**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to report allegations of drug diversion to the state agency (SA) and law enforcement within 24 hours for 4 of 4 residents (R1, R2, R3, R4) reviewed for drug diversion. This had the potential to affect all residents who were prescribed narcotics.Findings include:R1's quarterly Minimum Data Set, dated [DATE], identified R1 was cognitively intact and had diagnoses including quadriplegia and neurogenic bladder. R1 required assistance for activities of daily living (ADL's), had functional limitation in range of motion with bilateral upper and lower extremities and used a motorized wheelchair for locomotion. R1 had almost constant pain which occasionally affect sleep. R1's pain was rated #7 on a 0-10 scale (0=no pain, 10=worst pain) and received scheduled and as needed (PRN) opioid medications for pain.R1's physician orders report dated 6/30/25 through 7/30/25, identified orders for oxycodone 10 mg tablet give 1 tablet orally every 4 hours as needed for pain.R2's significant change MDS dated [DATE] identified R2 had functional limitation in bilateral upper and lower extremities, required staff assistance with all ADLs except eating and diagnoses included chronic osteomyelitis, paraplegia, chronic pain syndrome, and chronic pressure ulcers. R2 had almost constant pain that was rated #8/10. R2's pain frequently affected sleep and interfered with therapy and day-to-day activities, and almost constantly interfered with therapy activities. R2 received scheduled and PRN pain medication. R2's cognition section was not completed on assessment.R2's physicians orders report dated 6/30/25 through 7/30/25, identified orders for morphine immediate release 15 mg tablet give one tablet by mouth every 6 hours as needed for pain.R3's quarterly MDS dated [DATE], identified R3 was cognitively intact, and diagnoses included arthritis, osteoporosis, dementia, bipolar disorder and muscle weakness. R3 refused to ambulate, was independent with manual wheelchair locomotion and required assistance with all other ADL's. R3 had almost constant pain that was rated a #7/10. R3's pain occasionally affected day-to-day activities, rarely affected sleep, and received scheduled and PRN pain medication.R3's physician orders report dated 6/30/25 through 7/30/25, identified orders for oxycodone 5 mg tablet give 2.5 mg (half tablet) orally every 6 hours as needed for pain.R4's quarterly MDS dated [DATE], identified R4 was cognitively intact, and diagnoses included Guillain-Barre syndrome, trigeminal neuralgia, and quadriplegia. R4 had functional limitation in both lower extremities, was independent with ADL's and used a walker and motorized wheelchair for mobility. R4 had almost constant pain that was rated #7/10. R3's pain frequently affected sleep and interfered with therapy and day-to-day activities. R4 received scheduled and PRN pain medication. R4's physician orders report dated 6/30/25 through 7/30/25, identified R4 had orders for pregabalin 150 mg give 1 tablet by mouth three times daily and tramadol 50 mg give 1-2 tablets orally every six hours as needed for painThe facility reported incident submitted to the SA on 7/14/25 at 5:30 p.m., identified the facility found evidence of diversion of narcotic pain medication of one or more residents. A facility provided list identified R1, R2, R3, R4 were including in the list of residents whos medication were divertedOn 7/30/25 at 10:43 a.m., registered nurse (RN)-A stated the narcotic medications are counted by the outgoing and incoming nurse at the start of every shift. RN-A stated on 7/1/25, RN-A worked the morning shift starting at 6:00 a.m. and was counting narcotics with the outgoing nurse who was also alleged perpetrator (LPN-A). When we got to R3's medication, the number of pills left had not matched the narcotic record. LPN-A stated she forgot to write the administrations into the record and proceeded to write in the book. RN-A didn't think anything of it because everyone got busy at times and write the administrations into the record at the end of the shift. Later that morning R3 requested pain medication. RN-A reviewed the narcotic record and couldn't read LPN-A's handwriting. RN-A looked at the MAR and the administration was not signed off. RN-A immediately reported to the DON. RN-A stated there was another resident that complained the oxycodone medication had not tasted bitter like it should when LPN-A gave the medication. On 7/30/25 at 4:19 p.m., DON stated she and the administrator suspected LPN-A may have diverted narcotic pain medication because RN-A reported LPN-A had documented narcotic medication administrations while they were counting out at the end of LPN-A's shift. Later that morning RN-A checked the book to see when the last dose was given and couldn't read LPN-A's writing. The DON stated according to the facility abuse policy suspected drug diversion should be reported to the SA within 24 hours of notification. The DON was uncertain if suspected drug diversion should be reported to local law enforcement (LE). DON stated the incident was not reported to the SA within the required 24-hour timeframe because they didn't want to make an allegation unless they were sure it occurred; however it had not been reported to LE.On 7/30/25 at 5:32 p.m., the administrator stated she was