for the resident, and responded resident was 2 person pivot. When queried if the resident put their feet on the ground, Staff C responded, not really. When queried if during 2 person pivot if resident should have gait belt on, Staff C responded, yeah. When queried if going form broda chair to bed if the broda should be locked, Staff C responded, yeah. On 2/6/25 at 11:19 AM, Staff A, LPN, who was observed to assist with the resident's transfer on 2/5/25, queried if a gait belt used for the transfer. Staff A responded no. When queried if it should have been, Staff A responded the resident was 80 pounds and contracted, discussed positioning of a gait belt for the resident, and did not specify yes or no. When queried if the broda chair should have been locked for the transfer, Staff A acknowledged should have been, and could not remember if it had been. On 2/6/25 at 1:57 PM, the facility's Director of Nursing (DON) explained for two person transfer should have two staff members, gait belt, and then lock the chair, and have her stand pivot to the bed with walker if able to hold on to it. Review of the Facility Policy titled Accidents/Incidents or Unusual Occurence Reports (Skilled Nursing) dated May 2023 did not not address the area of concern.

Based on observation, interviews, and policy review the facility failed to ensure medications were disposed of in a safe, secure manner. Facility staff missed the medication cup with two pills and disposed of them in the garbage can on the medication cart, giving 18 residents on the floor access to unsecured medication. The facility reported a census of 88 residents. Findings include: During a medication cart observation on 4/30/24 at 7:51 AM, on the first floor, Staff C, Certified Medication Aide (CMA) prepared medications for a resident. While pushing them through the back of the medication card, the resident's Pantoprazole 40 mg and Metoprolol 50 mg landed on the cart. Staff C disposed of the medications in the garbage can on the medication cart. She pushed replacement pills from the same cards into the cup and carried them to the resident's room. The medication cart was unattended. Staff C, during an interview on 4/30/24 at 8:03 AM, stated she usually disposed of medications in the Sharps container or garbage can when they were not given to the resident. During an interview with Staff E, Licensed Practical Nurse (LPN) for floor 2, on 5/2/24 at 7:25 AM stated she usually disposed of medications that could not be given to a resident in the Sharps container. She stated for some medications she used drug buster that was stored in the locked medication room. On 5/2/24 at 7:43 AM Staff D, LPN on floor 3, stated he disposed of medications that could not be given to a resident in the garbage or Sharps container. An interview with the Director of Nursing on 5/2/24 at 8:02 AM revealed she expected staff to dispose of medications using drug buster, available in all three secure medication rooms. She was not aware they were throwing them away or using the Sharps container. Facility policy, titled Medication Administration and dated May 2008, documented the Director of Nursing was responsible for the supervision and director of all personnel with medication administration duties and function. The policy lacked documentation of procedures for medication disposal.

Based on record review, observations, and staff interviews the facility failed to ensure a hand-washing sink was present in 3 of 3 laundry rooms that contained washers and dryers that staff used to transfer presorted clothes from laundry hampers into the washer. The facility reported a census of 88 residents. Findings include: Record review of a document titled, FAQs for Clinicians about C. diff (also known as Clostridioides difficile or C. difficile (a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon) dated 10/25/2022 on the Centers for Disease Control and Prevention (CDC) instructed the following when taking care of a patient with C. Diff: a. Wear gloves and a gown when treating patients with C. diff, even during short visits. Gloves are important because hand sanitizer doesn't kill C. diff and hand-washing might not be sufficient alone to eliminate all C. diff spores. During a continuous walk through of the facility completing observations of each floor (3) designated laundry areas on 5/1/24 at 10:01 AM to 10:32 at AM revealed the following: a. First Floor room that held the washing machines and dryer did not have a hand-washing sink. b. Second Floor room that held the washing machines and dryer did not have a hand-washing sink. c. Third Floor room that held the washing machines and dryer did not have a hand-washing sink. During an interview with Staff A, Environmental Services (EVS) on 5/1/24 at 10:10 AM revealed she has worked at the facility for approximately [AGE] years and they have never had a hand-washing sink in the three rooms the washing machines are in. When asked how she would wash her hands after placing soiled items such as isolation materials for C. diff reveled they use gloves and proper Personal Protective Equipment (PPE) (worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) and then hand sanitizer that is on the wall in the room. She then informed if she had to wash her hands with soap and water she would have to touch the door to go out and then another door to go into the soiled utility room to wash her hands. During the survey no residents had C. diff.

