Based on clinical record review, staff interviews, observations, and facility policy review the facility failed to prevent drug diversion for 3 of 3 resident's controlled/narcotic medications (Resident#89, #90, #92). The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #89 dated 7/18/24, listed diagnoses of non-Alzheimer's dementia, Parkinson's disease, and seizure disorder. The Brief Interview for Mental Status (BIMS) reflected a score of 1, severe cognitive impairment. The Care Plan for R#89 dated 4/26/24, directed staff to administer medications as ordered. Monitor and record effectiveness. Report any adverse side effects. The Controlled Substance Count & Usage Record for R#89 dated 9/13/24 at 2:00 PM reflected 24 milliliters (ml) of Morphine remained at the shift change cosigned by Staff I, Licensed Practical Nurse (LPN) and Staff A, Registered Nurse (RN). The next entry on the document dated 9/13/24 at 10 PM, reflected 22 ml remained. The record failed to reflect 2 ml of the Morphine being administered. The document revealed a note on the left side of the form count corrected The document failed to give an explanation of what happened to the 2 ml of Morphine. The Medication Administration Record (MAR) dated 9/13/2024, listed Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 5 mg by mouth every 4 hours as needed (PRN) for Pain 0.25 ml or 5 mg every 4 hours as needed for pain. The MAR lacked a dose signed out/administered. 2. The MDS for Resident #90 dated 8/8/24, listed diagnoses of non-Alzheimer's dementia, diabetes mellitus, and heart failure. The MDS revealed a BIMS score of 00, that indicated sever cognitive impairments. The Care Plan for Resident #90 dated 6/24/24, directed staff to administer medications as ordered. The Controlled Substance Count & Usage Record for R#90 dated 9/13/24 at 2 PM, listed 8.75 ml of morphine remained. The record reflected Staff A, RN administered two 0.25 ml doses of the Morphine to Resident #90. One 0.25 ml dose at 2:57 PM and one 0.25 ml dose at 8:40 PM. The count at that time reflected 8.25 ml. At 10 PM the end of the shift count (CT) reflected 8.25 ml. The next line on the form revealed count correction 6 ml morphine remained. The document failed to explain why the count failed to include the location of the missing 2.25 ml. The MAR dated 9/2024, directed Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 0.25 ml by mouth three times a day for pain. The MAR also listed Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 0.25 ml by mouth every 2 hours as needed for Pain or dyspnea, none signed out PRN on 9/13/24. 3. The MDS for Resident #92 dated 9/12/24, listed diagnoses of lung cancer, non-Alzheimer's dementia, arthritis, and diabetes mellitus. Resident #92's MDS reflected her BIMS score of 15, intact cognition. The Care Plan for R#92 dated 9/19/24, directed staff to use pain management as appropriate. Monitor/document side effects and effectiveness. The MAR dated 9/19/24, directed Ativan Solution 2 MG/ML (lorazepam). Give 0.5 mg sublingually every 2 hours for terminal pass. The Controlled Substance Count & Usage Record for R#92 dated 9/19/24 at 12:35 PM showed 29.5 ml of morphine solution, staff gave 0.5 ml that left 29 ml. The next time on the record reflected 2 PM, and 28.75 ml remained. The count failed to reflect 0.25 ml of the morphine solution. The Controlled Substance Count & Usage Record for R#92 dated 9/19/24 at 5:45 PM showed 29.5 remained of the Ativan Solution. After 0.5 ml administered the count reflected the amount that remained as 27 ml. Review of the Daily Assignment sheet dated 9/13/24, listed Staff I, Licensed Practical Nurse (LPN), worked 6 to 2 PM, Staff A, Registered Nurse (RN) worked 2 PM to 10 PM and Staff D, RN worked the 10 PM to 6 AM shift. The medication signed out 4 times on the shift. Review of the Daily Assignment sheet dated 9/19/24, listed Staff H, RN worked the 6 AM to 2 PM shift, Staff, A worked the 2 PM to 10 PM shift, and Staff D, LPN worked 10 PM to 6 AM shift. On 1/9/24 at 9:28 AM, Staff I stated that when she signed the narcotic book it indicated the accurate dosing and the amount of the medication left in the supply. She reported if she signed the book that's the amount that remained. She confirmed when she signed the Narcotic book on 9/13/24 for R#89 and R#90 the amount she listed reflected the correct amount of the medication that remained. She reported if she found a controlled/narcotic mediation discrepancy with the count she would call the Director of Nursing (DON) or manager and not even take the keys from the nurse. On 01/08/25 at 11:27 AM, Staff D, RN confirmed she worked from 8:30 PM on 9/13/24 to 6 AM on 9/14/24. She reported she came to the shift as an agency nurse. The other nurse she took over for told her Staff A, RN took a long time to complete her documentation and directed Staff D to start her work. The other nurse told her Staff A would find her for shift report and narcotic/controlled count. Staff D reported some short-term narcotic medication were past the order date and needed destroyed. Staff D stated Staff A read the count she found the narcotics were significantly lower than what Staff A said for Resident #89 and Resident #90. She reported she refused to sign the count sheets. She stated Staff A told her that it was fine and Staff A documented count correction on the record. Staff D reported she told Staff A she needed to reconcile the doses signed out on the Medication Administration Record (MAR) to understand what happened to cross reference. Staff D revealed Staff A declined and told Staff D the facility told us what we needed to do is document count correction on the record. She identified concern that Staff A, failed to notify the DON or nurse manager. She reported she texted the Staff B, DON at the time, and alerted her of the discrepancy in the narcotic count. Staff D reported Staff A continued to work on documentation at the facility until around 2 AM. Staff D reported Staff A looked as if she was falling asleep and her eyes were glazed over. The Video surveillance provided by the facility dated 9/14/24 at 12:04:41 AM Staff A removed 2 boxes approximately 4 inches tall, 2 inches wide by 1 inch deep from the back-left corner of the med room she held them. Staff A pointed out the something on the boxes to Staff D. Staff D in the medication room with Staff A wasted pills in the drug buster solution. At 12:07:17 AM Staff A carried the 2 boxes and the medication cards out of the medication room to the medication cart. At 12:13:57 Staff A went to the left of the medication cart, got a pink bag, put it over her right shoulder and went to the med cart. At 12:14:33 Staff A took the two boxes from the top of the medication cart walked back over to where the bag hung before and placed the 2 boxes inside of the pink bag that she re-hung. The Video surveillance provided by the facility dated 9/19/24 at 7:38-7:40 PM, a nurse at the medication cart, Staff A, carried a hot pink cup into the medication room while she appeared to remove two boxes from her pocket approximately 4 inches tall, 2 inches wide by 1 inch deep. Then Staff A went to the sink in the medication room appeared to place some water in the hot pink cup held in reflection of the glass in the door. Staff A appeared to get into one of the boxes remove a bottle, opened the lid and at 7:39:36 dropped some drops to the cup, placed the bottle back into the box. At 7:40:16 Staff A put the lid back on the cup. She sat at the nurse's desk and drank from the cup. Video surveillance provided by the facility dated 9/19/24 at 10:05:14 PM, Staff A stood in the corner of the 200 Wing Medication Room out of the view of the camera, at 10:05:15 with something in her right hand she turned to the door. Staff A put her left hand in her left pocket and held her right hand near the door. Staff A held something with a dark top and a dark bottom in her right hand. The nurse moved the item from her right hand to her left put her empty right hand in her pocket she took the hot pink cup from the desk in the medication room with her left hand and left the room at 10:05:23 PM. At 10:05:23 Staff A removed the lid from the hot pink cup and set it on top of the medication cart. At 10:05:33 Staff A removed the hot pink cup from the top of the cart and took it out of view on the 200 Wing. At 10:05:52 Staff A moved a hot pink cup/mug back to the medication cart. At 10:05:54 PM Staff A opened a small bottle, she looked around, she used a dropper and appeared to put drops in the hot pink drink cup as she poured from the bottle into the hot pink cup shaking the bottle upside down. At 10:06:08 she replaced the lid onto the bottle and moved out of the view of the camera but not into the view of the next window. She reentered the camera view, placed the lid on the hot pink cup, and drank from the cup. The Video surveillance dated 9/19/24 at 11:01-11:02 On 200 Wing Video showed Staff A at the medication cart and Staff C walked in the medication room at 11:01:45 Staff A appeared to stagger, hung onto the door, swayed back and forth while the other nurse placed a jug under the sink wiped off the counter and rinsed her hands. At 11:02:34 they both exited the med room and went to the medication cart. On 1/08/25 at 2:27 PM, Staff H reported the E-kit locked and secure at the end of her shift on 9/19/24. She stated she failed to know of any discrepancies, her count was correct if she signed the book. On 1/07/25 at 6:47 PM, Staff E, Certified Nurses Aid (CNA) confirmed she worked on the night shift on 9/19/24. She reported Staff C, LPN paged her to come and help Staff A get to a place she could