notified of the medication discrepancy regarding LPN-A on 7/1/25 when the DON and administrator decided to investigate LPN-A's narcotic medication administration documentation. The administrator stated according to the facility policy drug diversion allegations should be reported to the SA within 24 hours of notification. The administrator stated a report should have been filed with LE when they were notified of a suspected drug diversion. The allegation was not reported within 24 hours because the administrator and DON wanted to ensure there was evidence supporting the allegations first. The administrator and DON wanted to investigate the incident prior to filing an allegation. The administrator stated the allegation should have been reported to the SA within 24 hours of suspicion and should also have been reported to LE.The facility Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy reviewed 11/24, identified abuse allegations would be reported per Federal and State Law. The facility would ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including misappropriation of residents property, were reported . no later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures. In addition, local law enforcement would be notified of any reasonable suspicion of a crime against a resident in the facility. The policy further identifies all reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated. Facility staff would fully cooperate with the local law enforcement designee. The policy failed to identify examples of reportable suspected crimes

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to identify a diagnosis for a medication for 1 of 5 residents (R4) reviewed for unnecessary medications. Findings include: R4's annual Minimum Data Set (MDS) dated [DATE], identified R4 had diagnoses of dementia with behavioral disturbance, bi-polar disorder (a chronic mental health condition characterized by significant and persistent shifts in mood), and manic depression. The MDS identified R4 received an antidepressant. R4's order summary report dated 1/15/25, included an order for escitalopram (a medication used to treat depression) 10 milligram (mg) tablet, take 15 mg each morning. The medication order failed to include a diagnosis or indication for use. During an interview on 3/12/25 at 5:23 p.m., registered nurse (RN)-A stated each prescribed medication needed a diagnosis or reason for use. RN-A had entered R4's escitalopram order after a medication change and forgot to put the diagnosis in. During an interview on 3/12/25 at 5:25 p.m., the director of nursing (DON) stated it was expected all medications would include a diagnosis or indication for use. It was important to have the diagnosis or indication of use to ensure R4 had not received the medication unnecessarily. The facility's Medication Order Transcription policy dated 10/17/24, identified medication orders mush include medication, dose, frequency, route, and diagnosis or indication for use.

Based on observation, interview and document review the facility failed to ensure medications were properly labeled to prevent medication errors for 1 of 7 residents (R11) observed during medication pass. Findings include: R11's quarterly minimum data set (MDS) identified R11 had moderate cognition and a diagnosis of chronic obstructive pulmonary disease (COPD). R11's physician orders report dated 2/12/25 through 3/12/25, identified R11 was to receive anoro ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation - administer 1 puff into the lungs one time a day with a start date of 7/24/24. On 3/12/25 at 7:18 a.m., licensed practical nurse (LPN)-A was observed during a medication pass. LPN-A removed a foil container from a medication cart. Inside the container was an inhaler with R11's name and a label identifying the medication as anoro ellipta 62.5-25 mcg/act LPN-A stated the inhaler belonged to R11 although it did not have a label identifying how the medication should be administered. LPN-A stated most-likely the facility received the inhaler in a box labeled with the residents identifying information and the instructions for use. LPN-A stated the box must have been thrown away. Prior to administering the medication, LPN-A would check the physicians orders for a current order and instructions. LPN-A further stated all medications should have a resident label and instructions from the pharmacy. On 3/12/25 at 1:24 p.m., the director of nursing (DON) stated all medications in the medication cart should have a label that includes the medication name, pharmacy it came from, date of order, expiration date, residents name and the orders/instructions for use. If the label did include all the appropriate information the nurse should remove the medication from the cart, not use the medication and contact the pharmacy right away. The Medication Management policy dated 8/8/24 identified prior to administering a medication staff were to compare the medication and dosage schedule on the medication administration record (MAR) to the medication label and review each for the right patient, right medication, right dose, right time and right route of administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview the facility failed to ensure residents' mail and packages were delivered on Saturdays for 2 of 2 residents (R2, R8) who voiced concerns with mail delivery. This deficient practice had the potential to affect all 20 residents residing in the facility. Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 was cognitively intact. R2's quarterly MDS dated [DATE], identified R2 was cognitively intact. During an interview on 3/11/25 at 1:10 p.m., at the resident meeting, R8 stated she did not receive mail or packages on Saturdays. R8 stated when packages were set to arrive late Friday or early Saturday, R8 would not receive them until Monday. R2 stated he did not receive mail or packages on Saturdays. R2 stated he received notifications when packages arrive at the facility on Saturday; however, would not receive the packages until Monday. R2 stated mail and packages come in through the main hospital and is sorted there and then delivered to the nursing home. During an interview on 3/12/25 at 2:34 p.m., the activities director (AD) stated when COVID started the mail delivery shifted from being delivered to the nursing home to being delivered to the hospital. The normal process was explained: mail/packages come in through the hospital and are sorted and then placed in the mailroom to be picked up by nursing home staff. When the mailroom is checked by staff on Saturdays there are usually no mail/packages for the nursing home, but AD was not sure if there were staff in the hospital to sort the mail. Any mail/packages delivered on Saturday would have to wait until Monday to be delivered. AD stated she would have to look into mail/packages for the resident on Saturdays, because they deserve to get their mail/packages quickly. An interview was conducted on 3/12/25 at 5:38 p.m., with director of nursing (DON), registered nurse (RN)-A, licensed social worker (LSW), and health unit coordinator (HUC). The HUC stated mail and packages came in through the hospital, they were sorted there and then placed in mailroom for nursing home staff to come down to pick it up. The LSW stated the areas where the was mail and packages were sorted was not staffed on weekends so anything that came in over the weekend would have to wait until Monday to be delivered to the resident. They were not sure if the city was delivering mail on Saturdays. The DON, RN-A, HUC and LSW all stated residents have the right to have received mail on Saturday. The facility's Patient Rights and Responsibilities policy dated 9/5/23, identified residents have the right to promptly receive mail/packages.

Based on interview and document review, the facility failed to accurately submit hours for the payroll-based journal system (PB&J) staffing data to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 20 residents residing in the facility. Findings include: The facility's PB&J data for quarter four submitted to CMS for 7/1/24 through 9/30/24, identified the facility was triggered for excessively low weekend staffing, and failed to have licensed nursing coverage 24 hours/day for the following days: 31 out of 31 days during the month of July 2024, 31 out of 31 days during the month of August 2024, and 30 out of 30 days during the month of September 2024. In addition the report identified the facility triggered for no registered nurse (RN) coverage for eight consecutive hours for the following days: 31 out of 31 days during the month of July 2024, 8/1/24, 8/5/24, 8/9/24, 8/15/24, 8/19/24, 8/21/24, 8/23/24, 8/24/24, 8/25/24, 8/26/24, 8/27/24, 8/28/24, 8/29/24, 9/3/24, 9/4/24, 9/6/24, 9/7/24, 9/8/24, 9/20/24, 9/21/24, 9/22/24, 9/24/24, and 9/25/24, The facility payroll and working schedules were reviewed for 7/1/24 through 9/30/24, and identified the following: - There were licensed nursing staff 24 hours/day for all 92 days identified on the PB&J report. - There was RN coverage 8 consecutive hours for all 54 days identified on the PB&J report. During joint interview with director of nursing (DON) and RN-A on 8/27/25 at 6:02 p.m., the DON stated the PB&J data was entered by the administrator. Both the DON and RN-A stated there was always a nurse in the facility. If there was a nurse call-in and they were unable to find a replacement the previous shift would be mandated to stay. On 3/12/25 at 7:39 p.m., the administrator stated the nursing hours were entered by an off-site corporate staff member and the administrator double checked the information by running a report. The administrator stated she knew there was a corporate wide problem regarding how the information was pulled, although did not know how to correct the issue. The administrator stated accurate PB&J information is important because it showed how many, and they type of staff working, and they are working as a corporate agency on correcting the issues. A policy/procedure regarding PBJ data submission was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R20: R20's admission Minimum Data Set (MDS) dated [DATE], indicated R20 had severe cognitive impairment with a diagnosis of non-Alzheimer's dementia. The MDS indicated R20 received antipsychotics on a regular basis but did not indicate the use of a as needed (PRN) antipsychotic medication. R20's Physician Order Report dated 4/18/24, had the following order for the antipsychotic medication quetiapine, 12.5 mg three times a day PRN, quetiapine 12.5 mg one time a day between 4:00 p.m. and 6:30 p.m., and quetiapine 25 mg one time a day