Based on observation, resident interviews, staff interviews, and policy review the facility failed to respond to resident's needs within the required fifteen minute time frame when residents activated their call lights. Call light observations revealed 5 of 11 call lights exceeded the fifteen minute response time (Resident #19, #4, #5, #15, and #61). The facility reported a census of 88 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #19 signed 3/19/24 documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. The resident had diagnoses including peripheral vascular disease, arthritis, and renal disease. The MDS revealed the resident required partial to moderate assistance for bathing, dressing, personal hygiene, and laying down as well as occasional bladder incontinence. On 5/1/24, observed Resident #19's call light was on from 6:53 AM to 8:15 AM. The call light system screen was in the hallway next to the medication cart. At 8:15 AM on 5/1/24 Staff D, Licensed Practical Nurse (LPN) stated the resident scratched her eye and wanted eye drops. He was not aware the resident's light was on since 6:53 AM. He confirmed his shift started at 7:00 AM. During an interview on 5/1/24 at 8:16 AM the resident stated she scratched her cornea while adjusting her hat and demonstrated. She said she put her call light on for help getting eye drops to relieve the discomfort. She stated someone answered the light earlier, told her what she wanted was a problem for the nurse, and then they left. The resident said she kept the call light on because this has happened between shifts before and she did not know if the message was passed along. Resident #19 then stated some staff turned the call lights off and back on again if they didn't help. 2. The MDS for Resident #4 signed 3/21/24 documented a BIMS score of 13 which indicated intact cognition. Diagnoses included atrial fibrillation, muscle weakness with pain in the right hip, and asthma. The MDS revealed the resident needed substantial/maximal assistance for lower body dressing, bathing, and toileting with occasional bladder incontinence. On 5/1/24 at 11:52 AM Resident #4 stated sometimes call lights took a long time. She said that there have been a few times she has been 'naughty' when she really had to go and it took too long, and confirmed that meant she went to the bathroom on her own to avoid incontinence. She said she knew staff were busy. 3. The MDS for Resident #5 signed 3/22/24 documented a BIMS score of 13 which indicated intact cognition. Diagnoses included chronic pain, heart failure, and anxiety. The MDS revealed the resident required substantial to maximal assistance for bathing, dressing, personal hygiene, and toileting as well as occasional incontinence of bowel and bladder. On 4/30/24, observed Resident #5's call light was on from 7:25 AM to 7:41 AM. The call light system screen was in the hallway near the medication cart. During an interview on 4/30/24 at 8:40 AM the resident stated call lights were answered very slowly. Sometimes very very slowly. She stated she tried to only use the call light when necessary, so she usually needed the bathroom when she pushed it. She had a clock on the wall that faced her bed, and indicated that on 4/28/24 she pushed her call light to use the bathroom for a bowel movement and no one answered for two hours before she fell asleep. Resident #5 stated she woke up at 4:00 AM and still needed to have a bowel movement, and at that time also needed pain medication. 4. The MDS for Resident #15 signed 2/20/24 documented a BIMS of 13 which indicated intact cognition. Diagnoses included neurogenic bladder, renal disease, and heart failure. The MDS revealed the resident required substantial/maximal assistance for lower body dressing and toileting, and partial to moderate assistance for bathing upper body dressing. The resident had an indwelling catheter. On 4/30/24, observed Resident #15's call light was on from 7:24 AM to 7:41 AM. The call light system screen was visible in the hallway. A document titled Grievance/Complaint Report dated 2/22/24 documented a complaint of long call light times. It included documentation of the resident's call lights from 2/12/24 through 2/19/24. Call lights over 15 minutes were documented once on 2/13, 3 times on 2/14, 3 times on 2/15, and once on 2/16 with 6 of them over 20 minutes. 5. The MDS for Resident #61 signed 3/19/24 documented a BIMS score of 9 which indicated moderately impaired cognition. The resident had diagnoses including heart failure, fibromyalgia, and arthritis. The MDS revealed the resident required substantial/maximal assistance lower body dressing and personal hygiene, and partial to moderate assistance for upper body dressing. Toileting required supervision or touching assistance and the resident was occasionally bowel and bladder incontinent. On 5/1/24, observed Resident #61's call light was on from 7:15 AM to 7:35 AM and 7:36 AM to 7:45 AM. The call light system screen was visible in the hallway. On 5/1/24 at 1:58 PM the Administrator stated she was not able to run a call light report from their computer system. An interview with Staff E, Licensed Practical Nurse (LPN), on 5/2/24 at 7:28 revealed staff answer call lights as quickly as possible. She stated they do the best they can. An interview with Staff D, LPN, on 5/2/24 at 7:43 AM determined he expected call lights to be answered in 2-5 minutes. He did not know if there was a call light policy and stated his job description indicated they should follow standard of practice. On 5/2/24 at 8:02 AM the Director of Nursing stated they have done call light audits because they heard in their neighborhood meetings this was an issue. She expected call lights to be answered within 10-15 minutes. A policy titled Answering Call Lights, reviewed/revised August 2021, advised staff to answer the call lights as soon as possible. The policy lacked documentation of the required 15 minute response time.

Based on record review and staff interviews the facility failed to ensure 1 of 1 residents newly admitted to the facility Preadmission Screening and Resident Review (PASRR) accurately reflected his admitting diagnosis (Resident #44). The facility reported a census of 88 residents. Findings include: Record review of Resident #44 current PASRR dated 1/22/24 informed he had no mental health diagnosis known or suspected, no mental health symptoms, and not on medications for his mental health. Record review of Resident #44 Diagnosis report dated 5/1/24 documented he was admitted to the facility with the following diagnoses on 1/24/24: a. Unspecified psychosis not due to a substance or know physiological condition b. Anxiety c. Depression Record review of Resident #44 current Care Plan dated 5/1/24 documented the following Problem: a. Behavior: Resident #44 has a diagnosis of anxiety and is taking medication. He has displayed mood/behavior changes related to dementia. He has delusions which can cause him to become agitated such as thinking there are people in his house or holding him against his will. He has become physically and verbally aggressive towards staff when they have attempted to calm and re-direct. During an interview on 5/2/24 at 11:31 AM with the facilities Social Worker revealed Resident #44 received the diagnosis of depression and anxiety on 1/29/24. She then informed if a diagnosis was new she would update the PASRR right away but obviously missed it for Resident #44.

Based on record review and staff interview the facility failed to ensure 1 of 1 residents as needed (PRN) anti-psychotic medication was reviewed by his Primary Care Provider (PCP) every 14 days or discontinued (Resident #45). The facility reported a census of 88 residents. Findings include: Record review of a Consultation Report dated 4/2/24 documented a rational to continue use of Seroquel 12.5 PRN - justified on 4/3/24 with rationale but nothing in the following 14 days to renew and still. The form also instructed the following: Rationale for Recommendation: Centers of Medicare and Medicaid Services (CMS) requires PRN orders for anti-psychotic drugs be limited to 14 days. A new order should not be written without the prescriber directly examining the resident and assessing the resident's conditions and progress to determine if the PRN anti-psychotic is still needed. Report of the residents condition from facility to the prescriber does not meet the criteria for an evaluation. Record review of Resident #45 April Medication Administration Record (MAR) documented he received his PRN anti-psychotic medication after it should of been discontinued on 4/17/24 (14 days) due to no documentation for continued use on: 4/18/24 at 10:06 AM 4/22/24 at 1:23 PM 4/24/24 at 1:05 PM - No effect 4/25/24 at 1:44 PM 4/29/24 at 12:11 PM During an interview on 5/2/24 at 11:31 AM with the facilities Social Worker revealed she was aware of 14 day PRN anti-psychotic and need for renewal, but his family is very adamant they want that available for him. During an interview on 5/2/24 at 11:00 AM - 11:38 AM with Staff G, Registered Nurse/MDS Coordinator 2 revealed she was aware of a requirement for PRN medications such as anti-depressant and anti-psychotics that need to be reviewed every 14 days.

