**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Iowa Physician Orders for Scope of Treatment (IPOST) form review, Electronic medical record review, and staff interview the facility failed to ensure consistent documentation of code status for 1 of 24 resident reviewed for advanced directives (Resident #64). The facility reported a census of 77 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 medical diagnoses included Heart disease, anemia, acquired absence of parts of digestive tract, and discitis referring to inflammation of the spinal column. The Brief Interview for Mental Status (BIMS) exam scored 15 out of 15 which indicated intact cognition. The electronic medical record, profile sheet for Resident #64 directed, Do not resuscitate, DNR. The Care Plan revealed a focus initiated [DATE] for Resident #64 advance directive status and included intervention, documented, the electronic medical record, chart to identify code status, DNR. An IPOST form signed by Resident #64 on [DATE] was located at the nurse's station in the code status binder for staff access in the event of an emergency, directed Cardiopulmonary Resuscitation (CPR). The form was signed by the provider on [DATE]. During an interview on [DATE] at 2:05 PM the Director of Nurses (DON) relayed the nursing staff can go to the electronic medical record to access resident code status or can view the code status from the IPOST document in the code status book. The DON relayed the code status would be the same in either location. The DON acknowledged the electronic medical record and IPOST did not match for Resident #64 and a correction was needed immediately to ensure resident wishes were followed in the event of a cardiac arrest. The DON reported there is not a policy to direct the advance directive process. The staff would follow the standard procedure if a resident requested DNR, the physician order is signed or the IPOST form is used.

Based on record review, staff interviews, and policy review the facility failed to submit a discharge Minimum Data Set (MDS) within the required time frame for 1 of 3 residents reviewed for MDS (Resident #53). The facility reported a census of 77 residents. Findings include: The MDS for Resident #53 dated 8/27/24 documented a planned discharge from the facility, return not anticipated. Staff B, MDS Coordinator, signed the completed document on 9/4/24. The MDS was not marked as submitted. Progress Notes for Resident #53, dated 8/27/24 at 2:58 PM, documented the resident was discharged to another facility. On 1/14/25 at 3:00 PM the Administrator stated they did not have a specific policy for MDS assessments and the facility followed regulations. An interview with Staff B on 1/15/25 at 9:12 AM revealed the document was somehow changed to do not submit in the electronic health record. She stated it was probably something she did and acknowledged the MDS should have been submitted. At 9:30 AM an additional interview with Staff B determined she followed the Resident Assessment Instrument (RAI) Manual for processing MDS data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, Preadmission Screening and Resident Review form (PASRR) the facility failed to code diagnosis of intellectual deficits (ID) and inaccurately coded for hospice on the Minimum Data Set (MDS) assessments for 2 of 3 residents MDS assessments reviewed (Resident #35, #45). The facility reported a census of 77 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #45 diagnoses included quadriplegia, seizure disorder, malnutrition, pressure ulcers, and unspecified intellectual disabilities. The Brief Interview for Mental Status (BIMS) was not scored, documented the resident was unable to complete the interview. The MDS section labeled PASRR did not code to reveal resident's intellectual disability. The PASRR form, notice date 10/9/24 relayed Resident #45 approved for 60-day convalescence, had suspected or confirmed PASRR condition that included intellectual disability. The form documented, the PASRR condition must be documented in the MDS. The PASRR form specifically directed to code on the MDS resident's diagnosis of intellectual disability. Review of the MDS indicated lack of completion of both sections directed to be completed. The Care Plan focus dated 10/11/24 for Resident #45 documented PASRR baseline, new admission, intervention to follow PASRR recommendations as applicable. The Care Plan focus initiated 10/18/24 documented the resident had impaired cognitive function and impaired thought process related to developmental and intellectual disability. On 1/15/24 at 9:30 AM the MDS Coordinator, Registered Nurse, Staff B relayed they are responsible for completing MDS documents and follow the Resident Assessment Instrument (RAI) Manual for MDS coding. Staff B relayed Resident #45 should have been coded for intellectual deficit. On 1/14/25 at 3:00 the Administrator voiced they do not have a specific policy on MDS completion, relayed they follow the federal mandated process. 2. Review of Resident #35's facility census indicated on 10/10/24 the resident was changed from Hospice private pay to private pay. Review of Resident #35's Significant Change MDS dated [DATE] indicated Resident #35 received Hospice services. Review of Resident #35's Physician Order Summary indicated admission to Hospice related to Lewy Body Dementia on 4/16/24 with a discontinue date of 10/9/24. Review of Resident #35's Care Plan indicated on 4/17/24 Hospice Care was required due to a diagnosis of Lewy Body Dementia and resolved on 10/11/24. Review of Hospice Discharge summary dated [DATE] indicated Resident #35 started Hospice care on 4/16/24 and effective discharge date of 10/9/24 as Resident #35 was determined to no longer meet criteria for hospice care. During an interview on 1/15/25 at 10:10 AM, Staff B, MDS Coordinator, stated the Significant Change MDS completed on 10/29/24 was due to Resident #35 being discharged from Hospice Care. While reviewing the Significant Change MDS, Staff B acknowledged the MDS indicated Resident #35 was receiving Hospice care and stated this was not accurate and needed to be corrected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and Preadmission Screening and Resident Review (PASRR) form evaluation the facility failed to ensure a re-screen for 1 of 2 residents reviewed in the PASRR sample. Resident #45 exceeded the sixty (60) day convalescent care approval without the required re-screening. The facility reported a census of 77 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #45 diagnoses included quadriplegia, seizure disorder, malnutrition, pressure ulcers, and unspecified intellectual disabilities. The Brief Interview for Mental Status (BIMS) was not scored, documented resident was unable to complete the interview. The Care Plan focus dated 10/11/24 for Resident #45 documented PASRR baseline, new admission, intervention to follow PASRR recommendations as applicable. The Care Plan focus initiated 10/18/24 documented the resident had impaired cognitive function and impaired thought process related to developmental and intellectual disability. The PASRR form dated 10/8/24 documented resident #45 evaluation determined a PASRR condition, noted suspected or confirmed PASRR condition that included intellectual disability. Approved for convalescence categorical approval for period of 60 days, expected to discharge within 60 days and If stay goes beyond the nursing facility must submit a status change, required prior to the 60th day. On 1/13/25 at 1:40 PM the Director of Nurses relayed the Social Services, Staff A, was responsible for the initial PASRR and follow up. During an interview on 1/13/25 at 1:45 PM the Social Service, Staff A, revealed they are new to working with PASRR's, acknowledged resident #45 was granted the 60-day approval and should have been reevaluated. On 1/14/25 at 3:00 the Administrator relayed the facility does not have a policy on PASRR completion and follows the regulation.

Based on record review, resident interviews, staff interviews, and facility reported payroll data the facility failed to provide adequate staffing to meet resident needs. The facility reported a census of 77 residents. Findings include: A document titled PBJ (Payroll Based Journal) Staffing Data Report representing 7/1/24 through 9/30/24 indicated data submitted by the facility triggered for excessively low weekend staffing. The undated Facility Assessment in effect at the time of the PBJ report documented 272 FT Licensed nursing hours per week and 952 nursing assistant hours per week based on an average daily census of 67.3. Page 1 of the assessment noted it was reviewed annually, updated if indicated and whenever there was a significant change in the assessment of the facility including but not limited to changes in facility capacity or services provided. An interview with Resident #64 (Brief Interview for Mental Status score of 15/15 indicative of intact cognition) on 01/12/25 at 11:04 AM revealed she sat on a bedpan for 'a long time.' A further interview on 01/15/24 at 11:45 AM determined she was left on the bedpan recently for 45 minutes. The resident could not remember the day but thought it might have been the past weekend during the day. When asked what she felt the cause was, Resident #64 stated it was a staffing issue. She reported the staff who were in the facility were great but had to 'run their asses off' because sometimes there were not enough of them to help everyone who needed it. During an interview on 01/13/25 at 02:03 PM the DON stated she thought the facility had enough staff during the weekends. She reported the facility did use more agency staff on the weekend. On 1/14/25 at 12:49 PM the Administrator provided a recap of the daily census for 7/1/24 through 9/30/24 that documented an average daily census of 76.8. He stated the Facility Assessment was not updated during that time, but was updated in November 2024. During an interview on 1/15/25 at 11:07 AM Staff C, Medical Records/Scheduler stated the facility used a matrix on a spreadsheet to determine staffing needed. She reported weekend staffing was the same as weekdays, determined by the number of residents entered. When asked if resident acuity was considered as part of the matrix, she said there was nothing in the spreadsheet for acuity. At 11:20 AM on 1/15/25 Staff D, Certified Medication Aide, stated the most important resident needs were met. When asked if there were enough staff to address all of the resident's care planned needs she said probably not all of them. She stated some residents took longer, had more to take care of, and used lifts that take time and two people. She indicated need depended on census and felt quality of care was important. Staff D also noted the ability to participate in team meetings, care planning meetings, training, and taking time with residents depended on staffing and census. On 1/15/25 at 11:50 AM the Administrator reported the facility had reviewed the data submitted for the PBJ and came up with the same result that indicated low weekend staffing.

Based on observation, policy review, and staff interview the facility failed to treat residents with dignity, respect, and honor residents' rights for 2 of 5 residents reviewed (Residents #12 and #14). The facility reported a census of 71 residents. Findings include: During an observation on 11/5/25 at 11:37 AM, Resident #12 was in the doorway to her restroom, facing out of the restroom utilizing the mechanical stand. Staff A, Certified Nursing Assistant (CNA) was in the Resident's room, in front of the resident. Staff B, CNA was in the restroom, directly behind the resident. The resident was receiving incontinence cares from Staff A and Staff B. She was unclothed and exposed from her waist to her knees. The resident was in full direct view of her roommate. The privacy curtain was not pulled. While Staff B was providing cares to Resident #12, Staff C, Guest Services Aide, entered the room, without knocking, and walked through the room to the closet. While Staff C was entering the room, Resident #12 was visible to anyone in the hallway. While Staff A and Staff B were continuing to provide cares, Staff D, Licensed Practical Nurse (LPN) entered the room after knocking but not waiting for a response, again exposing the resident to anyone in the hall. Staff D walked over to the roommate and then pulled the privacy curtain. During an observation on 11/5/24 at 1:02 PM Staff E, CNA assisted Resident #14 to the restroom. Resident #14 had a strong odor of urine. When standing from her wheelchair, her pants were observed to be wet with urine. Staff E assisted Resident #14 to use the toilet, applied a clean brief and pulled up the resident's wet pants. The resident was assisted to return to her wheelchair in the wet pants. Facility Policy titled Incontinent and Perineal Care last revised on 7/31/24 directed staff to provide privacy and avoid unnecessary exposure of resident. The policy also directed staff to make the resident comfortable, groom and change clothing. Facility Policy titled Mechanical Lift Transfer last revised on 2/2024 directed staff to provide privacy. Facility Policy titled Resident Rights - Dignity and Respect last revised 4/2024 directed staff to treat each resident with dignity, respect and reasonable accommodation of individual needs. During an interview on 11/6/24 at 11:18 AM, the Director of Nursing (DON) explained she would expect staff to knock on a resident room door and wait for a response prior to entering. She further explained she would expect residents to be provided privacy during cares and to have wet pants changed at the time of toileting.

Based on record review, policy review, and interviews the facility failed to ensure services provided to residents met professional standards of quality by failing to follow physician's orders for 1 of 5 residents reviewed (Resident #3). The facility reported a census of 71 residents. Findings include: The Minimum Data Set (MDS) for Resident #3 dated 9/23/24 documented diagnoses of benign prostatic hyperplasia (enlarged prostate), hemiplegia (loss of strength or paralysis) affecting the right dominant side, and non-Alzheimer's dementia. MDS Section C documented a Brief Interview for Mental Status (BIMS) of 10 out of 15, indicative of moderate cognitive impairment. The Care Plan dated 3/9/24 documented the resident required assistance with activities of daily living and had occasional urinary incontinence. A Progress Note labeled General Progress Note dated 10/20/24 at 6:56 PM indicated the resident was brought back to the facility from the emergency room at 6:56 PM. The note documented the cause of the resident's testicular pain was not clear. There was no evidence of a bladder infection. The ultrasound showed epididymal and testicular cysts. It included documentation that the resident was to have an appointment with a urologist on or around 10/27/24. An additional note at 7:22 PM documented a copy of the hospital note was faxed to the advanced registered nurse practitioner and a copy was placed in the Assistant Director of Nursing box to schedule the urology follow up the next day. A Progress Note completed 8 days later, dated 10/28/24 at 2:50 PM, revealed the call was made to urology and nursing was awaiting a return call. During an interview on 11/4/24 at 10:23 AM the resident indicated the cysts have caused some pain. He shrugged when asked when his appointment to have the cysts checked was. On 11/6/24 at 3:18 PM the Director of Nursing (DON) reviewed the resident's health record and stated her nurse should have made the appointment the next day (10/21/24). When she realized it had not been made, she called herself on 10/28/24. They said they would get back to her. On 11/7/24 at 8:36 AM the DON confirmed the information from the prior interview and stated the provider never called the facility back to say they were not going to see him. He was already established with another provider and was referred back to them. She stated she followed up today and the resident now had an appointment scheduled for Friday (11/8/24). A policy titled Physician's Orders, reviewed and revised 8/16/24, documented it was the policy of the facility to ensure all resident medications, treatments, and plan of care must be in accordance with the licensed physician's orders. The facility would follow physician orders as written and orders would be carried out in reasonable time.

Based on observation, clinical record review, and staff interview the facility failed to follow safe transfer techniques for 1 of 2 residents observed during a transfer (Resident #14). The facility reported a census of 71 residents. Findings include: The Minimum Data Set (MDS) for Resident #14, dated 9/26/24, documented the resident was frequently incontinent of urine. The Care Plan interventions for the resident included transfers with assist of 2, assist with toileting per the resident's routine, and the resident wears incontinence briefs. During an observation on 11/5/24 at 11:37 AM, Staff A, Certified Nursing Assistant (CNA) entered Resident #14's room with the mechanical stand lift. Staff A stated she did not know where her partner went and proceeded to attach the sling around the resident, fasten waist straps, connect the sling to the stand, and placed the resident's feet on the foot plate. Staff A turned to the surveyor, removed her mask and explained the resident was supposed to be an assist of 2 for transfers and there were supposed to be 2 people to run the stand lift but she didn't know where her partner was. She repeated she was supposed to have another person with her but didn't know where she was. Staff A then proceeded to use the stand lift to raise the resident from her wheelchair and move her from the wheelchair across the room towards the bathroom. As she approached the bathroom door, Staff B, CNA entered the room and assisted with completing the transfer to the toilet. The policy titled Mechanical Lift Transfer, last revised 2/2024, directed staff that it was advisable to have 2 staff members present (for use of the lift) and each person's plan of care should be followed. During an interview on 11/6/24 at 11:18 AM, the Director of Nursing (DON) explained she would expect the mechanical stand/lift to he used with 2 staff members.

Based on observation, policy review, and staff interview the facility failed to provide proper and complete incontinence and catheter care for 3 of 3 residents observed (Residents #12, #13, and #14). The facility failed to ensure staff wore masks in resident areas during the current COVID outbreak. The facility reported a census of 71 residents. Findings include: During an observation on 11/5/24 at 11:08 AM, Staff F, CNA and Staff G, CNA entered Resident #13's room to provide incontinence and catheter cares. Staff F and Staff G donned Enhanced Barrier Precautions (EBP) Personal Protective Equipment (PPE). Staff F removed the catheter drainage bag from the side of the bed. Staff F and Staff G worked collaboratively to remove the resident's pants and brief. Staff G cleansed the front perineal area and the catheter. The resident was assisted to turn on his right side. Staff F removed the resident's brief that had a small amount of BM observed. Staff F used personal cleansing wipes and wiped up the middle, between the buttocks. She did not clean the buttocks, hip or leg areas. The resident was assisted to roll onto his left side. Staff G cleansed the residents right buttock and placed a clean brief under the resident. The resident was assisted to roll onto his back. Staff F and Staff G worked collaboratively to fasten the brief. Staff G removed her gloves, did not perform hand hygiene, and put pants back on the resident up to his thighs. Staff F placed a plastic barrier on the floor, placed a graduate on the floor and proceeded to empty the catheter drainage bag. She dumped the urine in the toilet, rinsed the graduate using the faucet in the sink and placed cleaned graduate in storage area. Staff F and Staff G worked collaboratively, rolling the resident to his sides to finish pulling up the resident's pants. Staff F picked the resident's shoes up off the floor and put them on the resident. Both CNAs removed their gloves and washed their hands (this was the first time during the observation that Staff F removed her gloves or performed hand hygiene). During an observation on 11/5/24 at 11:37 AM Staff A, CNA entered Resident #14's room. Staff A removed her mask while standing within 6 feet of a resident, with both residents in the room, during a COVID outbreak to explain to the surveyor she did not know where her partner was and was going to proceed to provide care despite the resident being care planned for 2 staff members to assist. After repeating this a second time, she put her mask back on. After applying gloves, she pushed the mechanical stand up to the resident, put the sling around the resident, attached sling to the stand, ensured the resident's feet were on the foot plate. She used the lift to stand the resident and move towards the restroom. Staff B, CNA entered the room and applied gloves and guided the resident to the toilet, pulled the resident's pants and brief down. The resident was lowered to the toilet. Staff B removed gloves and left the room. Staff A remained in the room. A short time later Staff B reentered the room and washed her hands. Staff A removed her gloves and washed her hands. When she finished washing her hands, before drying or reaching for a paper towel, she shut off the water. Both CNAs applied gloves. The resident was assisted to stand using the mechanical stand lift run by Staff A while guided by Staff B. The resident was moved to the doorway allowing Staff B to stand directly behind the resident. Staff B cleansed the resident by reaching between the resident's legs from behind and wiping her perineal area. The reach from behind cleansing was only cleansing the middle. The resident's thighs, buttocks and hips were not cleansed. Staff A and Staff B worked collaboratively to pull up the resident's brief and pants. Staff B then removed her gloves. Staff A moved the resident to her wheelchair using the mechanical stand and lowered her to her wheelchair. Staff A removed her gloves and took the lift out of the room. She returned to the room, removed the concentrator tubing from the resident, placed the portable oxygen tubing in the resident's nose, turned on the portable oxygen and adjusted the resident's hearing aid before washing her hands. During an observation on 11/5/24 at 1:02 PM Staff E, CNA took Resident #12 to her room. Resident #12 had a strong urine odor when she was taken to her room. Staff E washed her hands and applied gloves. She then swung the foot pedals back on the wheelchair, angled the wheelchair towards the restroom and locked the brakes. She removed the resident's shawl, applied the gait belt, assisted the resident to stand and ambulate to the restroom. She then pulled down the resident's pants and brief. The brief was saturated with urine and discarded. She then removed the gait belt from the resident before removing her gloves and performing hand hygiene. When the resident was finished on the toilet, Staff E applied gloves, put a clean brief on the resident, pulled her brief and pants up to her knees, put the gait belt on the resident and assisted her to stand. She used personal cleansing wipes to clean the resident. She cleansed the perineal area, and inner thigh. She used the same wipe surface for multiple wipes. She failed to clean the hips and buttocks. Facility Policy titled Catheter Care: Indwelling Catheter, last revised 12/2023, directed staff to apply clean gloves before emptying a catheter drainage bag. Facility Policy titled Handwashing, last revised 5/20 directed staff to dry hands thoroughly with a paper towel and discard and then use a dry paper towel to turn off the water. Facility Policy titled Incontinent and Perineal Care directed staff to use clean gloves when putting on clean briefs. During an interview on 11/6/24 at 11:18 AM, the Director of Nursing (DON) explained she would expect staff to follow policy and procedure and EBP when emptying at catheter. She would expect clean gloves when going from dirty to clean, and would expect clean gloves between incontinent care and catheter emptying. She explained she would expect hand hygiene to be performed after glove removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and staff interviews the facility failed to follow physician orders for three of four residents reviewed. (Residents #3, #4, #6). The facility reported a census of 74 residents. Findings include: 1. The MDS (Minimum Data Set), an assessment tool dated 5/26/2024 revealed Resident #3 had moderate cognitive impairment, transferred with extensive assistance of staff and a mechanical lift, and had diagnoses including diabetes. The Care Plan identified the resident had a risk for complications related to diabetes. It directed staff to provide medications as ordered. The physician ordered Humalog (insulin) 15 units one time a day and 20 units one time a day on 4/17/2024. The April 2024 MAR (Medication Administration Record) revealed staff failed to administer the 20 units of Humalog on 4/17, 4/18, and 4/22/2024. Staff failed to administer the 15 units of Humalog on 4/23/2024. The physician ordered Atorvastatin (for high cholesterol) on 4/16/2024. The April MAR revealed staff failed to administer the medication on 4/21/2024. Progress Notes dated 4/17/2024 indicated the Humalog was unavailable and staff waited for the pharmacy to deliver it. 2. The MDS dated [DATE] revealed Resident #4 had moderate cognitive impairment, required extensive assistance to transfer from one surface to another and had diagnoses including diabetes and chronic kidney disease. The Care Plan identified the resident had a risk for complications related to diabetes and directed staff to administer medications as ordered. The physician's orders included an order for Humalog, 30 units three times a day for diabetes on 12/29/2023. The March 2024 MAR revealed staff failed to administer the medication on 3/29/2024, and indicated the medication was unavailable. The physician ordered Trulicity (for diabetes) 4.5 mg (milligrams) every Monday. The April 2024 MAR revealed staff failed to administer the medication on 4/1 and 4/22/2024, and indicated the medication was unavailable. 3. The MDS dated [DATE] revealed Resident #5 had moderate cognitive impairment, required extensive assistance to transfer from one surface to another, and had diagnoses including diabetes and BPH (benign prostatic hyperplasia). The Care Plan identified the resident had diabetes and a history of fluctuating blood sugars on 6/29/2023. It directed staff to administer medications as ordered by the physician and monitor blood sugars. The Care Plan also identified the resident had BPH with a history of urine incontinence on 7/31/2023. It directed staff to monitor urine output and administer medications as ordered. The physician orders included an order for Januvia, 50 mg by mouth every day for diabetes on 10/11/2023. The April 2024 MAR revealed staff failed to administer the medication on 4/21/2024. The physician ordered Mirabegron 50 mg every day for urinary obstruction on 7/29/2023. The March 2024 MAR revealed staff failed to administer the medication on 3/17 and 3/18/2024. Nurse's Notes dated 3/17, 3/18 and 4/21/2024 indicated the medications were not available. On 6/10/2024 at 2:15 P.M. Staff A, Administrator indicated the facility re-educated staff regarding ordering medications from pharmacy in a timely manner. The Veteran's Administration Case Manager made them aware of the concern. The facility followed up with medication audits and the pharmacy added a greater supply of medications to the Omnicel (facility medication bank). On 6/10/2024 at 10:00 A.M., Staff B, RN (Registered Nurse) indicated the pharmacy presented challenges at times. The facility identified a concern with certain medications and they added them to the medication bank. Staff received education regarding how to go about getting medications on time. The facility Medication Administration - Medication Pass policy dated and revised Rev. 5/2023. PURPOSE: To safely and accurately prepare and administer medication according to physician order and patient needs.