rest. Staff E revealed Staff A's eyes were glassy and she staggered as she walked. Staff C compared Staff A to a streetwalker that was going to fall over with their wobbly legs. Staff C reported she got a 4 wheeled walker with a seat for Staff A to sit on and she moved her into the conference room to get some rest before she drove home. Staff C stated she asked Staff A if she needed medical attention, but Staff A told her she worked too much and needed rest. Staff C reported Staff A's speech seemed slurred. Staff E stated she thought Staff A may fall and could not drive the way she was. Staff E reported She woke her up about 3-4 she said she was better and left the building after she got her coat and purse. Staff E said Staff A went to her car reclined the seat and one of the day shift staff got there and checked on her. Staff E revealed she called the Chief Operating Officer and reported the behavior of Staff A. On 1/8/25 at 6:30 AM, Staff C, LPN confirmed she worked 9/19/24, 6 PM on the other side of the building and at 10 PM took the rest of the building for the night until 6 AM. She reported she and Staff F, Medication Aid planned to count narcotic/controlled medication and destroy some medication after a death in the facility. She revealed Staff A immediately went right for the narcotic/controlled medication first, she indicated normally they do shift to shift report first. Staff C stated she walked into the medication room and Staff A had a bottle of Ativan or morphine open she poured and spilt it on the cart. Staff C thought Staff A seemed disorientated. Staff C said Staff A told her she was fine, but Staff A popped pills all over the place, they were flying. Staff C asked Staff A again if she was alright. Staff C reported Staff A was generally a slower moving person, but she stopped and looked like she drifted off. Staff C revealed she told her to sit down as she was dozing off while she talked. Staff A walked but seemed in slow motion. The CNA took Staff A to the conference room. Staff C reported she got to the unit around 10 and she thinks Staff A got out of the Wing around 10:30. Staff C said she didn't know she slept in the conference room until 2 AM. She said she didn't know what to do but let her sleep. She reported to the day shift after they asked if she stayed all night. On 1/08/25 at 1:09 PM, the Restorative nurse confirmed she got to the facility early in the AM on 9/20/24 and saw Staff A slumped over in the front seat of her car. She reported she thought someone went out on break and fell asleep. The Restorative nurse stated she knocked on the window of the car to wake Staff A. She reported Staff A's slurred speech and she told her she was tired. The Restorative nurse offered her a ride home and Staff A declined. On 01/08/25 at 7:33 PM, Staff B, Previous DON, reported she failed to identify any concerns with the nurses at the facility. She reported she received a text from one nurse about a hospice resident's morphine count that maybe was off. She revealed she got sick and forgot to look into it further. She stated she failed to know of the incident on 9/19/24 until in the mid-afternoon on 9/20/24. On 1/9/25 at 10:08 AM, the DON reported after the event on 9/19/24, she alerted the Pharmacy to review the records and the Emergency drug kit (E-Kit). She stated she thought they came and picked up the E-kit that Friday. She revealed the pharmacy called her the next week and reported 2 oxycodone tablets gone from the e-Kit with no order or explanation where they went. 01/09/25 02:51 PM, the DON reported she expected the nurses to count and sign the narcotic records to reflect an accurate count. She reported if the nurses found a discrepancy she expected staff to notify her immediately. The facility provided a policy titled Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy dated 10/2022, directed 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. It shall be the policy of this facility to implement written procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. These procedures shall include the screening and training of employees, protection of residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, mistreatment, and misappropriation of property, without fear of recrimination or intimidation. Exploitation of a dependent adult. Exploitation means a caretaker knowingly obtains, uses, endeavors to obtain to use or who misappropriates a dependent adult's funds, assets, medications, or property with the intent to temporarily or permanently deprive a dependent adult of the use, benefit, or possession of the funds, assets, medication or property for the benefit of someone other than the dependent adult 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. 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.

Based on clinical record review, staff interviews, and facility policy review the facility failed to implement Abuse Prevention policies for an investigation into reported misappropriated resident medications for 2 out of 3 residents reviewed (Residents #89 and #90). The facility reported a censes of 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #89 dated 7/18/24, listed diagnoses of non-Alzheimer's dementia, Parkinson's disease, and seizure disorder. The Brief Interview for Mental Status (BIMS) reflected a score of 1, severe cognitive impairment. The Care Plan for R#89 dated 4/26/24, directed staff to administer medications as ordered. Monitor and record effectiveness. Report any adverse side effects. The Controlled Substance Count & Usage Record for R#89 dated 9/13/24 at 2:00 PM reflected 24 milliliters (ml) of Morphine remained at the shift change cosigned by Staff I, Licensed Practical Nurse (LPN) and Staff A, Registered Nurse (RN). The next entry on the document dated 9/13/24 at 10 PM, reflected 22 ml remained. The record failed to reflect 2 ml of the Morphine being administered. The document revealed a note on the left side of the form count corrected The document failed to give an explanation of what happened to the 2 ml of Morphine. The Medication Administration Record (MAR) dated 9/13/2024, listed Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 5 mg by mouth every 4 hours as needed (PRN) for Pain 0.25 ml or 5 mg every 4 hours as needed for pain and lacked a dose signed out/administered. 2. The MDS for Resident #90 dated 8/8/24, listed diagnoses of non-Alzheimer's dementia, diabetes mellitus, and heart failure. The MDS revealed a BIMS score of 00, indicated sever cognitive impairments. The Care Plan for Resident #90 dated 6/24/24, directed staff to administer medications as ordered. The Controlled Substance Count & Usage Record for R#90 dated 9/13/24 at 2 PM, listed 8.75 ml of morphine remained. The record reflected Staff A, RN administered two 0.25 ml doses of the Morphine to Resident #90. One 0.25 ml dose at 2:57 PM and one 0.25 ml dose at 8:40 PM. The count at that time reflected 8.25 ml. At 10 PM the end of the shift count (CT) reflected 8.25 ml. The next line on the form revealed count correction 6 ml morphine remained. The document failed to explain why the count failed to include the location of the missing 2.25 ml. The MAR dated 9/2024, directed Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 0.25 ml by mouth three times a day for pain. The MAR also listed Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 0.25 ml by mouth every 2 hours as needed for Pain or dyspnea, none signed out PRN on 9/13/24. On 01/08/25 at 11:27 AM, Staff D, RN confirmed she worked from 8:30 PM on 9/13/24 to 6 AM on 9/14/24. She reported she came to the shift as an agency nurse. The other nurse she took over for told her Staff A, RN took a long time to complete her documentation and directed Staff D to start her work. The other nurse told her Staff A would find her for shift report and narcotic/controlled count. Staff D reported some short-term narcotic medications were past the order date and needed to be destroyed. Staff D stated Staff A read the count she found the narcotics were significantly lower then what Staff A said for Resident #89 and Resident#90. She reported she refused to sign the count sheets. She stated Staff A told her that it was fine and Staff A documented count correction on the record. Staff D reported she told Staff A she needed to reconcile the doses signed out on the Medication Administration Record (MAR) to understand what happened to cross reference. Staff D revealed Staff A declined and told Staff D the facility told us what we needed to do is document count correction on the record. She identified a concern that Staff A, failed to notify the DON or nurse manager. She reported she texted Staff B, DON at the time, and alerted her of the discrepancy in the narcotic count. Staff D reported Staff A continued to work on documentation at the facility until around 2 AM. Staff D reported Staff A looked as if she was falling asleep and her eyes were glazed over. On 01/08/25 at 7:33 PM, Staff B, previous DON, reported she failed to identify any concerns with the nurses at the facility. She reported she received a text from one nurse about a hospice resident's morphine count that maybe was off. She revealed she got sick and forgot to look into it further. She stated she failed to know of the incident on 9/19/24 until in the mid-afternoon on 9/20/24. The facility provided a policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 10/2022. These procedures shall include the screening and training of employees, protection of residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, mistreatment, and misappropriation of property, without fear of recrimination or intimidation.

