**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have a licensed administrator licensed in accordance with state law. This failure has the potential to affect all 19 residents residing in the facility.Findings include:V1's (Administrator) Illinois Department of Financial and Professional Regulation (IDFPR) Lookup Detail View documented a Licensed Nursing Home Administrator Temporary with a First Effective Date of [DATE], Effective Date of [DATE], and an Expiration Date of [DATE]. On [DATE] at 12:12 PM, V14 (Administrator In Training/ AIT) stated she had only been working in the facility for 3 to 4 weeks and was not sure about the history of V1's Administrator License. V14 said on the IDFPR website V1's Licensed Nursing Home Administrator Temporary documented an Active Status but was expired. V14 said she did not have a Licensed Nursing Home Administrator Temporary yet. V14 stated that V1 was currently unavailable due to a hospitalization. V1 was unable to be reached for interview during the survey. On [DATE] at 12:32 PM, V15 (Regional Director of Operations/ RDO) stated V1 had a Temporary Administrator License and V1 told V15 that V1 had taken the Licensed Nursing Home Administrator test but was unsure if V1 had passed or failed. V15 said a Temporary Administrator License was eligible to be extended if the person had attempted the Licensed Nursing Home Administrator test. V15 said V1 had applied for a licensure extension but due to IDFPR being slow to process any applications for licensure since COVID V1 had not received any notice of extension. V15 said he had called IDFPR to inquire about V1's licensure extension and was told it was being processed. On [DATE] at 2:45 PM, V14 stated she was not aware of any other Administrator License being connected and active in the facility. V14 was not able to provide any reproduceable documentation V1 had recently attempted to take the Licensed Nursing Home Administrator testing or of V1 filing for an extension on the Licensed Nursing Home Administrator Temporary. The facility's Resident Matrix printed [DATE] documented 19 residents residing in the facility.Illinois Administrative Code title 77, 399.510 documents .a) There shall be an administrator licensed under the Nursing Home Administrators licensing and Disciplinary Act .full-time for each licensed facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to promptly notify the resident representative of a fall for 1 (R1) of 3 residents reviewed for notification of changes in a sample of 7. Findings Include: R1's admission Record documented an admission date to the facility of 07/09/2024 with diagnoses including osteomyelitis, encounter for orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension. R1's MDS (Minimum Data Set) with an Assessment Reference date of 08/08/2024, documented as a quarterly assessment, documented a Brief Interview for Mental Status (BIMS) Score of 13, indicating R1 is cognitively intact. A Skilled Progress Note for R1 dated 10/05/2024 , authored by V2 (Director of Nursing), documented on 10/06/2024 at 2:30 A.M. R1 had a fall in the bathroom and that the day shift nurse would notify POA (Power of Attorney) of the incident due to non-emergent situation and being early in the morning. R1's (Name of Company) Quality Care Reporting Form under the section titled Responsible Party Notified it is documented as son with no date or time documented on the form. On 11/20/2024 at 8:39 A.M., V3 (Registered Nurse) stated on 10/06/2024 when she got shift report from V2 (Director of Nursing), V3 was informed that R1 had had a fall in the bathroom and hit his head. The fall caused him to have a scratch on his head that bled. V3 stated that V2 was going to finish all the paperwork and call the POA (Power of Attorney). V3 stated that she completed her shift and once she was home, she received a text message from V2 stating that she had forgotten to call the POA for R1 to notify them of a fall. V3 stated that it was her understanding from shift report that V2 was going to call and notify the POA. V3 stated that she doesn't think the family had ever been notified of the fall form 10/06/2024. On 11/21/2024 at 10:07 A.M., V2 (Director of Nursing) stated that R1 fell off the toilet and hit his forehead. V2 stated that she gave report to V3 and let her know about the fall and that she would attempt to make all notifications prior to V2 leaving. V2 stated that before she left, she verbally told V3 that she had not called the POA and asked her to do so. V2 stated that she then wrote on the 24-hour report to call the POA regarding R1's fall. V2 stated that she sent V3 a text later in the day on 10/06/2024 apologizing for V3 having to make notifications for her. V2 stated that several days after the fall she heard a rumor that V3 was telling other nursing staff that she didn't call the POA of R1 because it was V2's responsibility. V2 stated at this point she spoke to V1 (Administrator) about the concern of R1's POA not being notified. V2 stated that R1's family was in the facility one day and she notified them then. V2 stated she did not chart that she had done it and she also does not remember the day she talked to R1's POA. V2 stated that it is her expectation for staff to notify the POA's of a resident fall as soon as possible. V2 stated that it has been a facility policy for staff to wait until later in the morning to notify family of a fall if it occurs in the middle of the night or early morning hours. On 11/22/2024 at 12:40 P.M., V1 stated he was unaware that the POA was not notified on R1's fall until it was brought to his attention by V3. V1 stated that it was his understanding the V3 was supposed to call the POA because V2 had asked her to do it before she left the faciity on [DATE]. V1 stated that it is his expectation for staff to notify POA's of any type of change as soon as possible. The facility policy titled Accidents and Incidents with a revision date of 09/06/2023 documents, Responsibility: It is the responsibility of the charge nurse to complete the incident report, notify attending physician, and responsible parties and document information accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect and safeguard controlled substances for 1 (R1) of 3 residents reviewed for misappropriation of property in the sample of 7. Findings Include: R1's admission Record documented an admission date to the facility of [DATE] with diagnoses including osteomyelitis, encounter for orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension. R1's MDS (Minimum Data Set) with an Assessment Reference date of [DATE], documented as a quarterly assessment, documented a Brief Interview for Mental Status (BIMS) Score of 13, indicating R1 is cognitively intact. R1's Order Summary Report with a print date of [DATE] documented an order for Hydrocodone 5-325 mg (milligram), 1 tablet by mouth every 4 hours as needed for chronic pain with an order date of [DATE]. R1's Controlled Drug Administration Record documented that 24 Hydrocodone were received on [DATE] by V17 (Licensed Practical Nurse). The same form also documented R1 received Hydrocodone on [DATE] and [DATE] at 11:00 P.M. and was signed off by V11 (Licensed Practical Nurse) with 22 tablets remaining. On [DATE] V1 (Administrator) and V2 (Director of Nursing) were unable to produce the Controlled Drug Administration Record for the deliveries of Hydrocodone that were delivered on [DATE], [DATE], and [DATE]. R1's [DATE] MAR (Medication Administration Record) documented no doses of Hydrocodone were given on [DATE] or [DATE]. R1's Progress Note dated [DATE] and timed 12:54 P.M. documented, Upon doing narc (narcotic) count with (V11 Licensed Practical Nurse) this morning at 6:30am, which was correct, I noticed (R1's) slot for his as needed Hydrocodone was empty. I checked with electronic medical record following the discovery to verify the medication had not been discontinued. I then viewed the DON (Director of Nursing) box for recent narc count papers that may have been pulled, and also checked the destruction log. No narc count papers, or documentation of destruction of this medication was noted. Administrator was notified of this issue around 7am this morning. DON (V1) was notified as well. A facility incident report titled IDPH (Illinois Department of Public Health) Notification Form documented on [DATE] staff reported an allegation of misappropriation of resident property. Investigation initiated and follow up will be sent within 5 days. A pharmacy delivery slip dated [DATE] documented R1 had 5 Hydrocodone delivered to the facility and signed by V18 (Licensed Practical Nurse) at 11:39 P.M. A pharmacy delivery slip dated [DATE] documented that R1 had 24 Hydrocodone delivered to the facility and signed by V4 (Registered Nurse) at 11:43 A.M. A pharmacy delivery slip dated [DATE] documented that R1 had 24 Hydrocodone delivered to the facility and signed by V17 at 8:13 P.M. A pharmacy delivery slip dated [DATE] documented that R1 had 24 Hydrocodone delivered to the facility and signed by V17 at 11:16 P.M. On [DATE] at 12:06 P.M., V7 (Pharmacy Operator) stated that R1 had Hydrocodone delivered to the facility on [DATE]. V7 stated that it was delivered at 11:16 P.M. and signed by V17 (Licensed Practical Nurse). On [DATE] at 8:39 A.M., V3 (Registered Nurse) stated that on [DATE] she was completing the narcotic count. V3 said she thought that it was weird that there was a slot for R1 and there was no cards or narcotic sign out sheet. V3 stated the facility does not count cards, they just count the pills that are on the card. V3 stated the count was accurate for all the cards that were present. V3 stated she looked in the electronic medical record and knew that R1 had an order for a narcotic. V3 stated she looked on the destruction log and then looked in the DON's box at the nurses station and did not find any sheets for R1's narcotic. V3 stated that she called V1(Administrator) around 7:00 A.M. to report the potential diversion. V3 stated she is not sure the last time she saw it in the cart. V3 stated that R1 never takes anything for pain. V3 stated that when she worked the night shift on [DATE], she thought there was some in there but cannot remember 100 percent. V3 said that V1 instructed her to call V6 (Registered Nurse) to see if she knew anything about it. V3 then called V6 and V6 told V3 that she didn't recall if R1 had any or not. V3 stated she called the pharmacy, and the pharmacy told her that the script expired the end of October and there was not a new one on file to fill. On [DATE] at 10:05 A.M. narcotic count was completed with V4 (Registered Nurse). The cards that were present had the correct number of medications on them matching the count sheets. There were not narcotics in the narcotic box for R1. On [DATE] at 12:00 P.M., V4 (Registered Nurse) stated that there is an order for R1 to have Hydrocodone but she never gives him any. V4 verified that there were no narcotics in the lock box for R1 and that there was no count sheet. V4 repeated she is unsure if R1 had any because she never gives him any. V4 did not recall the last time that there were narcotics in the locked box for R1. On [DATE] at 2:17 P.M., R1 was sitting in his recliner rolling around in his room. R1 stated that he has no pain. R1 stated that if he did he would tell the nurse and she will ask the doctor for something. R1 stated he does not know what medications he takes because he takes a hand full of them. R1 stated that he does not have pain and doesn't ask for any pain medication. On [DATE] at 10:00 A.M., V6 (Registered Nurse) stated she never gives R1 any pain medication. V6 stated that R1 never complains of pain and never appears to be in pain. V6 stated that she thought the order for R1's narcotic was discontinued after a hospital visit. V6 then checked the EMAR (Electronic Medication Administration Record) and noted that R1 has an order. V6 stated that she assumes that the medication was destroyed and is not sure where it is. On [DATE] at 10:07 A.M., V2 (Director of Nursing) stated she was off with COVID from [DATE]-[DATE]. V2 stated that V17 sent her a message on [DATE] about the narcotic sheet of R1 because V16 found it folded up under supplies in the bottom of the medication cart. V2 stated that when she returned on [DATE] she was working on investigating the diversion and the medication error. V2 stated that she had kind of forgot about it because she was so sick when she had COVID. V2 stated that she found the narc sheet yesterday in her office and it jogged her memory about it. V2 stated that it was reported to police, physician, POA (Power of Attorney) and IDPH (Illinois Department of Public Health) yesterday. V2 stated that when a card is empty the name sticker should be removed, and the card thrown away. V2 stated the narcotic count sheet is then placed in her mailbox for review and to store. V2 stated that she thought she had the Controlled Drug Administration Record for