2. During an observation on 3/27/24 at 7:29 AM, Staff H, Registered Nurse (RN), left resident medication administration EHR open and unattended for approximately eight (8) minutes. During an observation on 3/27/24 at 7:45 AM, Staff H left resident medication administration EHR open and unattended for approximately four (4) minutes. During the same observation, Staff H left nine (9) oral medications in Resident #21's room and did not observe him take the medications, leaving the room prior to the resident taking his medication. Review of the EHR, Medication Administration Record, for Resident #21 revealed the resident was prescribed nine (9) medications to be taken orally everyday in the morning. During an interview on 3/27/24 at 8:07 AM, Staff H advised she would normally close resident EHR, but forgot to do that a few times this morning. Staff H acknowledged an expectation to close the screen or lock it. Staff H further acknowledged she would expect to watch the resident take their medications. During an interview on 3/28/24 at 9:00 AM, the Director of Nursing (DON) revealed her expectation of nursing staff is to ensure resident EHR would not be left open to view when not in use. The DON further informed she would expect the medication cart be locked at all times when staff step away from the medication cart, and she would also expect staff to stay with a resident until the resident had taken their medication. Review of facility policy Medication Administration - Medication Pass, with a revision date of 5/2023, documented under the procedure section of the policy to provide privacy and to remain with patient until the administration of the medication is complete, as well as to secure the cart as required, to lock the medication cart when not in direct view of the nurse administering medication. Based on record review, staff interviews, and policy review the facility failed to ensure medication carts were locked at all times when not in use. The facility also failed to ensure resident medical records on the Electronic Health Record (EHR) were not left open and unattended for others to view. The facility also failed to provide professional standards of practice during medication administration when 1 of 2 nurses observed for medication administration failed to stay with a resident (Resident #21) and ensure nine (9) medication pills were taken (swallowed). The facility reported a census of 62 residents. Findings include: 1. During a continuous observation on 3/25/2024 of Legacy Hall (a wing of the facility) medication cart revealed the following: 3:16 PM the Legacy medication cart was unlocked without staff present and the right third (3rd) drawer was open approximately two (2) inches. 3:20 PM Resident #33 rolled out into the hallway and was observed sitting in the doorway of his room in his wheelchair, next to the medication cart, he was close enough to be able to open drawers. 3:24 PM Resident #33 wheeled past the cart and was out of reach from opening it. 3:31 PM Staff G, Registered Nurse (RN) locked the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, policy review, and staff interview, the facility failed to provide and document the implementation of non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication. Some examples include exercise, diversion activity, snacks, toileting, naps, music, etcetera) prior to administration of as needed anti-anxiety medications for 1 of 5 residents sampled (Resident #43). The facility identified a census of 62 residents. Findings include: Resident #43's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status Score of 9/15 indicating moderate cognitive loss. The MDS documented Resident #43 received anti-anxiety medications for an anxiety disorder. The Care Plan dated 3/12/24 documented Resident #43 utilized anti-anxiety medications and directed the staff to monitor for increased risk of confusion, amnesia (memory loss), loss of balance, cognitive impairment that looks like dementia, and monitor as needed for safety. The Care Plan lacked revision to include non-pharmacological interventions to address agitation or restlessness prior to administration of as needed anti-anxiety medication. A 3/26/24 review of Resident #43's physician orders revealed the following orders: a. Clonazepam oral tablet 0.5 milligrams (mg), give 0.5 mg orally every 8 hours as needed for anxiety for 14 days. Start date 2/23/24. b. Clonazepam oral tablet 0.5 milligrams (mg), give 0.5 mg orally every 8 hours as needed for anxiety for 14 days. Start date 3/10/24. c. Clonazepam oral tablet 0.5 milligrams (mg), give 0.5 mg orally every 8 hours as needed for anxiety for 14 days. Start date 3/26/24. A 3/26/24 review of the February 2024 Medication Administration Record (MAR) documented the facility administered the medication at the following dates/times: a. 2/25/24 at 6:42 AM b. 2/26/24 at 7:16 AM and 7:10 PM c. 2/27/24 at 5:03 PM d. 2/28/24 at 2:07 AM e. 2/29/24 at 7:40 AM On 3/26/24 at 4:4 PM Staff A Registered Nurse (RN) reported nursing interventions should be tried and documented prior to given a as needed anti-anxiety medication. Staff A explained normally the nurses document the interventions in the Progress Note that is linked with the MAR. She reported the nurses get so busy, interventions may not get documented and if it wasn't documented, it didn't get done. A 3/27/24 review of the March 2024 MAR documented the facility administered the Clonazepam as needed medication 28 times from 3/01/24 to 3/27/24. A review of the February and March 2024 Progress Notes from 2/25/24 to 3/27/24 revealed the facility only documented implementing non-pharmacological interventions prior to the administration of as needed Clonazepam medication on 3/02/24 and 3/04/24. The Progress Notes also documented the following: a. 2/29/24 at 7:40 AM Nurse assessed. b. 3/1/24 at 7:15 AM Nurse assessed. c. 3/20/24 at 8:02 AM Nurse assessed. d. 3/26/24 at 3:27 PM Nurse assessed. e. 3/27/24 at 7:56 AM Nurse assessed. None of the nurse assessment entries documented if non-pharmacological interventions had been utilized, how many non-pharmacological interventions had been utilized and the outcome of those interventions. During an interview on 3/27/24 at 9:51 AM Staff B RN verbalized the Certified Nursing Assistant's (CNA's) provide interventions for behaviors that are listed in the Care Plan and communicated over into the [NAME] for the staff to see. The [NAME] communicates the behavioral interventions for the staff to provide. Interventions should be tried prior to administering as needed anti-anxiety medication and those interventions should be documented in the Progress Notes which link from the MAR. On 3/27/24 at 10:10 AM Staff C CNA reported she is agency, but has come to the facility several times. She reported many times when she comes on shift she doesn't have a computer login to be able to access the resident's electronic Care Plan or [NAME], so she has to rely on asking other staff about resident behaviors and what needs to be done. She verbalized she didn't really know if the resident behaviors and interventions are included in the Care Plan or [NAME]. She would just go by what other staff members tell her to do. She voiced Resident #43 didn't really have any behaviors that she was aware of. On 03/27/24 at 10:18 AM Staff D, CMA reported resident behaviors are listed in the Point of Care (POC) [NAME]. She would look there to see listed behaviors and interventions to address those behaviors. She explained when you work with residents for a long time, you just know their behaviors. She documents any resident behaviors in the POC Task record. Those records go directly to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) for review. She reported Resident #43 doesn't really have behaviors. She will just state she is shaky or is really cold at times, but those are not really behaviors. On 03/27/24 10:57 AM Staff E ADON explained staff should be able to go to the Care Plan to see resident behaviors and interventions should be listed in the [NAME] to address those behaviors. She reported the nurse should document the situation in the Progress Notes as to what led up to the need for the anti-anxiety medication and what interventions were done prior to given the medication. All that should be documented in the resident Progress Notes 100 percent. A review of the February 2024 Documentation Survey Report V2 documented from 2/23/24 to 2/29/24 Resident #43 had no behaviors or behaviors were documented as not applicable. The Report under Behaviors and Interventions documented NB from 2/23/24 to 2/29/24 indicating Resident #43 had No Behaviors. A Review of the March 2024 Documentation Survey Report V2 from 3/01/24 to 3/27/24 revealed only one day, 3/11/24, that Resident #43 exhibited anxiety/restlessness and had documented interventions of a meaningful activity and one to one activity provided with the Resident's behavior remaining the same. All other days of the month documented the Resident did not have behaviors; behaviors were not applicable to the resident or the resident was not available. A review of Resident #43 [NAME] on 3/27/24 lacked documentation of identified behaviors or interventions to address behaviors to direct staff in Resident #43's care. On 3/27/24 at 1:30 PM Staff F CMA reported she cannot give as needed medication unless approved by a nurse. She is required to inform the nurse of the resident situation, interventions that have been done, and get approval to give the as needed psychotropic medication. She reported it is the nurse's responsibility to document the situation and the interventions in the nursing Progress Notes. Staff F verbalized she can only document the administration of the as needed medication and then the nurse follows up on the response if it was effective. During an interview on 3/27/24 at 3:32 PM the DON reported there should be a nursing order to monitor resident behaviors and to provide three interventions. She reviewed Resident #43's orders and verbalized she did not see the nursing orders. She reported she expects three interventions to be tried and documented before as needed anti-anxiety medications are administered. The Behavior Management Guide revised 7/2023 provided by the facility directed non-pharmacological interventions should be attempted prior to the use of any psychoactive medication

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinic record review, State of Iowa document review, and Medical Director and staff interviews the facility failed to notify the doctor or honor a family request to send a resident to the emergency room (ER) for 1 of 5 residents reviewed (Resident #2). The facility reported a census of 79 residents. Findings Include: Resident #2's Minimum Data Set (MDS) dated [DATE], documented an admission date of [DATE]. The Electronic Health Record (EHR) Medical Diagnosis Section documented admission medical diagnosis including esophageal varices without bleeding and secondary esophageal varices with bleeding. The Progress Note written on [DATE] at 5:55 PM, documented the resident admitted from a local hospital by a transportation service. He was in the facility for strengthening. The resident oriented to his room, call light, and TV remote. Medication orders were faxed to the Pharmacy and the Doctor (MD) was aware of the admission. The Progress Note written on [DATE] at 9:48 AM, documented the resident vomiting and refused (his medications). The clinical record lacked documentation of a physical assessment, vital signs or physician notification at that time. The Progress Note written on [DATE] at 11:15 AM, documented the nurse entered the resident's room at 10:30 AM. The resident was making retching noises and had an emesis basin with spit and a tinge of blood. The resident asked the nurse if he was going to die that day and began to get worked up and breath heavy. The nurse encouraged the resident to deep breath through his nose and out through his mouth as he was exhibiting signs of an anxiety attack. His pulse was 102 beats per minute and his oxygen saturation was 100 % on room air. The nurse called the resident's daughter to ask medical questions as the resident did not appear to be an accurate historian. The daughter requested the resident be sent to the ER immediately. The nurse documented she told the daughter this was not an emergency situation, he was just anxious. The resident was given Zofran (medication given for nausea) and water, covered with a blanket and the nurse told the resident she would be back to see if the Zofran helped. At 11:05 the nurse entered the resident's room to see the resident with a blank stare, pupils fixed, his mouth and chin were blood stained. He did not have a pulse or respirations. The nurse documented an overhead page was made for the code blue and compression were started. The nurse, another nurse and the Activity Assistant rotated compression and the ambu bag (to provide breaths to resident). At 11:06 the Assistant Director of Nursing (ADON) called 911. At 11:13 AM the ambulance crew arrived and took over care. At 1:00 PM the Medical Examiner called and reported the cause of death to be ruptured esophageal varices. The State of Iowa Certificate of Death documents the date and time of death as [DATE] at 11:45 AM. The immediate cause of death is listed at exsanguination (sever blood loss) secondary to esophageal varices with other significant conditions being COVID-19. During an interview on [DATE] at 1:59 PM, the Director of Nursing (DON) explained if a resident or family member was requesting a resident be sent to the ER, she would expect an assessment to be completed, the doctor be notified and made aware of the request and assessment findings. She further explained the nurse would get the order to send at that time. She would expect that information to be documented. She explained that if it isn't documented that doesn't necessarily mean it wasn't done. If there was an emergency or something it could have slipped the nurse's mind. During an interview on [DATE] at 8:49 AM, Staff B, Licensed Practical Nurse (LPN) explained if a family member requested a resident go to the ER she would do an assessment, vitals, then notify the Doctor. During an interview on [DATE] at 8:52 AM, Staff C, LPN explained if a family member or resident was requesting the resident go to the ER she would do an assessment and notify the Doctor. During an interview on [DATE] at 8:58 AM, Staff D, Registered Nurse (RN), explained if a resident was requesting to go to the ER she would do an assessment, call the Doctor and would send the resident to the ER. She explained if a family member was requesting the transfer, the resident gets transferred, the request can't be declined. During an interview on [DATE] at 9:15 AM, Staff A, RN explained the resident passed away on her last day working in this facility. She recalled the resident wasn't feeling well and had a little blood in his mouth. She explained the resident was anxious that day ([DATE]) and he was in the facility for COVID. The resident felt nauseated and she gave him a Zofran. He did not vomit but spit up. She called the daughter from the resident's cell phone with his permission. She remembers the cell phone recording they talked for 13 minutes. The resident was spitting up pink tinged sputum and the daughter thought he should go to the emergency room. Staff A explained to the daughter that he was anxious, this was not an emergency and she was calling to get a better picture of his previous history and background. The daughter gave that picture. Staff A explained she left the resident with an emesis basin as he was feeling nauseated and his call light and went to tend to another resident. When she was done with the other resident, she went back to check on the resident and found him with a blank stare, pupils fixed. She stated she shouted his name and felt for a pulse. She did not find one. She explained she knew he was a full code (wanted life saving measures), she called the code overhead and called for the crash cart and began compressions. She reported bright red blood clots were coming out of his mouth with compressions. She stated she was not aware the resident had esophageal varices at that time. During an interview on [DATE] at 11:42 AM, Staff F, RN, Unit Manager explained she was working in another part of the building when she heard the code page. She explained 2 nurses were doing Cardiopulmonary Resuscitation (CPR) when she got to the room. She recalled she ran and grabbed the suction machine and took it into the room and called 911. She went back in the room to get the suction machine going and the ambulance crew was there very quickly. She recalled the resident had blood coming from somewhere on or near his face. His color was completely pale. She explained she called the resident's daughter and notified her the resident was on his way to the hospital. Staff F explained if a family member requested the resident be sent to the ER the doctor should be notified and she would get a Doctor's Order to send the resident to the hospital. When asked about a nurse refusing to call the doctor, she stated That would be wrong. She stated the nurse needed to put forth the effort to call the doctor and let the doctor know and decide what would happen next. During an interview on [DATE] at 11:59 AM, the DON acknowledged Staff A had received a request from the resident's daughter for the resident to go to the ED but she received that information later. She explained it would not be appropriate for the nurse in the facility to tell the family no, this is not an emergency and refuse to send the resident or even call the doctor. During an interview on [DATE] at 1:05 p.m. the DON reported they do not have a transfer out policy. They follow standards of care and call the physician and get an order to transfer out. During an interview on [DATE] at 4:12 PM the Medical Director explained when a resident or family member requests to go to the ER we send them. That's standard, we don't refuse to send them. He further explained if it is an emergent situation they can call 911 and send the resident to the ER, get them taken care of and then notify us (himself and his team). If it's not emergent we like to be notified ahead of time so we can give the order and be aware. He explained he would expect a new set of vitals and an assessment from the nurse's interaction with the resident, that is standard. If they call and don't have that information I will ask them to get that information and call back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, State of Iowa Certificate of Death review, Pre-admission Hospital record review, facility document review and Medical Director and staff interviews, the facility failed to complete a thorough assessment, provide interventions necessary, and notify the resident's Physician of significant changes for the resident and respect the resident's representative from exercising the resident's right to access emergency services for 1 of 5 residents reviewed (Resident #2). The facility reported a census of 79 residents. The Pre-admission Hospital Record documented diagnoses including COVID, acute cough, hematemesis, esophageal varices, and Grade D (sever) esophagitis. The hospital record documents the resident presented to the emergency room (ER) on or around [DATE] after his daughter observed coffee ground emesis. Resident #2's Minimum Data Set (MDS) dated [DATE], documented an admission date of [DATE]. The Electronic Health Record (EHR) medical diagnosis section documented admission medical diagnosis including esophageal varices without bleeding and secondary esophageal varices with bleeding. The Progress Note written on [DATE] at 5:55 PM, documented the resident admitted from a local Hospital by a transportation service. He was in the facility for strengthening. The resident was oriented to his room, call light, and TV remote. Medication orders were faxed to the Pharmacy and the Doctor (MD) was aware of the admission. The Progress Note written on [DATE] at 9:48 AM, documented the resident vomiting and refused (his medications). The clinical record lacked documentation of a physical assessment, vital signs or physician notification at that time. The Progress Note written on [DATE] at 11:15 AM documented the nurse entered the resident's room at 10:30 AM. The resident was making retching noises and had an emesis basin with spit and a tinge of blood. The resident asked the nurse if he was going to die that day and began to get worked up and breath heavy. The nurse encouraged the resident to deep breath through his and out through his mouth as he was exhibiting signs of an anxiety attack. His pulse was 102 beats per minute and his oxygen saturation was 100 % on room air. The nurse called the resident's daughter to ask medical questions as the resident did not appear to be an accurate historian. The daughter requested the resident be sent to the ER immediately. The nurse documented she told the daughter this was not an emergency situation, he was just anxious. The resident was given Zofran (medication given for nausea) and water, covered with a blanket and the nurse told the resident she would be back to see if the Zofran helped. At 11:05 the nurse entered the resident's room to see the resident with a blank stare, pupils fixed, his mouth and chin were blood stained. He did not have a pulse or respirations. The nurse documented an overhead page was made for the code blue and compression were started. The nurse, another nurse and the activity assistant rotated compression and the ambu bag (to provide breaths to resident). At 11:06 the Assistant Director