Based on clinical record review, staff interview, resident interview, and resident handbook review, the facility failed to implement their policy when the Administrator implemented a grievance resolution of assisting the resident to organize his money and gift cards in a locked drawer in the resident's room in regards to missing property and possible theft for 1 of 1 resident reviewed (Resident #43). The facility reported a census of 88 residents. Findings include: The undated Admission Minimum Data Set (MDS), documented an entrance date of 1/26/2024 for Resident #43 and identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS reflected the resident was able to make themselves understood and understood others. The Care Plan dated 1/29/2024 with a focus area of Person Centered Care Status: Active (Current) with the goal: to promote my quality of Life. The Care Plan documented the following interventions: a. I know this plan of care had been written to promote my quality of life, however there may be times I choose to exert my individual rights by making my own independent choice i.e. refusal of care, treatment and diet. My resident summary is an extension of my care plan. b. I prefer to have my bed against the wall to allow for more moveable space in my room. The Progress Notes lacked documentation regarding the missing property, the outcome of an investigation and any information regarding reimbursement. During an interview on 4/29/2024 6:45 PM Resident #43 advised he and his wife had some money in their drawer and that came up missing. Resident #43 believed it was between $60 to $80 dollars but is unsure of the exact amount. The Resident advised at the same time they were also missing approximately $300 in gift cards for Taco Bell and Wal-Mart. Resident #43 indicated this was approximately 2 weeks ago. The Resident advised he talked to the facility Administrator and several other staff members and a police report was made. The police came out to the facility and interviewed him. The resident advised he did not know if it was a resident or staff that took their money and gift cards. He advised he and his wife searched his room to make sure they hadn't misplaced them. Facility staff also came in and searched the room with his permission. Resident #43 was unable to specifically name any particular staff member he talked to other than the Administrator. He then inquired on whether they are able to get a camera for their room. During an interview on 4/30/24 10:46 AM The Administrator reported she was aware of the missing property/theft concern with this resident. The Administrator shared that prior to the incident the resident asked her if he was able to purchase gift cards because he was afraid he was running out of money. The Administrator shared she told the resident he could purchase gift cards just to be careful/mindful of the spend down limits. The Administrator advised she completed the 5 day investigation and also wrote up the concern as a grievance. The Administrator advised the resident always said missing money and didn't say theft. She advised staff looked through the resident's room and didn't find the missing property. The Administrator further shared, In January, the resident asked about gift cards and I told him to be careful for the look back of 5 years. I did not know he had cash or gift cards. The top cabinet door on the stand between their chairs wasn't locking because they did not have the right key so we provided a key that would work. The Administrator advised she asked other residents if they had any missing property. When queried, the Administrator advised she did not interview staff about the incident and did not inquire whether staff were aware the resident had money and gift cards in his room. On 4/30/24 at approximately 3:30 PM the administrator was queried if the facility had a plan to replace the missing items. The Administrator advised, at this time, there is not a plan to replace or reimburse the missing property. The Administrator was then asked if she had talked with any family members who may have assisted the resident in acquiring the gift cards and she replied she had not. The Administrator then shared she felt very comfortable with the conversations she had with the Resident. When asked, the Administrator advised the facility does not have a policy for missing or stolen items. The Administrator was asked for and provided the abuse policy. The Administrator also provided a document pertaining to the facility's investigation. The undated, untitled and unsigned document reads as follows: 5 day follow up investigation. The Resident continued to allow staff to search in his room. We did have nurse management be the one to help search for the items. Other gift cards were found lying in different places but none of the gift cards that the Resident reported missing were found. Police were notified and we have an open investigation on it. We encouraged the Resident to keep all his money and gift cards in the top drawer of the bed side cabinet. This cabinet can be locked he had a key, but we could not get it to work. We provided resident with the correct key, and he said he will keep the key in safe keeping and not tell anyone. We will work with him as long as he allows to help get all his valuable items in his locked boxes he has. Staff will be educated on encouraging residents to keep valuables in a locked and safe place. The Administrator also provided the following hand written note; I talked to three residents and all 3 deny having any concerns or missing items. I randomly picked one person from each section on the unit.-Staff G. The following document was also provided; 4/23/24 I, Staff G, Staff F, and Staff H with resident permission searched the Resident's room for the reported missing money and gift cards. During the search we found several gift cards, money ($2 bills, coins), various legal documents, bank statements, and check books unsecured through out the room stored in various places. The gift cards and money found were not the ones reported missing. We also identified the resident had two locked safe boxes with the keys stored in the lock. Staff G provided the resident with education on the need to get these items organized and locked. Staff G also provided resident with a lanyard to store the keys for the safe boxes and locked nightstand drawer. The resident was very nonchalant about the situation and stated, what are you going to do? this statement was rhetorical. Signed by Staff G and Staff F. On 05/01/24 at 8:20 AM Resident # 43 and his wife were observed in the main dining room. This worker again talked with the resident about the missing money and gift cards and he indicated he could not name any staff member specifically that usually works with them because the staff members always vary and no one staff member worked them more than another. They have not had any other items go missing. On 05/01/24 at 1:15 PM Staff I, Licensed Practical Nurse (LPN), was queried about the missing property. She indicated she thought the