August, and she cannot find it. She thought it was on her desk in a red folder, but she cannot find it now. V2 stated that she keeps all the count sheets in her office in boxes but cannot find the ones for R1. V2 stated that V1 was starting the investigation and the facility had put different methods in place of counting to ensure nothing is being missed. V2 stated that the facility will now count the sheets, the cards and the medication to ensure the accuracy of all controlled substances. On [DATE] at 10:40 A.M., V1 (Administrator) stated he was notified on [DATE] that there could be a potential drug diversion. V1 stated that once her and V2 arrived to work on [DATE], they started investigating the diversion and the medication error. V1 stated that once the narcotic sign out sheet was found, they knew they had a big issue and reported it. On [DATE] at 9:45 A.M., V11 (Licensed Practical Nurse) stated that R1 is occasionally in pain due to having a toe amputation. V11 stated that he never asks for pain medication, but she will ask him because she knows with R1's diagnosis that he could be in pain. V11 stated she has asked the day shift nurses if they ever give R1 any pain medication and she got told they do not. V11 stated that she knows she has given the medication to R1, but she must not sign that it has been given on the MAR. V11 stated that there was a card in the narcotic box, and she wasn't sure the last time that she saw it. V11 stated that she could recall there were pills remaining on the far right of the card. V11 stated that she always does the narcotic count with the off going nurse. V11 stated the policy was to only count the number of pills, not the actual number of cards. V11 stated that she could have received narcotics from the pharmacy for R1 in the past but has not recently. V11 stated that when she receives narcotics, she counts them and puts them in the narcotic box. V11 stated the pharmacy deliveries usually come around 7:00 P.M. - 11:00 P.M. V11 stated that occasionally the pharmacy will deliver medications around 6:00 A.M., but it is usually in the evening / nighttime. V11 stated again that she is bad about signing off medications in the MAR but verifies times on the narcotic sheet to make sure it is not too soon. On [DATE] at 9:56 A.M., V12 (Licensed Practical Nurse) stated she works PRN (as needed) in the facility and has only worked three days since September being [DATE], [DATE], and [DATE]. V12 stated that the procedure for checking in narcotics, is the pharmacy will deliver, typically on night shift, and the nurse will verify the count is right and sign the delivery sheet and give it back to the pharmacist. Once it is checked in, V12 stated the narcotic sheet goes in the book and the card with the medicine goes in the locked narcotic box. V12 stated that when she gives as needed medications, she will sign the narcotic count sheet and the MAR that the medication was given. V12 stated that R1 has never complained of pain to her and she has never given R1 any as needed pain medication. On [DATE] at 10:26 A.M., V13 (Licensed Practical Nurse) stated she can't remember ever giving R1 and as needed pain medications. V13 stated she only works one day a week on Wednesday nights but had been off for vacation. Prior to working [DATE], V13 stated the last time she worked prior to that was [DATE]. V13 stated that she can't remember there being a card with medication on it for R1 at that time or not. V13 stated that when she gives as needed medications, she knows to sign out the MAR and the narcotic count sheet. V13 stated that typically if she receives a pharmacy delivery it is around 10 P.M. at night. V13 doesn't remember the last time that there was a delivery of narcotics for R1. V13 stated that she has been educated on the new way of signing in narcs and counting the cards not just the pills. On [DATE] at 11:31 A.M., V14 (Licensed Practical Nurse / Business Office Manager) stated that she will occasionally work the floor when there is a call in. V14 stated that she has worked partial shifts twice in the last couple weeks. V14 stated she has never given R1 any pain medications. V14 stated that R1 has never asked her or complained about pain when she was working. V14 stated that she always does the narcotic count but does not remember when R1 had narcotics in the drawer last. V14 stated that when she does give as needed medications, she will document it on the MAR and on the narcotic sheet. On [DATE] at 11:38 P.M., V15 (Licensed Practical Nurse) stated she is a full-time night shift nurse for the facility. V15 stated that she has never given R1 any as needed pain medication. V15 stated she does narcotic counts prior to starting her shift. V15 stated she has never known a count to be wrong. V15 stated she never realized that the card was missing for R1. V15 stated that she does remember there being narcotics in the locked box for R1 but is unsure when the last time they were there. V15 stated that she never counted the cards, she would just always count the pills. On [DATE] at 11:54 A.M. V17 (Licensed Practical Nurse) stated she was working her shift on [DATE]. It was after midnight, and she started cleaning the medication cart. It was about 12:20 am on [DATE] that she was cleaning the bottom drawer and noted R1's pink narcotic sheet folded and under some dividers. V17 stated that she then took a picture and notified V2. V17 stated that V2 asked her to verify if the order was still active in the computer and to see if there was a card in the narcotic box. V17 stated that she checked, and the order was active in the computer for R1. V17 then stated she checked the narcotic box and there was not a card for R1's Hydrocodone. V17 stated that she then placed the narcotic sheet in V2's box for review. V17 stated she has given R1 pain medication before, but it has been several months. V17 stated that she left for vacation on [DATE] and the card was in the narcotic box then. V17 stated that she was not good about charting on the MAR when she did give R1 pain medication, but she would always document it on the narcotic count sheet. A Final Incident Report received by IDPH dated [DATE] documented Based on the results of the investigation, the facility has found no evidence to support abuse. The facility has determined the 22 Norco were probably accidentally thrown away due to disorganization and lack of attention. The facility has determined V11 administered Norco to R1 on 11/2 and after that administration, the card was accidentally thrown in the trash. Ms. V18 supports this by confirming she didn't count the Norco on [DATE]. The facility has contacted pharmacy and instructed pharmacy to bill the facility for any unaccounted-for Norco. The facility has conducted an Ad Hoc QA meeting related to counting narcotic and narcotic management. All licensed staff were in-serviced on counting cards, count sheets and pills with appropriate sign off. DON or designee will conduct audits 3 times per week for 4 weeks to ensure compliance. The facility policy titled (Name of Company) Abuse Prevention Program with a revision date of [DATE] documented , The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property and exploitation .This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and secure environment. Under the section titled Definitions it documents Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of misappropriation of resident property within the required time frames for 1 (R1) of 3 residents reviewed for misappropriation of property in the sample of 7. The Findings Include: R1's admission Record documented an admission date to the facility of [DATE] with diagnoses including osteomyelitis, encounter for orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension. R1's Order Summary Report with a print date of [DATE] documented an order for Hydrocodone 5-325 mg (milligram), 1 tablet by mouth every 4 hours as needed for chronic pain with an order date of [DATE]. A Progress Note dated [DATE], timed 12:54 P.M., authored by V3 (Registered Nurse) documented, Upon doing narc (narcotic) count with V11 (Licensed Practical Nurse) this morning at 6:30am, which was correct, I noticed R1's slot for his as needed Hydrocodone was empty. I checked with electronic medical record following the discovery to verify the medication had not been discontinued. I then viewed the DON (Director of Nursing) box for recent narc count papers that may have been pulled, and also checked the destruction log. No narc count papers, or documentation of destruction of this medication was noted. Administrator was notified of this issue around 7am this morning. I spoke with pharmacy regarding this medication, and they stated that they have not received any new orders, and previous order was last filled in August. DON was notified as well. On [DATE] at 8:39 A.M. V3 (Registered Nurse) stated that on [DATE] she was completing the narcotic count. V3 said she thought that it was weird that there was a slot for R1 and there was no cards or narcotic sign out sheet. V3 stated the facility does not count cards, they just count the pills that are on the card. V3 stated the count was accurate for all the cards that were present. V3 stated she looked in the electronic medical record and knew that R1 had an order for a narcotic. V3 stated she looked on the destruction log and then looked in the DON box and did not find any sheets for R1's narcotic. V3 stated that she called V1(Administrator) around 7:00 A.M. to report the potential diversion. V3 stated she is not sure the last time she saw it in the cart. V3 stated that R1 never takes anything for pain. V3 stated that when she worked the night shift, she thought there was some in there but cannot remember 100 percent. V3 said that V1 instructed her to call V6 (Registered Nurse) to see if she knew anything about it. V3 then called V6 and V6 told V3 that she didn't recall if R1 had any or not. V3 stated she called the pharmacy, and the pharmacy told her that the script expired the end of October and there was not a new one on file to fill. On [DATE] at 10:07 A.M. V2 (Director of Nursing) stated she was off during COVID from [DATE]-[DATE]. V2 stated V16 sent her a message on [DATE] about the narcotic sheet of R1 because V16 found it folded up under supplies in the bottom of the medication cart. V2 stated that when she returned on [DATE] she was working on investigating the diversion and the medication error. V2 stated that she had kind of forgot about it because she was so sick when she had COVID. V2 stated that she found the narc sheet yesterday in her office and it jogged her memory about it. V2 stated that it was reported to police, physician, POA (Power of Attorney) and IDPH (Illinois Department of Public Health) yesterday ([DATE]). V2 stated that V1 was starting the investigation and the facility had put different methods in place of counting to ensure nothing is being missed. V2 stated that the facility will now count the sheets, the cards and the medication to ensure the accuracy of all controlled substances. V2 stated she did not notify the admin at that time of a potential diversion. V2 stated that she was off with COVID when she was told by V17 about finding the narcortic slip in the bottom of the drawer. V2 stated V1 was off with COVID at the same time so she did not think there was anyone [NAME] who could do the investigation. V2 stated that once she came back to work on [DATE], she was working on other issues and forogt about the potential diversion. On [DATE] at 10:40 A.M. V1 (Administrator) stated he was notified on [DATE] that there could be a potential drug diversion. V1 stated that once her and V2 arrived to work on [DATE], they started investigating the diversion and the medication error. V1 stated that once the narcotic sign out sheet was found, they knew they had a big issue and reported it. An IDPH Notification Form documented on [DATE] staff reported an allegation of misappropriation of resident property. Investigation initiated, notification of physician, ombudsman and police done. Follow up will be sent within 5 days. The facility policy titled (Name of Company) Abuse Prevention Program with a revision date of [DATE] documented , Employees are required to immediately report any occurrences if potential/alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property they observe, hear about, or suspect to a supervisor and the administrator. , Supervisors shall immediately inform the administrator of all reports of potential / alleged mistreatment. The same policy under the category External Reporting of Potential Abuse documents 1. Initial reporting of Allegations: The facility must ensure that all alleged violations involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, misappropriation of resident property, and reasonable suspicion of crime, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures. The report must be made not later than 24 hours after forming the suspicion.