Based on clinical record review, staff interviews, and facility policy review the facility failed to report misappropriation of 2 out of 3 resident's medications (Resident #89, and #90) to the State Agency (SA) and law enforcement. The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #89 dated 7/18/24, listed diagnoses of non-Alzheimer's dementia, Parkinson's disease, and seizure disorder. The Brief Interview for Mental Status (BIMS) reflected a score of 1, severe cognitive impairment. The Care Plan for R#89 dated 4/26/24, directed staff to administer medications as ordered. Monitor and record effectiveness. Report any adverse side effects. The Controlled Substance Count & Usage Record for R#89 dated 9/13/24 at 2:00 PM reflected 24 milliliters (ml) of Morphine remained at the shift change cosigned by Staff I, Licensed Practical Nurse (LPN) and Staff A, Registered Nurse (RN). The next entry on the document dated 9/13/24 at 10 PM, reflected 22 ml remained. The record failed to reflect 2 ml of the Morphine as administered. The document revealed a note on the left side of the form count corrected The document failed to give an explanation of what happened to the 2 ml of missing Morphine. The Medication Administration Record (MAR) dated 9/13/2024, listed Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 5 mg by mouth every 4 hours as needed (PRN) for Pain 0.25 ml or 5 mg every 4 hours as needed for pain and lacked a dose signed out/administered. 2. The MDS for Resident #90 dated 8/8/24, listed diagnoses of non-Alzheimer's dementia, diabetes mellitus, and heart failure. The MDS revealed a BIMS score of 00, indicated sever cognitive impairments. The Care Plan for Resident #90 dated 6/24/24, directed staff to administer medications as ordered. The Controlled Substance Count & Usage Record for R#90 dated 9/13/24 at 2 PM, listed 8.75 ml of morphine remained. The record reflected Staff A, RN administered two 0.25 ml doses of the Morphine to Resident #90. One 0.25 ml dose at 2:57 PM and one 0.25 ml dose at 8:40 PM. The count at that time reflected 8.25 ml. At 10 PM the end of the shift count (CT) reflected 8.25 ml. The next line on the form revealed count correction 6 ml morphine remained. The document failed to explain why the count failed to include the location of the missing 2.25 ml of morphine. The MAR dated 9/2024, directed Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 0.25 ml by mouth three times a day for pain. The MAR also listed Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 0.25 ml by mouth every 2 hours as needed for Pain or dyspnea, none signed out PRN on 9/13/24. On 01/08/25 at 11:27 AM, Staff D, RN confirmed she worked from 8:30 PM on 9/13/24 to 6 AM on 9/14/24. She reported she came to the shift as an agency nurse. The other nurse she took over for told her Staff A, RN took a long time to complete her documentation and directed Staff D to start her work. The other nurse told her Staff A would find her for shift report and narcotic/controlled count. Staff D reported some short-term narcotic medications were past the order date and needed to be destroyed. Staff D stated Staff A read the count, she found the narcotics were significantly lower than what Staff A said for Resident #89 and Resident #90. She reported she refused to sign the count sheets. She stated Staff A told her that it was fine and Staff A documented count correction on the record. Staff D reported she told Staff A she needed to reconcile the doses signed out on the Medication Administration Record (MAR) to understand what happened to cross reference. Staff D revealed Staff A declined and told Staff D the facility told us what we needed to do is document count correction on the record. She identified a concern that Staff A, failed to notify the DON or nurse manager. She reported she texted Staff B, DON at the time, and alerted her of the discrepancy in the narcotic count. Staff D reported Staff A continued to work on documentation at the facility until around 2 AM. Staff D reported Staff A looked as if she was falling asleep and her eyes were glazed over. On 01/08/25 at 7:33 PM, Staff B, previous DON, reported she failed to identify any concerns with the nurses at the facility. She reported she received a text from one nurse about a hospice resident's morphine count that maybe was off. She revealed she got sick and forgot to look into it further. She stated she failed to know of the incident on 9/19/24 until in the mid-afternoon on 9/20/24. On 01/09/25 at 1:33 PM, Staff L, Chief Executive Officer (CEO) reported the previous Director of Nursing (DON) failed to report the inaccurate narcotic counts for Resident #89 and #90 to the Administrator for further investigation and reporting. The facility provided a policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 10/2022, directed 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. It shall be the policy of this facility to implement written procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. These procedures shall include the screening and training of employees, protection of residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, mistreatment, and misappropriation of property, without fear of recrimination or intimidation. 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 allegations of abuse to the Administrator, or designated representative. All allegations of Resident abuse shall be reported to SA not later than two (2) hours after the allegation is made. All allegations of Resident neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the SA, 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. If there is a 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 be reported to SA within 2 hours, the Elder Justice Act has a different time frame for reporting to the police/sheriff. If the allegation 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 (See Elder Justice Act requirements on page 9). A report shall be made by calling the SA reporting hotline, submitting an e-mail to the, submitting an online report or sending a fax. If the person in charge is the alleged abuser, the staff member shall directly report the abuse to the SA immediately, pursuant to the deadlines established above. If the allegations of dependent adult abuse involve a caretaker who is not an employee of the facility (e.g. family member, visitor), a report must also be made immediately to both the DIA and DHS.

Based on clinical record review, staff interviews, and facility policy review the facility failed to investigate a reported incident of misappropriated resident medications for 2 of 3 residents reviewed (Resident#89, and 90) and failed to prevent further misappropriation of medication of 1 resident (Resident #92). The facility reported a census 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #89 dated 7/18/24, listed diagnoses of non-Alzheimer's dementia, Parkinson's disease, and seizure disorder. The Brief Interview for Mental Status (BIMS) reflected a score of 1, severe cognitive impairment. The Care Plan for Resident#89 dated 4/26/24, directed staff to administer medications as ordered. Monitor and record effectiveness. Report any adverse side effects. The Controlled Substance Count & Usage Record for R#89 dated 9/13/24 at 2:00 PM reflected 24 milliliters (ml) of Morphine remained at the shift change cosigned by Staff I, Licensed Practical Nurse (LPN) and Staff A, Registered Nurse (RN). The next entry on the document dated 9/13/24 at 10 PM, reflected 22 ml remained. The document revealed a note on the left side of the form count corrected The document failed to an explanation of what happened to the 2 ml of Morphine. The Medication Administration Record (MAR) dated 9/13/2024, listed Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 5 mg by mouth every 4 hours as needed (PRN) for Pain 0.25 ml or 5 mg every 4 hours as needed for pain. Lacked a dose signed out/ administered. 2. The MDS for Resident #90 dated 8/8/24, listed diagnoses of non-Alzheimer's dementia, diabetes mellitus, and heart failure. The MDS revealed a BIMS score of 00, indicated sever cognitive impairments. The Care Plan for Resident #90 dated 6/24/24, directed staff to administer medications as ordered. The Controlled Substance Count & Usage Record for R#90 dated 9/13/24 at 2 PM, listed 8.75 ml of morphine remained. The record reflected Staff A, RN administered two 0.25 ml doses of the Morphine to Resident #90. One 0.25 ml dose at 2:57 PM and one 0.25 ml dose at 8:40 PM. The count at that time reflected 8.25 ml. At 10 PM the end of the shift count (CT) reflected 8.25 ml. The next line on the form revealed count correction 6 ml morphine remained. The document failed to explain why the count failed to include the location of the missing 2.25 ml. The MAR dated 9/2024, directed Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 0.25 ml by mouth three times a day for pain. The MAR also listed Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 0.25 ml by mouth every 2 hours as needed for Pain or dyspnea, none signed out PRN on 9/13/24. 3. The MDS for Resident #92 dated 9/12/24, listed diagnoses of lung cancer, non-Alzheimer's dementia, arthritis, and diabetes mellitus. Resident #92's MDS reflected her BIMS score of 15, intact cognition. The Care Plan for R#92 dated 9/19/24, directed use pain management as appropriate. Monitor/document side effects and effectiveness. The MAR dated 9/19/24, directed Ativan Solution 2 MG/ML (lorazepam). Give 0.5 mg sublingually every 2 hours for terminal pass. The Controlled Substance Count & Usage Record for R#92 dated 9/19/24 at 12:35 PM showed 29.5 ml of morphine solution, staff gave 0.25 ml that left 29.25 ml. The next time on the record reflected 2 PM, and 28.75 ml remained. The count failed to reflect 0.5 ml of the morphine solution discrepancy. The Controlled Substance Count & Usage Record for R#92 dated 9/19/24 at 5:45 PM showed 29.5 remained of the Ativan Solution. After 0.5 ml administered the count reflected the amount that remained as 27 ml. Review of the Daily Assignment sheet dated 9/13/24, listed Staff I, Licensed Practical Nurse (LPN), worked 6 to 2 PM, Staff A, Registered Nurse (RN) worked 2 PM to 10 PM and Staff D, RN worked the 10 PM to 6 AM shift. The medication signed out 4 times on the shift. Review of the Daily Assignment sheet dated 9/19/24, listed Staff H, RN worked the 6 AM to 2 PM shift, Staff, A worked the 2 PM to 10 PM shift and Staff D, LPN worked 10 PM to 6 AM shift. On 1/9/24 at 9:28 AM, Staff I stated that when she signed the narcotic book it indicated the accurate dosing and the amount of the medication left in the supply. She reported if she signed the book that's the amount that remained. She confirmed when she signed the Narcotic book on 9/13/24 for R#89 and R#90 the amount she listed reflected the correct amount of the medication that remained. She reported if she found a controlled/narcotic mediation discrepancy with the count she would call the Director of Nursing (DON) or manager and not even take the keys from the nurse. On 01/08/25 at 11:27 AM, Staff D, RN confirmed she worked from 8:30 PM on 9/13/24 to 6 AM on 9/14/24. She reported she came to the shift as an agency nurse. The other nurse she took over