incident happened about one week ago. She was made aware of the incident by staff J, Certified Nursing Assistant (CNA). Staff J and myself assisted in helping Resident #43 look for some missing property. Staff I did not remember exactly but thought they were looking for several gift cards and some cash. Staff I advised she made the DON aware of the incident and that the DON informed the Administrator. Staff I advised she made management aware of the missing items the same day she learned about it. Staff I also shared she was not aware of the gift cards or money prior to the incident. She was not aware of any other prior instances. On 05/01/24 at 1:20 PM Staff K, Certified Nursing Assistant (CNA), was queried about the incident. She advised Resident #43 told her about the money and gift cards after someone had stolen them. That same day the police came in and talked with the resident. She was not told how much money was missing or what denomination the gift cards were. The resident said a lot of money but I didn't know what that meant. Not aware of management interviewing any staff. Was not aware of the money or cards prior to the incident. Hasn't heard any staff talking about it or any rumors. On 05/01/24 at 1:31 PM The facility Director of Nursing (DON), was interviewed regarding Resident # 43's missing property. The DON advised it was reported the resident was missing money or gift cards. Staff J told her about it and Staff J and Staff L CNA, went in the resident's room and with his permission helped look for the missing property. The DON then notified the Administrator and then she and I went through some things with his permission. The resident provided varied amounts of money missing. The resident reported he was also missing at least one gift card and that may have been for Taco Bell. The DON shared they did locate some gift cards and those were found just sitting in a drawer not locked up or anything. The DON continued by saying staff asked other residents and no one reported anything missing. Incident was on Monday the 22nd. The DON shared, to her knowledge there have never been any issues with theft in the past. When queried, the DON advised she does not know if a facility investigation including staff was conducted. 4/22/24 Grievance/Complaint Report filed by the resident. Grievance/Complaint Staff member J CNA asked if she could organize a few things in the bathroom closet-and the resident responded yes. Then the resident disclosed he was missing some things out of his drawer between the chairs. Money and gift cards. Documentation of Facility Follow-Up: Individual designated to investigate/take action on this concern: Administrator and Nursing Staff 4/23 Reported to DIA-Resident thinks a total of $60 to $70 dollars cash and a $100.00 Taco Bell gift card and$ 50.00 Wal-mart gift card. Notified the Police, came in to review and the resident allowed staff to do a deep clean in room-other gift cards found laying around in various areas- Resolution of Grievance/Complaint: Help the Resident organize his money and gift cards and put them in the top draw-start using the key we provided for locking the cabinet. On 5/1/2024 at 5:55 PM a phone interview was conducted with Staff L CNA. She advised she really didn't know much about the situation other than her co-worker staff J ,came and got her and asked her to help her look for a few things in Resident #43's room as he was missing some money and gift cards. Staff L shared they did not find the items the resident reported missing. She was not aware that the resident had money or gift cards in his room and does not know if any other workers or residents were aware of the money or gift cards in the resident's room. On 5/02/24 at 08:06 AM Staff F RN/MDS Coordinator 1 was interviewed. Staff F advised a few CNA's had already went in and looked through the room with the resident's permission and did not find the missing items. Staff F, Staff G, and Staff H all three went in and again with the resident's permission went though the resident's possessions looking for the missing items. Staff F initially I found a tote with bank statements, legal documents, and other items. In the night stand a few gift cards were found but they were not the ones reported missing. Resident #43's wife's wallet and bank card were found. Also, in the resident's nightstand two small safes with the keys still in the locks were located. Staff F then shared she did not specifically write an all inclusive Progress Note about the missing property but did document the resident was issued a new debit card and he had asked her to shred the old one. Staff F advised she checked with other residents regarding missing items and no one identified any concerns. Staff F was not sure if staff on that floor were formally interviewed but she assumed the Administrator would have completed interviews. Staff F shared there were some inconsistencies with amount of money and gift cards the resident reported missing. To her knowledge, there had never been any concerns with staff/theft etc. The night stands in the resident rooms lock but we encourage them to keep there money in the resident trust fund. Staff F was not aware the key the resident had was the wrong key for that night stand. On 05/06/24 at 11:52 Staff J CNA/Certified Medication Aide (CMA), was interviewed. When queried about the incident Staff J advised she was organizing Resident #43's bathroom closet and the resident told her maybe she could organize this drawer next because he thought he was missing something. At first when the resident told her about it he started with approximately 50 to 60 dollars missing and the amount kept going up and he advised he was also missing some gift cards. Staff J advised she then went and got Staff L and they reported the concern to the DON. Then Staff L and myself looked all over the room and did not locate the missing property. After that the Administrator took over. Staff J advised prior to the incident she was aware the resident had coins in his room and she knew he had some gift cards. Staff J did not know if other staff had knowledge of the money or gift cards. The first few days the resident moved to 2nd floor from 1st floor there were a lot of people in and out helping them get settled. After the incident occurred Staff J learned the lock on the drawer did not work and reported this information to the Administrator. The resident was educated if he had anything of value he could be lock it up in the medication room or he should keep it up front. When queried,Staff J advised facility staff were provided education for staff last week while the State Surveyors were in the building. The Facility Resident Handbook dated 5/1/2019 page 26 of 42 Section Q. Money & Other Valuable Items documents the following: Our Community does not accept responsibility for the loss or theft of money or valuables. Thus, jewelry and other valuables should not be kept in your room. You may, however, create a Resident Trust account with us by contacting the Business Office during regular business hours.