Based on interview and record review, the facility failed to timely initiate an investigate of an allegation of missing controlled substances for 1 of 3 residents (R1) reviewed for misappropriation of property in a sample of 7. Findings Include: R1's admission Record documented an admission date to the facility of 07/09/2024 with diagnoses including osteomyelitis, encounter for orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension. R1's MDS (Minimum Data Set) with an Assessment Reference date of 08/08/2024, documented as a quarterly assessment , documented a Brief Interview for Mental Status Score of 13, indicating that R1 is cognitively intact. R1's Order Summary Report with a print date of 11/22/2024 documented an order for Hydrocodone 5-325 mg (milligram), 1 tablet by mouth every 4 hours as needed for chronic pain with an order date of 10/29/2024. R1's Controlled Drug Administration Record documented that 24 Hydrocodone were received on 09/17/2024 by V17 (Licensed Practical Nurse). The same form also documented R1 received Hydrocodone on 11/01/2024 and 11/02/2024 at 11:00 P.M. and was signed off by V11 (Licensed Practical Nurse) with 22 tablets remaining. R1's November 2024 MAR (Medication Administration Record) documented no doses of Hydrocodone were given on 11/01/2024 or 11/02/2024. On 11/20/2024 at 8:39 A.M. V3 (Registered Nurse) stated that on 11/16/2024 she was completing the narcotic count. V3 said that she thought that it was weird that there was a slot for R1 and there was no cards or narcotic sign out sheet. V3 stated the facility does not count cards, they just count the pills that are on the card. V3 stated the count was accurate for all the cards that were present. V3 stated she looked in the electronic medical record and knew that R1 had an order for a narcotic. V3 stated she looked on the destruction log and then looked in the DON (Director of Nursing) box and did not find any sheets for R1's narcotic. V3 stated that she called V1 (Administrator) around 7:00 A.M. to report the potential diversion. V3 stated she is not sure the last time she saw it in the cart. V3 stated that R1 never takes anything for pain. V3 stated that when she worked the night shift, she thought there was some in there but cannot remember 100 percent. V1 instructed V3 to call V6 (Registered Nurse) to see if she knew anything about it. V3 then called V6 and V6 told V3 that she didn't recall if R1 had any or not. On 11/22/2024 at 9:55 A.M. V2 (Director of Nursing) stated that she was notified by V17 (Licensed Practical Nurse) on 11/12/2024 at 12:20 A.M. via text message that she found a narcotic sheet for R1 folded in the bottom of the medication cart under supplies. V2 stated she did not start investigating until she found the narcotic sheet on her desk 11/20/2024. V2 stated she was out with COVID which is why she did not immediately investigate it. On 11/21/2024 at 10:40 A.M. V1 (Administrator) stated he was notified on 11/16/2024 that there could be a potential drug diversion. V1 stated that once he and V2 arrived to work on 11/18/2024, they started investigating the diversion and the medication error. V1 stated that once the narcotic sign out sheet was found on 11/20/2024, they knew they had a big issue and reported it. The facility policy titled (Name of Company) Abuse Prevention Program with a revision date of 11/28/2016 documented, Supervisors shall immediately inform the administrator of all reports of potential / alleged mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an investigation.

Based on interview, observation, and record review the facility failed to account for, maintain records of, and document the administration of controlled substances for two (R1 and R3) of three residents reviewed for pharmacy services in the sample of 7. Findings Include: 1. R1's admission Record documented an admission date to the facility of 07/09/2024 with diagnoses including osteomyelitis, encounter for orthopedic aftercare, absence of left toes, chronic obstructive pulmonary disease, dementia, atrial fibrillation, heart failure, depression, and essential hypertension. R1's MDS (Minimum Data Set) with an Assessment Reference date of 08/08/2024, documented as a quarterly assessment, documented a Brief Interview for Mental Status (BIMS) Score of 13, indicating R1 is cognitively intact. R1's Order Summary Report with a print date of 11/22/2024 documented an order dated 10/29/2024 for Hydrocodone 5-325 mg (milligram), 1 tablet by mouth every 4 hours as needed for chronic pain. R1's Controlled Drug Administration Record documented that 24 Hydrocodone were received on 09/17/2024. The same form also documented R1 received Hydrocodone on 11/01/2024 and 11/02/2024 at 11:00 P.M. and was signed off by V11 (Licensed Practical Nurse) with 22 tablets remaining. On 11/27/2024 V1 and V2 stated they were unable to produce the Controlled Drug Administration Record for the deliveries of Hydrocodone that were delivered on 08/06/2024, 08/14/2024, and 09/02/2024. R1's November 2024 MAR (Medication Administration Record) documented no doses of Hydrocodone were given on 11/01/2024 or 11/02/2024. R1's Progress Note dated 11/16/2024, timed 12:54 P.M., authored by V3 (Registered Nurse) documented, Upon doing narc (narcotic) count with (V11 Licensed Practical Nurse) this morning at 6:30am, which was correct, I noticed (R1's) slot for his as needed Hydrocodone was empty. I checked with electronic medical record following the discovery to verify the medication had not been discontinued. I then viewed the DON (Director of Nursing) box for recent narc count papers that may have been pulled, and also checked the destruction log. No narc count papers, or documentation of destruction of this medication was noted. Administrator was notified of this issue around 7am this morning. DON (V2) was notified as well. A pharmacy delivery slip dated 08/06/2024 documented R1 had 5 Hydrocodone delivered to the facility and signed by V18 (Licensed Practical Nurse) at 11:39 P.M. A pharmacy delivery slip dated 08/14/2024 documented that R1 had 24 Hydrocodone delivered to the facility and signed by V4 (Registered Nurse) at 11:43 A.M. A pharmacy delivery slip dated 09/02/2024 documented that R1 had 24 Hydrocodone delivered to the facility and signed by V17 at 8:13 P.M. A pharmacy delivery slip dated 09/17/2024 documented that R1 had 24 Hydrocodone delivered to the facility and signed by V17 at 11:16 P.M. On 11/20/2024 at 10:05 A.M. narcotic count was completed with V4 (Registered Nurse). There were not narcotics in the narcotic box for R1 and there were no count sheets in the narcotic book for R1. On 11/20/2024 at 12:00 P.M., V4 (Registered Nurse) stated that there is an order for R1 to have Hydrocodone but she never gives him any. V4 verified that there were no narcotics in the lock box for R1 and that there was no count sheet. V4 kept repeating she is unsure if R1 had any because she never gives him any. V4 did not recall the last time that there were narcotics in the locked box for R1. On 11/21/2024 at 10:00 A.M., V6 (Registered Nurse) stated she never gives R1 any pain medication. V6 stated that R1 never complains of pain and never appears to be in pain. V6 stated that she thought the order for R1's narcotic was discontinued after a hospital visit. V6 then checked the EMAR (Electronic Medication Administration Record) and noted that R1 has an order. V6 stated that she assumes that the medication was destroyed and is not sure where it is. On 11/22/2024 at 9:45 A.M., V11 (Licensed Practical Nurse) stated that R1 is occasionally in pain due to having a toe amputation. V11 stated that he never asks for pain medication, but she will ask him because she knows with R1's diagnosis that he could be in pain. V11 stated she has asked the day shift nurses if they ever give R1 any pain medication and she got told they do not. V11 stated that she knows she has given the medication to R1, but she must not sign that it has been given on the MAR. V11 stated that there was a card in the narcotic box, and she wasn't sure the last time that she saw it. V11 stated that she could recall there were pills remaining on the far right of the card. V11 stated that she always does the narcotic count with the off going nurse. V11 stated the policy was to only count the number of pills, not the actual number of cards. V11 stated that she could have received narcotics from the pharmacy for R1 in the past but has not recently. V11 stated that when she receives narcotics, she counts them and puts them in the narcotic box. V11 stated the pharmacy deliveries usually come around 7:00 P.M. - 11:00 P.M. V11 stated that occasionally the pharmacy will deliver medications around 6:00 A.M., but it is usually in the evening / nighttime. V11 stated again that she is bad about signing off medications in the MAR but verifies times on the narcotic sheet to make sure it is not too soon. On 11/22/2024 at 11:38 P.M., V15 (Licensed Practical Nurse) stated she is a full-time night shift nurse for the facility. V15 stated that she has never given R1 any as needed pain medication. V15 stated she does narcotic counts prior to starting her shift. V15 stated she has never known a count to be wrong. V15 stated she never realized that the card was missing for R1. V15 stated that she does remember there being narcotics in the locked box for R1 but is unsure when the last time they were there. V15 stated that she never counted the cards, she would just always count the pills. On 11/21/2024 at 10:07 A.M., V2 (Director of Nursing) stated it is her expectation for all nursing staff to count the narcotic box each shift with the off going nurse to ensure that the narcotic count for all residents are accurate. V2 stated that it is her expectation for licensed staff to not take, discard, or misuse the narcotics in the narcotic box. V2 stated that all staff should count the narcotics with the other nurse to make sure the counts are accurate. V2 stated that when a card is empty the name sticker should be removed, and the card thrown away. V2 stated the narcotic count sheet is then placed in her office mailbox for review and to store. V2 stated that she thought she had the Controlled Drug Administration Record for August, and she cannot find it. V2 said she thought it was on her desk in a red folder, but she cannot find it now. V2 stated that she keeps all the count sheets in her office in boxes but can not find the ones for R1. 2. R3's admission Record documented an admission date to the facility of 08/06/2024 with diagnoses including nondisplaced comminuted fracture of shaft of humerus, atherosclerotic heart disease of native coronary artery, diastolic heart failure, essential hypertension, chronic atrial fibrillation, muscle weakness and hypothyroidism. R3's MDS (Minimum Data Set) with an Assessment Reference date of 11/13/2024, documented as a quarterly assessment, documented a Brief Interview for Mental Status (BIMS) Score of 08, indicating that R3 has moderate cognitive impairment. R3's Order Summary Report with a print date of 11/27/2024 documented an order dated 08/19/2024 for Hydrocodone 5-325 mg (milligram), 1 tablet by mouth every 6 hours as needed for pain. A pharmacy delivery slip dated 09/02/2024 documented R3 had 30 Hydrocodone delivered to the facility and signed by V18 at 8:13 P.M. On 11/27/2024 at 2:00 P.M., R3 stated she does not take her pain medicine as much as she was. R3 stated that she was taking it more frequently but as her broken bone is healing, she doesn't need it as often. R3 stated that if her pain gets bad, she knows she can ask the nurse and they will get her a pain pill. R3's September MAR (Medication Administration Record) documented on the back, R3 was given Hydrocodone on 09/03/2024 at 09:00 A.M., 09/06/2024 at 07:30 A.M., 09/07/2024 at 09:00 A.M, 09/09/2024 at 7:30 A.M., 09/10/2024 at 07:30 A.M., 09/13/2024 at 12:00 P.M., and 09/13/2024 at 3:30 P.M. On 11/27/2024 at 1:38 PM, a narcotic count was observed and completed by V4 (Registered Nurse). During the narcotic count it there was a card for R3 in the narcotic box with pills on it and there was a narcotic count sheet in the book for R3. On 11/27/2024 at 3:46P.M. V2 stated she cannot find the controlled drug count sheet that matches the delivery slip of 09/02/2024. V2 stated she will continue to look in her office as she knows she has it there. The facility policy titled Storage of Controlled Substances with an effective date of 09/2018 documented, 2. Schedule II through V medications and other medications subject to abuse or diversion are stored in either a permanently affixed, double locked compartment separate from all other medications. 