of Nursing (ADON) called 911. At 11:13 AM the ambulance crew arrived and took over care. At 1:00 PM the Medical Examiner called and reported the cause of death to be ruptured esophageal varices. The State of Iowa Certificate of Death documented the date and time of death as [DATE] at 11:45 AM. The immediate cause of death is listed at exsanguination (sever blood loss) secondary to esophageal varices with other significant conditions being COVID-19. During an interview on [DATE] at 1:59 PM, the Director of Nursing (DON) explained if a resident or family member was requesting a resident be sent to the ER, she would expect an assessment to be completed, the doctor be notified and made aware of the request and assessment findings. She further explained the nurse would get the order to send at that time. She would expect that information to be documented. She explained that if it isn't documented that doesn't necessarily mean it wasn't done. If there was an emergency or something it could have slipped the nurses mind. During an interview on [DATE] at 8:49 AM, Staff B, Licensed Practical Nurse (LPN) explained if a family member requested a resident go to the ED she would do an assessment and vitals and notify the doctor. During an interview on [DATE] at 8:52 AM, Staff C, LPN explained if a family member or resident was requesting the resident go to the ER she would do an assessment and notify the doctor. During an interview on [DATE] at 8:58 AM, Staff D, Registered Nurse (RN), explained if a resident was requesting to go to the ER she would do an assessment, call the doctor and would send the resident to the ER. She explained if a family member was requesting the transfer, the resident gets transferred, the request can't be declined. During an interview on [DATE] at 9:15 AM, Staff A, RN explained the resident passed away on her last day working in this facility. She recalled the resident wasn't feeling well and had a little blood in his mouth. She explained the resident was anxious that day ([DATE]) and he was in the facility for COVID. The resident felt nauseated and she gave him a Zofran. He did not vomit but spit up. She called the daughter from the resident's cell phone with his permission. She remembers the cell phone recording they talked for 13 minutes. The resident was spitting up pink tinged sputum and the daughter thought he should go to the emergency room. Staff A explained to the daughter that he was anxious, this was not an emergency and she was calling to get a better picture of his previous history and background. The daughter gave that picture. Staff A explained she left the resident with an emesis basin as he was feeling nauseated and his call light and went to tend to another resident. When she was done with the other resident, she went back to check on the resident and found him with a blank stare, pupils fixed. She stated she shouted his name and felt for a pulse. She did not find one. She explained she knew he was a full code (wanted life saving measures), she called the code overhead and called for the crash cart and began compressions. She reported bright red blood clots were coming out of his mouth with compressions. She stated she was not aware the resident had esophageal varices at that time. During an interview on [DATE] at 11:42 AM, Staff F, RN, Unit Manager explained she was working in another part of the building when she heard the code page. She explained 2 nurses were doing Cardiopulmonary Resuscitation (CPR) when she got to the room. She recalled she ran and grabbed the suction machine and took it into the room and called 911. She went back in the room to get the suction machine going and the ambulance crew was there very quickly. She recalled the resident had blood coming from somewhere on or near his face. His color was completely pale. She explained she called the resident's daughter and notified her the resident was on his way to the hospital. Staff F explained if a family member requested the resident be sent to the ED the doctor should be notified and she would get a doctor's order to send the resident to the hospital. When asked about a nurse refusing to call the doctor, she stated That would be wrong. She stated the nurse needed to put forth the effort to call the doctor and let the doctor know and decide what would happen next. During an interview on [DATE] at 11:59 AM, the DON acknowledged Staff A had received a request from the resident's daughter for the resident to go to the ED but she received that information later. She explained it would not be appropriate for the nurse in the facility to tell the family no, this is not an emergency and refuse send the resident or even call the doctor. During an interview on [DATE] at 4:12 PM the Medical Director explained when a resident or family member requests to go to the ER we send them. That's standard, we don't refuse to send them. He further explained if it is an emergent situation they can call 911 and send the resident to the ED, get them taken care of and then notify us (himself and his team). If it's not emergent we like to be notified ahead of time so we can give the order and be aware. He explained he would expect a new set of vitals and an assessment from the nurse's interaction with the resident, that is standard. If they call and don't have that information I will ask them to get that information and call back. The facility document titled Change in Condition, dated 11/2016, directed staff to consult with the resident's Physician for any need to alter treatment or a decision to transfer the resident from the facility. The document further directed staff to immediately notify the Physician for any symptom, sign or apparent discomfort that is acute or sudden onset and a marked change in relation to usual symptoms and signs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, document review, Iowa Department of Inspection and Appeals On-Line Facility Reported Incident Report review, Facility Investigation, Abuse Policy and staff interviews, the facility failed to ensure allegations of misappropriation of resident narcotic medications had been reported to the State agency within 24 hours of the allegation of abuse for 1 of 1 resident's sampled (Resident #3). The facility identified a census of 79 residents. Findings include: An Iowa Department of Inspection and Appeals (DIA) On-Line Facility Report Incident Report (FRI) documented the Administrator from Harmony Cedar Rapids filed an on-line report with the DIA on 3/21/23 at 6:33 p.m. for a criminal act regarding a nurse alleging on 3/19/23 her signatures were forged on a Narcotic Record for Resident #3. The FRI detailed a report type of a criminal act that occurred on 3/18/23 at 8:00 a.m. The Incident Summary documented during the Narcotic Count, Staff G, Registered Nurse (RN) noticed it seemed like her signature had been forged on the Narcotic Count Sheet. She had signed out two pills of oxycodone for Resident #3. Staff G stated that had not occurred. The narcotic sheet documented one pill of oxycodone had been given on 3/18/23 at midnight and 4:00 a.m. The Electronic Medication Administration Record (EMAR) lacked documentation these narcotic medication doses had been documented as administered to Resident #3. Staff G stated she had given Resident #3 Tylenol around 2:00 a.m. on 3/18/23 to address his pain. Staff G stated the Pharmacy had not delivered Resident #3's oxycodone. The Pharmacy confirmed the card of oxycodone had been delivered to the facility on 3/18/23 at 5:22 a.m. Therefore, Staff G could not have possibly given the medication at midnight and 4:00 a.m. Staff G had handed the keys off to Staff A, RN around 6:00 a.m. Staff G recalled the Narcotic Count for Resident #3 being 30 for the card of oxycodone. The next dose had been given by Staff A around 8 a.m. This led the facility to suspect Staff A took the two doses of medication and signed Staff G's name on the narcotic sheet. The FRI report further documented the incident had been reported to the Cedar Rapids Police Department. The Facility failed to notify the State Department within 24 hours of the allegation of misappropriation of resident property. A Facility Investigation, undated and unsigned, provided by the facility documented under the initial report during narcotic count Staff G noticed it seemed like her signature had been forged on the controlled drug administration record (CDAR) and she had signed out two pills of oxycodone for a patient. Staff G stated that had not occurred. The narcotic sheet documented one pill of oxycodone had been given at midnight on 3/18/23 and one pill given 3/18/23 at 4:00 a.m. to Resident #3. The March 2023 EMAR did not reflect the two doses of narcotic medication had been administered. Staff G stated she had given Tylenol around 2:00 a.m. on 3/18/23 to address the patients pain. The medication was effective and had been documented in the EMAR. Staff G stated the patient's oxycodone had been delivered to the facility on 3/18/23 at 5:22 a.m. Therefore, she couldn't have administered the medication at midnight and 4:00 a.m. Staff G had handed the keys to the next nurse on duty, Staff A around 6:00 a.m. Staff G recalled the narcotic count being 30 for the card of oxycodone as she had just received the medication from the pharmacy. The next dose given had been around 8:00 a.m. by Staff A leading them to suspect that Staff A took the two doses and signed Staff G's name on the narcotic sheet. A Statement hand written by Staff G addressed to the Director of Nursing (DON) and Staff F, Assistant Director of Nursing (ADON)/Nursing Supervisor on 3/17/23 documented the pharmacy had been unable to deliver medications for Patient #3 until the morning of 3/18/23 between 5 a.m. - 6 a.m. Staff G had been on [NAME] Hallway when Staff I, RN, informed her the pharmacy had delivered medications. Staff G counted 30 tablets of oxycodone for Resident #3. Staff G detailed in her statement she had given Resident #3 975 milligrams (mg) of Tylenol for complaints of pain since the oxycodone had not been available from the pharmacy. Staff G documented she gave report that morning to Staff A, RN and they both counted the narcotics before she left shift. Staff G returned 3/18/23 for the 10 p.m. - 6:30 a.m. shift to find that her signature had been forged to show administration of oxycodone at midnight and 4 a.m. Staff G documented she had never administered oxycodone on her shift on 3/17/23. She attached a copy of the March 2023 EMAR and the Pharmacy Delivery Slip for verification. The March 2023 EMAR documented Staff G administered 975 mg of Tylenol per the physician order 3/18/23 at 2:04 a.m. which had been effective for pain control. On 3/20/23 Staff E, RN, wrote a statement noting it had been 1:40 a.m. when Staff G alerted her about her signature being forged. Staff E wrote Staff G's signature had been forged twice. Staff G called Staff F, Assistant Director of Nursing (ADON)/Unit Supervisor and informed her of what had happened. Staff F told Staff G to write a statement and leave a copy for her and she would review it on Monday 3/20/23. Staff E came to work (3/19/23), she knew how many pills she had counted with Staff G since there were not many narcotics on the Medbridge hallway. Staff E noticed some CDARs had forged signatures with different names, Staff I, RN, Staff M, RN and Staff D, RN for the same day. Staff E wrote she asked Staff A about it and she hadn't been satisfied with the answer because clearly pills were taken illegally or administered in suspicious ways. Staff E called the DON and reported the situation. During an interview on 5/17/23 at 11:19 a.m., the DON reported she received a text message from Staff E on 3/19/23 sometime in the late afternoon notifying her of the issue with Staff A. Staff E noted something wrong with the narcotic sign out and she had tried to message Staff F. Staff E seemed pretty upset so she came to the facility. Staff E showed her the narcotic sheet that had Staff G's signature on it at a time when the narcotics were not even in the facility for Resident #3. The DON voiced she did not receive any messages from Staff A on 3/18/23. Staff F had been on call on 3/18/23. The DON voiced she thought they had 24 hours to report abuse, but she had to go through the Administrator for reporting. She had not been familiar with the process at that time. She had only been the DON for about one year. After she came to the facility, she called the Human Resource Coordinator to come to the facility and notified the Administrator. They called Staff A into the office. She interviewed Staff A, then walked her out of the facility. The DON reported she arrived at the facility sometime after 2:00 p.m. She asked Staff A if she had documented every time she administered a scheduled narcotic and as needed (PRN). Staff A responded she tried too, but couldn't say if she had missed one. The DON reported she point blank asked Staff A if she signed out narcotics that were not administered. Staff A told her no. Staff A gave no explanation at all for that and appeared tearful as the DON walked her out of the facility. Staff A understood being suspended until they could complete an investigation. At 11:31 a.m., the DON concluded that Staff A had been stealing narcotics. The DON reported she did not know how to file an on-line report with the State of Iowa. She had never had to do that. She did not call the State hot-line number to report. The Administrator had been made aware on the 19th that Staff A had been suspended due to missing medications and forged signatures. The DON did not know if the Administrator had reported the incident via phone to DIA prior to 3/21/23. On 5/17/23 at 12:56 p.m., Staff F reported she had been called by Staff G in the wee hours of the morning. She doesn't recall the date she received the call. She reported Staff G as a very upstanding nurse. She couldn't remember exactly what Staff G told her. Staff G had either reported a narcotic medication had been missing or someone had falsely signed out a narcotic using her signature. The writing on the narcotic record had not been Staff G's hand writing. It had been one of those situations. She did remember it had been one narcotic pill and involved one resident. She doesn't recall the specific direction that she gave to Staff G but did tell her she would report the situation to the DON and it would be taken care of. She did remember that Staff G had been upset and stated she had not given the resident the narcotic medication and Staff A had been the only other nurse to handle the narcotic medication. Staff F reported she had been the nurse on call at the time. She remembered she had been dead asleep when she got the call. She could not recall the exact medication, but it had been a narcotic medication. She could not recall which resident had been involved. She thought it occurred on the Medbridge hallway. The facility policy is to alert the DON of missing medications. She did not call the DON right away, but thought she had called her later the same morning. She believes the DON investigated it but doesn't recall what she actually reported-off to the DON. If there is missing resident property she alerts the DON and the Administrator. She would not be the one to call the State office. If she saw resident abuse, she would report to the State immediately, but as far as missing items, she would just report those to the DON and the Administrator. On 5/16/23 at 10:47 a.m., Staff G reported she tried to call Staff F who had been on call that morning (3/19/23), but Staff F couldn't take the call. Then she called the DON and left a message. She then tried to call Staff F on her personal cell phone. Staff F (ADON) informed her to write a statement and leave it in the office and she would address it on Monday when she came in. A Missed Punch Form for Staff F provided by the facility documented Staff F worked at the facility from 10 a.m. - 2:40 p.m. on 3/19/23. During an interview on 5/17/23 at 1:24 p.m., the DON reported she is not the Abuse Coordinator. The Abuse Coordinator is the Administrator. She stated when they first looked at it they had thought they were looking at a forgery for signatures on the narcotic sheets. They weren't aware of everything that had been going on at that point. On 5/17/23 at 6:34 p.m., the Administrator voiced he had first become aware of the situation on the evening of 3/19/23 by the DON. The DON went to the facility and got a statement from Staff A and suspended her from duty. At that point they didn't think they had an allegation of abuse. The narcotic counts were not off, but something had been fishy. He had not been able to verify Staff G's statement until the evening of 3/20/23 when the pharmacy receipt came to verify the date and time the medication had been received by the facility. That confirmed Staff G's story. Looking back, he stated he got it, they probably should have been looking at it from a different perspective, but he likes to think the best of people. Getting the Pharmacy Receipt had been the verification he needed. He reported the incident to the State Department on 3/21/23. He had verified with the DON on 3/19/23 that the narcotic count had been accurate. They thought it may have been a simple case of someone forgetting they had administered a dose of medication and it turned into someone stealing medications. He had never seen anything like it. From their final investigation, it had affected up to 9 residents and showed a trend that Staff A had taken the pills. He stated they had reported Staff A to the Board of Nursing. He further reported Staff A would be terminated. He didn't feel this had been the first time that Staff A had taken medications. She seemed to know exactly what she was doing. He wondered if it had happened at other facilities and they never did anything about it. They tried to do the right thing and get it reported into the State. On 5/18/23 at 9:41 a.m., the Pharmacist/Director of Quality reported the customer service representative had been contacted on 3/20/23 by the DON from Harmony. He didn't have an exact time but felt that he did respond with getting her the information within 30 minutes of the request. He provided her with a copy of the pharmacy delivery slip with the wet signature from the nurse with the date and time of delivery for Resident #3's medications and a copy of the unsigned packing slip. The Pharmacist confirmed the copies were sent to the DON via email on 3/20/23 at 8:35 p.m. Due to their internal information technology, she could not provide a copy of the information. On 5/23/23 at 11:42 a.m. the DON reported initially when Staff G brought forward the concern, it had only affected Resident #3. They initiated an investigation, but didn't know about the other residents affected until later into the investigation. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, dated July 2019, provided by the facility, included a Policy Statement: all residents have the right to be free from abuse, neglect misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking acts that result in person degradation. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It shall be the policy of this facility to implement written procedures to prohibit abuse, neglect, exploitation and misappropriation of resident property. The Policy included the following definition: 1. 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. This includes misappropriation or diversion of resident medications. The Policy under Reporting directed the following: 1. All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegation of abuse to the Administrator or designated representative. 2. All allegations of Resident abuse shall be reported to the Iowa Department of Inspection and Appeals not later than two (2) hours after the allegation is made. 3. All allegations of Resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections and Appeals, not later than two (2) hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than twenty-four (24) hours if the events that cause the allegation involve neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury. 4. If there is reasonable suspicion that the allegation of abuse also constitutes a crime committed against the resident by any person, whether or not the alleged perpetrator is employed by the facility, the Elder Justice Act requires the matter must also be reported to law enforcement. While the federal regulations require all abuse allegations to be reported to DIA within 2 hours, the Elder Justice Act has a different time frame for reporting to the police/sheriff. If the allegations of abuse (that results from a crime) results in serious bodily injury to a resident, a report must be made to law enforcement not later than two (2) hours after the allegation is made. If the allegation of abuse does not result in serious bodily injury, a report must be made to law enforcement not later than twenty-four 24) hours. 5. A report shall be made by calling the Department of Inspection and Appeals reporting hotline at (877) [PHONE NUMBER], submitted an e-mail to the Department at HFD_Complaint@dia.iowa.gov, submitting an online report or sending a fax to (515) 28107106. 6. If the person in charge is the alleged abuser, the staff member shall directly report the abuse to the Department immediately pursuant to the deadlines established above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility investigation, document review, staff interviews and policy review, the facility failed to conduct a timely and thorough investigation after discovering a reportable incident for possible drug diversion for 3 of 8 residents sampled (Resident #4, #14 and #16). The facility identified a census of 79 residents. Findings Include: An Electronic Census showed Resident #4 admitted to the facility on [DATE] and discharged on [DATE]. 