Based on record review, observations, and interviews the facility failed to ensure individual resident's narcotic records were maintained and reconciled for 2 of 3 medication carts reviewed. The facility failed to ensure an accurate count of controlled medications was maintained. Findings: Review of the facility's Drug-Controlled Substances Policy dated 11/17 revealed the following: Controlled medications are to be signed out on Form NS-618--Individual Residents Narcotic Record at the time they are to be administered. RNs (Registered Nurses) and LPNs (Licensed Practical Nurses) only will sign out for and/or administer controlled medications, recording the date, time, resident's name, and signature of the administering nurse on the narcotic count sheet. The administering nurse will also check for the accuracy of the remaining count. Observation of the medication cart for 800 hall on 03/05/2025 at 8:15 a.m. with S2 LPN revealed resident #50's medication card for Norco 10/325 mg (milligrams) had a count of 6. Observation of medication pass on 03/05/2025 at 8:15 a.m. revealed S2 LPN administered resident #50's Norco 10/325 mg one tablet for pain without signing it out on resident #50's Individual Residents Narcotic Record. Observation on 03/05/2025 at 8:17 a.m. of resident #50's Individual Residents Narcotic Record for Norco 10/325 mg with S2 LPN revealed a count of 5, failing to reconcile with the count of 6 on resident #50's medication card for Norco 10/325 mg. During an interview on 03/05/2025 at 8:17 a.m. S2 LPN reported she had signed out resident #50's Norco 10/325 mg prior to administering it and confirmed it should have signed out at the time of administration. Observation on 03/06/2025 at 8:05 a.m. with S3 LPN of the medication cart for 1000 hall revealed resident #121's medication card for Modafinil 200 mg had a count of 4, and resident #121's Individual Resident Narcotic Record had a count of 5 and failed to reconcile. Further observation revealed a medication cup on the top of the medication cart with 5 tablets inside that included a white oval pill that S3 LPN identified as resident #121's Modafinil 200 mg tablet. During an interview on 03/06/2025 at 8:05 a.m. S3 LPN reported, she had already pulled resident #121's Modafinil 200 mg up, and pointed to a cup of tablets on the top of the medication cart. S3 LPN stated, I just hadn't signed it out. S3 LPN confirmed resident #121's medication should not have been pre-pulled up and resident #121's Modafinil 200 mg should have been removed and signed out of locked narcotic stock at the time of administration and not before. During an interview on 03/06/2025 at 11:30 a.m. S1 DON (Director of Nurses) confirmed controlled medications, including resident #50's Norco 10/325 mg and resident #121's Modafinil 200 mg should have been signed out on each residents Individual Narcotic Records at the time of administration. S1 DON further confirmed the count of resident #50 and resident #121's controlled medications should have reconciled.

Based on observation, interviews and record reviews, the facility failed to ensure 1 (#40) of 1(#40) resident received reasonable accommodation of needs by failing to ensure the resident's call button was within reach. Findings: Observation on 1/9/2023 at 8:40 a.m. revealed resident #40 yelling Help! Help! Help! from the resident's room. Upon entering the room, an observation was made of resident #40's call button on the floor out of the resident reach. Review of resident #40's BIMS (Brief Interview Mental Status) revealed a score of 10 indicating mildly impaired. Review of resident #40's MDS (Minimum Data Set) revealed resident #40 requires extensive assistance with bed mobility. Review of resident #40's record revealed a diagnosis of dementia and anxiety. Review of resident #40's medical record revealed resident #40 was care planned for risk of falls with an intervention which included placing the call light/button within reach. During an interview on 1/9/2023 at 8:42 a.m. S10 CNA (Certified Nurse Assistant) confirmed the call light should have been within the resident's reach.

Based on record reviews and interviews, the facility failed to ensure each resident's MDS (Minimum Data Set) assessment was transmitted within 14 days of completion for 2 (#85 and #279) of 3 (#67, #85, and #279) residents who were reviewed for Resident Assessment. Findings: Resident # 279 Review of resident #279's admission MDS with a care plan completion date of 12/13/2022 failed to reveal a transmission date. Resident #85 Review of resident #85's Discharge MDS with an ARD (Assessment Reference Date) of 9/12/2022 failed to reveal a completion or transmission date. During an interview on 1/11/2023 at 10:30 a.m. S7 MDS Nurse confirmed resident #279's MDS had not been transmitted and should have been. During an interview on 1/11/23 at 3:45 p.m. S9 MDS Nurse confirmed resident #279's admission MDS had not been transmitted and should have been. S9 MDS Nurse further confirmed resident #85's discharge MDS had not been transmitted and should have been.