Based on observation, record review and staff interviews, the facility failed to maintain a therapeutic diet for 2 of 4 residents (Resident#1 and #12) reviewed with weight loss and the dietary supervisor failed to communicate with other members of the health care team regarding nutritional needs of residents when necessary. The facility failed to notify the dietician, family and physician regarding weight loss for Resident #1. The facility failed to identify and initiate a therapeutic and nutritional diet in an acceptable amount of time, failed to identify the resident's diet on the Diet Roster menu and failed to administer the recommended supplements for Resident #12. The facility identified a census of 116 residents. Findings include: 1. The Face Record dated 03/28/11 identified Resident #12 with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Minimum Data Set (MDS) assessment with a reference date of 07/04/12 identified the resident with short and long term memory loss, moderately impaired with making daily decisions. The MDS noted the resident had no weight loss/gain, was on a mechanically altered diet, had no oral problems, weighed 156 pounds and required extensive assistance of 1 staff person with eating. The MDS report failed to identify the resident with an accurate weight which would have indicated a significant weight loss. The resident's Care Plan dated 02/01/12 (reviewed on 07/11/12) identified the resident with nutrition less than body requirements related to the intake of nutrients insufficient to meet metabolic needs. The care plan's intervention directed staff the resident would receive high calorie potatoes 3 times a week (undated to when this was initiated, but was noted on the 02/01/12 date). Added on to the intervention dated 07/17/12 directed staff to give the resident healthy shakes 3 times a day and start high calorie cereal each day. Observation on 07/25/12, 07/26/12 and 07/27/12 for the breakfast meal revealed the resident did not receive high calorie cereal (HCC). Observation on 07/26/12 for breakfast and the noon meal revealed the resident did not receive a healthy shake. Observation for 6 meals during the survey revealed the resident mostly cooperative with the staff and had a fair to good intake. The resident may refuse a bite one time but after a short interval could be persuaded to take another bite. Record review of the resident's Menu Plan (Tray Ticket which is printed with the diet listed) dated 07/26/12 and for 07/27/12 did not identify the HHC and HCP supplements. The Diet Roster printed out on 07/24/12 documented the resident's diet as regular, dysphagia 2. The diet roster did not identify the HCC and HCP to be given. The Physician order [REDACTED]. The resident's Individual Monthly Weight Record for 2012 revealed the following (admission weight of 175 pounds): a. January-160 pounds. b. February-152 pounds. c. March-156 pounds. c. April-154 pounds. d. May-154 pounds. e. June-157 pounds. f. July-148 pounds. Record review of the resident's Dietary Notes completed by the Dietary Manager included the following: On 02/06/12-General diet, current weight is 160 pounds reflecting a 10 pound loss, the dietary pattern is unchanged. On 04/13/12-resident receives a healthy shake 3 times a day and high calorie potatoes 3 times a week, weight 156 pounds-with a 4 pound weight loss. Dietary pattern unchanged. The note did not identify any recommendations. On 07/09/12-weight is 157 pounds-1 pound gain. Dietary pattern unchanged. The note did not identify the resident's July weight and recorded the resident's June weight. When the resident's July weight was completed it was 148 pounds, indicating a weight loss of 9 pounds-which is a significant weight loss of 5.73 percent. Dietary record did not document the resident's average intake and if the resident would benefit with more supervision at mealtimes. A Weight Loss Monitoring Pathway was started on 02/16/12 (after the 10 pound weight loss) noted the current supplement as a healthy shake 3 times a day with recommendations for high calorie potatoes 3 times a week. A Dietary Progress Note completed by the Dietician (Staff P-alternate dietician) dated 07/13/12 (4 days after an accurate weight for July should have been recorded) included the following: A 6 percent weight loss noted this past month. The resident's intake is down as the resident doesn't allow assistance with eating at times. The resident has severe dementia and it is likely the weight and intake may continue to decline. The resident may benefit from Healthy Shakes 3 times a day. The record did not note the resident had been care planned to be on healthy shakes since 02/06/12 and was on HCP since 02/16/12. The note did not provide any further recommendations. A Weight Loss Clinical Pathway dated 07/17/12 was started 8 days after the critical weight loss should have been identified and 4 days after the Dietician's Progress note which identified the significant weight loss. The Pathway noted the current nutritional supplement/vitamin with healthy shakes 3 times a day and high calorie potatoes 3 times a week. The Pathway recommended starting the resident to eat high calorie cereal daily (which was not observed to be given on 3 days during the survey). On 07/27/12 at 7:50 a.m., the Dietary Manager was interviewed and stated the resident's July weight was not available for the July 9th quarterly assessment, so staff recorded the June weight for the MDS and dietary note. The Dietary Manager did not ask for a current weight for the report and commented the Nursing staff complies that information and sends it to her. When the resident's weight for July came in to the Nursing Department it was passed on to her who passed it onto the Dietician who comes in weekly and wrote the 07/13/12 progress note. On 07/27/12 at 8:14 a.m., Staff O, Certified Nursing Assistant (works with the resident) was interviewed and stated every resident is weighed every month, unless there is a weight loss then the residents are weighed more frequently. Staff O commented the facility staff usually will start weighing residents at the end of a month, say the 28th, so they can get all the residents weighed by the first week of the new month. Staff will record the weight on paper and in the computers Caretracker. The papers go to the DON who checks all weights and monitors. Staff O stated she just started to assist feed the resident about a month ago and it has gone well, as now the resident doesn't wheel away from the table and can stay more focused. On 07/27/12 at 8:17 a.m., Staff Q, Certified Nursing Assistant, was interviewed and stated staff just started