for told her Staff A, RN took a long time to complete her documentation and directed Staff D to start her work. The other nurse told her Staff A would find her for shift report and narcotic/controlled count. Staff D reported some short-term narcotic medication were past the order date and needed destroyed. Staff D stated Staff A read the count she found the narcotics were significantly lower then what Staff A said for Resident #89 and Resident #90. She reported she refused to sign the count sheets. She stated Staff A told her that it was fine and Staff A documented count correction on the record. Staff D reported she told Staff A she needed to reconcile the doses signed out on the Medication Administration Record (MAR) to understand what happened to cross reference. Staff D revealed Staff A declined and told Staff D the facility told us what we needed to do is document count correction on the record. She identified a concern that Staff A, failed to notify the DON or nurse manager. She reported she texted the Staff B, DON at the time, and alerted her of the discrepancy in the narcotic count. Staff D reported Staff A continued to work on documentation at the facility until around 2 AM. Staff D reported Staff A looked as if she was falling asleep and her eyes were glazed over. On 1/08/25 at 2:27 PM, Staff H reported the E-kit was locked and secure at the end of her shift on 9/19/24. She stated she failed to know of any discrepancies, her count was correct if she signed the book. On 1/07/25 at 6:47 PM, Staff E, Certified Nurses Aid (CNA) confirmed she worked on the night shift on 9/19/24. She reported Staff C, LPN paged her to come and help Staff A get to a place she could rest. Staff E revealed Staff A's eyes were glassy and she staggered as she walked. Staff C compared Staff A to a streetwalker that was going to fall over with their wobbly legs. Staff C reported she got a 4 wheeled walker with a seat for Staff A to sit on and she moved her into the conference room to get some rest before she drove home. Staff C stated she asked Staff A if she needed medical attention, but Staff A told her she worked too much and needed rest. Staff C reported Staff A's speech seemed slurred. Staff E stated she thought Staff A may fall and could not drive the way she was. Staff E reported She woke her up about 3-4 AM she said she was better and left the building after she got her coat and purse. Staff E said Staff A went to her car reclined the seat and one of the day shift staff got there and checked on her. Staff E revealed she called the Chief Operating Officer and reported the behavior of Staff A. On 1/8/25 at 6:30 AM, Staff C, LPN confirmed she worked 9/19/24, 6 PM on the other side of the building and at 10 PM took the rest of the building for the night until 6 AM. She reported she and Staff F, Medication Aid planned to count narcotic/controlled medication and destroy some medication after a death in the facility. She revealed Staff A immediately went right for the narcotic/controlled medication first, she indicated normally they do shift to shift report first. Staff C stated she walked into the medication room and Staff A had a bottle of Ativan or morphine open she poured and spilt it on the cart. Staff C thought Staff A seemed disorientated. Staff C said Staff A told her she was fine, but Staff A popped pills all over the place they were flying. Staff C asked Staff A again if she was alright. Staff C reported Staff A was generally a slower moving person, but she stopped and looked like she drifted off. Staff C revealed she told her to sit down as she was dozing off while she talked. Staff A walked but seemed in slow motion. The CNA took Staff A to the conference room. Staff C reported she got to the unit around 10 PM and she thinks Staff A got out of the Wing around 10:30 PM. Staff C said she didn't know she slept in the conference room until 2 AM. She said she didn't know what to do but let her sleep. She reported to the day shift after they asked if she stayed all night. On 1/08/25 at 1:09 PM, the Restorative nurse confirmed she got to the facility early in the AM on 9/20/24 and saw Staff A slumped over in the front seat of her car. She reported she thought someone went out on break and fell asleep. The Restorative nurse stated she knocked on the window of the car to wake Staff A. She reported Staff A's slurred speech and she told her she was tired. The Restorative nurse offered her a ride home and Staff A declined. On 01/08/25 at 7:33 PM, Staff B, previous DON, reported she failed to identify any concerns with the nurses at the facility. She reported she received a text from one nurse about a hospice resident's morphine count that maybe was off. She revealed she got sick and forgot to look into it further. She stated she failed to know of the incident on 9/19/24 until in the mid-afternoon on 9/20/24. On 1/9/24 at 10:08 AM, the DON reported after the event on 9/19/24, she alerted the Pharmacy to review the records and the Emergency drug kit (E-Kit). She stated she thought they came and picked up the E-kit that Friday. She revealed the pharmacy called her the next week and reported 2 oxycodone tablets gone from the e-Kit with no order or explanation where they went. 01/09/25 02:51 PM, the DON reported she expected the nurses to count and sign the narcotic records to reflect an accurate count. She reported if the nurses found a discrepancy she expected staff to notify her immediately. The facility provided a policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 10/2022, directed 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. It shall be the policy of this facility to implement written procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. These procedures shall include the screening and training of employees, protection of residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, mistreatment, and misappropriation of property, without fear of recrimination or intimidation. Exploitation of a dependent adult. Exploitation means a caretaker knowingly obtains, uses, endeavors to obtain to use or who misappropriates a dependent adult's funds, assets, medications, or property with the intent to temporarily or permanently deprive a dependent adult of the use, benefit, or possession of the funds, assets, medication or property for the benefit of someone other than the dependent adult 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. 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. Investigation Protocols Should an incident or 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.

Based on observations, staff interviews, and facility policy review the facility failed to securely store medication 2 out of 2 times on 1 out of 2 medication carts on 1 out of 4 days observed. The facility reported a census of 35 residents. Finding include: 1. On 1/07/25 at 10:39 AM, the 200 Wing medication cart sat unlocked in the lounge area. 5 residents sat in the area in recliners with their feet up. Between 10:39 and 10:47 AM, 4 people walked by the unlocked medication cart. On 1/07/25 at 10:48 AM, Staff K, Licensed Practical Nurse (LPN), came to the medication cart from a Residents room. She reported she doesn't normally leave the medication cart unlocked. 2. On 1/07/25 at 10:57 AM the medication cart sat in the 200-lounge unlocked. On 1/07/25 at 10:59 AM Staff K, walked back down from the dining room area, and locked the medication cart. On 1/09/25 at 2:51 PM, the Director of Nursing (DON) confirmed she expected the medication carts locked at all times. The Medication Labeling and Storage policy dated 10/2023, directed the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, Center for Disease Control and Prevention (CDC) 2025 Adult Immunization Schedule, and staff interview the facility failed to offer pneumococcal vaccinations according to the CDC for 1 of 5 residents reviewed (Resident #4). The facility identified a census of 35 residents. Findings include: Resident #4 Order Summary Report signed by the Provider on 10/14/24 documented Resident #4 had no known allergies and listed the following physician orders: a. May give Prevnar 20 (PCV20) if resident has not had one since age [AGE], follow CDC pneumococcal vaccine timing for adults. Must obtain signed consent from resident or responsible party. Dated 7/12/22. b. May give Prevnar 13 (PCV13), follow CDC pneumococcal vaccine timing for adults. Must obtain signed consent from resident or responsible party. Dated 7/12/22. c. May give Pneumovax (PPSV23) if resident has not had one since age [AGE], follow CDC pneumococcal vaccine timing for adults. Must obtain signed consent from resident or responsible party. Dated 7/12/22. A Provider Progress Note, Encounter Date 10/17/24 documented a follow-up (physician) visit for transfer to intermediate level of care. The Progress Note documented Resident #4 with a recent hospitalization for a diagnosis of Respiratory failure. Resident #4 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 00 indicating a severe cognitive loss. The MDS documented diagnoses of cancer, heart failure, Alzheimer's Dementia, Non-Alzheimer's Dementia, and sleep apnea. The MDS documented the pneumococcal vaccination had not been offered. A 1/07/25 review of Resident #4 Point Click Care (PCC) Electronic Health Care Record (EHR) MDS Screen documented an original admission date of 7/12/22. Further review of the Progress Notes from the facility last survey to 1/07/25 lacked documentation Resident #4 had been offered a pneumococcal vaccination. A review of the PCC Immunization Record documented Resident #4 received the Pneumococcal 23 (PPSV23) vaccination on 9/26/14. The Pneumococcal Prevnar 13 (PCV13) vaccination was documented as ineligible. During an interview on 1/07/25 at 7:30 AM the Director of Nursing (DON) reported Resident #4 was documented as not eligible for the pneumococcal vaccination based on Resident #4 History and Physical from 2018 that documented he was not eligible at that time. She voiced she was now aware the pneumococcal could be offered every five years. She confirmed she was responsible for the vaccination tracking. Interview on 1/08/25 at 3:21 PM the DON voiced she had not reviewed the 2018 History and Physical but had only seen Resident #4 was not eligible as listed in the the PCC EHR Immunization Record. She voiced she had received further pneumococcal education in December 2024 but hadn't fully understood the CDC requirements for the vaccination at that time. She verbalized the Nurse Consultant had completed an audit in December 2024 and provided her with a list before Christmas of 35 residents that needed to have updated pneumococcal vaccination addressed. The Immunization Policy dated 2/06/17 signed by the Medical Director directed all new residents would receive a pneumococcal immunization unless the immunization was medically contraindicated, the resident had already been immunized, or the resident/resident representative refused vaccination. The CDC 2025 Adult Immunization Schedule for Pneumococcal Vaccination for adults age [AGE] or over directed when PPSV23 is the only pneumococcal vaccination received, then one dose of PCV15, PCV20, or PCV21 should be offered at least 1 year after the last PPSV23 dose.