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 showed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive loss. The MDS documented Resident #4 utilized scheduled and as needed medication for frequent pain of a 4 on a 1-10 scale. The Resident received opioid medication 3 out of 7 days of the look-back period. The MDS listed diagnoses of fracture of the pubis ramus (pelvic fracture), coronary artery disease, heart failure, hypertension, arthritis and long-term use of opioids. A Physician Order electronically signed by the Provider on [DATE] listed a current order as of [DATE] for Roxicodone (generic oxycodone, narcotic/opioid medication) oral tablet 5 milligrams (mg), give one tablet by mouth every 4 hours as needed (PRN) for pain control. The [DATE] EMAR showed the following doses of oxycodone (Roxicodone) oral tablet 5 mg, give 1 tablet by mouth every 4 hours as needed for pain control: a. On [DATE] at 7:40 a.m., for a pain level of 10 on a 1-10 pain scale by Staff A; dose effective. b. On [DATE] at 7:27 p.m., for a pain level of a 4 on a 1-10 pain scale by Staff E; dose effective. c. On [DATE] at 4:08 a.m., for a pain level of a 5 on a 1-10 pain scale by Staff C; dose effective. d. On [DATE] at 6:15 a.m., for a pain level of 9 on a 1-10 pain scale by Staff A; dose ineffective. e. On [DATE] at 6:36 a.m., for a pain level of 5 on a 1-10 pain scale by Staff A; dose ineffective. f. On [DATE] at 6:18 a.m., for a pain level of 10 on a 1-10 pain scale by Staff A; dose ineffective. A review of Resident #4's CDAR showed a Pharmacy Label reading: oxycodone immediate release (IR) 5 mg tablets, take 1 tablet by mouth every four hours as needed for pain x 7 days. The CDAR documented the facility received 12 tablets on [DATE]. Further review revealed no doses of the oxycodone medication had been signed out on the CDAR. The CDAR documented the signature of the Director of Nursing (DON) and Staff E, Registered Nurse (RN) destroyed 12 tablets of the narcotic medication. The CDAR did not contain a date or time the destruction took place. On [DATE] at 2:30 p.m., Staff E reviewed Resident #4's CDAR from [DATE]. She confirmed the signature on the CDAR for 12 oxycodone tablets as her signature. She remembered wasting the Resident's narcotics with the DON, but stated she can't remember how many tablets they wasted or when. It had been too long ago. On [DATE] on 2:42 p.m., the DON reviewed the [DATE] EMAR for oxycodone as needed order and the [DATE] CDAR. She reported she remembered wasting Resident #4's narcotics. The DON reviewed the [DATE] EMAR and Controlled Drug Administration Record. She did not have an explanation for why the oxycodone had been signed out as administered on the [DATE] EMAR and were not signed out on the [DATE] CDAR. On [DATE] at 2:57 p.m., the DON reported she did not have an answer for the discrepancy on Resident #4's records. She had a call out to the pharmacist to see if she could find more information. She acknowledged the 7 day limit on the oxycodone label the pharmacy had placed on the CDAR and the facility physician order for oxycodone did not have a time limit on the order. The DON returned at 3:02 p.m. and reported the pharmacy verified they sent out 12 tablets of oxycodone. The DON also reported the pharmacy confirmed they sent out a medication card containing 30 tablets of oxycodone that the facility did not have a CDAR on. She reported it had been Staff E, RN or M, RN that signed for the medication card. The DON provided a copy of the Pharmacy Delivery Slip showing Staff M signed for the delivery of 30 tablets of oxycodone for Resident #4 at 3:30 p.m. A review of the [DATE] Daily Deployment Sheet listed Staff M as the charge nurse assigned to Medbridge hallway where Resident #4 resided. An interview with the Pharmacist on [DATE] at 9:55 a.m., revealed the Pharmacy had sent 9 tablets of oxycodone to the facility on [DATE]; 30 tablets of oxycodone on [DATE] and 12 tablets of oxycodone on [DATE]. The Pharmacist checked the records at 10:03 a.m. and voiced the facility had not returned any of the medication cards to the pharmacy. On [DATE] the Pharmacist supplied the follow documentation: a. A Pharmacy Manifest dated [DATE] documented 9 tablets of oxycodone IR 5 mg tablets had been delivered to the facility and signed for by Staff G. b. A Pharmacy Manifest dated [DATE] showed 30 tablets of oxycodone had been delivered to the facility and signed for by Staff M. c. A Pharmacy Packing Slip dated [DATE] showed Staff E signed for delivery of 12 tablets of oxycodone from the pharmacy for Resident #4. During an interview on [DATE] at 10:25 a.m., the Administrator explained they initiated their investigation on Monday [DATE]. The drug investigation took a very long time. It had also been during the transition from Promedica to Harmony and that muddied everything. They initially had issues printing Physician Orders and they had to take some time to get that figured out so that they could look into things. It ended up being much longer than 5 days to completed the investigation. He reviewed the investigation summary on [DATE] at 10:29 a.m. He verified he had typed the investigation up and had not signed/dated the investigation. He swore he put something in the summary about Resident #4's missing narcotic record and medication card because he had looked forever for the narcotic record. He got a report from the Pharmacy of what medications had been received for Resident #4 and he looked at the EMAR. After looking for a long time, he finally concluded that Staff A had disposed of the CDAR and taken the narcotic medication card. The facility could not produce documentation of Resident #4's oxycodone CDAR to show the doses documented out on the [DATE] EMAR or the destruction of the narcotic medication and number of oxycodone tablets left when the Resident discharged on [DATE]. The Facility Investigation lacked documentation of Resident #4 oxycodone order, EMAR administrations, missing CDAR for 30 tablets of oxycodone or medication card. On [DATE] at 10:50 a.m., Staff P, Medical Records/Scheduler reported she could not find a CDAR for Resident #4 oxycodone 9 tablets. She stated she had reported it to the Administrator and he had already talked to the Surveyor about it. On [DATE] at 11:11 a.m., Staff D, RN reported she remembered being asked about Resident #6's missing CDAR which she had later found in his chart. They CDARs were to go to the 24-hour communication book, not the resident charts. She doesn't recall the Administrator or DON asking her about any missing CDAR or medications for Resident #4. She voiced two nurses have to destroy narcotic medications. They fill out a paper and attach it to the CDAR sheet. The paper has the room number, resident's name, script number and amount of the medication destroyed. The nurse both sign at the bottom of the record. They destroy the narcotic medication by disposing into a Drug Buster system. On [DATE] at 11:59 a.m., Staff A, RN responded via phone text message she didn't remember the Administrator or DON asking her about missing CDARs or missing narcotic medication cards as part of the facility investigation. During an interview on [DATE] at 12:15 p.m., the DON reported she had not been aware of Resident #4 missing a CDAR for an oxycodone count of 9 tablets. The nurses are to document the narcotic delivery on the Master Controlled Substance Log and they circle the count number received on the CDAR however, she commented they do this, but it is not a facility policy. She had just started a new process of having the nurses put the pharmacy delivery slips into a pharmacy binder as part of their investigation process. She said sometimes the nurses put the pharmacy delivery slips into the 24-hour communication book or they just throw them away. The don't have a policy on what the nurses are to do with the delivery slips. She reported two nurses have to destroy narcotics and document the destruction on the CDAR record. She stated the paper they filled out and attached to the CDAR following destruction had been under the old processes and management. They no longer do that. Both nurses sign the CDAR for the quantity of tablets destroyed. On [DATE] at 12:40 p.m., the Administrator reported he had looked in his computer and he had a file saved from [DATE] where he reviewed Resident #4's EMAR for the oxycodone. He had looked all over the facility for the CDARs and couldn't find them. He explained the review included the CDAR for the oxycodone of 9 tablets and the CDAR of 30 tablets. The Facility Investigation lacked documentation of any review of Resident #4's use of oxycodone, missing CDAR's or medication cards. During an interview on [DATE] at 10:35 a.m., the Administrator reported he did not interview all Certified Nursing Assistants (CNA's), Housekeepers, Maintenance or other personnel as part of the investigative process. He reported he felt that the Pharmacy documentation backed up Staff G's story on what had happened and pointed to Staff A. They had audited narcotic sheets prior to Staff A being hired and they may have had a narcotic pain medication here and there that had not been signed out on the EMAR, but it had not been a trend like with Staff A. Obviously, the nurses couldn't have signed out a narcotic pain medication on the EMAR if they were not the actual nurse signing it out on the CDAR. Then with all the nurses coming forward and citing the signatures on the CDAR's were not their signatures, it pointed to Staff A. He reported the CNA interviews they did were in regard to Resident #6 as Staff A had documented really high pain levels for him. They did CNA interviews to try to see how much pain Resident #6 had. Resident #6 had been a hard case as when staff repositioned him, he had pain. When he laid still, he never exhibited any signs of pain and he had been a pretty happy guy. He just felt the trends from the investigation pointed to Staff A. There were no other staff that he suspected of taking narcotic medications. On [DATE] at 9:55 a.m., the Administrator provided an Audit Record dated [DATE] that detailed the for Resident #4 use of the hydrocodone-acetaminophen 5-325 mg, pharmacy delivery of 14 tablets, the CDAR showed 10 tablets signed out. The EMAR documented 4 doses signed out for administration. The medication card had 4 remaining tablets. The Audit Report documented 6 discrepancies in the records. and detailed one dose had been signed out by agency staff. The facility could not confirm the accuracy so would reimburse out of good faith. The Audit Report [DATE] documented for a oxycodone IR 5 mg for a pharmacy delivery of 9 tablets, the EMAR showed 4 doses signed out as administered. The audit detailed the facility had no CDAR and no amount remaining due to no CDAR. For a delivery of 30 tablets of oxycodone IR 5 mg, the facility had no CDAR. The EMAR showed two doses signed out for administration and an unknown remaining on the card as the facility did not have a card or CDAR for the medication. 2. On [DATE] at 9:55 a.m. the Administrator provided an Audit Record dated [DATE] that detailed Resident #14 had a pharmacy delivery on [DATE] of oxycodone IR 5 mg, 30 tablets. The facility had no CDAR. The EMAR showed no doses of the medication had been signed out as administered. The amount remaining on the medication card could not be accounted for. The audit detailed 30 discrepancies from the audit. 3. On [DATE] at 9:55 a.m., the Administrator provided an Audit Record dated [DATE] that detailed Resident #16 had a Pharmacy delivery on [DATE] of hydrocodone-acetaminophen 5-325 mg, 16 tablets. The facility had no CDAR for the count of 16 tablets. The EMAR had 6 doses of the medication signed out as administered. The amount remaining on the card could not be accounted for. The audit detailed 10 discrepancies found. A review of the undated, unsigned Facility Investigation provided by the facility lacked documentation of the missing CDAR for Residents #4, #14 and #16. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, dated [DATE], provided by the facility specified under key definitions misappropriation of resident property included the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. This included misappropriation of resident medications. The Policy further detailed should a suspected incident of resident abuse as defined above be reported or observed, the Administrator or his/her designee will designate a member of management to investigate the alleged incident. The Administrator or designee will complete documentation of the allegation of resident abuse and collect any supporting documents relative to the alleged incident: 1. Review documentation in the resident record, including review of assessment if resident injury. 2. Assess the resident for injury if the allegation involves physical or sexual abuse; 3. Provide proper notification to primary care provider, responsible party, etc. 4. Attempt to obtain witness statements (oral and/or written) from all known witnesses. 5. If there is physical evidence that can be preserved, attempt to do so, and maintain in a safe location to minimize risk of evidence being tampered with.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, document review, resident and staff interviews the facility failed to ensure residents remained free from misappropriation of narcotic pain medications including oxycodone, hydrocodone-acetaminophen, and hydromorphone for 8 of 8 residents reviewed (Resident #3, #4, #5, #6, #14, #15, #16, #17). The facility identified a census of 79 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 showed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive loss. The resident required extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene. The MDS documented Resident #3 utilized as needed pain medication for occasional pain of 5 on a 1-10 scale receiving opioids 6 out of the 7 day look-back period. The MDS listed diagnoses of left hip fracture, anemia, hypertension, end stage renal disease, chronic obstructive pulmonary disease (COPD) and a wound infection. The Care Plan dated 3/17/23 identified Resident #3 at risk for pain related to arthritis, surgical incision and infection to a wound site. The Care Plan directed the nurses to provide analgesics as ordered and evaluate efficacy of pain management. A Hospital After Visit Summary dated 3/17/23 documented a Physician Order for oxycodone 5 milligrams (mg) immediate release (IR) by mouth every 4 hours as needed for pain of the left hip. A review of the Controlled Substance Administration Record (CDAR), Pharmacy Delivery Slip, March 2023 EMAR, March 2023 Daily Deployment Sheets, Facility Investigation, March 2023 Vital Signs Records and Narcotic Count by Nurses March 2023 for Resident #3's use of oxycodone hydrochloride (HCL) oral tablet 5 mg. Give 5 mg by mouth every 4 hours as needed for left hip pain revealed the following discrepancies: a. A Statement hand written by Staff G, Registered Nurse (RN) addressed to the Director of Nursing (DON) and Staff F, Assistant Director of Nursing (ADON)/Nursing Supervisor on 3/17/23 documented the pharmacy had been unable to deliver medications for Patient #3 until the morning of 3/18/23 between 5 a.m. - 6 a.m. Staff G had been on [NAME] Hallway when Staff I, RN, informed her Pharmacy had delivered medications. Staff G counted 30 tablets of oxycodone for Resident #3. Staff G detailed in her statement she had given Resident #3 975 mg of Tylenol for complaints of pain since the oxycodone had not been available from the pharmacy. Staff G documented she gave report that morning to Staff A, RN and they both counted the narcotics before she left shift. Staff G returned 3/18/23 for the 10 p.m. - 6:30 a.m. shift to find that her signature had been forged to show administration of oxycodone at midnight and 4 a.m. Staff G documented she had never administered oxycodone on her shift on 3/17/23. She attached a copy of the March 2023 EMAR and the Pharmacy Delivery Slip for verification. The March 2023 EMAR documented Staff G administered 975 mg of Tylenol per the physician order 3/18/23 at 2:04 a.m. which had been effective for pain control. b. On 3/18/23 at midnight and 4:00 a.m., the CDAR showed the doses of medication signed out by Staff G. The March 2023 EMAR lacked documentation by Staff G of the administration of the medication doses. A Pharmacy Packing Slip signed by Staff G contained Staff's G signature that she signed for 30 tablets of oxycodone IR 5 mg tablets on 3/18/23 at 5:30 a.m. The 3/18/23 Daily Deployment Sheet showed Staff A assigned to Resident #3's hallway (Medbridge). The Facility Investigation detailed the signature for the doses on the CDAR did not match Staff G's signatures. The Investigation further detailed during the Narcotic Count the next day (3/19/23) Staff G noticed it seemed like her signature had been forged on the narcotic count sheet and that she had signed out 2 pills of oxycodone for Resident #3. She reported that had not occurred. The doses were not documented on the March 2023 EMAR. The Investigation also detailed Staff G stated the Resident's oxycodone had not yet been delivered from the pharmacy, so she couldn't have administered the medication at midnight and 4:00 a.m. She had handed the medication cart keys off to Staff A around 6:00 a.m. Staff G recalled the narcotic count being at 30 tablets for the oxycodone card because she had just received it from pharmacy. The Narcotic and Controlled Substance Shift to Shift Count Sheet for 3/18/23 showed Staff G completed the narcotic count with Staff A at the change of from night shift to day shift, handing the keys off to Staff A for Medbridge hallway. A Time Card Report for 3/18/23 showed Staff A worked from 5:58 a.m. - 4:28 p.m. c. On 3/18/23 at 7:45 a.m., the March 2023 EMAR showed Staff A administered a dose of oxycodone 5 mg for Resident #3 at 7:46 a.m. which had been ineffective and at 7:57 a.m. documented the administration of a second dose of the medication. The CDAR documented one tablet of oxycodone signed for 3/18/23 at 8:00 a.m. and 12:30 p.m. by Staff A. The Facility Investigation noted the discrepancy from the time documented on the March 2023 EMAR of 7:46 a.m. to the CDAR dose of the medication which had been signed out at noon. The March 2023 CDAR for oxycodone count 30 tablets documents the dose had been signed out by Staff A at 12:30 p.m. d. On 3/19/23 at 4:00 a.m. the CDAR documented one tablet of oxycodone 5 mg had been signed out by Staff G. The dose had not been signed out on the March 2023 EMAR. The 3/18/23 - 3/19/23 Daily Deployment Sheet listed Staff G assigned to the Resident's wing (Medbridge) 2:00 a.m. - 6:30 a.m. The Facility Investigation documented Staff G reported she only administered the resident one dose of the medication at 00:18 a.m. which had been signed out on the CDAR and March 2023 EMAR appropriately. Staff G reported the signature on the 4:00 a.m. dose had not been her signature. The 3/19/23 Daily Deployment Sheet documented Staff A assigned to work on Resident #3's hallway (Medbridge). The Narcotic and Controlled Substance Shift to Shift Count Sheet for the Medbridge Hallway dated 3/11/23 showed Staff G as the off-going nurse handed the medication cart keys to Staff A as the on-coming nurse. e. On 3/19/23 at 8:30 a.m. and 12:30 p.m., Staff A signed out a 5 mg oxycodone doses on the CDAR. She failed to document the doses on the March 2023 EMAR. A Time Card Report dated 3/19/23 showed Staff A worked 6:03 a.m. - 7:04 p.m. f. The Facility Investigation documented Resident #3 had been interviewed on 3/19/23 and reported he didn't recall receiving any narcotics on 3/18/23. g. Resident #3's Vital Signs Record documented reflected pain levels from 3-9 on a 1-10 pain scale for 3/18/23 and pain levels from 4-7 on a 1-10 pain scale on 3/19/23. h. On 3/19/23 at 6:45 p.m., Staff A wrote a statement when she completed Narcotic Count with Staff G the Narcotic Count had been correct. At 6:58 p.m. Staff A wrote in a statement she did not sign any medications out under Staff G's name. i. On 3/20/23 Staff E, RN, wrote a statement noting it had been 1:40 a.m. when Staff A alerted her about her signature being forged. Staff E wrote Staff G's signature had been forged twice. She wrote Staff G called Staff F and informed her of what had happened. Staff F told Staff G to write a statement and leave a copy for her and she would review it on Monday 3/20/23. When Staff E came to work (3/19/23), she knew how many pills she had counted with Staff G since there were not many narcotics on the Medbridge hallway. Staff E noticed some CDARs had forged signatures with different names, Staff I, RN, Staff M, RN and Staff D, RN for the same day. Staff E wrote she asked Staff A about it and wasn't satisfied with the answer because clearly pills were taken illegally or administered in suspicious ways. Staff E called the DON and reported. She had also reported to Staff F as well. The 3/19/23 Daily Deployment Sheet dated 3/19/23 showed Staff E worked 2 p.m. - 10:30 p.m. on the Medbridge Hallway. A Time Card Report showed Staff A worked 6:03 a.m. - 7:04 p.m. An interview conducted via phone on 5/16/23 at 9:52 a.m., Resident #3 voiced he had received oxycodone and a muscle relaxant medication during his stay at the facility. The nurses would only give him his oxycodone every 4 hours. He thought there had been an incident of a nurse signing out his medications and he didn't think that he had received them. He thought he