to assist feeding the resident about a month ago, or around the first of July, and it has gone well. On 07/27/12 at 11:30 a.m., the DON (Director of Nursing) was interviewed and stated if the resident is care planned for supplements and dietary recommends them, the resident should be receiving the supplements. The DON commented the staff do not record the supplement consumption. The DON voiced being unaware that the resident did not have the HCC and HCP on the diet list, but stated the Diet Manager may know why it is not listed, as they are responsible and also stated of not knowing if the resident received the supplements. The DON stated the resident's MDS dated [DATE] should account for the resident's current weight not the weight for last month. If the weight wasn't available the resident should have been asked to be weighed. The DON noted the expectation is to have the resident's monthly weights completed by the 12th of each month. The DON noted the monitoring of the resident's weights are usually completed by the ADON (Assistant Director of Nursing). The DON stated it would be appropriate to have a Pathway (to monitor the weight loss) started on Monday if the report came in on the previous Friday. If diet recommendations came in during the week, it would be appropriate to expect the change would start the following day. When it was noted to the DON that the resident's Dietician's Progress note came in on Friday 07/13/12, which was a significant weight loss and a Weight Loss Clinical Pathway was initiated on a Tuesday, there was no comment. When it was pointed out the resident did not receive the high calorie cereal for 3 mornings during the survey and a healthy shake at 2 different meals, the DON said it would be corrected as they had the best interest in mind for the resident. 2. The quarterly MDS assessment with a reference date of 5/30/12 identified Resident #1 with the following Diagnoses: [REDACTED]. The MDS identified the resident required extensive staff assistance with most activities of daily living, weighed 86 pounds and not identified with a weight loss of more than 20% in the past six months. The Care Area assessment dated [DATE] did not identify the resident with a weight loss, however, identified the resident consumed 25% to 50% and received healthy shakes three times daily due to poor intake. The care plan with goal dates of 9/4/12 identified the resident with the potential for hot liquid risk, not for weight loss and directed staff to provide healthy shakes three times daily. The physician orders [REDACTED]. Observations of the resident during meals revealed the resident was served a glass of 2% milk and no carton of health shake on 7/24/12 at 12:08 p.m., 7/25/12 at 8:40 a.m., 7/26/12 at 8:49 a.m. and 7/26/12 at 12:12 p.m. In an interview on 7/26/12 at 7:45 a.m., the resident reported "I don't get health shakes". The resident' s monthly weight record revealed the following weights (in pounds) for 2012: January: 108 February: 94 March: 85 (20% weight loss in 3 months) April: 85 May: 86 June: 86 July: 83 (23% weight loss in 7 months) Interviews with Staff A, RN, Staff C, dietary manager, Staff D, LPN and the director of nursing revealed the following protocol should be followed when a resident has a significant weight loss: a. Initiate the weight loss pathway b. Weigh the resident weekly c. The dietary manager or nursing will notify the dietitian d. Nursing to notify the physician and family and document dates notified on the weight loss pathway e. There should be one pathway per month f. Weight losses are reported at weekly quality meetings by the dietary manager In an interview on 7/26/12 at 2:45 p.m., Staff B, dietitian, reported she did not receive notification of the resident's weight loss as she did not write a note in the resident's record to reflect this. She would make the following recommendations: a. Whole milk b. A couple of extra pats of butter c. Fortified mashed potatoes d. Super cereal e. If food was not taken at all, would try health shakes or commercially prepared beverage in addition to what the resident was drinking In an interview on 7/26/12 at 3:23 p.m., Staff C, dietary manager reported she notified the dietitian of the weight loss in March with a hard copy of the weight loss/gain report placed in the dietitian's mailbox, however, did not have proof as it was an ongoing report. The 2012 treatment administration records directed staff to weigh the resident twice a week on Tuesdays and Fridays. After the 20% weight loss, only two weights were recorded in April 6th: 86 pounds and on the 13th: 84 pounds. Only one weight was recorded in May on the 8th: 78 pounds which showed a 28% weight loss in 5 months. A review of the physician progress notes [REDACTED]. 2/25/12 weight 90 pounds, plan to observe the appetite and weight loss 3/9/12 weight is stable, no longer losing weight 6/1/12 weight 77 pounds, weight has been stable The resident's tray tickets dated 7/26/12 for breakfast and lunch revealed the resident should have been served a health shake with the meals. The typed dietary notes completed by the Staff C, dietary manager did not have an assessment in March 2012, after the initial weight loss was identified. The note dated 4/6/12 did not have documentation to show the physician and family were notified of the 23 pound weight loss in 3 months. The dietary progress note completed by the alternate dietitian dated 6/20/12 revealed the resident had a weight of 83 pounds, a 25 pound weight loss since January, and nursing staff contacting the physician for a [MEDICATION NAME] order to increase the resident ' s appetite. If the resident continued to lose weight, a feeding tube may need to be considered. The weekly Medicare conference records from 3/8/12 through 6/6/12 revealed only one entry dated 3/13/12 which addressed the resident ' s weight of 85 pounds and intervention to upgrade the diet. The weekly dietary/Medicare meeting reports from 3/8/12 through 4/26/12 did not have documentation of the weight loss or weight loss interventions. The weight loss clinical pathway dated 6/20/12 revealed the dietitian, physician and family were notified of the weight loss, 3 months after the 23 pound weight loss over 3 months. The facility policy dated as last reviewed May 2009 and titled: weight loss directed staff to: a. Initiate the weight loss clinical pathway (initiated by the dietary supervisor) b. A weekly weight will be done by nursing staff until the resident ' s weight is stable c. Dietary supervisor will evaluate the resident ' s nutritional needs and implement a plan of care d. Dietary supervisor will notify nursing staff of recommended plan of care e. Nursing staff will notify the resident ' s physician and family of weight change and plan of care f. Nursing staff will notify the physician of the resident's current nutritional status and weight following the next month ' s assessment or sooner if needed