Based on observation, clinical record review, staff interview and facility policy review the facility failed to accurately account for controlled/narcotic medications for 3 of the 3 residents reviewed (Residents #89, #90, and #92). The facility reported a census of 35 residents. Finding include: 1. The Minimum Data Set (MDS) assessment for Resident #89 dated 7/18/24, listed diagnoses of non-Alzheimer's dementia, Parkinson's disease, and seizure disorder. The Brief Interview for Mental Status (BIMS) reflected a score of 1, severe cognitive impairment. The Care Plan for R#89 dated 4/26/24, directed staff to administer medications as ordered. Monitor and record effectiveness. Report any adverse side effects. The Controlled Substance Count & Usage Record for R#89 dated 9/13/24 at 2:00 PM, reflected 24 milliliters (ml) of Morphine solution remained at the shift change cosigned by Staff I, Licensed Practical Nurse (LPN) and Staff A, Registered Nurse (RN). The next entry on the document dated 9/13/24 at 10 PM, reflected 22 ml remained of the Morphine solution. The document revealed a note on the left side of the form count corrected. The document failed to give an explanation of what happened to the missing 2 ml of Morphine. The Medication Administration Record (MAR) dated 9/13/2024, listed Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 5 mg by mouth every 4 hours as needed (PRN) for Pain 0.25 ml or 5 mg every 4 hours as needed for pain. Lacked a dose signed out/ administered. 2. The MDS for Resident #90 dated 8/8/24, listed diagnoses of non-Alzheimer's dementia, diabetes mellitus, and heart failure. The MDS revealed a BIMS score of 00, indicated sever cognitive impairments. The Care Plan for R#90 dated 6/24/24, directed staff to administer medications as ordered. The Controlled Substance Count & Usage Record for R#90 dated 9/13/24 at 2 PM, listed 8.75 ml of morphine remained. The record reflected Staff A, RN administered two 0.25 ml doses of the Morphine to Resident #90. One 0.25 ml dose at 2:57 PM and one 0.25 ml dose at 8:40 PM. The count at that time reflected 8.25 ml. At 10 PM the end of the shift count (CT) reflected 8.25 ml. The next line on the form revealed count correction 6 ml morphine remained. The document failed to explain why the count failed to include the location of the missing 2.25 ml. The MAR dated 9/2024, directed Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 0.25 ml by mouth three times a day for pain. The MAR also listed Morphine Sulfate (Concentrate) Solution 20 MG/ML. Give 0.25 ml by mouth every 2 hours as needed for Pain or dyspnea. The MAR lacked a PRN dose administered on 9/13/24. 3. The MDS for Resident #92 dated 9/12/24, listed diagnoses of lung cancer, non-Alzheimer's dementia, arthritis, and diabetes mellitus. Resident #92's MDS reflected her BIMS score of 15, intact cognition. The Care Plan for R#92 dated 9/19/24, directed staff to use pain management as appropriate. Monitor/document side effects and effectiveness. The MAR dated 9/19/24, directed Ativan (lorazepam) Solution 2 milligrams (mg)/ml. Give 0.5 mg sublingually (under the tongue) every 2 hours for terminal pass. The Controlled Substance Count & Usage Record for R#92 dated 9/19/24 at 12:35 PM showed 29.5 ml of morphine solution, staff gave 0.25 ml that left 29 ml. The next time on the record reflected 2 PM, and 28.75 ml remained. The count failed to reflect the 0.25 ml discrepancy of the morphine solution. The Controlled Substance Count & Usage Record for R#92 dated 9/19/24 at 5:45 PM showed 29.5 remained of the Ativan Solution. After 0.5 ml administered the count reflected the amount that remained as 29 ml. The next entry on the document dated 9/19/24 at 10 PM revealed 29 ml on hand with nothing given at the time and 27 ml remained. The document lacked an explanation what happened to the 2 ml unaccounted for. Review of the Daily Assignment sheet dated 9/13/24, listed Staff I, Licensed Practical Nurse (LPN), worked 6-2 PM and Staff A, Registered Nurse (RN) worked 2-10 PM and Staff D, RN worked the 10-6 AM shift. The medication signed out 4 times on the shift. 4. Observation on 1/06/25 at 2:05 PM, Staff I, Licensed Piratical Nurse from day shift stood at the end of the medication cart and read the numbers from the Narcotic book while Staff J, LPN the evening nurse knelt at the bottom drawer of the medication cart confirmed the number of narcotic medications that remained in the drawer. Staff I failed to make visual confirmation of the medication that remained in the drawer. On 9/9/24 at 9:28 AM, Staff I reported the process to count narcotic and controlled medication required 2 nurses will look at the amount and look at the book. She stated that when she signed the narcotic book it indicated the accurate dosing and the amount of the medication left in the supply. She reported if she signed the book that's the amount that remained. She confirmed when she signed the Narcotic book on 9/13/24 for R#89 and R#90 the amount she listed reflected the correct amount of the medication that remained. She reported if she found a narcotic discrepancy with the count she would call the DON or manager and not even take the keys from the nurse. On 1/09/25 02:51 PM the Director of Nursing (DON) confirmed she expected the medication carts locked at all times. The DON reported she expected the nurses to count and sign the narcotic records to reflect an accurate count. She reported if the nurses found a discrepancy she expected staff to notify her immediately. The DON stated if a discrepancy is found she will let the Administrator know and an investigation initiated. The facility provided a policy titled Controlled Substances dated 5/2024, the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. The director of nursing services documents irreconcilable discrepancies in a report to the administrator. If a major discrepancy or a pattern of discrepancies occurs, or if there is apparent criminal activity, the director of nursing notifies the administrator and consultant pharmacist immediately. The director of nursing services consults with the provider pharmacy and the administrator to determine whether any further legal action is indicated. Some controlled substances may be stored in the emergency medication supply. Reconciliation of controlled substances in the emergency supply is conducted at intervals established by the director of nursing services. The director of nursing services maintains and disseminates to appropriate individuals a list of staff who have access to medication storage areas and controlled substance containers.