voiced that situation to Staff G but couldn't recall a date or time of the incident. Resident #3 didn't want to get anyone in trouble, but he felt he needed to get out of the nursing home before they killed him there. A nurse had brought insulin into his room and informed him it was time for his insulin. Resident #3 didn't receive insulin and immediately voiced this to the nurse. The nurse went out to double check the EMAR and he did not receive the insulin. During an interview on 5/16/23 at 10:47 a.m., Staff G reported she worked that Friday and Saturday (3/17/23 and 3/18/23) at the facility. She remembers it involved a new admit in room [ROOM NUMBER] B (Resident #3). The facility had switched to a new pharmacy that delivered the medications in the early morning. She recalled Resident #3 had called with a pain level of 8 and asked for his oxycodone. She specifically remembered she told him the medication had not been delivered from the pharmacy. She explained he had Tylenol available to take for pain. She gave him 3 tablets of 325 mg (975 mg) of APAP around 2 a.m. She went in to hang his intravenous medication later and he reported being fine at that time. He didn't seem to have much for pain. At 5:30 a.m. the nurse from the TCU hallway came over and informed her of a pharmacy delivery. The pharmacy provided a CDAR with the delivery of each narcotic medication card. She went to record the time received on the CDAR and noticed the absence of an area to document the time of delivery down on the form. She wrote 5:30 a.m. on the CDAR for receiving 30 oxycodone pills delivered. Staff A had been the nurse that followed her coming onto dayshift. They counted the narcotics and she handed the keys off to Staff A. She reported when she returned back to work, she received report from Staff E on Saturday night (3/18/23). Staff E specifically told her that Resident #3 had not complained of any pain and she had not given him any pain medications. She recalled Resident #3 called around 12:00 a.m. for pain medication. Resident #3 said he hadn't had pain medication for a long time. She asked him about his pain level and went to the cart to get medication. When she opened the cart and checked his oxycodone card, there had been a lot of medication that had been pulled from the card. She double checked with his orders. He could take the oxycodone medication every 4 hours. She specifically remembered that Staff E had told her she had not given the resident any pain medication. The Resident adamantly voiced he hadn't had pain medications in a long time. She compared the oxycodone medication card with the EMAR and the CDAR. She realized oxycodone had been signed out for 12:00 a.m. and 4 a.m. for Friday night during her shift. She had not given the medication as it had not been delivered from the pharmacy and the signatures on the CDAR were not her signatures. She had only given Tylenol around 2:00 a.m. She called Staff E to come look at the signatures as a second witness. They compared the signatures from the pharmacy delivery slip on 3/18/23 to the CDAR. Her signature had been forged by someone else. Staff G stated they are trained to sign off medications in the EMAR and the CDAR. She had always been taught to sign out a narcotic with her full signature when she gave a PRN pain medication. The charge nurse is the only one that has keys to the medication cart. She keeps the medication cart keys on her. During an interview on 5/16/23 at 2:10 p.m., the Human Resource Coordinator voiced the first day during Staff A's orientation she left for about 3 hours. She said she had a therapy appointment via phone. She thought that was odd it hadn't come up before. Looking back, she didn't know if she had taken something and had to go sleep or something. She seemed sort of shell shocked when she came back, visibility upset and not able to pay attention when she returned. She had 3-4 days of in-services to do and she had to redirect her. She wanted to go to the town hall meeting on the change of company. She directed Staff A to stay on task. Staff A went to the floor to work and they saw a big change in her. Her professionalism changed. She had a dental appointment the first week she worked the floor. They honored it, but wondered why she hadn't brought up these appointments ahead of time since she was a new hire. There had been a time when she kept asking the Certified Nurse Aides (CNA's) to get her coffee and food. She wondered if Staff A had been trying to clear staff out of the area so that no one would be around. They provide meals at 10 a.m. and 4:00 p.m. for staff and coffee in the break room. They don't allow those things at the Nurses' Station and Staff A needed constant reminders. On 5/16/23 at 3:11 p.m., Staff M, RN explained the Director of Nursing (DON) asked him to verify signatures on shifts that he worked. He did verify several signatures were not his handwriting. It happened a long time ago and he couldn't recall exactly which residents he had been asked about. He did report with Staff A and passed the keys on to her a lot. Staff M reported he worked Medbridge hallway. On 5/17/23 at 6:34 p.m., the Administrator voiced he had first become aware of the situation on the evening of 3/19/23 by the DON. The DON went to the facility and got a statement from Staff A and suspended her from duty. At that point they didn't think they had an allegation of abuse. The narcotic counts were not off, but something had been fishy. He had not been able to verify Staff G's statement until the evening of 3/20/23 when the pharmacy receipt came to verify the date and time the medication had been received by the facility. That confirmed Staff G's story. He reported to the Iowa Department of Inspection and Appeals (DIA) on 3/21/23. He had verified with the ADON on 3/19/23 that the narcotic count had been accurate. They thought it may have been a simple case of someone forgetting they had administered a dose of medication and it turned into someone stealing medications. He had never seen anything like it. From their final investigation, it had affected up to 9 residents and showed a trend that Staff A had taken the pills. He stated they had reported Staff A to the Board of Nursing. He further reported Staff A would be terminated. He didn't feel this had been the first time that Staff A had taken medications. She seemed to know exactly what she was doing. He wondered if it had happened at other facilities and they never did anything about it. They tried to do the right thing and get it reported into the State. An interview on 5/18/23 at 11:37 a.m. with Staff K revealed when she gives a narcotic she documents it in the EMAR and the CDAR. She voiced she does not give out a lot of narcotics as she works night shift. She just does the as needed doses of narcotic pain medications. She is assigned to two hallways at night, usually TCU and Legacy. She has the medication cart keys for those two carts. She is the only one that has the medication cart keys as a charge nurse. Unless you have to leave the building, you keep the keys on you, even at break. She recalled the DON asking her to verify her signatures on the CDAR after the incident. She documents narcotics out in both places the CDAR and the EMAR. If both places were not documented out, she did not administer that dose of narcotic. She can't remember the specific residents involved, it has been too long ago. She reviewed the Facility Investigation and reported the findings were accurate regarding her signatures. On 5/22/23 at 10:50 p.m., Staff I, RN, voiced she identified the issue as the Narcotic Count had always been correct. The medication cards matched the CDAR counts. No one had been looking at the actual signatures on the sheets. At the time she had worked all the hallways. If the counts were correct, they didn't pay attention to the signatures. Two nurses perform the Narcotic Count at the shift change. One nurse holds the book and looks at the CDAR and the other nurse compares the narcotic medication cards. The medication cart keys are between two nurses on the cart usually at shift change. Once the count is done they officially hand over the keys to the oncoming nurse. The keys stay on her the whole shift including break times. If she leaves the building she will give them to another nurse. That did not affect any of the signatures she reviewed on the narcotic sheets. She is required to document the administration of as needed (PRN) pain medication in the EMAR as well as where the pain is and the level of the pain. There is a Progress Note that comes up and they record the pain level and location. If generalized pain they don't write a location. The Progress Notes flag for a follow-up pain level. The pain follow-up is flagged in the computer as yellow to indicate a pain follow-up is needed. If it shows up in red, the pain assessment is overdue. If it changes to green, the follow-up is completed. That is how they communicate the as needed pain medication follow-up through the computer system. Staff I voiced Staff A had an odd flighty personality. She would pop from one subject to another. It was hard to follow her. In her opinion she had been like that throughout her employment. She didn't have a clue that Staff A had been taking narcotics. If someone got a narcotic and they were in a lot of pain they would alternate the narcotic with Tylenol. They would stagger the two medications to try to keep an even [NAME] going for the pain control. They also would use ice packs. On 5/23/23 at 9:12 a.m., Staff G reported she had called Staff F (ADON/Unit Supervisor) between 1-2 a.m. on 3/19/23. Twice she called with no answer. She called the DON's personal cell phone. The DON missed the call, so she left a voicemail. She called Staff F's personal cell phone and Staff F answered. Staff F directed her to write a statement and leave copies in the office. Staff F said she would deal with it on Monday. Staff A reported she specifically told Staff F someone had forged her signature for narcotics on the narcotic record that she hadn't given. Once you give report and hand off the keys, that is the only nurse that has medication keys to the narcotic lockup. Staff G suspected Staff A as she had been the only person that could have given Resident #3 his narcotic pain medication. Staff E worked the 2-10:30 p.m. shift following Staff A. When staff G returned to work the early morning of 3/19/23 Staff E had reported off to her that Resident #4 had not taken any pain medication. Staff A had been the only other nurse that had access to his narcotic medications. Resident #3's CDAR had been blank when she left duty on the morning of 3/18/23. He had no complaints after the Tylenol she administered on 3/18/23 around 2:00 a.m. She handed the keys off to Staff A around 6:00 a.m. on 3/18/23. Staff E followed Staff A on the evening shift and Staff E had specifically told her in report she had not given any pain medications to the resident. When she reviewed the CDAR and reviewed Resident #3's physician order. He could only have his oxycodone every 4 hours. She reported not being happy about the situation. Staff G had no relation to Staff A prior to working with her at the facility. During an interview on 5/25/23 at 11:31 a.m., the DON reported the CDAR once all doses have been administered or doses destroyed are to go to the Unit Supervisor to put the CDAR into the folder. If it is a weekend, the nurses can put the CDAR into the folder. Prior to the incident she had just looked at the CDARS to see if the narcotic doses were signed. She had not been going back and checking the EMAR or the actual medication cards. The nurses were initialing on the CDAR to sign out narcotic doses. Now she is encouraging the nurses to sign with their full last name. That is her preference but not facility policy. She didn't know of any real processes in place prior to the incident regarding missing CDAR's. They just followed standard procedures. Going forward, she has asked the pharmacy to email her a list of all narcotics that are delivered to the facility so she can check the medication cards have been signed in, counts verified and the medication card is in the double lock up. She will ensure narcotics are signed in correctly. She plans to utilize the Master Controlled Substance Log. She provided more education this morning (5/25/23) to the nurses. She is requiring two nurses to sign in narcotic medication cards with pharmacy delivery and place into lock-up. Both nurses have to sign the Master Controlled Substance Log to document the delivery of the narcotics and both nurses have to sign the Log after destruction of any narcotics. The EMAR to the CDAR to the Master Controlled Substance Log should all match. She reported she carries the accountability for the accuracy of the process. She expects the nurses to sign out narcotics on both the EMAR and the CDAR. During an interview on 5/23/23 at 1:35 p.m., the DON reported she would expect the nurses to document out all as needed narcotic medication doses on the CDAR and on the EMAR so that a follow-up pain assessment could be completed. She reported they had concluded from their investigation that Staff A had been taking resident narcotic pain medications. On 5/31/23 at 9:55 a.m., the Administrator provided a copy of an audit list dated 4/25/23 that detailed for Resident #3 use of oxycodone IR 5 mg the pharmacy delivered of 30 tablets, with the CDAR showing 9 doses signed out. The March 2023 EMAR showed only 2 doses signed out. The medication card had 21 doses remaining on the card at the time of the audit with 7 discrepancies found. The Audit contained a note that documented two doses had been given by Staff A and were questionable so the facility reimbursed out of good faith. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, dated July 2019, provided by the facility, included a Policy Statement: all residents have the right to be free from abuse, neglect misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking acts that result in person degradation. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. It shall be the policy of this facility to implement written procedures to prohibit abuse, neglect, exploitation and misappropriation of resident property. The Policy included the following definition: 1. 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. This includes misappropriation or diversion of resident medications. 2. The MDS assessment dated [DATE] for Resident #4 showed a BIMS score of 11 indicating moderate cognitive loss. The Resident required limited assistance with transferring, dressing and toileting. The MDS documented Resident #4 utilized scheduled and as needed medication for frequent pain of a 4 on a 1-10 scale (1 being the least amount of pain and 10 being the worst pain). The Resident utilized opioid (narcotic) medication 3 out of 7 days of the look-back period. The MDS listed diagnoses of fracture of the pubis ramus (pelvic fracture), coronary artery disease, heart failure, hypertension, arthritis and long-term use of opioids. Resident #4's Care Plan dated 3/05/23 had a focus the Resident is at risk for pain related to arthritis, neurogenic cause, orthopedic surgery and musculoskeletal issues. The Care Plan directed the nurses to provide analgesic as ordered and monitor for non-verbal signs of pain. A Physician Order electronically signed by the Provider on 3/09/23 showed a current order as of 3/04/23 as follows: a. Roxicodone (generic: oxycodone, narcotic/opioid pain medication) oral tablet 5 milligrams (mg), give one tablet by mouth every 4 hours as needed for pain control. b. Hydrocodone-acetaminophen (narcotic/opioid pain medication) oral tablet 5-325 mg, give 1 tablet by mouth every 24 hours as needed for pain control to be given at bedtime. A review of the CDAR, March 2023 MAR, March 2023 Daily Deployment Sheets and Facility Investigation for Resident #4's use of hydrocodone-acetaminophen, give 1 tablet by mouth every 24 hours as needed for pain control to be given at bedtime, revealed the following discrepancies: a. 3/04/23 at 11:10 p.m., dose of hydrocodone-acetaminophen 5-325 mg one tablet signed out on the CDAR with an unknown signature. The dose had not been signed out on the March 2023 EMAR. The Daily Deployment Sheet for 3/04/23 showed Staff G assigned 2:00 a.m. to 6:30 a.m. the Resident's hallway (Medbridge) at that time. A Facility Investigation, undated, documented stated she did not administer the medication and it is not her signature on the CDAR. Staff G further voice she could not have given the medication at 11:10 p.m. as the medication had not been delivered from the pharmacy at that time. A Pharmacy Delivery Slip showed a signed wet signature Staff G signed for the medication delivery 3/05/23 at 3:52 a.m. The 3/05/23 schedule documented Staff A, worked 6-2:30. Staff G handed the medication cart keys off to Staff A at the change of shift. b. On 3/05/23 the CDAR documented Staff G signed receipt of 14 tablets of hydrocodone-acetaminophen 5-325 mg tablets from the pharmacy. c. On 3/11/23 at 5:45 a.m., hydrocodone-acetaminophen 5-325 mg 1 tablet signed out on the CDAR by Staff L, RN. The dose had not been signed out on the March 2023 EMAR. d. on 3/13/23 at 3:00 a.m. and 3/14/23 at 5:30 a.m., the CDAR documents one tablet of hydrocodone-acetaminophen 5-325 mg medication signed out by Staff I. Neither of the medication doses were documented in the March 2023 EMAR. The Facility Investigation noted Staff I reported she did not administer those doses of hydrocodone-acetaminophen to Resident #4 and the signatures on the CDAR were not her signatures. The 3/13/23 - 3/14/23 daily schedules documented Staff I worked 2:00 a.m. - 6:30 a.m. on the Medbridge hallway and handed the medication cart keys off to Staff A who worked 6-2:30 p.m. on the Medbridge hallway. A witness statement signed by Staff I as part of the facility investigation documented the 3/13/23, 3/14/23 and 3/15/23 doses that were signed out on the CDAR in Staff I's name were not her signatures. A Time Card Report showed Staff I did not work on 3/14/23 and 3/15/23. e. On 3/14/23 at 6:05 p.m., Staff E, RN, signed out one tablet of hydrocodone-acetaminophen 35-325 mg on the CDAR, but failed to sign the medication dose out on the March 2023 MAR. The Facility Investigation documented Staff E confirmed she did administer the medication dose. f. On 3/15/23 at 4:00 a.m., the CDAR documents one tablet of hydrocodone-acetaminophen 5-325 mg signed out by Staff D, RN. The dose had not been signed out on the March 2023 MAR. The Facility Investigation documented Staff D verbalized she did not give this medication. The 3/14/23 daily schedule documented Staff D worked 2 a.m. - 4 a.m. on Medbridge. The 3/15/23 daily schedule documented Staff A worked 6:00 a.m. - 2:30 p.m. on Medbridge. The March 2023 Narcotic and Controlled Substance Shift to Shift Count Sheet for Medbridge hallway showed Staff D completed narcotic count with Staff A and handed the medication cart keys to Staff A. A Time Card Report dated 3/15/23 showed Staff A worked 5:59 a.m. - 4:51 p.m. Staff D's Time Card revealed she clocked in 3/15/23 at 1:54 a.m. - 10:57 a.m. g. On 3/15/23 at 0000, the CDAR showed Staff I signed out one tablet of hydrocodone-acetaminophen 5-325 mg. The dose had not been documented on the March 2023 MAR. The 3/15/23 daily schedule showed Staff I had not been working at the facility at that time. The Facility Investigation detailed the signature on 3/15/23 at 0000 p.m. had not been Staff I's actual signature. The 3/14/23 - 3/15 23 Daily Deployment Sheet documented Staff A worked 6-2:30 p.m. A Time Card Report dated 3/15/23 showed Staff A worked 5:59 a.m. - 4:51 p.m. A Time Card Report for Staff I supported she did not work on 3/15/23. h. On 3/16/23 at 5:30 a.m. the CDAR detailed one tablet of hydrocodone-acetaminophen 5-325 mg had been signed out by Staff L. The 3/15/23 into 3/16/23 Daily Deployment Sheet revealed Staff L had not been working at that time. The dose had not been documented on the March 2023 EMAR. i. A Written Statement dated 3/23/23 by Staff I documented the narcotic sign out sheet (CDAR) documented with her initials for March 13, 14, and 15, were not her signatures. A Time Card Report supported Staff I did not work on 3/14/23 and 3/15/23. On 5/16/23 at 2:46 p.m., Staff D reported she became aware of missing narcotic medication the Monday after Staff A had been walked out of the facility. Staff E informed her she may want to look back at the CDAR's as her signature had been used a lot. Staff D looked back at the CDAR's and found her signature had been used when she had not even been working. It was bad enough that Staff A stole medication but she was trying to take other staff down with her. Staff D voiced she had been made when she found out. She thought she had counted at least 15 times that A had signed medications out under her initials. Staff D voiced Resident #4 had been on oxycodone for pain, but she didn't take it that much. Staff D remember the weekend prior to the time change, Resident #4 had pain and took Tylenol and her oxycodone. She voiced she didn't feel good afterward. Later that day Resident #4 had voiced it had been too much pain medication and she wouldn't do that again. However, if you look back, Staff A according to the CDAR had been giving a lot of them. Staff D didn't think Resident #4 would have been taking that many pills. She reviewed Resident #4's CDAR and reported dose #7 3/14/23 at 4:00 a.m. had not been her handwriting. She has not found any other signatures that are not hers since 3/19/23 when [NAME] was walked out of the facility. She is the only one that has keys to the