Based on observation, record review and staff interviews, the facility failed to timely assess and measure wounds for 1 of 7 residents reviewed with pressure ulcers (Resident #12) and implement preventive and pressure reliving devices to prevent pressure ulcers. The facility reported a census of 122 residents. On 9/22/2011, the facility notified the resident ' s physician of an open pressure ulcer (Stage 2) on the right buttock area/coccyx area. The area was not assessed again until 10/11/2011. The area had increased in size and pressure relieving devices had not been implemented for the resident when sleeping in the recliner. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 9/8/11 identified Resident #12 with the following Diagnoses: [REDACTED]. It also identified the resident with intact memory and decision making skills, required staff assistance with moving in and out of bed, walking in the room, dressing, toileting, personal hygiene and bathing, and the resident at risk for developing pressure sores and had pressure sores during the previous assessment with none present at this assessment date. Review of the physician's orders dated 8/1/11 through 10/15/11 revealed an order to complete weekly skin assessments and see skin sheets for any needed follow-up. According to a 9/20/11 fax, Staff D, Wound Nurse, informed the physician of an open area on the right buttock, Stage 2 with a measurement of 0.5 centimeter (cm) wide and 1 cm long with a scant amount of blood. The fax indicated an Allevyn dressing was applied and Staff D requested an order for [REDACTED]. Review of the telephone physician's order dated 10/6/11 revealed an order for [REDACTED]. Review of the lab reports revealed the resident with an [MEDICATION NAME] level (indicated protein intake to aid in healing) of 2.8 on 4/25/11 and 5/9/11 with normal range between 3.3 and 5.2. Review of the dietitian progress notes from 4/26/11 through 9/8/11 revealed no documentation of pressure sores. Review of the Treatment Administration Record (TAR) revealed an order dated 9/20/11 for Allevyn dressing to the coccyx area and change every 72 hours and as needed and an order dated 10/3/11 for Allevyn dressing to the open area on left buttock and change every 72 hours and as needed. Review of the pressure ulcer/non-pressure ulcer healing records and skin condition record revealed the following: Upon admission, a pressure ulcer/non-pressure ulcer healing record dated 4/23/11 indicated the resident had pressure ulcers to the left heel and right heel, no open areas identified to the coccyx or buttocks areas. The Ulcer/Non-Pressure Ulcer Healing Record form revealed an ulcer to the buttock/coccyx/gluteal area with an onset date of 9/20/11. The wound measured 0.5 cm long and 1 cm wide and 0 cm deep. There was no documentation of measurement and assessment of the wounds for the following 3 weeks. On 10/13/11, the DON provided a copy of the pressure ulcer healing record for the coccyx date late entry 10/12/11 for an assessment completed 10/11/11. The wound then measured as overall 8 cm long and 6.5 cm wide and 0 cm deep (the last assessment on 9/20/11 was measured as 0.5 cm long and 1 cm wide and 0 cm deep). Staff D, Wound Nurse, also documented measurement overall was larger and instructed to notify the physician, that the Roho cushion was in place, the resident still refused the healthy shot nutritional supplement, wished to continue sleeping in the recliner and staff aware of positioning with pillows in recliner to aid in less pressure. On 10/11/11 the Director of Nursing (DON) provided a skin condition record for Non-Pressure Ulcer Skin conditions for an open area to the left buttock with an onset date of 10/3/11. On 10/13/11, the DON provided a copy of a pressure ulcer healing record which now identified the ulcer with onset date of 10/3/11 as a pressure ulcer and a late entry dated 10/12/11 for an assessment completed 10/11/11. An observation on 10/11/11 at 2:20 p.m. revealed Staff E, Certified Nursing Assistant (CNA) and Staff F, CNA, assisted the resident to the toilet and after the resident's pants and incontinent briefs were pulled down, there were no dressings covering the multiple open areas over the coccyx and upper gluteal areas. During observation on 10/11/11 at 4:00 p.m. Staff K, Registered Nurse (RN), assisted the Nurse Practitioner to obtain a wound culture from the open area to the left gluteal wound. Dressings were not applied afterward. On 10/11/11 at 2:28 p.m., Staff C, Licensed Practical Nurse (LPN) reported the wounds were left open to air as she had anticipated the nurse practitioner to come in to assess them and to be at the facility at 1:30 p.m. When interviewed on 10/11/11 at 4:20 p.m., Staff K, RN, reported the resident refused to have new dressings applied to the open areas as the resident wanted to stand in the bathroom to hold on to the grab bar while new dressings were applied. In an interview on 10/13/11 at 3:13 p.m., Staff D, Wound Nurse, reported on 10/11/11 she assessed and measured the wounds that morning at 7:30 a.m., however, did not apply a new dressing as she was needed to work as a floor nurse and could not remember if there was a dressing over the coccyx area and informed Staff C, LPN, of the need to put a dressing on the wounds. Staff D said if the dressings come off, the expectation as to apply new dressings right away. Staff D could not recall the exact number of open areas over the coccyx and upper gluteal areas but reported there were more than 5 open areas. When she did not work on an assessment day, she would leave staff a note to inform of their responsibility for assessments and dressings. Review of the facility policy titled "Wound Care " dated revised 10/13/11 revealed the previous policy directed staff to have the floor nurse complete the initial assessment and begin treatment. It did not provide guidelines on how often the staff was to assess and document. The policy directed staff under the heading of "Procedure " to assess the wound and document findings on the appropriate record, i.e., Decubitus Ulcer Record or Skin Integrity Flow Sheet. The 10/13/11 revision included: In the absence of the wound nurse, the primary nurse working on the unit will be responsible for the required weekly measurement, assessment and any needed follow-up with the physician, dietary and family.