Based on observation, clinical record review, and staff interview, the facility failed to provide interventions/treatments for 1 of 3 residents with skin breakdown (Resident #3) and the facility failed to obtain physician's orders for 1 of 3 residents reviewed (Resident #3). The facility identified a census of 36 residents. Findings include: Provider Progress Notes form dated 7.17.24 at 8:02 a.m. thru 7.19.24 at 9:02 a.m. indicated Resident #3 had active diagnoses that included Lymphedema of both lower extremities, a stage III pressure ulcer to her right thigh, venous stasis ulcers to her bilateral lower legs dated 7.15.24, a non pressure injury to the residents right foot, and an infestation of maggots to the resident's left extremity wounds. The form also included photos and measurements of all of the resident's wounds for the facility nurse's to have reviewed and addressed accordingly. The recommendations for care and treatment included the following: a. Triad Wound Paste cream to the coccyx, sacrum, posterior thighs, medial thighs, right lateral thigh, deep tissue injury, left breast wound, right abdominal wound, gluteal cleft and buttocks 3 times a day (TID) and as needed (PRN) for incontinence. b. Elevated heels off the bed surface. c. Repositioned every two (2) hours. d. Bariatric low air loss to bed surface. e. Avoidance of the use of incontinence briefs when in bed and at night. f. Miconazole cream to breast folds, groin folds, pannus folds, posterior knee folds, gluteal cleft, posterior and medial thighs 2 times a day (BID) for 14 days. f. Right dorsal foot to have cleansed with saline, pat dry, covered wound bed with a silicone bordered foam dressing to have been changed every other day (EOD) and PRN. g. The right and left circumferential legs, venous to have been cleansed with saline, pat dried, cut plan foam to have been 2 centimeters (cm) larger than the wound base on all sides and applied. Secured with Kerlix and tape and changed QD and PRN. A facilities Admit/Readmit Screen form signed 7.25.24 contained the following skin/wound assessments: a. Right buttock pressure area that measured 6.0 centimeters (cm) by (x) 8.0 cm x 0.2 cm deep. b. Right rear thigh unstageable pressure area that measured 9.5 cm x 8.0 cm x 0.2 cm. c. Right lower extremity (RLE) stage III area on her calf that measured 18.0 cm x 28.0 cm x 0.3 cm. e. Left lower extremity (LLE) stage III area on her calf that measured 20.0 cm x 32.0 cm x 0.3 cm. f. Right gluteal fold stage II pressure area that measured 2.0 cm x 2.0 cm x 1.0 cm. g. A coccyx pressure area (not staged) that measured 3.0 cm x 2.0 cm x 0.2 cm. h. The groin, abdominal, and chest areas with moisture associated skin damage (MASD) not measured. i. Right anterior foot stage II area that measured 0.8 cm x 1.0 cm x 0.1 cm. Review of a Medication Administration Record (MAR) and Treatment Administration Record (TAR) form dated 7.1.24 thru 7.31.24 revealed no physician treatment orders from 7.24.24 thru 7.28.24. A Fax form dated 7.25.24 contained the following documentation: Resident admitted 7.24.24 with the following skin issues: a. Right buttock, stage II area that measured 6.0 cm x 8.0 cm x 0.2 cm deep. b. Right thigh unstageable pressure area that measured 9.5 cm x 8.0 cm x 0.2 cm. c. Right lower extremity, stage III pressure ulcer that measured 18.0 cm x 28.0 cm x 0.3 cm. d. Left lower extremity, stage III pressure ulcer that measured 20.0 cm x 32.0 cm x 0.3 cm. f. Right gluteal fold, stage II 2.0 cm x 2.0 cm x 1.0 cm. g. Coccyx pressure area (not staged) that measured 3.0 cm x 2.0 cm x 0.2 cm. h. Groin, abdomen and chest area with MASD. j. Right anterior foot, stage II that measured 0.8 cm x 1.0 cm x 0.1 cm. A Verbal order form dated 7.24.24 at 4:37 a.m. included the following physician order: Triad Hydrophilic Wound Dressing External Paste (wound dressing) applied to coccyx, buttocks topically every morning and at bedtime for the wounds after staff cleansed the affected areas thoroughly with soap and water, rinsed and dried well. Application of the ointment should have occurred to all areas of rash rubbing in well to one inch past areas of redness confirmed by the Director of Nursing (DON). A separate Verbal order form dated 7.24.24 at 4:37 a.m. included the following physician order: Micatin Cream 2% applied to affected area topically BID for a wound (area not specified). During an interview 8.16.24 at 8:30 a.m. the Interim Administrator confirmed on 7.28.24 at approximately 7 p.m. Staff A, Licensed Practical Nurse (LPN informed her via a telephone call that she had been unable to locate treatment orders on the resident's MAR and TAR for this resident admitted with multiple skin wounds/ulcerated areas. The Interim Administrator then called the DON who indicated she faxed the admission measurements of the wounds to the Physician on 7.25.24 but she had been pulled to work as a nurse on the floor so she inadvertently forgot to follow up with the Physician as a means to obtain treatment orders as expected. During an interview 8.16.24 at 10:17 a.m. the DON confirmed the resident admitted to the facility on 7.24.24 as Staff B, LPN /admission and Wound Care Nurse performed the admission assessment and addressed all of the resident's wounds/ulcerated areas. On 7.25.24 when the DON arrived to work she noted no wound treatment orders had been addressed on the TAR so she faxed the Physician for orders. Also note, Verbal orders dated 7.24.24 at 4:37 a.m. for treatments that were not placed on the MAR/TAR until 7.29.24. The DON had originally been unable to explain why the Physician orders had not been transcribed onto the MAR/TAR. At 10:30 a.m. the DON then confirmed on 8.1.24 she had backdated the above documented orders because that had been when the Physician orders should have been initiated and performed by the nursing staff. During an interview 8.16.24 at 10:40 a.m. Staff C, RN/Corporate Nurse Consultant and the Administrator confirmed they expected any nurse who cared for this resident to have obtained Physician orders for the resident's wounds which had been a nursing standard of practice and an expectation of the facility management team.

Based on employee file review, policy review and staff interview, the facility failed to obtain a Department of Criminal Investigation (DCI) report clearing staff to work for 1 of 2 Certified Nursing Assistants (CNA) reviewed (Staff B). The facility reported a census of 31 residents. Findings include: A Facility New Hire List provided by the facility on 3/11/24 showed Staff B with a hire date of 3/6/23. On 3/12/24 at 9:12 AM the Administrator reported Staff B's employee file did not have a Department of Human Services (DHS) check and the facility had pulled her from the schedule. A 3/12/24 review of the CNA schedule for the timeframe 2/18/24 to 3/12/24 revealed Staff B scheduled to work the following: a. February 26, 27, 28, 29 from 10 PM to 6 AM. b. March 2, 3, 4, 7, 11, 12, 13, 14, 16 from 10 PM to 6 AM. A review of Staff B's employee file on 3/12/24 at 10:22 PM revealed a Single Contact License and Background Check dated 2/23/23 at 11:32 AM. The Background Check, under Criminal History Background, documented further research was required and to please await the Department of Criminal Investigation's (DCI's) final response for the criminal history. The employee file lacked documentation of further investigation findings from DCI regarding criminal history showing Staff B could work in the facility. On 3/12/24 at 12:57 PM the Human Resource Director reported she had started her position at the end of September 2023. She reported there had been issues with employee files and they had to do some audits and change up some processes. During an interview on 3/12/24 at 12:59 PM the Administrator reported they had found issues within the employee files and completed audits. She reported new employees should not be hired without the DCI returning showing the employee is cleared to work. On 3/14/24 at 12:36 PM the Administrator reported Staff B had signed paperwork on 3/6/23, then started working the floor the week of 3/12/23. Staff B's Time Card provided by the facility on 3/14/24 documented Staff B worked the following hours from 3/12/23 - 3/18/23 in the facility: a. 3/12/23 4.15 hours; pay code training. b. 3/13/23 7.3 hours; pay code training. c. 3/14/23 7.45 hours d. 3/15/23 7.45 hours e. 3/16/23 7.45 hours f. 3/17/23 7.30 hours g. 3/18/23 7.45 hours The Facility Abuse Prevention, Identification, Investigation and Reporting Policy, dated October 2022, provided by the facility documented the facility shall screen all potential employees for a history of abuse, neglect, exploitation, misappropriation of property, or mistreatment of residents. The facility will not employ or otherwise engage individuals who: (i) Have been found guilty of resident abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into a State nurse aide registry concerning resident abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. The facility will conduct an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to residents, prior to hire, in the manner prescribed under 481 Iowa Administrative Code § 58.11(3). The facility will conduct a criminal record check and dependent adult/child abuse registry check on all current employees and other individuals engaged to provide services to residents who have criminal convictions or founded abuse determinations after hire, or where the facility received credible information that an employee has had a criminal conviction or a founded abuse determination subsequent to hire.