medication card. She keeps the keys on her until the shift change over. She doesn't feel anyone could have gotten her keys. The narcotic counts were never off when she counted. She trained Staff A when she came on staff. She noticed during Staff A's orientation, she had been really flighty. She had a hard time staying focused. She would take medications into a resident room and then start doing other tasks for the residents. She had to really try to keep her on task. Staff A seemed to always be seeking out something to eat and drink all the time. She would wander off. During an interview on 5/17/23 at 4:24 p.m., Staff E reported she questioned that Sunday (3/19/23) the CDAR. There had been two residents, she knew that resident would never take 6-7 pain medications in a shift. She voiced it seemed like Staff A had two different signature styles. She would sign one way and give a resident their narcotic medication, then sign her signature another way to steal a medication. She couldn't watch someone steal resident medication. Staff E checked her cell phone and brought up a voicemail on her phone dated 3/19/23 at 4:50 p.m. that contained a recording from the ADON instructing her to keep all staff at the facility (since there had been an issue with the narcotic records). She reported she called the DON and the DON stated she would be coming to the facility. During an interview on 5/22/23 2:52 p.m., Staff E reviewed Resident #4's CDAR from March 2023. She stated dose #9 and #10 from the sheet were signed out to look[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, document review, resident and staff interviews, the facility failed to follow Physician Orders regarding the administration of narcotic pain medication for 4 of 8 resident sampled (Resident #3, #4, #6, #17) and failed to show proper documentation for clarification of a narcotic pain medication order for 1 of 8 residents sampled (Resident #14). The facility identified a census of 79 residents. Findings Include: 1. The MDS assessment dated [DATE] for Resident #3 showed a BIMS score of 12 indicating moderate cognitive loss. The Resident required extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene. The MDS documented Resident #3 as utilized as needed pain medication for occasional pain of 5 on a 1-10 scale receiving opioids 6 out of the 7 day look-back period. The MDS listed diagnoses of left hip fracture, anemia, hypertension, end stage renal disease, chronic obstructive pulmonary disease (COPD) and a wound infection. The Care Plan dated 3/17/23 identified a focus Resident #3 at risk for pain related to arthritis, surgical incision, infection to wound site. The Care Plan directed the nurses to provide analgesics as ordered and evaluate efficacy of pain management. A Hospital After Visit Summary dated 3/17/23 documented a Physician Order for oxycodone 5 milligrams (mg) immediate release (IR) by mouth every 4 hours as needed for pain of the left hip. The March 2023 Electronic Medication Administration Record (EMAR) showed Staff A, Registered Nurse (RN), administered an oxycodone hydrochloride (HCL) oral tablet (narcotic opioid medication), give 5 mg by mouth every 4 hours as needed for left hip pain 3/18/23 at 7:46 a.m. for a pain level of a 9 on a 1-10 pain scale (10 being the worst pain). Staff A documented the 7:46 a.m. dose as I for ineffective and according to the E[DATE]/18/12 at 7:57 a.m. administered a second 5 mg oxycodone HCL tablet to Resident #3. The March 2023 Controlled Drug Administration Record (CDAR) showed Staff A signed out doses of the medication on 3/18/23 at 8 a.m. and 12:30 p.m. A undated Facility Investigation documented Resident #3 received a dose of as needed oxycodone on 3/18/23 at 7:45 a.m. by Staff A. The dose had not been documented on the March 2023 EMAR. The March 2023 EMAR showed a second dose of the oxycodone had been administered by Staff A at 8:00 a.m. but the March 2023 CDAR showed the dose had not been signed out until noon on 3/18/23 by Staff A. On 5/22/23 at 10:50 p.m., Staff I, RN, voiced she is required to document the administration of as needed pain medication in the EMAR where is the pain and what level is the pain. There is a progress note that comes up and they record the pain level and location. If generalized pain they don't write a location. The progress note flags for a follow-up pain level. The pain follow-up is flagged in the computer as yellow to indicate a pain follow-up is needed. If it shows up in red, the pain assessment is overdue. If it changes to green, the follow-up is completed. That is how they communicate the as needed pain medication follow-up through the computer system. On 5/23/23 at 1:35 p.m., the Director of Nursing (DON) reported she expected the nurses to document out narcotic medications on the CDAR and the EMAR. She expects the nurses to follow the physician orders as written. She stated she didn't think the facility had a policy on following physician orders. On 5/23/23 at 1:35 p.m., the DON reported she expected the nurses to document out narcotic medications on the CDAR and the EMAR. She expects the nurses to follow the physician orders as written. She stated she didn't think the facility had a policy on following physician orders. 2. The MDS assessment dated [DATE] for Resident #4 showed a BIMS score of 11 indicating moderate cognitive loss. The Resident required limited assistance with transferring, dressing and toileting. The MDS documented Resident #4 utilized scheduled and as needed medication for frequent pain of a 4 on a 1-10 scale (1 being the least amount of pain and 10 being the worst pain). The Resident utilized opioid (narcotic) medication 3 out of 7 days of the look-back period. The MDS listed diagnoses of fracture of the pubis ramus (pelvic fracture), coronary artery disease, heart failure, hypertension, arthritis and long-term use of opioids. Resident #4's Care Plan dated 3/05/23 had a focus the Resident is at risk for pain related to arthritis, neurogenic cause, orthopedic surgery and musculoskeletal issues. The Care Plan directed the nurses to provide analgesic as ordered and monitor for non-verbal signs of pain. A Physician Order Recertification electronically signed by the Provider on 3/09/23 showed a current order as of 3/04/23 as follows for narcotic (opioid) pain medication: a. Roxicodone (generic oxycodone) oral tablet 5 mg, give one tablet by mouth every 4 hours as needed for pain control b. Hydrocodone-acetaminophen oral tablet 5-325 mg, give 1 tablet by mouth every 24 hours as needed for pain control to be given at bedtime. The CDAR for Resident #4 dated 3/4/23 - 3/18/23 documented the following pharmacy label at the top: hydrocodone-APAP (Tylenol) 5-325 mg tab, take 1 tablet by mouth nightly as needed for pain. The Record documented the following hydrocodone doses had been signed out on the Record: a. On 3/4/23 at 11:10 p.m. one tablet. b. On 3/9/23 at 2:30 p.m. one tablet. c. On 3/10/23 at 5:45 a.m. one tablet. d. On 3/13/23 at 1:40 a.m. one tablet. e. On 3/13/23 at 3:00 a.m. one tablet. f. On 3/14/23 at 5:30 a.m. one tablet. g. On 3/14/23 at 6:05 p.m. one tablet. h. On 3/15/23 at 4:00 a.m. one tablet. j. On 3/15/23 at midnight one tablet. k. On 3/16/23 at 5:30 a.m. one tablet. l. On 3/18/23 at 6:10 a.m. one tablet. The March 2023 EMAR showed the following doses of hydrocodone-acetaminophen 5-325 mg tab, take 1 tablet by mouth every 24 hours as needed for pain control to be given at bedtime documented: a. On 3/09/23 at 2:31 a.m., for a pain level of a 3 on a 1-10 pain scale by Staff I; dose effective. b. On 3/13/23 at 1:42 a.m., for a pain level of a 3 on a 1-10 pain scale by Staff I; dose ineffective. c. On 3/18/23 at 6:40 a.m., for a pain level of a 5 on a 1-10 pain scale by Staff A; dose effective. The March 2023 EMAR lacked documentation of the hydrocodone-acetaminophen 5-325 mg doses signed out by the Nursing Staff on the March 2023 CDAR Record. The March 2023 EMAR showed the following doses of Roxicodone oral tablet 5 mg, give 1 tablet by mouth every 4 hours as needed for pain control: a. On 3/05/23 at 7:40 a.m.,. for a pain level of 10 on a 1-10 pain scale by Staff A; dose effective. b. On 3/05/23 at 7:27 p.m., for a pain level of a 4 on a 1-10 pain scale by Staff E; dose effective. c. On 3/07/23 at 4:08 a.m., for a pain level of a 5 on a 1-10 pain scale by Staff C; dose effective. d. On 3/10/23 at 6:15 a.m., for a pain level of 9 on a 1-10 pain scale by Staff A; dose ineffective. e. On 3/18/23 at 6:36 a.m., for a pain level of 5 on a 1-10 pain scale by Staff A; dose ineffective. f. On 3/19/23 at 6:18 a.m., for a pain level of 10 on a 1-10 pain scale by Staff A; dose ineffective. A review of Resident #4's CDAR showed a Pharmacy label reading: oxycodone immediate release 5 mg tablets take 1 tablet by mouth every four hours as needed for pain x 7 days. The CDAR documented the facility received 12 tablets on 3/18/23. Further review revealed no doses of the oxycodone medication had been signed out on the CDAR. The CDAR documented the signature of the DON and Staff E, RN destroyed 12 tablets of the narcotic medication. The CDAR did not contain a date the destruction took place. During an interview on 5/23/23 at 1:35 p.m., the DON reviewed Resident #4's CDAR with the March 2023 EMAR. She noted the as needed doses of the hydrocodone-acetaminophen ordered to be given at bedtime as needed had been given at times other than bedtime. She reported she would expect the nurses to document out all PRN narcotic medication doses on the CDAR and on the EMAR so that a follow-up pain assessment could be completed and she expected the physician orders to be followed. On 5/23/23 at 2:30 p.m., Staff E reviewed Resident #4's Controlled Drug Administration for March 2023. She confirmed the signature on the Record had been hers. She remembered wasting the Resident's narcotics with the DON, but stated she can't remember how many tablets they wasted. It had been too long ago. On 5/23/23 on 2:42 p.m., the DON reviewed the March 2023 EMAR for Roxicodone PRN order and the March 2023 Controlled Drug Administration Record. She reported she remembered wasting Resident #4's narcotics. The DON reviewed the March 2023 EMAR and CDAR. She did not have an explanation for why the Roxicodone had been signed out as administered on the March 2023 EMAR and were not signed out on the March 2023 CDAR. She wanted to look further into the matter. 5/23/23 at 2:57 p.m., the DON reported she did not have an answer for the discrepancy on Resident #4's records. She acknowledged the 7 day limit on the oxycodone (Roxicodone) label the pharmacy had placed on the CDAR and the facility physician order for oxycodone did not have a time limit on the order. The DON returned at 3:02 p.m. and reported the pharmacy verified they sent out 12 tablets of oxycodone. The DON also reported the pharmacy confirmed they sent out a medication card containing 30 tablets of oxycodone that the facility did not have a CDAR on. The DON provided a copy of the Pharmacy Delivery Slip showing Staff M signed for the delivery of 30 tablets of oxycodone for Resident #4 at 3:30 p.m. A review of the 3/11/23 Daily Deployment Sheet listed Staff M as the charge nurse assigned to Medbridge hallway where Resident #4 resided. An interview with the Pharmacist on 5/24/23 at 9:55 a.m., revealed the pharmacy had sent 9 tablets of oxycodone to the facility on 3/5/23; 30 tablets of oxycodone on 3/10/23 and 12 tablets of oxycodone on 3/18/23. The Pharmacist checked the records at 10:03 a.m. and voiced the facility had not returned any of the medication cards to the pharmacy. During an interview on 5/24/23 at 10:25 a.m., the Administrator explained he had been aware of the missing CDAR's for Resident #4. He had looked all over the facility for the CDAR and had not found the records. On 5/24/23 at 10:50 a.m., Staff P Medical Records/Scheduler reported she could not find a CDAR for Resident #4 oxycodone 9 tablets. She stated she had reported it to the Administrator and he had already talked to the Surveyor about it. During an interview on 5/24/23 at 12:15 p.m., the DON reported she had not been aware of Resident #4 missing a CDAR for an oxycodone count of 30 or 9 tablets. The nurses are to document the narcotic delivery on the Master Controlled Substance Log and they circle the count number received on the CDAR however, she commented they do this, but it is not a facility policy. She reported two nurses have to destroy narcotics and document the destruction on the CDAR record. She stated the paper they filled out and attached to the CDAR following destruction had been under the old processes and management. They no longer do that. Both nurses sign the CDAR for the quantity of tablets destroyed. On 5/24/23 at 12:40 p.m., the Administrator reported he had looked in his computer and he had a file saved from 4/15/23 where he reviewed Resident #4's EMAR for the oxycodone. He had looked all over the facility for the CDARs and couldn't find them. He explained the review included the CDAR for the oxycodone of 9 tablets and he CDAR of 30 tablets. During an interview on 5/25/23 at 11:31 a.m., the DON reported the CDAR once all doses have been administered or doses destroyed are to go to the Unit Supervisor to put the CDAR into the folder. If it is a weekend, the nurses can put the CDAR into the folder. Prior to the incident she had just looked at the CDARS to see if the narcotic doses were signed. She had not been going back and checking the EMAR or the actual medication cards. The nurses were initialing on the CDAR to sign out narcotic doses. Now she is encouraging the nurses to sign with their full last name. That is her preference but not facility policy. She didn't know of any real processes in place prior to the incident regarding missing CDAR's. They just followed standard procedures. Going forward, she has asked the pharmacy to email her a list of all narcotics that are delivered to the facility so she can check the medication cards have been signed in, counts verified and the medication card is in the double lock up. She will ensure narcotics are signed in correctly. She plans to utilize the Master Controlled Substance Log. She provided more education this morning (5/25/23) to the nurses. She is requiring two nurses to sign in narcotic medication cards with pharmacy delivery and place into lock-up. Both nurses have to sign the Master Controlled Substance Log to document the delivery of the narcotics and both nurses have to sign the Log after destruction of any narcotics. The EMAR to the CDAR to the Master Controlled Substance Log should all match. She reported she carries the accountability for the accuracy of the process. She expects the nurses to sign out narcotics on both the EMAR and the CDAR and follow the physician orders. She expects the nurses will follow the physician orders for administering narcotic medications. 3. The MDS assessment dated [DATE] for Resident #6 showed a BIMS score of 15 indicating intact cognition. The Resident required extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene. The MDS documented Resident #6 utilized as needed pain medication for occasional pain of a 3 on a 1-10 pain scale. The MDS showed the Resident utilized opioid medications 4 out of 7 days of the look-back period. The MDS listed a diagnosis of cellulitis, end stage renal disease and Non-Alzheimer's Dementia. The Care Plan dated 3/14/23 identified Resident #6 at risk for pain related to arthritis, diabetic neuropathy, and incision to a right below knee amputation and directed the nurses to provide analgesics as physician ordered and monitor for non-verbal signs of pain. An Order Recap Report detailed the following narcotic (opioid) physician orders: a. Hydrocodone-acetaminophen oral tablet 5-325 mg. Give 1 tablet by mouth every 6 hours as needed for pain. Start Date 3/14/2023. Discontinuation date 3/15/23. b. Hydrocodone-acetaminophen oral tablet 5-325 mg. Give 1 tablet by mouth every 8 hours as needed for pain. Start Date 3/15/2023. Discontinuation date 3/25/23. c. Hydrocodone-acetaminophen oral tablet 5-325 mg. Give 1 tablet by mouth every 6 hours as needed for pain. Start Date 3/31/2023. Discontinuation date 4/18/23. The March 2023 CDAR for a count of 9 tablets hydrocodone 5-325 mg, take one tablet by mouth at bedtime as directed revealed the following documentation: a. On 3/04/23 I tablet signed out at 5:00 a.m. b. On 3/17/23 I tablet signed out at 7:00 a.m. c. On 3/17/23 I tablet signed out at noon. d. On 3/17/23 I tablet signed out at 4:30 p.m. e. On 3/18/23 I tablet signed out at 4:20 a.m. f. On 3/18/23 I tablet signed out at 8:30 a.m. g. On 3/18/23 I tablet signed out at 1:00 p.m. The Facility failed to follow the physician orders regarding administration of the hydrocodone-acetaminophen as needed order. 4. The MDS dated [DATE] for Resident #14 showed a BIMS score of 14 indicating intact cognition. The Resident required extensive assistance with bed mobility, dressing and toileting. The MDS identified the resident received scheduled pain management for frequent pain of a 4 on a 1-10 pain scale and utilized opioid medication 1 day during the 7 day lookback period. The MDS listed diagnoses of right fibula fracture, diabetes mellitus, hyperlipidemia and chronic obstructive pulmonary disease. The Care Plan dated 3/01/23 documented Resident #14 with pain to the right leg related to a fracture. The Care plan detailed a goal to reduce periods of breakthrough pain and directed the nurses to notify the physician if pain frequency/ intensity worsens or if the analgesia regimen becomes ineffective. A Hospital After Visit Summary electronically signed by the Provider on 3/01/23 listed the following medication orders: a. Oxycodone-acetaminophen 5-325 mg per tablet. Take 1-2 tablets by mouth every 4 hours as needed for pain. Alongside the physician order in hand writing appeared a triangle indicating change with 1 tab written in. The handwriting did not contain any signature or initials to indicate who wrote in the 1 tab. A review of Resident #14's medical record lacked documentation of a clarification order if the oxycodone-acetaminophen 5-325 mg dose should have been 1 tablet or 2 tables. A review of the March 2023 CDAR for Resident #14's use of oxycodone-acetaminophen (APAP) 5-325 mg tab, take 1 tablet by mouth every four hours as needed for pain revealed the following documentation that physician orders were not followed: a. On 3/05/23 at 10:30 a.m., 1 tablet signed out. b. On 3/05/23 2:00 p.m., 1 tablet signed out. c. On Dose #9 1 tablet signed out on the CDAR with no date documented. d. On 3/14/23 3:30 a.m., 1 tablet signed out. e. On 3/14/23 6:30 a.m., 1 tablet signed out. f. The last dose on the CDAR dated 3/14/23 lacked any documentation for time of administration. A second March 2023 CDAR with a count of 30 oxycodone-APAP 5-325 mg, take one tablet every 4 hours as needed for pain revealed the following documentation showing physician orders were not followed for administration: a. On 3/13/23 at 9:30 a.m., 1 tablet signed out. b. On 3/13/23 at 1:10 p.m., 1 tablet signed out. During an interview on 5/30/23 at 11:35 a.m., the DON explained the After-Visit Summary contained the documented initials of the in-house nurse practitioner on the page of the oxycodone-acetaminophen order. She reported they would not have written a separate physician order for the clarification of the oxycodone-acetaminophen order. They just write the 1 tab by the original order and then the nurse practitioner signs the document. The After-Visit Summary contained no date by the nurse practitioner's signature as to when the dose for the oxycodone-acetaminophen as needed order dose had been clarified. A Review of the facility Progress Notes on 5/30/23 revealed no documentation of verification of the admission orders by the Nurse Practitioner on 3/01/23. The Progress Notes showed documentation the Nurse Practitioner did a visit on 3/06/23 at 12:49 p.m. The Facility failed to be able to show documentation as to the date of the clarification order for the oxycodone-acetaminophen medication order upon admission to the facility on 3/01/23. 5. The MDS for Resident #17 dated 2/9/23 showed a BIMS score of 14 indicating no cognitive impairment. The Resident required limited assistance for ambulation, dressing and toileting. The MDS documented the Resident received scheduled and as needed pain medication for occasional pain of a 5 on a 1-10 pain scale as well as received opioid medication 1 day during the seven day lookback period. The MDS listed diagnoses of retroperitoneal abscess, cancer, and adult cell lymphoma/leukemia. The Care Plan dated 1/30/23 detailed Resident #17 had voiced abdominal pain related to disease process and recent surgery. The Care Plan documented a goal the Resident would express the pain management within acceptable limits and directed the nurses to administer pain medications according to the physician orders. A Physician order Sheet electronically signed by the provider on 2/03/23 showed an order effective 1/30/23 for oxycodone HCL oral capsule 5 mg, give 5 mg by mouth every 6 hours and as needed (PRN) for pain. The February 2023 Controlled Medication Utilization Record documented the following discrepancies with following the physician orders for Resident #17's use of oxycodone immediate release 5 mg tablet, take 1 tablet by mouth every 6 hours as needed for pain: a. On 2/23/23 at 8:00 p.m., one tablet signed out for administration. b. On 2/23/23 at 1:30 p.m., one tablet signed out for administration. The Facility failed to follow the 6 hour administration for the PRN medication per the physician order for the oxycodone as needed medication.