4. A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule II, III, IV, and V medications, including those in emergency supply.5. A. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed personnel and is documented. 6. Any discrepancy in controlled substance counts is reported to the Director of Nursing immediately and/ or in accordance with facility policy. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The Facility policy titled (Name of Company) Storage of Controlled Substances with a revision date of 08/2020 documented 8. Completed accountability sheets are submitted to the Director of Nursing and kept on file for five years at the facility in accordance with facility policy and state regulations. The facility policy titled (Name of Company) Administrations Procedures for All Medications with a revision date of 08/2020 documented under section IV. Administration 7. After administration, return to cart, replace medication container (if multi dose and doses remain), and document the administration in the MAR or TAR (Treatment Administration Record) and the controlled substance sign out record.

Based on interview and record review the facility failed to ensure that residents are free from significant medication errors for 1 (R4) of 3 residents reviewed for medication administration in the sample of 7. Findings Include: R4's admission Record documented an admission date to the facility of 04/14/2023 with diagnoses including unspecified dementia, acute cystitis, gastro-esophageal reflux disease, essential hypertension, insomnia, mixed hyperlipidemia, major depressive disorder, generalized anxiety and delusional disorders. R4's Order Summary Report with a printed date of 11/22/2024, with an order date of 10/29/2024 documented an order for Clonazepam (benzodiazepine) 0.5 mg (Milligram) by mouth two times a day . R4's (Name of Pharmacy) Controlled Drug Administration Record documented on 11/08/2024 that R4 was administered Clonazepam at 5:00 A.M. by V15 (Licensed Practical Nurse) 6:00 P.M., by V14 (Licensed Practical Nurse) and 8:00 P.M. by V11 (Licensed Practical Nurse). On 11/09/2024 R4 was administered Clonazepam at 5:00 A.M. by V11, 6:00 P.M. by V3 (Registered Nurse) and at 8:00 P.M. by V11. On 11/15/2024 R4 was administered Clonazepam at 5:00 A.M. by V3, 6:00 P.M. by V6 (Registered Nurse) and at 8:00 P.M. by V11. On 11/16/2024 R4 was administered Clonazepam at 8:00 A.M. by V11, 6:00 P.M. by V13 and 8:00 P.M. by V11. R4's November 2024 Medication Administration Record documented that R4 received Clonazepam twice daily at 08:00 A.M. and 6:00 P.M. The 4 additional doses that were administered by V11 were not documented in the electronic medication administration record (eMAR). R4's Progress Note dated 11/16/2024 authored by V3 (Registered Nurse) documented Notified Administrator (V1) and Director of Nursing (V2) of potential issues with electronic medical record and Clonazepam script. (V1) requested for me to leave note under door to remind him to further investigate on 11/18/2024. (V2) stated that she would check to see if she can figure out what is going on. R4's Progress Note dated 11/21/2024 with a time of 6:04 P.M authored by V2 documented Investigation into possible medication error initiated by myself (V2), and after investigation completion it was found and determined that this resident (R4) had been given her Clonazepam at 5:00 P.M. and then again by (V11 Licensed Practical Nurse) at 8:00 P.M. and a medication error had occurred. This nurse went down and spoke to resident an assessed her condition at that time with no noted negative effects of duplicate medication being administered noted. V/S (vital signs) @ (at) this time resident baseline as well. Attempted to notify POA (Power of Attorney) of med error incident with no answer. Left message to return call to facility. Attempted to contact (V16 Nurse Practitioner) with no answer, NP (Nurse Practitioner) scheduled to come to facility on 11/19/2024 and will notify her at that time if unable to reach prior to that time. R4's Progress Note dated 11/21/2024 with a time of 6:52 P.M. authored by V2 documented Late entry 11/20/24. Follow up on medication error. On 11/19/24 at approximately 1:00 P.M. I (V2) spoke with (V16-Nurse Practitioner) while she was present in the facility and notified her of the medication error that had occurred. (V16) stated she had assessed this patient (R4) and did not see any S/S (signs and symptoms) of any adverse reactions or harm that may have been caused by this error occurring. Then stated to monitor her for the remainder of the current day and if no ADR (Adverse Drug Reaction) noted still then may discontinue. A document title (Name of Company) Quality Care Reporting Form with a date of 11/19/2024 documented the nurse on duty on 11/16/2024, noticed a medication error for R4. R4 had received additional doses of Clonazepam due to going from paper MAR (Medication Administration Record) to electronic and the times were changed. This document stated Nurse failed to follow the electronic MAR causing the medication error. On 11/20/2024 at 8:39 A.M., V3 (Registered Nurse) stated that she discovered that R4 was getting her Clonazepam incorrectly. V3 stated that since going to the EMR (Electronic Medical Record), the times changed and the night nurse V11 was not giving the medications as per the MAR. V3 said that V11 was going ahead and giving R4 another dose of Clonazepam at 8 P.M. even though V3 had given it at 5 P.M. V3 stated on 11/16/2024 she notified V1 and V2 of the medication error and was told they will look into it on 11/18/2024. On 11/21/2024 at 10:07 A.M., V2 (Director of Nursing) stated that she was out with COVID when she was notified of the potential of a medication error. V2 stated that she was notified on 11/16/2024 that there was a potential medication error. V2 said that V3 notified her of the potential medication error. V2 stated that she started the investigation on the medication error on 11/18/2024. V2 stated that she notified the physician on 11/19/2024 as she confirmed that there was an issue. V2 stated that when the facility went live with EMAR (Electronic Medication Administration Record), the times were changed on R4's Clonazepam. V2 stated that the nurse was not looking at the EMAR, she was just signing it off like she had done for the last two years. V2 stated that she notified the physician, and then tried to notify the family. V2 stated that she left messages for the POA (Power of Attorney), and they have not returned her call. R4 received extra doses of Clonazepam on 11/8/24, 11/09/24, 11/15/24 and 11/16/24. V2 stated that there were no ill side effects to R4 for receiving the extra medications. On 11/21/2024 at 10:40 A.M., V1 (Administrator) stated that he was unaware of the medication error until V3 notified him. V1 stated at that point it was a possible medication error and V2 was going to investigate it. V1 stated that V2 talked with the nurse in question and notified V16. On 11/22/2024 at 9:45 A.M., V11 (Licensed Practical Nurse) stated she was the nurse who gave the extra doses of Clonazepam to R4. V11 stated that she was unaware that the time had changed on the MAR, and she was simply giving it like she always had. V11 stated I have to accept responsibility for this because I did not look at the MAR before giving the medication, I gave it according to my memory. V11 stated that R4 was already in bed when she gave it, and she doesn't get up at night. V11 stated that she did not notice any ill effects to R4 on the 4 nights it was given. The facility policy titled Medication Administration Policy / Procedure with a revision date of 09/27/2022 documented, Medications will be administered safely to residents within the facility by licensed nurses at the specified time/time frame, following the recommended administration method and will be documented as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop person centered comprehensive care plans for 1 (R18) of 12 residents reviewed for care plans in the sample of 22. Findings Include: R18's Profile Face sheet documented R18 as [AGE] years old with an admission date to the facility of 02/20/2024. Diagnoses listed on the Cumulative Diagnosis Log include Odynophagia, Diabetes Mellitus Type II, Chronic Pancreatitis, Superior Mesenteric Artery Syndrome, Distal Esophageal ulceration with possible Barrets, and microcytic anemia. R18's current Physician's Orders documented Tube Feeding Orders Flush Gastrointestinal (G) Tube with 60 ml (milliliters) each side every shift. Also documented is an order for Isosource 1.5 at 25 ml/hour for 240 ml daily if meal intakes are less than 50 percent. R18's Resource: Nutritional Progress Record Form with a date of 04/11/24 titled RD (Registered Dietitian) note documented April weight 123 pounds with a BMI (body mass index) of 16.7 which indicates R18 is underweight. R18's current diet order is pureed, thin liquids, per nursing no longer using enteral feedings. The RD recommended magic cups BID (twice daily) and 60 ml Med Pass TID (three times a day) to provide additional calories / protein to ensure proper nutrient intake and promotion of weight gain. Monitor oral intake and weights. R18's Care Plan documented a Focus Area of The resident has nutritional problem or potential nutritional problem (Specify) r/t (related to) with a date initiated of 2/26/24 and revision on 3/26/24. The Goal documented The resident will comply with recommended diet for weight reduction daily through review date. The Interventions/Tasks listed include: Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors. Obtain and monitor lab/diagnostic work as ordered. Report results to MD (Medical Doctor) and follow up as indicated. The care plan does not specify the reason for R18's nutritional problem focus area was due to him being underweight. There is no information included regarding R18 having a G/J tube nor the feedings ordered as needed according to meal intake. The care plan also does not document the most recent information from 4/11/24 that indicates R18 was no longer using enteral feedings. On 05/01/24 at 02:29 PM, V6 (Minimum Data Set [MDS]/Care Plan Nurse) stated the care plans should not have the (Specify) left in the areas. V6 stated that she was rushing trying to complete them and must have forgotten to finish them. V6 stated that R18 should have a care plan regarding gastrointestinal tube, and acknowledged that it had been left out. On 05/02/2024 at 9:24 A.M. V6 stated she had corrected R18's care plan. Review of the care plan now notates specific person centered care. The Comprehensive Care Planning policy with a most recent revision date of 11/1/17 stated, It is the policy of (Corporation Name) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to add identified problem areas and to revise care plans timely for 1 (R12) of 12 residents reviewed for care plan timing and revision in the sample of 22. Findings Include: R12's Profile Face Sheet documents R12 was admitted to the facility on [DATE]. Diagnoses listed on R12's Cumulative Diagnosis Log include Type II Diabetes Mellitus, Gout, Osteoporosis, Squamous Cell Carcinoma, Neuropathy, Peripheral Artery Disease, Coronary Artery Disease, and Dementia. On 5/2/24 at 9:31 AM, R12's wound treatment was observed. R12 was noted to have a betadine treatment applied to the left toes which appeared to be scabbed over. R12 was also observed to have a pressure wound to the left heel. R12's Physician's Orders dated May 2024 documents under Treatment Orders to paint left great toe with iodine daily. Under the same area also documents calcium alginate wet to dry dressing to left heel, cut to fit heel ulcer, moisten calcium alginate with normal saline. Paint margins of heel with betadine and cover with gauze daily. R12's Care Plan lists a Category of Pressure Ulcers and under that category documents Fragile Skin. Prone to bruising and/or Skin Tears. Related diagnosis/condition Dementia. Other Risk Factors Decrease in activities and ADLs (Activities of Daily Living). Resident specific information. All skin tears and/or bruises healed throughout next 90 days. Interventions documented with a start date of 06/02/2022 list the following: Weekly skin checks-document results; Skin checks as needed after injury or combative episodes; Assess new areas for size and injury, report findings to MD (Medical Doctor) and family as indicated; Investigate causes of injury/bruise/skin tear. Consider preceding activity and resident's attention to safety; Treatment as ordered. Cleansing, application of medication, packing an/or dressings change w (with) wound status and progress - See POS (Physician Order Sheet) for current treatments; Monitor site for infection-redness, swelling, drainage, foul smell, decline in function, reduced mobility. Report S & S (signs/symptoms) to MD for follow up orders; Assess for pain and medicate as ordered - See POS for current med, dosage, and schedule. Evaluate effectiveness of pain med, report ineffective pain management to MD for recommendation. R12's care plan shows no updates or revisions added since initiation on 6/02/2022, other than a handwritten note dated 2/17/23 that documents Skin Sleeves to bilateral arms. On in AM (morning) off at hs (night). R12's care plan has no documentation regarding wounds to the left great toe and left heel. There is no documentation noting when R12's wounds were identified, current treatment orders, nor any person centered interventions for pressure ulcer care. On 05/01/24 at 02:29 PM, V6 (Minimum Data Set [MDS]/Care Plan Nurse) stated that she was rushing trying to complete care plans and must have forgotten to finish them. On 05/01/24 at 03:05 PM, V6 stated that the most up to date care plan was in R12's chart. V6 stated if there were any interventions they would be documented on the page under the specific section on the care plan. The Comprehensive Care Planning policy with a most recent revision date of 11/1/17 stated, It is the policy of (Corporation Name) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being a. The CCP (Comprehensive Care Plan) shall be reviewed after each Annual, Significant Change and Quarterly MDS (Minimum Data Set) and revised as necessary to reflect the resident's current medical, nursing, and mental and psychosocial needs as identified by the IDT (Interdisciplinary Team)

Based on observation, interview and record review, the facility failed to follow policy and procedure for enhanced barrier precautions for 3 of 12 residents (R2, R12, and R18) reviewed for infection control in the sample of 22. The Findings Include: During initial tour of the facility on 4/30/24 there were no isolation rooms observed in the facility. On 4/30/24 a Resident Matrix was provided with no residents marked for transmission based precautions. 1. R18's Profile Face Sheet documents an admission date of 2/20/24. R18's May 2024 physician orders document a tube feeding order of Isosource 1.5 240mL (milliliters) daily after each meal if meal intake is less than 50% at meals. On 5/2/24 at 10:19AM, V9 (Registered Nurse/Infection Preventionist) stated that R18 has MRSA (Methicillin-resistant Staphylococcus Aureus) in his gastrointestinal tube site so they just keep it covered, but do not do any kind of treatment to the site at this time. On 5/1/24 at 10:00 AM, V3 (Housekeeping) was observed in R18's room folding linens with no Personal Protective Equipment (PPE) on until she put gloves on to empty the trash. At this time, there was an isolation bin located outside of R18's door with PPE in it, and a sign on the door that says stop check with nurses prior to entering. At this time, V3 stated that (R18's) MRSA is worse and he is on isolation. V3 stated that she should have had a gown and gloves on while in his room per policy, and will be sure to do that next time. On 5/1/24 at 11:30 AM, V2 (Director of Nursing/DON) stated that they have placed R18 on isolation due to the culture coming back on his G-tube site. V2 stated that she just learned of this change this morning and that she would expect her staff to follow the policy and procedure on wearing PPE in these rooms. V2 stated at this time they have only talked about enhanced barrier precautions, but have not implemented anything in the facility as of yet, but will start that as soon as a possible. V2 acknowledged that R18 should have been on the precautions prior to the culture resulting in isolation and that all (residents with) wounds and catheters need to be placed on these precautions as well. V2 stated that they have no (residents with) catheters at this time. 2. R2's Profile Face Sheet documents an admission date of 6/6/17. R2's Physician Order Sheet (POS) for May of 2024 includes the following diagnoses: Edema, Hypertension, Diabetes, and Congestive Heart Failure. The POS also includes a treatment order of barrier spray to left and right lower extremities until healed. A 4/26/24 Wound Assessment and Plan in R2's chart documented a venous wound to R2's left lower extremity and included a treatment order to apply a thin layer of zinc barrier cream and loosely wrap with gauze every shift and as needed. R2 was not observed to be on Enhanced Barrier Precautions during the survey on 4/30/24 or 5/1/24. 3. R12's Profile Face Sheet documents an admission date of 5/20/22. A physician order dated 5/1/24 documents R12 has wounds to the left foot and left great toe with a treatment order of calcium alginate wet to dry dressing once daily. On 5/1/24 at 11:30 AM, V2 (DON) stated that they do not do the treatments on R12 because her daughter prefers R12 to go to the wound doctor, but sometimes they do an in-between treatment if needed. On 5/1/24 at 9:31AM, V10 (Registered Nurse) verified that R12 receives the treatments by the nurses here in the facility, but she goes out to see her own wound doctor; R12 does not see the one who comes to the facility. On 5/2/24 at 9:31 AM, R12's wound treatment was observed. R12 was noted to have a betadine treatment applied to the left toes which appeared to be scabbed over. R12 was also observed to have a pressure wound to the left heel. R12 was not observed to be on Enhanced Barrier Precautions during the survey on 4/30/24 or 5/1/24. The Enhanced Barrier Precautions policy and procedure dated 7/13/23 documents the purpose is: To reduce transmission of multidrug-resistant organisms (MDRO). The policy states that the enhanced barrier precautions should be used when contact precautions do not apply, for residents with any of the following: open wounds that require a dressing change, indwelling medical devices, and infections or colonized with MDRO .Enhanced Barrier Precautions require use of gown and gloves during high contact resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. Enhance Barrier Precautions is primarily intended to use for care that occurs within a resident's room, when high contact resident care activities are bundled together

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to keep resident care areas and equipment clean and in a good state of repair for 19 (R1, R2, R3, R5, R6, R7, R9, R10, R11, R12, R13, R14, R15, R17, R18, R121, R122, R123, R171) of 20 reviewed for clean, comfortable, homelike environment in the sample of 22. Findings include: On 04/30/24 at 11:27 AM, the hallway outside of room [ROOM NUMBER] has carpet on the lower portion of the wall that had runs/strings and was observed to be peeling from the wall. The communal bathroom observed beside room [ROOM NUMBER] had paint chips and scratches to the lower half of the door and door frame. [NAME] discoloration was noted to floor tiles, below the baseboards throughout the bathroom. A baseboard was observed to be missing from one wall within the shower exposing a black/brown substance. Gray discoloration was also observed to the wall in a dripping pattern below the water faucet in the shower. A section of approximately 6 wall tiles in the bathroom were observed to be bowing, along with chipped color to several tiles. On 04/30/24 at 11:39 AM, the nurses station was observed as having multiple areas of gray chipped paint to the front of the station. On 04/30/24 at 11:42 AM, the dining room walls had multiple areas of chipped and scratched paint ranging in size, up to approximately 12 inches in diameter. On 04/30/24 at 11:43 AM, the hallway outside of room [ROOM NUMBER] had large areas of chipped paint ranging up to approximately 10 inches long. On 5/1/24 at 10:00 AM, R1, R9, R13, R14, and R17 stated that they would expect the facility to be kept clean and well maintained. On 5/1/24 at 10:15 AM, R13's window blinds were observed to have missing blind slats. R13 confirmed she would like functioning blinds. On 5/1/24 at 10:07 AM, V4 (Family Member) stated that the facility could be a little nicer. V4 confirmed she was alluding to the physical maintenance and upkeep of the facility. On 05/02/24 at 09:47 AM, V7 (Maintenance) confirmed the above identified physical environment concerns. V7 stated he regularly works on building maintenance and repairs. V7 stated at times due to the lack of materials and funding provided to the facility, or the amount of time he has to make all repairs needed, they just haven't been done yet. V7 acknowledged the present need for repairs and maintenance needing done. On 5/2/24 at 12:00 PM, V2 (Director of Nursing) stated that with the exception of R8, anyone else in the facility could potentially use the communal bathroom located beside room [ROOM NUMBER]. V2 stated R8 does not utilize the shower room as she only receives bed baths. V2 confirmed this includes the use of no rinse hair wash. This means that R1, R2, R3, R5, R6, R7, R9, R10, R11, R12, R13, R14, R15, R17, R18, R121, R122, R123, R171 could all use the communal bathroom in the facility. The undated facility policy titled Physical Plant & Environmental Policy & Guidelines documented, It is of the utmost importance to provide a safe, hospitable, clean and organized facility and grounds to ensure an environment that is conductive to providing the best care, comfort and home-like surroundings for residents. A well maintained building and environment is also important for creating safe work surroundings across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so. The building and grounds must be maintained in the best presentable state and must be done so through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and NFPA ( National Fire Protection Association) codes. The Long-Term Care Facility Application for Medicare and Medicaid dated 5/1/24 documented 20 residents reside in the facility.