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and facility admission agreement, the facility failed to provide notice to the resident and/or the legal representative of the facility's bed-hold policy prior to and upon transfer to the hospital for 2 of 2 residents sampled (Resident #2 and #10). The facility identified a census of 31 residents. Finding include: 1. A 3/12/24 review of Resident #10's Electronic Census Record documented the following: a. Hospital leave 2/18/24; return to the facility on 2/20/24. b. Hospital leave 11/24/23; return to the facility on [DATE]. c. Hospital leave 11/13/23; return to the facility on [DATE]. A 3/12/24 review of the Progress Notes and Electronic Record Assessments lacked documentation the facility had addressed a bed hold within 48 hours for each hospital leave from 11/13/23 - 2/20/24. On 3/13/24 at 7:36 AM the Administrator reported the facility only had a 10/11/23 bed hold for Resident #10. All other bed hold documentation could not be located. On 3/13/24 at 4:22 PM Staff C Licensed Practical Nurse (LPN) verbalized she is a full-time nurse at the facility and in her experience it is typically a nurse manager's job to follow-up on the bed hold notice. The charge nurses do not know when a resident goes to the emergency room if they will be admitted to the hospital or not. The nurses have not received any education on how to do the bed hold process. She would expect a nurse manager to follow-up and address if a bed hold is needed. On 3/13/24 at 4:26 PM the Interim Director of Nursing (IDON) explained the facility does not have a bed hold policy and she is not sure how the bed holds are addressed, but the Administrator would have more information. During an interview on 3/13/24 at 4:27 PM the Administrator reported the prior DON had the responsibility to call the family and follow-up on the bed hold, but she had not been documenting the bed hold status. The Administrator verbalized bed holds are an issue they are going to put through quality analysis and she expects the bed hold to be done. The Facility admission Agreement, revised 1/23, provided by the Facility documented when a Resident is temporarily absent from the Facility for medical treatment, the Facility shall provide written information to the Resident specifying (1) the duration of the bed hold policy under applicable governmental regulations, if any, during which the Resident shall be permitted to return and resume residence in the facility and (2) the Facility's policies regarding bed hold periods. The Facility shall then ask the Resident or the Resident's Representative if he or she wishes the facility to hold open the bed. The Facility shall document in the Resident's records the fact that such information was given and the response of the Resident or the Resident's Representative. Upon request of the Resident or the Resident's Representative, the Facility shall hold open the bed for at least 10 days during the Resident's absence, and the Facility shall receive payment for the absence in accordance with the provisions of this Agreement. 2. A 3/12/24 review of Resident #2's Electronic Census Record documented the Resident out to the hospital on 2/14/24 and returned to the facility on 2/19/24. A 3/12/24 review of the Progress Notes and Electronic Record Assessments lacked documentation the facility had addressed a bed hold within 48 hours of the hospital leave on 2/14/23. On 3/13/24 at 7:36 AM the Administrator reported the facility could not locate any bed hold for Resident #2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, policy reiew and staff interview, the facility failed to provide appropriate catheter care when the urinary drainage bag and tubing came into contact with the floor for 1 of 1 residents sampled (Resident #8). The facility identified a census of 31 residents. Findings include: Resident #8's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interiew for Mental Status (BIMS) score of 7/15 indicating a severe cognitive loss. The Resident required substantial/maximal asistance (the helper does more than half of the effort. The helper lifts or holds the trunk or the limbs and provides more than half the effort) with toileting, personal hygiene and was dependent upon the staff to provide lower body dressing. The MDS documented Resident #8 utilized an indwelling catheter for a diagnosis of retention of urine. The Care Plan revised 8/17/23 listed Resident #8 utilized an indwelling catheter and directed the staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. A Urinalysis (UA) dated 1/31/24 documented a white blood cell, urine count of 58 (high) and moderate bacteria present, noting the UA would be set up for culture. A 2/02/24 UA culture addressed by the Provider on 2/05/24 documented an order for Macrobid (antibiotic medication) 100 milligrams (MG) by mouth twice a day for 10 days. A Review of the February 2024 Medication Administration Record (MAR) showed Resident #8 had completed a physician order for Macrobid oral capsule 100 MG, one capsule two times a day for 10 days from 2/06/24 to 2/16/24 for a diagnosis of urinary tract infection (UTI). On 3/11/24 at 12:11 PM Resident #8 sat in her wheelchair at the dining room table. A three inch portion of the catheter tubing lay directly in contact with the floor underneath the table. Two staff members were seated around the table with their shoes making contact with the floor. One CNA staff sat near the resident with her shoes near the urinary drainage bag tubing on the floor. During an observation on 3/12/24 at 1:49 PM Staff A Certified Nursing Assistant (CNA), after emptying the urinary drainage bag, hung the drainage bag from under the Resident's recliner foot rest, then flipped the privacy cover over the bag. The privacy bag cover opened at the bottom allowing the bottom of the urinary drainage bag to come into contact with the floor. At 1:52PM the Interim Director of Nursing (IDON) confirmed the catheter drainage bag was a little bit in contact with the floor. During an interview on 3:12 24 at 1:54 PM the IDON voiced the urinary drainage bags should not come into contact with the floor. During an observation on 3/14/24 at 7:35 AM Staff D CNA completed hand washing and set up a basin of water and washcloths for catheter care. Resident #8 lay on her back in bed. Staff D cleansed down the left front groin, changed the fold on the washcloth and then cleansed up and down several times along the right groin fold. Staff D took a new washcloth and cleansed in a circle around the catheter insertion site, then dabbed the washcloth several times back and forth, up and down around the catheter insertion site. Staff D failed to cleanse down the catheter from the meatus (catheter insertion site) four inches down the tubing or to the connection site. During an interview on 3/14/24 in the absence of the IDON, the Administrator reported she expected staff to follow the facility catheter care policy. The Procedure for Clinical Skill: Catheter Care and Emptying, dated 8/2023, provide by the facility, under step 6 directed the staff to hold/anchor the catheter and cleanse the tubing with one swipe away from the meatus down to the Y or connection site. The Policy directed under step 11 to position the catheter bag at a height that allows for emptying but does not touch the floor when emptying the catheter bag. The Policy failed to address to keep the urinary drainage bag and tubing from coming into contact with the floor during general care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, Nurse Practitioner (NP) interview and facility policy review, the facility failed to notify one (1) resident's Physician and/or Nurse Practitioner (NP) related to a new skin/pressure area (Resident #4). The facility identified a census of 39 residents. Findings Include: A Minimum Data Set (MDS) Assessment Form dated 5-2-23 indicated Resident #4 had diagnoses that included anemia, diabetes mellitus (DM), a displaced fracture of her left humerus, reduced mobility, rhabdomylosis (breakdown of muscle tissue that releases protein into the blood). The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 (moderately impaired cognitive skills), required extensive assistance of staff with bed mobility, transfers, ambulation, dressing toilet use, personal hygiene, supervision with eating and as occasionally incontinent of her bowels and bladders. The assessment documented the resident as at risk for pressure ulcers, with no pressure ulcers and not on a turning and repositioning program when admitted [DATE]. A Care Plan with a Focus area initiated 5-5-23 identified the resident as at risk for skin breakdown related to (R/T) impaired mobility and incontinence. The Interventions included the following all initiated 5-5-23: a. Assessment of the resident for presence of risk factors, treatment, reduction and elimination. b. Assistance with repositioning. c. Skin monitored during cares and reported redness, sore, [NAME] and breakdown. d. Skin treatments as ordered for any areas of impaired skin breakdown. A Braden Scale For Predicting Pressure Sore Risk form dated 4-26-23 at 5:30 p.m. identified a score of 17 which placed the resident at risk for pressure ulcers. Review of the facilities Progress Notes included the following entries as dated: a A Physician Order for non-weight bearing status. (dated 5-8-23 at 3:15 p.m.) b. The resident complained of buttock discomfort. Observation revealed three (3) small open areas with no Physician notification documented. (dated 5-9-23 at 8:30 p.m.) During an interview 9-6-23 at 8:43 a.m., the Director of Nursing (DON) confirmed she would have expected both of the nurses who assessed the resident to have notified the Physician and failure to have done so lead to a delay in treatment. An undated Physician Notification Policy directed the facility staff on the expectation of notification of the Physician on a resident's change of condition. The Procedure included the following: a. A significant change in a resident condition which could have been life threatening. 1. Any change in condition which may have been life-threatening should have been called to the physician (not faxed) immediately. b. A significant change in a resident condition which had the potential for clinical complication (i.e. open skin and etc.)