Based on clinical record review, document review and staff interview the facility failed to safeguard against potential loss, and/or diversion of controlled substances due to a lack of complete documentation when administering narcotics for 8 of 8 residents sampled (Resident #3, #4, #5, #6, #14, #15, #16, #17). The facility reported a census of 79 residents. Findings Include: 1. A clinical record review revealed staff had signed out a narcotic on the Controlled Drug Administration Records (CDAR), but lacked documentation of administration documentation on the Electronic Administration Record (EMAR) for the following residents: a. Resident #3: 3/18/23 one entry lacked a dose signed out on the EMAR. Another narcotic dose had been signed out at 7:46 a.m. on the March 2023 EMAR, but the CDAR showed the dose signed out at 12:30 p.m. 3/19/23 (3) doses not signed out on the EMAR. b. Resident #4: On 3/04/23, 3/11/23, 3/13/23, 3/14/23 (2) doses, 3/15/23 (2) doses, 3/16/23. c. Resident #5: On 3/08/23 (2) doses, 3/12/23 (2) doses, 3/13/23 (2) doses. d. Resident #6: On 3/14/23, 3/15/23, 3/17/23 (2) doses, 3/18/23 (2) doses. f. Resident #14: On 3/04/23 (4) doses, 3/05/23 (5) doses, 3/09/23, 3/10/23 (3) doses, 3/13/23 (3) doses, 3/14/23 (6) doses, 3/15/23, 3/17/23, 3/18/23 (3) doses, 3/19/23 (3) doses. g. Resident #15: On 2/18/23 (2) doses, 2/22/23 (2) doses, 2/23/23, 2/24/23, 2/25/23 (2) doses, 2/28/23 (3) doses, 3/14/23 (4) doses, 3/14/23, 3/15/23 (2) doses, 3/18/23 (2) doses, 3/19/23 (3) doses. h. Resident #16: On 2/24/23 (2) doses, 2/25/23, 2/28/23 (2) doses, 3/04/23 (3) doses, 3/05/23 (3) doses, 3/10/23 and 3/11/23. i. Resident #17: On 2/10/23, 2/11/23, 2/15/23, 2/18/23, 2/19/23 (2) doses, 2/20/23, 2/23/23 (2) doses. During an interview on 5/25/23 at 11:31 a.m., the Director of Nursing (DON) reported the Controlled Drug Administration Record (CDAR) once all doses have been administered or doses destroyed are to go to the Unit Supervisor to put the CDAR into the folder. If it is a weekend, the nurses can put the CDAR into the folder. Prior to the incident she had just looked at the CDARS to see if the narcotic doses were signed. She had not been going back and checking the EMAR or the actual medication cards. The nurses were initialing on the CDAR to sign out narcotic doses. Now she is encouraging the nurses to sign with their full last name. That is her preference but not facility policy. She didn't know of any real processes in place prior to the incident regarding missing CDAR's. They just followed standard procedures. Going forward, she has asked the pharmacy to email her a list of all narcotics that are delivered to the facility so she can check the medication cards have been signed in, counts verified and the medication card is in the double lock up. She will ensure narcotics are signed in correctly. She plans to utilize the Master Controlled Substance Log. She provided more education this morning to the nurses. She is requiring two nurses to sign in narcotic medication cards with pharmacy delivery and place into lock-up. Both nurses have to sign the Master Controlled Substance Log to document the delivery of the narcotics and both nurses have to sign the Log after destruction of any narcotics. The EMAR to the CDAR to the Master Controlled Substance Log should all match. She reported she carries the accountability for the accuracy of the process. She expects the nurses to sign out narcotics on both the EMAR and the CDAR. She expects nurses will follow the physician orders for the administration of narcotic medications. On 5/31/23 at 9:55 a.m., the Administrator provided an Audit Record dated 4/25/23 that detailed for Resident #3 use of oxycodone (narcotic/opioid pain medication) immediate release (IR) 5 milligrams (mg) a pharmacy delivery of 30 tablets, with the CDAR showing 9 doses signed out. The March 2023 EMAR showed only 2 doses signed out. The medication card had 21 doses remaining on the card at the time of the audit with 7 discrepancies found. The notes documented two doses had been given by Staff A, Registered Nurse (RN) and were questionable so the facility reimbursed out of good faith. 2. The March 2023 EMAR for Resident #4 revealed administration of oxycodone (Roxicodone) oral tablet 5 mg, give 1 tablet by mouth every 4 hours as needed for pain control as follows. a. On 3/05/23 at 7:40 a.m., for a pain level of 10 on a 1-10 pain scale by Staff A; dose effective. b. On 3/05/23 at 7:27 p.m., for a pain level of a 4 on a 1-10 pain scale by Staff E (RN); dose effective. c. On 3/07/23 at 4:08 a.m., for a pain level of a 5 on a 1-10 pain scale by Staff C, Licensed Practical Nurse (LPN); dose effective. d. On 3/10/23 at 6:15 a.m., for a pain level of 9 on a 1-10 pain scale by Staff A; dose ineffective. e. On 3/18/23 at 6:36 a.m., for a pain level of 5 on a 1-10 pain scale by Staff A; dose ineffective. f. On 3/19/23 at 6:18 a.m., for a pain level of 10 on a 1-10 pain scale by Staff A; dose ineffective. A review of Resident #4's CDAR showed a pharmacy label reading: oxycodone IR 5 mg tablets, take 1 tablet by mouth every four hours as needed for pain x 7 days. The CDAR documented the facility received 12 tablets on 3/18/23. Further review revealed no doses of the oxycodone medication had been signed out on the CDAR. The CDAR documented the signature of the DON and Staff E, RN destroyed 12 tablets of the narcotic medication. The CDAR did not contain a date the destruction took place. On 5/15/23 at 12:01 p.m., Staff C, RN explained she signs out the narcotics in the CDAR and the EMAR. She administers her own as needed pain narcotic medications. The medication keys always stay with her. She ensures the oncoming nurse does the narcotic count with her. They look at both the medication narcotic card and the narcotic sign out sheets. The counts are done at the beginning and end of the shift. She has never had a narcotic count be off, if she did, she would report it to the DON. On 5/16/23 at 7:20 a.m., Staff D reported the Pharmacy sends out a narcotic count sheet with each medication card. Some of the nurses throw all the narcotics they sign out on one sheet instead of using the narcotic sheet that comes with the card. She verifies the count when pharmacy delivers a new narcotic medication card and circles the count number on the narcotic sheet. She writes the amount received on the top of the narcotic sheet. She reported at 7:31 a.m. in regard to documenting out a narcotic medication they assess the resident's pain level, why they are requesting the medication, check the physician order, sign out in the EMAR and on the narcotic count sheet. If the count is off, she would notify the DON or ADON for an immediate investigation. She has never had the count be off. On 5/18/23 at 7:56 a.m., Staff D reported when the Pharmacy delivers the medications to the facility, the pharmacy requires them to sign a sheet of paper showing they received the medication. The Pharmacy person takes a copy and leaves a copy for the facility. The Pharmacy provides a CDAR for each narcotic card of medication that is delivered. She circles the number of doses on the CDAR to match the number that were delivered on the delivery slip. They are required to sign a narcotic pain medication out on the resident's CDAR and the EMAR. The Pharmacy Delivery Slip goes into the 24 hour communication book. On 5/22/23 at 2:22 p.m., Staff O, LPN voiced she had worked at the facility since September 2022. She received training from Staff D as her preceptor and went through medication administration and signing out of narcotics as part of her orientation. She explained she signs out a narcotic for administration in the EMAR and the CDAR. If the count is off, she would report to the DON. She would review to see if a nurse forgot to sign out a dose, but if there is a mistake in the narcotic count she would notify the DON immediately. She has never had to report any issues with the narcotic count to the DON. During an interview on 5/23/23 at 1:35 p.m., the DON reported she expected the nurses to document out all as needed narcotic medication doses on the CDAR and on the EMAR so that a follow-up pain assessment could be completed. On 5/23/23 2:35 p.m., Staff Q, LPN, reported they are required to sign narcotic pain medications out on the CDAR and the EMAR. He has to record the amount of pain and the location of the pain. The EMAR system will flag for him to do a follow up on any pain medications that will go to a progress note in the resident's chart. On 5/23/23 on 2:42 p.m., the DON reviewed the March 2023 EMAR for oxycodone as needed order and the March 2023 CDAR. She reported she remembered wasting Resident #4's narcotics. She did not have an explanation for why the oxycodone had been signed out as administered on the March 2023 EMAR and had not been signed out on the March 2023 CDAR. 5/23/23 at 2:57 p.m., the DON reported she did not have an answer for the discrepancy on Resident #4's records. She acknowledged the 7 day limit on the oxycodone label the pharmacy had placed on the CDAR and the facility physician order for oxycodone did not have a time limit on the order. The DON returned at 3:02 p.m. and reported the pharmacy verified they sent out 12 tablets of oxycodone. The DON also reported the pharmacy confirmed they sent out a medication card containing 30 tablets of oxycodone that the facility did not have a CDAR on. An interview with the Pharmacist on 5/24/23 at 9:55 a.m., revealed the Pharmacy had sent 9 tablets of oxycodone to the facility on 3/5/23; 30 tablets of oxycodone on 3/10/23 and 12 tablets of oxycodone on 3/18/23. The Pharmacist checked the records at 10:03 a.m. and voiced the facility had not returned any of the medication cards to the pharmacy. During an interview on 5/24/23 at 10:25 a.m., the Administrator explained he had been aware of the missing CDAR for Resident #4. He had looked all over the facility for the CDAR and had not found the records. On 5/24/23 at 10:50 a.m., Staff P Medical Records/Scheduler reported she could not find a CDAR for Resident #4 oxycodone 9 tablets. She stated she had reported it to the Administrator and he had already talked to the Surveyor about it. During an interview on 5/24/23 at 12:15 p.m., the DON reported she had not been aware of Resident #4 missing a CDAR for an oxycodone count of 9 tablets. The nurses are to document the narcotic delivery on the Master Controlled Substance Log and they circle the count number received on the CDAR however, she commented they do this, but it is not a facility policy. She reported two nurses have to destroy narcotics and document the destruction on the CDAR record. She stated the paper they filled out and attached to the CDAR following destruction had been under the old processes and management. They no longer do that. Both nurses sign the CDAR for the quantity of tablets destroyed. 5/25/23 at 10:24 a.m., Staff P reported she receives the CDAR from the two-unit managers or the DON. They personally hand the CDARs to her or put them in her mailbox which is in the Administrator's office. The CDAR's are kept in individual resident folders. The folders are not in locked cabinets, but the medical records office is locked. Outside of her office, she didn't know who had the responsibility to ensure the CDAR records were maintained. Most times once the documents were in her office, they made copies if needed so the documents did not leave the office. They retain the records for 3 years and then the records go to medical storage provider. On 5/25/23 at 10:36 a.m., Staff R, LPN, ADON/Nursing Supervisor explained the narcotic medications have to be destroyed by two nurses. The remaining doses of narcotic medication are popped out and put into the Drug Buster. Both nurses sign the destruction on the CDAR. The CDAR once all doses are gone or after destruction are turned into her as the Unit Supervisor. She puts the CDAR into the DON ' s folder. The DON picks up the papers from the folder every day or on Mondays following the weekend. She reported there is a Master Controlled Substance Log. Hypothetically, the nurses should also log the destruction of the narcotics on that record. She thought that may be a newer process but the DON would know more about that. During an interview on 5/25/23 at 11:31 a.m., the DON reported the CDAR once all doses have been administered or doses destroyed are to go to the Unit Supervisor to put the CDAR into the folder. If it is a weekend, the nurses can put the CDAR into the folder. Prior to the incident she had just looked at the CDARS to see if the narcotic doses were signed. She had not been going back and checking the EMAR or the actual medication cards. The nurses were initialing on the CDAR to sign out narcotic doses. Now she is encouraging the nurses to sign with their full last name. That is her preference but not facility policy. She didn't know of any real processes in place prior to the incident regarding missing CDAR's . They just followed standard procedures. Going forward, she has asked the pharmacy to email her a list of all narcotics that are delivered to the facility so she can check the medication cards have been signed in, counts verified and the medication card is in the double lock up. She will ensure narcotics are signed in correctly. She plans to utilize the Master Controlled Substance Log. She provided more education this morning to the nurses. She is requiring two nurses to sign in narcotic medication cards with pharmacy delivery and place into lock-up. Both nurses have to sign the Master Controlled Substance Log to document the delivery of the narcotics and both nurses have to sign the Log after destruction of any narcotics. The EMAR to the CDAR to the Master Controlled Substance Log should all match. She reported she carries the accountability for the accuracy of the process. She expects the nurses to sign out narcotics on both the EMAR and the CDAR. She expects nurses will follow the physician orders for the administration of narcotic medications. On 5/31/23 at 9:55 a.m., the Administrator provided an Audit Record dated 4/25/23 that detailed for Resident #4's hydrocodone-acetaminophen 5-325 mg, the pharmacy delivered 14 tablets, the CDAR showed 10 tablets signed out. The EMAR documented 4 doses signed out for administration. The medication card had 4 remaining tablets. The Audit Report documented 6 discrepancies in the records and detailed one dose had been signed out by agency staff. The facility could not confirm the accuracy so would reimburse out of good faith. The Audit Report 4/25/23 documented for an oxycodone IR 5 mg pharmacy delivery of 9 tablets, the EMAR showed 4 doses signed out as administered. The audit detailed the facility had no CDAR and no amount remaining due to no CDAR. For a delivery of 30 tablets of oxycodone IR 5 mg, the facility had no CDAR. The EMAR showed two doses signed out for administration and an unknown remaining on the card as the facility did not have a card or CDAR for the medication. 3. On 5/31/23 at 9:55 a.m., the Administrator provided an Audit Record dated 4/25/23 that detailed Resident #14 had a pharmacy delivery on 3/02/23 of oxycodone IR 5 mg, 30 tablets. The facility had no CDAR. The EMAR showed no doses of the medication had been signed out as administered. The amount remaining on the medication card could not be accounted for. The audit detailed 30 discrepancies from the audit. 4. On 5/31/23 at 9:55 a.m., the Administrator provided an Audit Record dated 4/25/23 that detailed Resident #16 had a pharmacy delivery on 3/12/23 of hydrocodone-acetaminophen 5-325 mg, 16 tablets. The facility had no CDAR for the count of 16 tablets. The EMAR had 6 doses of the medication signed out as administered. The amount remaining on the card could not be accounted for. The audit detailed 10 discrepancies found. The Medication Pass Policy, revised 7/28/22, provided by the facility included a Policy Statement the facility would adhere to all Federal and State regulations with medication pass procedures. The Procedure for oral medications specified the following: a. Follow hand hygiene procedure before and after each resident. b. After each medication is administered to each resident, sign the MAR that it was given. The Policy specified under Controlled Substances all scheduled 2 controlled substances will be stored properly and double locked. All medications are to be stored in room at temperature recommended by the manufacturer. The Policy lacked any direction on signing out narcotics on the CDAR and storage of the CDAR forms once completed. The Receiving Controlled Substances Policy, revised 8/2020, provided by the facility documented medications classified by the Drug Enforcement Administration (DEA) as controlled substances and medications classified as controlled substances by state law are subject to special ordering, receipt, and record keeping requirements by the facility in accordance with federal and state laws and regulations. The Policy Procedure specified the DON, in collaboration with the consulting pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized, licensed nursing and pharmacy personnel have access to controlled substances. The Procedure outlined the following: 1. The pharmacy dispenses medication listed in Schedule II, III, IV and V in readily accountable quantities and containers designed for each counting of contents. 2. Unless otherwise directed by the facility, an individual resident's controlled substance record is prepared by the pharmacy for each controlled substance prescribed for a resident. The following information is completed upon dispensing or upon receipt of the controlled substance: a. Name of the resident. b. Prescription number. c. Drug name, strength, dose, form of medication. d. Date received. e. Quantity received. f. Name of person receiving the medication supply. 3. Controlled substances listed in the Schedules II, III, IV, V are stored under double lock. The access key to controlled substances is not the same key that allows access to other medications. The medication nurse on duty maintains the possession of a key to the controlled substances. The DON and the pharmacy keep back-up keys to all medication storage areas, including controlled substance storage. 4. Only licensed personnel may receive controlled substances from the pharmacy courier. The Procedures for receiving controlled substances include: a. A nurse signs for the medications, including the controlled substances, on the pharmacy delivery ticket and inspects the medications. b. If a discrepancy or dispensing error is identified for a controlled substance, the nurse must notify the pharmacy at point of delivery. The nurse should document the description of the discrepancy/error on the delivery packing slip/manifest and refuse/reject the delivery of the affected medication(s). c. The receiving nurse transfers medications and accompanying inventory sheets to an authorized nurse on the unit (if different than the nurse who received the medication) or in accordance with facility policy. d. Two nurses, and/or in accordance with facility policy, witness placement of the controlled substances in the secured compartment of the medication cart. e. Controlled substance inventory sheets are filed appropriately. A hard-bound log book, or in accordance with the facility policy, is utilized to track the controlled substance from delivery to disposition. The Storage and Destruction of the Designated Record Set Policy, revised 11/19/21, specified the facility will maintain accurate and completed medical and billing records for each facility resident in a designated record set, in a secure manner, at locations approved by facility in accordance with facility policy. Protected health information (PHI) is kept in locations approved by the facility administration. The Policy Guidelines directed: a. The resident's Designated Record Set is comprised of the resident's medical record and billing record. b. The Designated Record Set may be physically maintained in different locations at the facility (e.g., medical records may be kept at the nurses station and billing /financial records kept in the business office). c. Facility staff will ensure that documentation in the resident's medical record complies with the facility's medical records policies and procedures, particularly in relation to accuracy, completion, and legibility. The Policy, under Storage of Designated Record Set documented the facility would follow storage procedures to ensure that (PHI) is accessed by authorized individuals. The Policy further specified active medical records would be stored either in the medical records office or at the Nurses' Station. Archived medical records would be stored in the medical records office or at a secured off-site location. The Policy defined under Staff Access to Designated Record Set that staff will not copy, keep or maintain parts of a resident's designated record set, except as required to perform their job duties or approved by the facility policy. Under Destruction of the Designated Record Set, the Policy directed facility records must be destroyed in a manner that ensures the confidentiality of the records and renders the information unrecognizable. For PHI paper records, proper disposal methods may include shredding, burning, pulping, or pulverizing the records so that the PHI is rendered essentially unreadable, indecipherable, and other wise cannot be reconstructed. The Facility may not dispose of resident PHI by throwing whole documents in the trash can because this is not a method of destruction which ensures the resident information will be unrecognizable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the MDS dated [DATE] shown Resident #34 scored a BIMS of 15 out of 15, indicating intact cognition. This had been the first BIMS score completed. Review of the facility electronic chart assessments shown on an admission Assessment Evaluation completed 11/2/22 at 1:15 PM that Resident #34 documented as zero falls under question 4 a.; which inquires about the number of falls in the past year. A chart review shown the facility Social Worker documented an admission Note on 11/2/22 at 5:29 PM and documented the resident's admission had been from an acute facility where the resident received care related to a known fall that had resulted in known fractures at Cervical 6, Cervical 7 (a bone is fractured in the neck area) and Thoracic 1 (a bone is fractured in the upper spine) therefore the resident had been admitted with orders to wear a hard-cervical collar. Documentation included Resident #34 had known acute weakness with known limited mobility due to fractures. The documentation further stated prior to admission to the facility the resident's acute hospitalization had been complicated by an infected scalp (head) laceration. Review of the Electronic Medication Administration Record (EMAR) shown upon admission, Resident #34 had been admitted with hypotension (low blood pressure) and prescribed scheduled Midodrine HCL oral tablet, 10 milligrams (mg), take three times a day (to help raise blood pressure). Further review of the EMAR had shown Resident #34 had been prescribed an as needed narcotic for pain as follows: Oxycodone HCL give 5 milligrams by mouth every six hours as needed for pain on the following days: a. On 11/2/22 at 4:50 PM with an effective result. b. On 11/3/22 at 7:44 AM with an effective result. c. On 11/3/22 at 4:32 PM with an effective result. d. On 11/4/22 at 10:30 AM with an effective result. e. On 11/4/22 at 4:30 PM with an effective result. f. On 11/5/22 at 8:12 AM with an effective result. g. On 11/6/22 at 8:12 AM with an effective result. h. On 11/7/22 at 7:49 AM with an effective result. Review of a Care Plan dated 11/3/22, shown Resident #34 with a goal that stated Resident #34 would receive assistance with all activities of daily living and an intervention implemented that stated Resident #34 to be transferred safely by a gait belt and walker with assist of one staff to have met the goal. Further review of facility electronic chart review had shown Resident #34 had a Fall Assessment/Evaluation dated 11/6/22 at 5:00 AM. There were no additional interventions added to the person-centered care plan. A Fall Assessment/Evaluation completed for a second fall since admission to the facility on [DATE] at 8:00 AM, showed no additional interventions added to the person-centered care plan. On 11/7/22 at 9:00 AM, Resident #34 had a third fall and a Fall Assessment/Evaluation completed with no further additional interventions added to the person-centered care plan. Review of the Nurse Practitioner (NP) second note on 11/7 at 1:32 PM documented the resident mentally oriented to self only during the exam. The NP ordered for the resident to be evaluated at an acute facility. During an interview with Resident #34 on 1/4/23 at 9:31 AM, the subject of falls were discussed. The resident failed to remember falling at the facility in November 22. When asked if the falls had led to a re-hospitalization for a few days the resident unable to recall. The resident instead wanted to talk about a fall at work two years ago. The resident unable to state he had been asked to put his call light on if he needed to get up from bed however Resident #34 was unaware of further Care Plan goals or interventions when asked. On 1/9/23 at 10:50 AM, an interview completed with Staff C, the Nurse Practitioner, who provided medical care for Resident #34 since 11/2/22. Staff C stated an initial assessment of the resident had been completed on 11/4/22. Staff C stated the next assessment had been completed on 11/7/22 and two assessments had been completed on that date due to resident falls and change in resident cognitive mentation. Staff C further stated on 11/5 and 11/6 that an on-call provider would have taken information about the resident falls as the dates had been a Saturday and Sunday (does not have weekend call). Staff C stated the resident oriented to self only when a second evaluation completed on 11/7/22. Staff C further stated the resident had been treated for acute encephalopathy (an alteration of mental status) prior to facility admission and the disease had been slow to resolve. An interview completed on 1/9/22 at 11:30 with the facility Director of Nursing (DON) and the Assistant Director of Nursing (ADON). When asked about staff expectations after a resident falls the DON stated the facility had a Falls Practice Guide Algorithm staff were expected to follow. The DON stated the staff had been educated to call the DON or ADON after a resident fall. The DON further stated staffs had an on-call calendar. Both the DON and ADON aware Resident #34 had three falls after admission to the facility. The ADON stated the staff had not known the resident well due to recent admission. The DON also stated the staff followed the fall algorithm and put the resident bed in the low position and a body pillow implemented. When asked if the interventions were expected to be documented on the Care Plan then both the DON and ADON stated that was the expectation. When asked about the body pillow intervention placement, the DON stated the nurse working the unit would have been responsible to assure interventions implemented correctly. 