Based on observation, interview and record review, the facility failed to maintain a clean and sanitary ice machine. This failure has the potential to affect all 20 residents residing in the facility. The Findings Include: During initial tour of the kitchen on 4/30/24 at 9:30 AM, the ice machine was found to have a black substance on the inside flap of the ice machine where the ice drops into the bin. Along the hinges of the door and the edges of the lid of the ice machine was a white hard water build up. On 4/30/24 at 9:30AM, V8 (Dietary Manager) stated that the maintenance man cleans the ice machine once a month after hours so the kitchen staff are done with feeding residents. V8 stated that there was not a 2024 monthly cleaning log in the kitchen, so she cannot say for sure when it was last cleaned. On 5/1/24 at 11:30 AM, V7 (Maintenance) stated that he had not yet put a log in the kitchen for the maintenance cleaning of the ice machine but he cleaned it in April. V7 stated that when he cleans it, he tries his best to get it clean and scrub at that black stuff, but it isn't easy to get to that part of the ice machine. V7 stated that he uses a descaler solution to clean the hard water build up and black that grows on the flap. V7 stated that he needs to take it outside and pressure wash it probably to get it cleaned up better. V7 stated that he will put that on his list to get done. The undated Ice Machine Cleaning and Sanitizing Procedures policy documents 19. remove the evaporator cover and spray and wash all interior surfaces of the freezing compartment including the evaporator cover with sanitizer solution. Treated surfaces must remain wet for 60 seconds The Long Term Care Facility Application for Medicare and Medicaid dated 5/1/24, documents that 20 residents reside in the facility.

2. On 03/29/23 at 10:15 AM, R11 was alert and oriented to person, place and time, and stated, Something is going around here. When asked what she was referring to, R11 stated, Can't you tell by looking at me? I'm sick. I feel crappy. R11 stated she had been sick for the past week. She is not taking any medication for it but is drinking a honey and pepper drink brought from home that is supposed to help. When asked if she had been tested for Covid-19, R11 stated she had not. R11 was in bed with bedside table over her, experiencing congestion, runny nose, watery eyes, and was wiping her nose with a tissue sniffling and physically looked ill. On 03/29/23 at 1:53 PM, V5 (RN/Infection Control Preventionist) was asked if R11 had been tested for Covid-19. V5 stated they are not required to test any more unless someone is displaying symptoms. When asked what would be considered a symptom that might warrant testing, V5 stated any respiratory symptom like a cough or runny nose, elevated temperature, vomiting, or diarrhea. To (V5's) knowledge, R11 had not been tested for Covid-19. R11's record does not document any information regarding R11's symptoms until 03/29/23 at 2:10 PM when V5 writes the following - Resident rapid tested for Covid-19 d/t (due to) complains of not feeling well. Resident negative for Covid-19 @ (at) this time. According to the Centers for Disease Control guidelines (https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html) - Symptoms of Covid-19 . People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. Anyone can have mild to severe symptoms. Possible symptoms include: Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea . When to Get Tested for COVID-19 - Key times to get tested: If you have symptoms, test immediately Further CDC guidance at https://www.cdc.gov/flu/professionals/diagnosis/testing-management-considerations-nursinghomes.htm states, Place symptomatic residents in Transmission-Based Precautions using all recommended PPE (Personal Protective Equipment) for care of a resident with suspected .(Covid)infection. The facility policy titled, Testing of Staff and Residents dated Revised 11/07/22 included - Purpose: To enhance efforts to keep Covid-19 from entering and spreading through our facility . Testing of Residents with Covid-19 Symptoms or Exposure: 1. Residents displaying symptoms of Covid-19 must be tested . Residents with symptoms must be placed on TBP (Transmission-Based Precautions) until the test results are received . The facility's Resident Census and Conditions dated 03/29/23 documented a total of 25 residents living at the facility. Based on observation, interview and record review, the facility failed to operationalize its Covid-19 Policy and to follow CDC (Centers for Disease Control) guidelines by testing and immediately isolating two residents (R9, R11) with respiratory symptoms consistent with infection by the Covid-19 virus. This failure has the potential to affect all 25 residents living at the facility. Findings include: 1. R9's Nursing Progress Notes dated 3/17/23, all authored by V3 (Registered Nurse/RN) documented the following: 1:00pm: o2 sat (Oxygen Saturation) (dropped to) 87% (percent), o2 at 2 liters via NC (Nasal Cannula) applied. 3:00pm: o2 sat at 96%, will continue to monitor. 5:45pm: (V11/Physician) (was) called with condition report regarding o2 (sat) dropping. Applied 2 liters o2 via NC. With the o2 her sat came up to 96%. We will continue to monitor . There was no documentation in these notes to indicate R9 was rapid tested for Covid, nor that R9 was isolated upon displaying symptoms suggestive of infection with Covid. According to https://www.medicinenet.com/what_are_blood_oxygen_levels/article.htm, normal range for oxygen saturation is 95-100%. A Nursing Progress Note dated 3/18/23 at 11:40am authored by V5 (RN/Infection Control Preventionist) documented: Upon obtaining vital signs, CNA (Certified Nursing Assistant) notified (this) nurse of (R9's) pulse (being) 125 (beats per minute). o2 (sat) 90 (percent) on 3 liters (o2). (V11) (was) notified of condition and gave orders to send (R9) to emergency room for evaluation and treatment. A 3/18/23 Hospital admission History and Physical documented, W/U (Work up) in ED (Emergency Department). CXR (chest x-ray) remarkable for bilateral patchy infiltrates, small pleural effusion. Covid lab test-negative. February and March 2023 Covid Testing Logs document that the facility had not done Covid testing on any residents or staff members since 02/03/23. On 3/31/23 at 8:39am, V3 stated that when R9's o2 sats decreased on 3/17/23 as outlined in the above referenced nurses notes, R9 began complaining of shortness of breath. V3 acknowledged shortness of breath and decreased o2 sats can be symptoms of an active infection with Covid. V3 stated in retrospect, it would have been a good idea to immediately isolate R9 and to do a Covid rapid test. On 3/31/23 at 9:47am, V5 (RN/Infection Control Preventionist) stated that although she had not documented it, R9's o2 sat when the CNA had initially notified V5 was at 87%. V5 acknowledged shortness of breath and decreased o2 sats can be symptoms of an active infection with Covid. V5 stated when R9 began experiencing these symptoms, It would not have been a bad idea to test her for Covid. V5 confirmed R9 was not isolated at the time the symptoms began, but R9 was in a private room. V5 stated the facility will soon be implementing staff training regarding Covid testing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide restorative nursing range of motion services for residents with limited range of motion and contractures for 2 of 2 residents (R15, R8) reviewed for range of motion in the sample of 20. Findings include: 1. On 05/03/22 at 10:22am, R15 was alert and oriented to person, place, and time. R15 stated she has a history of CVA(Cerebrovascular Accident) which has primarily affected her right side, resulting in her inability to move her right upper and lower extremities. R15 stated since shortly after her July 2021 admission to the facility, she has not received physical therapy. R15 stated she does not receive restorative nursing range of motion services. R15 stated, I am pretty stiff and immobile. I probably need something like that. R15 stated she has never refused to allow staff to perform range of motion for her. R15's Minimum Data Set (MDS) dated [DATE] documented that R15 has range of motion impairment of the upper extremities on one side, and the lower extremities on both sides. The same MDS documented that R15 has a diagnosis of hemiplegia or hemiparesis, and received zero days of restorative nursing range of motion services within the last 7 calendar days that the MDS was completed. R15's Care Plan with a review date of 02/10/22 documented a problem area, Mobility, impaired, related to right side hemiplegia, with a corresponding goal, Will remain as independent as possible for the next 90 days. The facility could not provide documentation indicating R15 had any range of motion services for March, April, and May 2022. On 05/05/22 at 11:05am, V10 Certified Nursing Assistant was observed providing range of motion exercises for R15. R15 was noted to display bilateral foot drop. V10 stated R15 is supposed to be getting range of motion exercises done daily. V10 performed limited range of motion as tolerated to all extremities except the left leg. V10 stated, I don't usually do the left leg, maybe I should be. When asked why she did not include the left leg, V10 stated she was unsure of R15's restorative nursing goals and interventions. The surveyor asked R15 if she felt her range of motion had improved, stayed the same, or declined since her admission, and R15 stated her abilities have declined. R15 was asked in the presence of V10 how often she was getting range of motion, to which R15 replied, Like I told you before (5/03/22), not at all, none.V10 did not correct R15's statement. 