Based on clinical record review and staff interview, the facility staff failed to follow resident Care Plans for 1 of 3 residents reviewed (Resident #1). The facility identified a census of 39 residents. Findings Include: A Minimum Data Set (MDS) Assessment form dated 6-15-23 indicated Resident #1 had diagnoses that included cancer, orthostatic hypotension, Parkinson's disease, adult failure to thrive, malaise and atrial fibrillation (AF). The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 (moderately impaired cognitive status), required extensive assistance of staff with dressing and personal hygiene, limited assistance of staff with transfers, ambulation and toilet use. A Care Plan with a Focus area initiated 10-31-22 indicated the resident as at risk for falling related to (R/T) Parkinson's disease. The Interventions included the following as dated: a. The resident ambulated with a gait belt, walker and 1 staff assistance. (revised 1-9-23) b. Staff directed to not have left the resident unattended in the bathroom. (initiated 11-20-22) Progress Note entries included the following as dated: a. On 7-1-23 at 11:32 p.m.: At 7 p.m. the resident yelled for help from a common area bathroom. When the nurse arrived she found the resident as she laid on the floor next to the toilet. Prior to the fall the resident asked to use the restroom about three (3) times but failed to urinate. During supper she asked to use the bathroom. The Certified Nursing Assistant (CNA) assisted her to the bathroom. As the resident sat on the toilet she decided to self-transfer, lost her balance and fell. A head to toe assessment had been completed with no injuries noted. During an interview 8-31-23 at 10:57 a.m., Staff A, CNA confirmed she took the resident to the spa/bathroom via a wheel chair at around 6 p.m. Staff A transferred the resident onto the toilet with the use of a gait belt assistive device and told the resident to pull the call light upon completion. Staff A then left the resident unattended in the bathroom and returned to the dining room. The nurse then came to her in the dining area and told her the resident had fallen. Staff A returned to the bathroom and observed the resident as she laid on her right side in a weird position further described as all tensed up. The nurse performed range of motion (ROM) to the resident's extremities while positioned on the floor as the resident complained of pain to her hip and legs. The nurse then gave the directive to transfer the resident off the floor. Staff A indicated the resident had fluctuating cognition and not a fall risk.

Based on clinical record review, staff interview and facility policy review, the facility failed to follow Physician's Orders for 3 of 3 residents reviewed (Residents #3, #4 and #5). The facility identified a census of 39 residents. Findings Include: 1. Review of a Medication Administration Audit Report form for Resident #3 dated 8-30-23 at 2:54 p.m. revealed the following Physician Orders and actual administration times of the following medications: a. On 10-6-22: Levothyroxine 75 micrograms (mcg) one (1) tablet by mouth (po) for low thyroid levels, Losartan Potassium oral tablet 25 milligrams (mg) 1 tablet po one time a day (QD) for high blood pressure - all scheduled at 7 a.m. and administered at 10:17 a.m. 2. Review of a Medication Administration Audit Report form for Resident #4 dated 8-30-23 at 2:52 p.m. revealed the following Physician Orders and actual administration times of the following medications: a. On 4-27-23: Senna-Docusate Sodium oral tablet 8.6-50 mg 1 tablet po two (2) times a day (bid) for constipation, Lisinopril oral tablet 5 mg 1 table po QD for hypertension, Atenolol 25 mg 1 table po QD for hypertension, Ascorbic acid 500 mg 1 tablet QD as a supplement, Topiramate 50 mg 1 bid for headaches, Escitalopram oxalate 20 mg 1 po QD for depression, Metformin Hydrocloride (HCl) 500 mg 1 tablet BID for diabetes, Pantoprazole Sodium delay release 40 mg 1 tablet po QD for gastric reflux, Potassium Chloride extended release tablet 10 millequivalents (meq) 1 tablet po BID for hypokalemia, Ferrous Sulfate 325 mg 1 table po QD for anemia, Hydrochlorothiazide tablet 12.5 mg 1 table po QD for athersclerotic heart disease - all scheduled at 7 a.m. and administered at 8:25 a.m. b. On 5-3-23: Ferrous sulfate 325 mg 1 tablet po QD, Hydrochlorothiazide 12 mg 1 po QD, Oxycodone-acetaminophen 7.5-325 mg 1 tablet po bid, Potassium Chloride ER 1 table po bid, Senna-Docusate Sodium 8.6-50 mg 1 table po bid, Escitalopram Oxalate 20 mg 1 tablet po QD, Pantoprazole sodium 40 mg 1 tablet po QD, Metformin HCl 500 mg 1 table po bid, Lisinopril 5 mg 1 tablet po QD, Atenolol 25 mg 1 tablet QD, Ascorbic acid 500 mg 1 tablet QD - all scheduled at 7 a.m. and administered at 8:30 a.m. 3. Review of a Medication Administration Audit Report form for Resident #5 dated 8-30-23 at 2:37 p.m. revealed the following physician orders and actual administration times of the following medications: a. Fluticaone Propionate nasal suspension 50 mcg 1 spray in both nostrils QD for allergies, Sinement tablet 25-100 mg 3 tables po bid for Parkinson's disease, Ferrous Sulfate 325 mg table po bid for iron deficiency anemia, Aspirin 81 mg 1 tablet po QD for athersclerotic heart disease, Calcium-Vitamin D3 250-3 125 mg-mcg tablet 1 po QD for a supplement, Amantadine HCL 100 mg capsule 1 po bid for Parkinson's disease, Amiodarone HCL 200 mg table 1 po QD for atrial fibrillation, Protonix 40 mg delay release tablet 1 po QD for gastro-esophageal reflux, Donepezil HCL 10 mg table 1 po QD for Parkinson's disease, Miralax oral powder 17 gm 1 scoop po every other day for constipation, Fexofenadine HCL 180 mg table 1 po QD for allergies - all scheduled at 7 a.m. and administered at 8:26 a.m. According to an email dated 9-13-23 at 4:19 p.m., the Administrator confirmed she expected staff to have administered medications according to Physician's Orders. A Medication Administration policy form effective 10-10-19 indicated medications should have been administered per Physician Order. The Procedure included the following: a. Medications may be administered one (1) hour prior and 1 hour after the scheduled administration times.

Based on clinical record review, staff interviews and facility policy review the facility failed to notify one out of four resident representatives of a condition change for a resident (Resident #89). The facility reported a census of 36 residents. Findings Include: The Minimum Data Set (MDS) Assessment for Resident #89 dated 11/17/21, listed diagnoses of fracture of right Tibia, end stage renal disease (ESRD), and diabetes mellitus. The MDS recorded a Brief Interview of Mental Statues (BIMS) score of 1 out of 15 indicating severe impaired cognition. The MDS reflected Resident #89 totally dependent on the assist of 2 staff for bed mobility, transfers, toileting, dressing and bathing. The MDS documented Resident #89 totally dependant on 1 staff for personal hygiene and at the time of the MDS lacked any pressure ulcers and at risk for development of pressure ulcers. The Care Plan for Resident #89 dated 11/24/21, directed check all of body for breaks in skin and treat promptly as ordered by doctor. The Wound Skin Healing Record for Resident #89 dated 1/4/22, described Slough- yellow or white tissue that adheres to the wound bed in strings or thick clumps, or is mucinous. Necrotic tissue (Eschar)- Black or brown or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than the surrounding skin. The record showed an unstageable wound to the right posterior knee measured 5.6 centimeters (cm) by 2.7 cm and 0.4 cm. The description of the wound read a small amount of purulent drainage with a foul odor and described the wound bed with slough and back or brown eschar. The skin around the wound is described as bright red, hardness or indurated edges. The record reflected the Physician notified on 1/3/22, but the form failed to reflect resident representative notification. Resident #89's Health Status Note dated from 1/3/22 through 1/5/22, failed to reflect documentation the resident representative notified of the necrotic wound to the right posterior knee. On 01/11/23 at 4:51 PM, Staff A Listened Practical Nurse (LPN), stated she failed to remember notifying the resident representative of the wound. She revealed that she may possibly left that for the day shift to complete. On 01/12/23 at 11:30 AM , the Administrator/Registered Nurse (RN), reported she expected the nurses to notify the resident representative or Power of Attorney (POA), and document after any assessment that resulted in an abnormality for the resident. She reported the facility failed to have a cast care policy. On 01/12/23 at 11:58 AM, the Administrator confirmed the facility failed to document any notification of the Resident Representative of Resident #89's wound. The facility provided a policy titled Skin Checks, dated 7/12/18, the policy read the Bath Aides will observe all residents' skin for abnormalities during each bath or shower and report abnormalities to the Charge Nurse. Any abnormalities noted during resident bathing will be documented by the Bath Aide on the Skin Check Forms. This form will be given to the Charge Nurse upon completion. The Charge Nurse will complete an assessment of the skin and document on the appropriate Skin Assessment Form. The Physician will be notified of any new or worsening area and a treatment order will be obtained and the resident representative will be notified. The facility provided a policy titled Notification, Resident Representative dated 10/10/19, read the resident's representative shall be notified of any accident, injury, or adverse change in a resident's condition requiring physician notification. The policy continued to include the Procedure - Resident representatives shall be notified of the following: a. Any accident or unusual incident, regardless of injury. b. A significant change in a resident's condition. c. Death. d. Discharge or transfer to another healthcare facility or home. e. Any change in condition which may be life-threatening should be called immediately. f. Same day notification may be utilized for condition changes that are not life-threatening. g. Next day notification may be utilized for condition changes that are not life-threatening and occur during sleeping hours. h. Attempts to notify the resident representative shall be documented in the clinical record. A minimum of 3 attempts must be made.