Based on record review and interviews, the facility failed to plan for and direct nursing services to ensure one of three residents received adequate supervision from hazards. Resident #1 sustained a fall and fractured his/her left femur and interviews established the staff had not worked with the resident before and had been unaware of the resident's care plan safety interventions. The facility reported a census of 118 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 with [DIAGNOSES REDACTED]. The MDS further identified resident with a BIMS score of 9 of 15. The MDS noted the resident required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use and personal hygiene and assist of one staff for eating. The assessment noted the resident had a fall in the last month prior to admission. The MDS assessment further identified the resident has a Foley catheter and is continent of bowel. Review of History and Physical dated 2/18/11 indicated Resident #1 fell at his/her assisted living facility, where he/she resided with spouse. The resident used a walker to ambulate. The resident sustained [REDACTED]. Review of Resident's #1 face sheet information reviewed the resident had been admitted to the nursing home on 2/23/11 with a [DIAGNOSES REDACTED]. Review of Physical Therapy Evaluation dated 2/26/11 indicated resident had been living in a assisted living facility with spouse and had been independent with mobility, transfers, and ambulation with a walker. The resident's caregiver indicated that he/she would like resident to get better to the point that resident would be able to return back to assisted living with spouse. The plan of treatment was for physical therapy 5 times a week for 13 weeks. The evaluation further indicated the resident's fall risk as high. Review of Resident's #1 Admission Care Plan dated 2/23/11 indicated the resident to have a vision loss and wears glasses. The care plan also indicates the resident was at risk for injury due decrease mobility post hip repair, cognitive loss, weakness and history of falls. The care plan directed staff that the resident required a wander tab alarm, speaking chair alarm, bed alarm, and a floor mat by bed. The care plan also directed staff to remind and assist resident with transfers, using a gait belt, and walker/wheelchair for ambulation. Incident report dated 3/18/11 at 4:55 p.m. revealed Resident #1 had been observed lying on the floor of his/her room on left side. Resident had a small laceration to left eyebrow, pressured applied and ambulance called. The incident report further indicated that the alarms were on and malfunctioning. Review of Interdisciplinary Progress Notes dated 3/18/11 at 5:30 p.m. indicated Resident #1 transported to emergency room by ambulance. Review of hospital visit summary dated 3/18/11 revealed Resident #1 had fractured his/her left hip from a fall one month ago and had joint replacement surgery for [REDACTED]. The summary documented the resident cried and experienced pain when his/her left leg was moved in the hospital. Review of Interdisciplinary Progress Notes dated 3/28/11 revealed Resident #1 returned to the nursing home by ambulance from hospital. The note documented the resident had an incision on left leg that measured 17 1/2 inches long, no redness noted, dressing dry and intact. Interview on 4/6/11 at 1:15 p.m., Staff C, C.N.A. (certified nurse aide) indicated at 4:30 or 4:35 p.m. Staff C checked on Resident #1 in resident's room and noted the resident lying in bed and noted the bed pressure alarm on with two red lights and one green light, Staff C stated green means the alarm was activated. Staff C did not check if the wander tab alarm was in place and on, nor did she notice whether the floor mat was in place. Staff C indicated that the resident required a pressure bed alarm, wander tab alarm on, and floor mat on floor by bed when resident was in bed. Staff C further indicated that he/she did not hear any alarms sounding prior to finding the resident on the floor at 4:55 p.m. and the clip alarm did not sound and was not connected to the resident. Staff C stated no power outage/surge prior to resident's fall and the floor was not wet. During a phone interview with Staff G, LPN on 4/16/11 at 12:49 p.m. she stated the fall incident regarding Resident #1 happened a while back and she did not recall everything. The resident required frequent reminders not to attempt to get up on his/her own. Staff G stated she recall assisting Staff E, RN to transfer the resident from the toilet via shower chair to his/her bed about 15 to 20 minutes prior to fall. Staff G stated Staff E turned on the bed alarm, and she left the room while Staff E finished providing cares to the resident. Staff G stated she did not know if the resident had the wander tab in place and on him/her. Staff G stated she did not know if the floor mat was on the floor before she left the room. Staff G stated Resident #1 required a pressure alarm on while in bed, wander tab alarm, and floor mat by side of bed. Staff G stated she thought Staff E knew the fall safety preventions necessary for Resident #1. Staff G stated she did not hear any alarms sounding, nor was the call light on prior to finding the resident on the floor. Staff G stated if alarms were in place and working then they would have sounded. Staff G stated she receive a written warning from the facility due to not ensuring that all safety interventions were properly used prior to resident ' s fall. Staff G stated she had training from the facility when she first started in February 2011 regarding alarms and resident's care plans. Interview on 4/6/11 at 2:03 p.m., Staff E, LPN (Licensed Practical Nurse) indicated at 4:30 p.m. he/she transferred the resident from the toilet to the bed. Staff E reports he/she then turned on the pressure bed alarm after resident laid down in bed and the two red lights along with the green light were on. Staff E indicated another nurse (Staff G) assisted her/him with transferring the resident into bed. Staff E reports that it had been her second night on the floor as a new nurse in training at the facility. Staff E further reported that he/she did not connect the wander tab alarm or see Staff G attached it. Staff E stated she did not see or place the floor mat on the floor by the bed after transferring the resident. Staff E further indicated that he/she did receive training with the alarms prior to training on the floor; but did not know what safety devices were to be in place for the resident. Interview on 4/6/11 at 2:17 p.m., Staff F indicated that he/she seen the resident about an hour before the fall. Staff F states he/she looked in the room of the resident and the resident at that time were lying down in bed and the bed alarm on and the wander tab alarm in place and on. Staff F stated he/she checked the wander tab alarm it was working and the pressure alarm had the lights on indicating that it was activated and it had been in place at that time. Staff F further indicates that he/she did not note if the floor mat had been on the floor or not. Staff F states later he/she walked by resident's room and seen resident on floor and nurse and other staff in room with resident. Staff F reports not hearing any alarms sounding prior to resident's fall. Staff F stated she had never had any incident of alarm being in place and turned on and then not sound. Interview on 4/6/11 at 1:40 p.m., Staff D, RN (Registered Nurse), indicated he/she did not here any alarms sounding prior to Resident's fall. Staff D further indicated that the resident were to have a wander tab alarm and pressure bed alarm that should have sounded and mat on the floor. Staff D stated he/she does not recall if alarm sounded or not or if the mat had been on the floor. Interview on 4/6/11 at 8:30 a.m., Staff A, Maintenance Supervisor, revealed during the investigation of Resident's #1 fall, he noted the bed pressure alarm had no batteries for back if electrical failure and that if the alarm loses power that it needs to be manually reset to be activated and in working order, as alarm will not reset itself. Staff A states when the surveyor asked for the manufacturer ' s manual is the first they realized the manual also states the pressure bed alarm has a battery for back up. Staff A demonstrated how the pressure bed alarm will not work if it loses electrical power. Staff A further indicated they have no system in place to check the pressure bed alarms for batteries, they just make sure they work before being used given out to staff. Staff A stated he/she was in communication with the manufacturer of the alarms at the time of the survey. During an interview with the Administrator on 4/6/11 at 7:59 a.m., she stated the facility get ' s power surges and she thinks the power surge may have turned the alarm off. The Administrator stated two new nurses (Staff E and Staff G) put Resident #1 in bed and did not put the mat on the floor. The Administrator stated now the facility added the tab alarm when he/she was in bed or chair. The Administrator stated they had checked all alarms after and found no problems with any other alarms. The facility provided a list of approximately 40 residents using bed alarms. The facility provided no documentation of other residents alarms turned off or affected by a possible power surge.