2. On 05/03/22 at 11:15am, R8 was alert and oriented to person, place, and time. R8 was observed to have contracted hands bilaterally. R8 stated she has no control over the left side and limited control of the right side of her body due to a history of a brain aneurysm. R8 stated she was admitted to the facility in December of 2019. R8 stated she does not receive any restorative nursing range of motion services. R8 stated she is not sure when she last received physical therapy services. R8's Minimum Data Set (MDS) dated [DATE] documented that R8 has range of motion impairment of the upper and lower extremities on both sides of the body. The same MDS documented that R8 has a diagnosis of quadriplegia and received seven days of restorative nursing range of motion services within the last 7 calendar days that the MDS was completed. R8's Care Plan with a review date of 01/24/22 documented a problem area, (R8) is quadriplegic and has little to no movement of any extremities, with a corresponding goal, Passive range of motion with no resistance or pain through the next 90 days. and corresponding intervention, Perform range of motion exercises .Do not move the joint further in range if pain occurs. The facility could not provide documentation to indicate if R8 had been getting range of motion in March, April, and May 2022. On 05/05/22 at 09:19am, V10 stated R8 is to be receiving range of motion services daily. V10 stated R8 has never refused to let her perform range of motion. On 05/05/22 at 10:22 am, V10 was observed providing range of motion exercises for R8. V10 moved all joints through limited range of motion due to R8 not being able to tolerate full range. R8 was observed to have foot drop bilaterally. R8 was again asked how often she is receiving range of motion exercises, to which she replied, Maybe three times a week. I guess I was wrong before when I said never. On 05/06/22 at 10:08am, V2, Director of Nurses, stated that residents who require range of motion are to receive 15 minutes twice daily, in the morning and again in the afternoon or evening. V2 stated R8, Honestly, probably isn't getting it daily. When you asked her in front of (V10), she may not have wanted to say how little she is getting as she likes to please staff. V2 stated R15 has not been receiving range of motion at all, but she needs to be. V2 stated the facility will immediately begin providing these services. A Range of Motion Policy with a revision date of 01/02 documented, Range of motion exercises will be provided for residents in need of exercise as identified in the care plan .Procedure Range of Motion exercises will be conducted at least twice a day .Documentation of response to the range of motion exercises and resident abilities will be documented at least monthly.

Based on interview and record review the facility failed to accurately document resident behaviors for 1 (R1) of 2 residents reviewed for dementia care services in the sample of 20. Findings Include: Review of R1's Profile Face Sheet documents an Original admit date to the facility as 9/11/20. Diagnosis listed on this document include but are not limited to unspecified dementia with behavioral disturbance. Review of R1's Nursing Notes documents on 4/16/22 at 5:20 AM, CNA (Certified Nurse Assistant) was heard screaming from resident's room let go of my hair. Nurse responded to assist, resident let go of her hair as nurse entered room and started yelling at the nurse to get out. Resident admitted to hitting CNA and pulling her hair. Nurse had CNA leave room. Nurse followed CNA and called V12 (Physician) for a one time order. V12 granted one time order at 5:00 AM for Haldol, 2 mg (milligram) dose to be given IM (intramuscularly). On 05/05/22 at 1:46 PM, V5 (Licensed Practical Nurse) stated she works 3rd shift at the facility and recalls the night R1 was pulling hair and received an IM dose of Haldol. V5 stated she recalled the event was early in the morning and R1 was wanting out of bed. V5 stated R1 had an incontinence episode and staff told her they would get supplies to get her cleaned up and out of bed. V5 stated R1 was screaming and cussing that she wanted up now! V5 stated V6 (CNA) and V13 (CNA) had R1 sitting on the side of the bed. V5 stated she left the room to go care for other residents and V13 left to go grab a gait belt. V5 stated shortly after leaving the room, she heard V6 yelling for help and telling R1 to let go. V5 stated she walked in R1's room to witness R1 letting go of having both hands full of V6's hair. V5 stated she had V6 leave the room and herself and V13 placed R1 in her chair. V5 stated the whole time they were working with R1 she was cursing and hitting them. V5 stated she tried to talk to her about her farm, animals, her husband, but stated R1 was convinced her husband would be here to pick her up and she wouldn't be ready to go. V5 stated even after being sat in her chair R1 continued to curse and state that she wanted to walk, even though she physically couldn't. V5 stated she called V12 (physician) due to the behaviors and he ordered Haldol to be given x 1 dose. V5 stated it was effective and 20 minutes later R1 was a different person, happy/friendly, having no recollection of the occurrences. V5 stated R1 frequently has behaviors at night consistent with dementia. V5 described R1 as having increased confusion and is physically and verbally abusive towards staff. V5 stated at times you can leave R1 alone and she will calm herself down, and other times you can't because she will try to stand and can't. V5 stated behaviors are documented in the resident record. On 05/05/22 at 2:12 PM, V6 stated she regularly works 3rd shift. V6 stated R1 frequently has behaviors during night shift. V6 stated R1 always wants faster care, even when at the bedside actively caring for her. V6 stated the night she had her hair pulled by R1, herself and V13 were getting R1 out of bed. V6 stated V13 left the room to get a gait belt and R1 reached up with both hands and just grabbed her hair. V6 stated she yelled for help and told R1 to stop. V6 stated V5 and V13 came running to the room and told her to leave the room so they could try and calm R1 down. V6 stated at times R1 can calm if left alone, and other times presents as a fall risk if left alone. V6 stated R1 likes to talk about her husband, kids, grandchildren, etc. V6 stated R1 was given a shot of medicine, calmed, and was fine shortly after receiving the medication, ready for breakfast. V6 stated behaviors are supposed to be documented on the behavior tracking logs. On 05/05/22 at 1:35 PM, V11 (CNA) stated that she works day shift and stated R1 does not have behaviors usually in the day. V11 stated there have been times when 3rd shift has reported during shift change that R1 was combative during the night when they would try to be providing care. V11 stated during the daytime, though R1 is awake and alert to person, place, and time. On 05/05/22 at 1:39 PM, V10 (CNA) stated that she works 1st shift and has received report from 3rd shift when coming on duty that R1 was verbally aggressive with staff during the night. V10 stated during the day R1 is alert and oriented to person, place, and time. On 05/05/22 at 1:42 PM, V9 (CNA) stated she occasionally works night shift, but usually day shift. V9 stated she has never had a problem with R1 having behaviors when she has worked with her. V9 stated night shift has said in report at times that R1 was verbally aggressive, and maybe once physically. On 05/04/22 at 2:07 PM, R1 was alert and oriented to person, place, and time. R1 stated everyone at the facility is kind to her and she has never had a problem or altercation with any staff or other residents. R1 stated she did not recall any incidents in which she would have pulled a staff member's hair and has never been abused in anyway by staff. R1 stated she is lucky because she still has her mind, and is just at the facility due to her lack of physically being able to care for herself or walk. R1 stated she has no concerns to express regarding care provided. Review of R1's Behavior Tracking Record for March - May 2022 documents R1 is tracked for: Episodes of Tearfulness and Episodes of cursing at staff. Interventions listed for Cursing at Staff are listed as: Allow R1 (Name) to call her husband, Offer R1 (Name) her sewing supplies, Offer R1 (Name) other areas of interest, Offer R1 (Name) to do a window visit with her spouse. With the exception of 1 entry during 3rd shift on 3/2/22, no behaviors have been documented for March - May 2022, including on 4/16/22 when R1 received an IM injection of Haldol specifically for behaviors. No behavior intervention plan is in place for episodes of physical aggression. On 05/06/22 at 12:26 PM, V7 (Social Services Director) stated that she develops behavior tracking plans for residents in the facility. V7 stated that plans are developed by identifying psychotropic medications residents are on and behaviors associated with those medications. V7 stated that additional behavior plans with tracking are created by staff completing a additional notes / new behavior form. V7 stated that once she has received 3 new behavior forms for the same behaviors within a month, the facility will hold an interdisciplinary team meeting to develop a person centered behavior plan for that behavior. V7 stated she has received no documents indicating R1 has had any episodes of physical aggression.

Based on observation, interview, and record review the facility failed to administer controlled substance medications per current standards of practice for 1 (R7) of 9 residents reviewed for medication administration in the sample of 20. Findings Include: On 5/3/22 at 11:17 AM, V4 (Registered Nurse) was observed removing a medication card of Hydrocodone-Acetaminophen 7.5/325 MG (milligrams), labeled for R7 from the locked controlled substance box within the medication cart. V4 dispensed a tablet from the card, and immediately replaced the medication card back into the locked box. V4 was asked if there is any sort of controlled medication count / documentation that needs done when administering controlled medications. V4 stated there is a controlled substance count book at the nurses station. V4 stated she doesn't keep the book on her medication cart, due to lack of space and will just sign out the controlled medications later. Review of R7's Physician's Orders dated for 5/1/22 - 5/31/22 documents an as needed order for Hydrocodone-Acetaminophen 7.5/325 MG, take 1 tablet every 4 hours as needed for pain. On 5/3/22 at 3:15 PM, V2 (Director of Nursing) states it is the expectation that controlled medications are counted and signed out in the count book at the time of the medication administration. Review of the facility policy titled Controlled Substances with a revision date of 11/6/18 documents, All Schedule II drugs must be administered and recorded on a disposition sheet as follows: Date and time of administration; Signature of nurse administering drug; Quantity on hand/balance left.