Based on observation, record reviews and interviews, the facility failed to ensure the plan of care was implemented and developed for 2(#102, #126) of 4 (#67, #102, #126, #279) residents reviewed for accidents. 1. The facility failed to ensure x-rays were done as ordered by a physician. 2. The facility failed to develop a plan of care for resident #126's use of a wanderguard bracelet for safety. Findings: Resident #102 Review of the facility's Incident Log revealed resident #102 had a fall on 1/1/2023 at 10:30 p.m. and was found on the floor. Review of resident #102's nurse's notes dated 1/2/2023 at 4:51 a.m. revealed on 1/1/2023 at 10:30 p.m. resident #102 was found lying on the floor. Resident #102's physician was notified and a new order was given for x-rays on resident #102's left hip and left knee. Review of the resident's #102's medical record failed to reveal x-rays on resident #102's left hip and left knee had been done. During an interview on 1/11/2023 at 10:52 a.m., S8 Corporate Nurse confirmed resident #102 did not get x-rays of the left hip and left knee as ordered by the physician. Resident #126 Observation on 1/9/2023 at 2:13 p.m. revealed resident #126 had a wanderguard bracelet placed to the left ankle. Review of resident #102's BIMS (Brief Interview Mental Status) score of 15 indicating intact cognition. During an interview on 1/9/2023 at 2:13 p.m., resident #126 reported she fell outside. Resident #126 further reported a wanderguard bracelet was placed on her ankle after the incident. Review of resident #126's care plan failed to reveal a care plan for use of a wanderguard bracelet. During an interview on 1/11/2023 at 3:25 p.m., S7 MDS nurse confirmed resident #126 was not care planned for use of a wanderguard bracelet and should have been. During an interview on 1/11/2023 at 3:30 p.m., S1 Administrator confirmed resident #126 should have been care planned for use of a wanderguard bracelet.

Based on record reviews and interview the facility failed to ensure State Registry verifications were completed prior to hire for 2 [S3 CNA (Certified Nursing Assistant) and S4 CNA] of 5 CNA personnel files reviewed. Findings: 1. Review of S3 CNA's personnel file revealed a hire date of 07/28/2022. Further review of S3 CNA's personnel file revealed CNA Registry check was completed on 08/10/2022. 2. Review of S4 CNA's personnel file revealed a hire date of 11/08/2018. Further review of S4 CNA's personnel file revealed Criminal Background and Sex Offender Registry checks were completed on 11/09/2022. During an interview on 01/11/2023 at 2:00 p.m. S2 HR (Human Resources) acknowledged State Registry verifications were not completed prior to hire for S3 CNA and S4 CNA and should have been.

Based on observations and interviews the facility failed to ensure food was served in accordance with professional standards for food service safety for the 114 residents served a meal tray from the kitchen. There were a total of 114 residents receiving meal trays from the kitchen according to the Resident Census and Conditions of Residents form dated 01/09/2023. Findings: Review of the facility's Monitoring Temperatures of Cooked Foods policy revealed in part: Policy: The temperature of potentially hazardous cooked foods will be monitored to insure that the foods are not in the danger zone (above 41 degrees F (Fahrenheit) and below 135 degrees F) for more than six hours. Procedure: 1. Potentially hazardous cooked foods, after being cooked to the required minimum internal temperature, will be held on hot holding equipment that will keep the food at a minimum 135 degrees F or higher. 2. The temperature of each potentially hazardous food will be taken at the following times. a. When the cooking process is completed. Foods must be cooked to the proper internal temperature for fifteen seconds. Food will be placed in hot holding equipment immediately after the cooking process is completed. b. When the food is placed in the hot holding equipment . 3. Cooking, holding and storage temperatures should be recorded on a Food Temperature Monitoring Log. Review of the facility's Daily Food Temperature Monitoring Logs for December 2022 and January 2023 revealed: 12/08/2022 - 12/12/2022 - Temperatures for Dinner meals had not been documented. 12/13/2022 - 12/14/2022 - Temperatures for Breakfast, Lunch, and Dinner meals had not been documented. 12/15/2022 - 12/19/2022 - Temperatures for Dinner meal had not been documented. 01/01/2023 - Temperatures for Dinner meal had not been documented. 01/06/2023 - Temperatures for Lunch meal had not been documented. 01/07/2023 - Temperatures for Breakfast and Lunch meals had not been documented. During an interview on 01/09/2023 at 8:30 a.m. S5 DM (Dietary Manager) and S6 ADM (Assistant Dietary Manager) reviewed the December 2022 and January 2023 Daily Food Temperature Monitoring Logs. S5 DM and S6 ADM acknowledged temperatures had not been monitored for prepared meals and should have been.