2. The MDS Assessment Tool, dated 9/17/22 listed the diagnoses for Resident #5 included schizoaffective disorder (mental health condition including schizophrenia and a mood disorder), and history of a stroke. The MDS documented the resident required extensive assistance of two staff for transfer, extensive assistance of one to move between locations within a unit in a wheelchair, and total dependence to move off a unit in a wheelchair. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 10 out of 15, indicating a moderate impaired cognition. The resident's Care Plan, dated 7/29/16, identified a focus area the resident at risk for behavior symptoms due to impaired cognition, history of mental illness, past history of drug abuse evident by cat calling, and inappropriate comments to male staff. An incident reported dated 9/30/22 revealed while the resident sat in her wheelchair outside of her room a male resident placed his head under her shirt. A initial revision of the Care Plan occurred on 10/6/22 to include lifting shirt on the focus area, with a new intervention directing staff to redirect patient with reminders of her behavior not appropriate, A second Care Plan revision occurred on 12/13/22 with a new focus area on: Inappropriate dressing/undressing such as removing clothing or layering clothing, lifting shirt related to cognitive impairment, resists care, will swear, attempt to hit out at staff with care. With interventions to: notify family and make arrangements to obtain adaptive clothing if needed; redirect and remove from public areas if inappropriate; and use undershirts. A third Care Plan revision occurred on 1/4/23. An intervention directing staff to redirect the resident away from sexual connotations if observed was added to the focus area for Mood and Behavior. During an interview on 1/9/23 at 2:55 PM, the Director of Nursing (DON) stated after the incident the team to develop Care Plan revisions. The DON stated the intervention to educate the resident was added on 10/6/22 knowing it probably would not be effective due to the residents low BIMS. The DON stated no further interventions were developed on 10/6/22. The DON stated the team asked the family to bring the resident snug fitting tank tops to make it difficult for her to lift her shirt. The DON stated the family agreed, but did not bring in the tank tops until December. The DON stated tank top intervention started ten weeks after the incident. The facility reported they do not have a Care Plan policy. Based on observation, clinical record review, and staff interviews the facility failed to update the Care Plan and address medications in 1 out of 5, residents reviewed for unnecessary medications (Resident # 61), the facility also failed to update the Care Plans after accidents and incidents for 2 out of 7 resident reviewed (Resident #5 and #34). The facility reported a census of 73 Residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #61 dated 11/29/22, listed diagnoses of Atrial Fibrillation (A FIB), and congestive heart failure (CHF), The MDS showed the resident with a Brief Interview of Mental Status (BIMS) of 13 out of 15 indicating mildly impaired cognition. The Medication Administration Record (MAR) dated 1/23, read Bumetanide (diuretic) 2 milligrams (mg) give (1 tablet) two times a day for A FIB, CHF. The MAR dated 1/23, read rivaroxaban (blood thinner) 15 mg give one tablet in the afternoon with supper for A FIB. The Care Plan for Resident # 61 dated 11/23/22, failed to address the blood thinner and the diuretic medication usage and the side effects the staff are expected to monitor for. On 01/09/23 at 9:16 AM, the Director Of Nursing, (DON) reported she expected the Care Plan to address the use of blood thinning medication and the use of diuretics medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interview the facility failed to implement proper interventions after falls assessments completed for 1 of 4 residents reviewed for falls (Resident # 34). The facility reported a census of 73. Findings Include: Review of the MDS dated [DATE] shown Resident #34 scored a BIMS of 15 out of 15, indicating intact cognition. This had been the first BIMS score completed. Review of the facility electronic chart assessments shown on an admission Assessment Evaluation completed 11/2/22 at 1:15 PM that Resident #34 documented as zero falls under question 4 a.; which inquires about the number of falls in the past year. A chart review shown the facility Social Worker documented an admission Note on 11/2/22 at 5:29 PM and documented the resident's admission had been from an acute facility where the resident received care related to a known fall that had resulted in known fractures at Cervical 6, Cervical 7 (a bone is fractured in the neck area) and Thoracic 1 (a bone is fractured in the upper spine) therefore the resident had been admitted with orders to wear a hard-cervical collar. Documentation included Resident #34 had known acute weakness with known limited mobility due to fractures. The documentation further stated prior to admission to the facility the resident's acute hospitalization had been complicated by an infected scalp (head) laceration. Review of the Electronic Medication Administration Record (EMAR) shown upon admission, Resident #34 had been admitted with hypotension (low blood pressure) and prescribed scheduled Midodrine HCL oral tablet, 10 milligrams (mg), take three times a day (to help raise blood pressure). Further review of the EMAR had shown Resident #34 had been prescribed an as needed narcotic for pain as follows: Oxycodone HCL give 5 milligrams by mouth every six hours as needed for pain on the following days: a. On 11/2/22 at 4:50 PM with an effective result. b. On 11/3/22 at 7:44 AM with an effective result. c. On 11/3/22 at 4:32 PM with an effective result. d. On 11/4/22 at 10:30 AM with an effective result. e. On 11/4/22 at 4:30 PM with an effective result. f. On 11/5/22 at 8:12 AM with an effective result. g. On 11/6/22 at 8:12 AM with an effective result. h. On 11/7/22 at 7:49 AM with an effective result. Review of a Care Plan dated 11/3/22, shown Resident #34 with a goal that stated Resident #34 would receive assistance with all activities of daily living and an intervention implemented that stated Resident #34 to be transferred safely by a gait belt and walker with assist of one staff to have met the goal. Further review of facility electronic chart review had shown Resident #34 had a Fall Assessment/Evaluation dated 11/6/22 at 5:00 AM. There were no additional interventions added to the person-centered care plan. A Fall Assessment/Evaluation completed for a second fall since admission to the facility on [DATE] at 8:00 AM, showed no additional interventions added to the person-centered care plan. On 11/7/22 at 9:00 AM, Resident #34 had a third fall and a Fall Assessment/Evaluation completed with no further additional interventions added to the person-centered care plan. Review of the Nurse Practitioner (NP) second note on 11/7 at 1:32 PM documented the resident mentally oriented to self only during the exam. The NP ordered for the resident to be evaluated at an acute facility. During an interview with Resident #34 on 1/4/23 at 9:31 AM, the subject of falls were discussed. The resident failed to remember falling at the facility in November 22. When asked if the falls had led to a re-hospitalization for a few days the resident unable to recall. The resident instead wanted to talk about a fall at work two years ago. The resident unable to state he had been asked to put his call light on if he needed to get up from bed however Resident #34 was unaware of further Care Plan goals or interventions when asked. On 1/9/23 at 10:50 AM, an interview completed with Staff C, the Nurse Practitioner, who provided medical care for Resident #34 since 11/2/22. Staff C stated an initial assessment of the resident had been completed on 11/4/22. Staff C stated the next assessment had been completed on 11/7/22 and two assessments had been completed on that date due to resident falls and change in resident cognitive mentation. Staff C further stated on 11/5 and 11/6 that an on-call provider would have taken information about the resident falls as the dates had been a Saturday and Sunday (does not have weekend call). Staff C stated the resident oriented to self only when a second evaluation completed on 11/7/22. Staff C further stated the resident had been treated for acute encephalopathy (an alteration of mental status) prior to facility admission and the disease had been slow to resolve. An interview completed on 1/9/22 at 11:30 with the facility Director of Nursing (DON) and the Assistant Director of Nursing (ADON). When asked about staff expectations after a resident falls the DON stated the facility had a Falls Practice Guide Algorithm staff were expected to follow. The DON stated the staff had been educated to call the DON or ADON after a resident fall. The DON further stated staffs had an on-call calendar. Both the DON and ADON aware Resident #34 had three falls after admission to the facility. The ADON stated the staff had not known the resident well due to recent admission. The DON also stated the staff followed the fall algorithm and put the resident bed in the low position and a body pillow implemented. When asked if the interventions were expected to be documented on the Care Plan then both the DON and ADON stated that was the expectation. When asked about the body pillow intervention placement, the DON stated the nurse working the unit would have been responsible to assure interventions implemented correctly.

Based on observation, clinical record review, resident and staff interviews, the facility failed to provide necessary respiratory care and failed to label and date oxygen equipment for 2 of 2 residents reviewed for respiratory care (Resident #275 and Resident #277). The facility reported a census of 73 residents. Findings Include: During an observation on 1/03/23 at 1:43 PM, it was noted that Resident #275 and Resident #277 were receiving supplemental oxygen via nasal cannula with no date, time, nor signature labeled on the oxygen tubing. A second observation of Resident #275 and Resident #277 on 1/04/23 at 10:38 AM revealed the supplemental oxygen tubing remained unlabeled with no date, time, nor signature present. On 1/04/23 at 2:33 PM, record review indicated an order for 2 liters-per-minute of continuous supplemental oxygen through nasal cannula for Resident #275 and 2.5 liters-per-minute of continuous supplemental oxygen through nasal cannula for Resident #277. A review of the Care Plans for Resident #275, dated 12/29/22, and Resident #277, dated 12/23/22, identified limitations for both residents related to oxygen dependence. A review of the Minimum Data Set (MDS) for Resident #275, dated 1/6/23, and Resident #277, dated 12/30/22, documented existing dependence on supplemental oxygen for both residents. On 1/05/23 at 10:25 AM, a review of an undated document labeled Oxygen Administration revealed no specifications of labeling oxygen tubing but indicated staff were to follow applicable practice acts. On 1/05/23 at 1:40 PM, a review of the electronic Treatment Administration Record (eTAR) of Resident #275 and Resident #277 revealed the oxygen tubing was not changed or replaced for neither residents. During an interview on 1/05/23 at 11:43 AM, the Director of Nursing (DON) stated oxygen tubing is changed every week during the night (PM) shift nurse. She also verbalized the facility with no policy regarding oxygen tubing.

Based on clinical record review, facility staff and resident interviews, the facility failed to provide professional standards of practice with providing the ongoing provision of assessment, care planning and provision of care in order to meet the resident's Dialysis care needs for one out of one resident reviewed receiving hemodialysis provider services (Resident #44). The facility reported a census of 73. Findings Include: The Minimum Data Set (MDS) Assessment Tool dated 11/10/22 for Resident #44, shown a Brief Interview Mental Status (BIMS) score of 6 out of 15, which indicated the resident with severe mental impairment. The resident dependent on staff for activities of daily living which had included a Dialysis access site. Review of the current Care Plan updated 12/30/22 for Resident #44 lacked specific goals and interventions related to Resident #44's hemodialysis Plan of Care as follows: a. The Care Plan failed to state the fluid restriction amount. b. The arterial-venous fistula (AVF), care per the resident's outpatient hemodialysis facility protocol not identified. c. Lacked identification of the AVF being in the right or left arm. Review of the December 2022 Electronic Medication Administration Record (EMAR) shown Resident #44 ordered two blood pressure medications for a diagnosis of hypertension (high blood pressure). The medication, Coreg 25 milligrams oral tablet, administer one tablet orally twice a day at 7:00 AM and 5:00 PM. Resident #44 also ordered Metoprolol Tartrate 25 milligrams, administer one tablet orally twice a day at 7:00 AM and 5:00 PM for hypertension. The EMAR lacked identification of which arm to check the blood pressure when the resident had an access, AVF in the upper right arm. Review of the December Treatment Administration Record (TAR) lacked the following hemodialysis tasks: a. There had not been an identified area to document removal of AVF dressing at bedtime on hemodialysis days. b. There had not been an identified area to daily document assessment of the AVF (Standard protocol had been to use a stethoscope to hear the AVF bruit and to physically feel the AVF for thrill). During an interview with Resident #44 on 1/4/23 at 7:49 AM, the resident observed while sitting in a wheelchair by bedside and stated the transportation service would be arriving for her dialysis. Observation of the dialysis access shown the dressing and tape still in place from the last hemodialysis treatment on 1/2/23 as evidenced by two folded gauze squares and paper tape to the resident's skin. When asked about post dialysis treatment dressing and the length of time the dressing had been in place, the resident had not been able to provide an answer. In an interview with Staff F, Licensed Practical Nurse (LPN) on 1/5/22 at 1:39 PM, Staff F shown a hemodialysis form that the facility and Dialysis unit had in place for communication. The outpatient Dialysis form had been sent back to the facility with the resident after each clinic visit. The form had an area for post Dialysis instructions. The Dialysis form had been kept as part of the resident's paper chart. When asked about AVF care, Staff F stated the assessment had been completed on dialysis days. When an outpatient Dialysis form had been reviewed with Staff F then a discussion took place on interventions to complete if an outpatient form had been sent back incomplete. Staff F stated that if she received the form returned blank then she would call the outpatient unit for post Dialysis instructions and the time to remove AVF dressing. A Dialysis form dated 1/2/23 had been sent back with Resident #44 and noted incomplete regarding post treatment access directions and length of time completed for removing AVF. Review of a Dialysis form dated 1/4/23 shown post Dialysis instructions and had stated to remove the AVF dressings 4-6 hours post dialysis treatment. An interview had been completed on 1/5/23 at 3:00 PM with the facility DON and ADON. When asked about expectations of the facility staff when providing care for a Dialysis resident the DON had stated the facility staff expected to take the resident's vital signs pre and post dialysis, had been expected to assess the AVF daily and document. When asked where the documentation advised to be completed, the DON stated staff documented the information on the Monthly TAR. When asked about Care Plan goals and interventions, the ADON stated staff were expected to review with the resident and expected a Dialysis resident to have a Plan of Care that had included specific goals and interventions. Resident #44's Care Plan emphasized the total BIMS score of 6 for mentation and the dependence on staff for activities of daily living. The facility provided a Dialysis policy that failed to address hemodialysis and post treatment assessments and evaluations expected of staff.

Based on multiple observations, facility staff interviews, Dietary Manager interview and review of facility policies/ procedures the facility failed to meet professional standards of food service and prepare food under sanitary conditions. The facility reported a census of 73 residents. Findings Include: The initial kitchen observations on 1/03/23 at 10:30 AM, shown contaminated equipment as follows: a. The Vulcan Brand oven for food preparation contained an upper and lower oven with double vertical opening doors. The doors noted with built-up substances, that had dried onto the oven glass, and the stainless steel above and below the oven glass doors. The substance buildup blocked viewing inside the oven with no visual access through the glass doors. b. The back of the ovens contained an exposed motor casing with a fan and vent system. The motor casing area noted with a buildup of gray dust and dirt, that clung to the motor, shelf-lip of motor, the horizontal vents at the bottom of the oven, and the electrical cord. A clean supply rack butted up to the back of the Vulcan oven unit therefore allowing an opened box of paper product supplies be exposed to the back of the oven motor which lacked sanitation. c. The clean supply rack contained boxes of paper and plastic individual supplies. Several of the items had the top of the box torn off for easy staff accessibility. Noted a box of 10-gallon coffee filters opened and exposed to the unsanitary back of the Vulcan oven unit. d. The wall prior to entering the kitchens' back storage area had visible vertical brown streaked stains visible against the off-white paint. e. The clean preparation area counter had small appliances that had included an APW At Express Conveyor Toaster Oven with a build up of a substance across the front of the appliance and on top of the appliance. The grate area where bread products rotated through had a buildup of brown substance. f. The same counter also had a small microwave with a build up of substance on the inside and the outside. Part of the outside of the small microwave's buildup of substance noted brown and thickened to look 3D. The end of the counter had a brand-new stainless steel ten-gallon capacity coffee pot with visible brown vertical streaks down the front. g. The linoleum floor observed stained with old food stains and visible dirt in front of the cooking area and pureed prep area. A second observation on 1/4/23 at 10:30 AM, shown that all of the kitchen contaminated equipment observed on 1/03/23 at 10:30 AM remained contaminated. On 1/4/23 at 2:15 PM during an interview with the Dietary Manager, the discussion of equipment cleaning took place. The Dietary Manager stated the Maintenance Director takes care of the kitchen ceiling vents, fridge filter and ceiling fans. A ceiling fan not observed in the kitchen or kitchen storage area. When asked about the cleaning of daily used kitchen equipment the Dietary Manager stated the staff instructed to wipe off equipment as spills happened. During an interview on 1/4/23 at 4:00 PM with the Dietary Manager, the topic of kitchen cleaning took place. The Dietary Manager checked with the Facility Administrator and provided a one-page document titled, 'Cleaning Schedules', dated 11/2020. The document emphasized the need for individualized schedules to be developed for cleaning of equipment and kitchen areas per facility. The facility also utilized a one-page log document titled, 'Monthly/As Needed Cleaning' that listed the equipment area to be cleaned along with dates and initials of staff who completed the cleaning. On 1/5/23 at 10:30 AM, a third observation shown the kitchen contaminated equipment remained unchanged. On 1/9/23 at 10:30 AM, a fourth observation shown the kitchen contaminated equipment remained unchanged.