Based on interview and record review the facility failed to implement an Antibiotic Stewardship Program to include tracking and identifying organisms to ensure appropriate antibiotic use for 3 (R172, R2, and R173) of 12 residents reviewed for Antibiotic Stewardship in the sample of 20. Findings Include: 1. Review of the Resident Infection Control and Antimicrobial Log for August 2021 documents an entry for R172 with the onset date of 8/25/21, infection related site listed as urine, a blank microbiology result area, with the Antibiotic order of Cipro 500 MG (milligrams) po (by mouth) BID (twice a day) for 7 days documented. The area of date resolved is left blank. 2. Review of the Resident Infection Control and Antimicrobial Log for September 2021 documents an entry for R172 with an onset date of 9/24/21, infection related site listed as urine, a blank microbiology result area, with the Antibiotic order of Augmentin 500 MG BID x 10 days documented. The area of date resolved is left blank. 3. Review of the Resident Infection Control and Antimicrobial Log for November 2021 documents an entry for R172 with no onset date, infection related site documented as UTI (urinary tract infection), a blank microbiology result area, with the Antibiotic order of Bactrim DS BID x 10 days. The area of date resolved is left blank. 4. Review of the Resident Infection Control and Antimicrobial Log for July 2021 document an entry for R2 with no onset date, infection related site listed as leg wound, a blank microbiology results area, with the Antibiotic order of Cephalexin 500 MG x 5 days. The date resolved area is left blank. 5. Review of the Resident Infection Control and Antimicrobial Log for March 2022 documents an entry for R2 with an onset date of 3/14/22, infection related site listed as UTI, a blank microbiology result area, with the Antibiotic order of Cipro 250 MG BID x 5 days documented. The area of date resolved is left blank. 6. Review of the Resident Infection Control and Antimicrobial Log for April 2022 documents an entry for R173 with an onset date of 4/1/22, infection site listed as UTI, a blank microbiology result area, with the Antibiotic order of Macrodantin 100 MG TID (3 times a day) x 7 days. The area of date resolved is left blank. On 5/5/22 at 10:07 AM, V2 (Director of Nursing) stated that while some cultures may have been complete, some may not have been with antibiotics ordered and no organism identified. V2 stated the facility utilizes a document titled, Resident Infection Control and Antimicrobial Log to track and document infections. V2 acknowledges there are blank areas on this log notating incomplete tracking entries and/or no microbiology results with the implementation of antibiotics. Review of the facility policy titled, Antibiotic Stewardship Program with a revision date of 10/20/21 documents the purpose of this policy is, To improve the use of Antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reduced adverse events associated with antibiotic use. This policy documents responsibilities of the RN (Registered Nurse), DON (Director of Nursing), IP (Infection Preventionist), or LPN (Licensed Practical Nurse) is to, Maintaining antibiotic logs, identifying any trends with physicians not adhering to programs, ensuring need for an antibiotic and if the antibiotic is appropriate based on symptoms and microbiology. Review of current standards of practice found in the present State Operations Manual, Appendix PP, F881 documents that As part of their IPCP (Infection Prevention and Control Programs) programs, facilities must develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This means that the antibiotic is prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to add identified problem areas and to update care plans quarterly for 4 residents of 12 residents (R17, R11, R8, R4) whose care plans were reviewed in the sample of 20. Findings include: 1. R17's Face Sheet documented that R17 was admitted to the facility on [DATE]. R17's May 2022 Physicians Order Sheet listed diagnoses of Hyperlipidemia, Hypertension, Hypothyroidism, and Osteoarthritis. R17's Minimum Data Set (MDS) dated [DATE] indicated R17 has a Brief Interview for Mental Status Score of 3, indicating R17 has severe deficits in cognitive functioning. The same MDS documented that R17 requires extensive assistance from at least two staff members for transfers and toileting. R17's Care Plan documented that it was last reviewed and updated on 12/21/21. 2. R11's Face Sheet documented that R11 was admitted to the facility on [DATE] This Face Sheet documented diagnoses of Major Depressive Disorder, Type 2 Diabetes, and Hypertension. R11's Minimum Data Set (MDS) dated [DATE] indicated R11 has a Brief Interview for Mental Status Score of 5, indicating R11 has severe deficits in cognitive functioning. The same MDS documented that R11 requires extensive assistance from at least two staff members for transfers and toileting. R11's Care Plan documented that it was last reviewed and updated on 08/13/21. 3. R8's Face Sheet documented that R8 was admitted to the facility on [DATE]. This Face Sheet documented diagnoses of Malformation of Cerebral Vessels, Diabetes Type 2, and Pseudobulbar Affective Disorder. R8's Minimum Data Set(MDS) dated [DATE] indicated R8 has a Brief Interview for Mental Status Score of 15, indicating R8 has no deficits in cognitive functioning. The same MDS documented that R8 is totally dependent on at least two staff members for transfers and toileting. R8's Care Plan documented that it was last reviewed and updated on 01/24/22. 4. R4's Face Sheet documented an admission date of 11/23/21. This Face Sheet documented diagnoses of History of Left Femur Fracture, and Muscle Weakness. R4's Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status Score of 10, indicating R4 has moderate deficits in cognitive functioning. The same MDS documented that R4 receives dialysis services outside of the facility. On 05/03/22 at 12:01pm, R4 was observed in the dining room awaiting lunch service. R4 was observed to be upset and crying. R4 stated she lives by the cemetery outside of town and needs to get a ride to go home. V11, Certified Nursing Assistant, who was also in the dining room at that time, stated R4 had dialysis today. V11 stated when R4 returns from dialysis, sometimes R4 doesn't feel well because it is a very tiring process for R4. V11 stated R4 sometimes exhibits tearfulness and confusion for the remainder of the day. V11 stated this has been occurring for several weeks. R4's Care Plan with a review date of 03/28/22 documented that on that date, a problem area of Fluid volume excess related to dialysis, was added, with corresponding interventions, Administer fluids per plan, monitor compliance with diet and fluid restriction. There was no problem area nor corresponding interventions for the dialysis related mood changes and confusion that R4 has been experiencing. On 05/06/22 at 10:41am V2, Director of Nurses, stated V14, Minimum Data Set/Care Plan Coordinator, had been out sick for most of the week of the survey. V2 confirmed Care Plans are to be updated every three months. V2 stated she is not sure why V14 did not update the above referenced care plans. V2 stated V2 will begin updating the care plans immediately. V2 stated R4 has been on dialysis prior to her admission to the facility. V2 confirmed that R4 often does not feel well when R4 returns from dialysis. V2 stated she is not sure why V14 did not add the dialysis mood changes and confusion to the care plan. V2 stated V2 will update R4's Care Plan immediately. A Baseline Care Planning/Care Plans Policy dated 11/1/17 documented, A plan of care shall be developed to include instructions needed to provide effective person centered care to each resident .The overall care plan should be oriented toward preventing avoidable declines in functioning .managing risk factors to the extent possible (and) using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities .Care Plan Requirements: Describes the residents medical, nursing, and psychosocial needs, (and) describes how those needs will be met .Quarterly, the care plan must be reviewed by the IDT(Interdisciplinary Team).Show proof that each problem was reviewed by writing reviewed and the date.

Based on observation, interview and record review the facility failed to store food in accordance with professional standards for food service safety, maintain sanitizer level per manufacturers guidelines, and ensure food prepared met temperature requirements. This has the potential to affect all 21 residents the facility. Findings Include: On 5/03/22 at 9:10 AM the following concerns were noted on the initial walk though of the kitchen: 1. Observation inside the freezer noted a wire slide out bin in the bottom of the freezer containing greater than 10 pieces of garlic bread open to air with the sides of the bag folded over the wire bin sides. No label or date was noted to the bag. 2. A bag of pink ground meat appearing to be hamburger was observed with no label or date in the refrigerator. 3. The bucket of sanitizer that is used to wipe down surfaces and stationary equipment was tested and registered below 200 parts per million of Quaternary ammonium of product. 4. Sanitizer solution test strips labeled as QT40 were observed as having an expiration date of 3/1/22 with no strips that weren't expired available for use. V2 (Dietary Supervisor) stated the plastic bag of bread should not have been left open like that in the freezer and all items should be labeled and dated. V2 stated the facility checks the sanitizer level with each meal service. V2 confirmed the sanitizer solution was maybe registering at a level of 100, and stated the level should be 200. V2 stated staff would manually mix the solution until the machine could be repaired. V2 also confirmed the facility had no test strips for testing the sanitizer level that were not expired. V2 stated he would have some strips brought to the facility for use from a sister facility until he could get more ordered. Review of the facility policy with a revision date listed at 10/09, 10/14 stated, .Any item to be placed in the refrigerators and freezers must be covered, labeled and dated with a date-marking system that tracks when to discard perishable foods. Review of the sanitizer solution manufacturers label for Quaternary Sanitizer documented, This product is an effective food contact sanitizer in 1 minute at 200 ppm (parts per million) on hard, non porous surfaces. On 5/03/22 at 11:54 AM the following concern was noted during meal service inside the kitchen: Swiss Steak was observed being removed from a pan out of the oven, and placed into the steam registering a temperature of 150 degrees Fahrenheit. When asked to confirm the Swiss Steak had met the required cooking temperature, V2 stated, I think I checked it. I'm pretty sure I did. V2 was observed returning the meat to the oven to ensure appropriate cooking temperature had been obtained. Review of the facility recipe for Swiss Steak/Tomatoes documents, The internal temperature of cooked steak should register at least 155 degrees Fahrenheit for 15 seconds at completion of cooking time. The resident Census and Conditions of Residents dated 5/03/212 documents 21 residents reside in the facility.