between 7:00 p.m. and 10:00 p.m. R20's Medication Pharmacy Regimen Review dated 4/30/24, stated if a new 14-day order for antipsychotic med is to be written, need examination by md to determine if still needed. R20's electronic medical record (EMR) lacked evidence that a provider had completed in person assessments of R20 every 14 days for the continued use of PRN antipsychotic medication. In addition, there was not a documented provider response to the pharmacist recommendations made on the 4/30/24. During an interview on 5/15/24 at 9:23 a.m., the director of nursing (DON) stated R20 was admitted to the facility with scheduled and PRN quetiapine. The DON pulled up R20's electronic medical record (EMR) and indicated R20 was last seen by a provider on 4/18/24, and had not been evaluated in person since admit for the continued use of PRN quetiapine. The DON indicated the pharmacy medication review recommendations drove when the provider was notified to complete a in person resident assessment and review of PRN antipsychotic medication orders. The facility did not have additional processes in place that ensured in person provider assessments and order discontinuation, or renewal occurred every 14 days for PRN antipsychotic medication. The facility policy Psychotropic Medication dated 11/27/17, indicated PRN antipsychotic medications would be limited to 14 days and would not be renewed unless the provider evaluated the resident for appropriateness of the medication. Based on interview and document review, the facility failed to ensure as-needed (PRN) antipsychotic medication use was limited to 14 days or notes from a provider face to face visit to demonstrate medical justification was provided to support ongoing use for 2 of 5 residents (R16, R20) reviewed for unnecessary medication use. Findings include: R16: R16's quarterly Minimum Data Set (MDS), dated [DATE], identified R16 had severe cognitive impairment, consumed antipsychotic medication daily and on an as needed (PRN) basis. R16's diagnoses included Alzheimer's and dementia. R16's most recent Physician Order Report, dated 5/16/24, identified R16's current physician-ordered medications. These included Haldol and Risperdal (both antipsychotic medication) on a PRN basis. The start date for Risperdal was 5/25/23 with no stop date documented. The start date for Haldol was 10/11/23 with no stop date documented. R16's medical record was reviewed and lacked evidence the provider had done every two weeks face to face visits to justify the continued use of PRN antipsychotic medication or had new orders for the PRN antipsychotics every 14 days. During an interview on 5/16/24 at 9:43 a.m., registered nurse (RN)-A stated all antipsychotic medications ordered PRN could only be ordered for 14 days and then needed a provider in person visit with documented medical need to continue the use. Also, the order had to be reordered every 14 days after the provider in person visit. RN-A was unaware who had the responsibility to ensure the visit and reorder were completed. During an interview on 5/16/24 at 10:56 a.m., hospice registered nurse (RN)-B stated the hospice provider does not round every two weeks and only renews antipsychotic medications yearly, unless there is a change to the dose. During an interview on 5/16/24 at 1:20 p.m., the pharmacy consultant (PC) stated all PRN antipsychotics needed to be renewed every 14 days after the provider performed an in person visit and documented medical need for the continued use. During an interview on 5/16/24 at 1:53 p.m., the director of nursing (DON) stated all PRN antipsychotic medication needed to be renewed every 14 days. It was up to the floor nurses who worked the cart to keep track of when that time was up and communicate the need with the provider. Facility Policy Psychotropic Medication last reviewed 11/27/17, indicated PRN antipsychotic medications would be limited to 14 days and would not be renewed unless the provider evaluated the resident for appropriateness of the medication.

Based on observation, interview, and record review, the facility failed to ensure that residents dining in the main dining room were given an opportunity to sanitize their hands prior to meal consumption. This deficient practice had the potential to impact all resident who dined in the main dining room. Findings include: During a dinner meal observation on 5/13/24 that started at 5:36 p.m., there were residents seated at five tables in the main dining room waiting for their meals to be delivered. None of the tables had hand sanitizing products on them. During dining observation, there were no observations of staff offering hand sanitization to residents that entered the dining room or to those already seated in the dining room. During a breakfast meal observation on 5/15/24 that started at 7:00 a.m., several residents were seated at tables in the dining room. None of the tables had any hand sanitizing products on them tables. Staff were observed assisting residents with clothing protector application. Staff appropriately sanitized their own hands at the sink between residents and tasks; however, staff did not offer hand sanitization to seated residents or to any additional residents as they entered the dining area for breakfast. During a lunch meal observation on 5/15/24 that started at 11:52 a.m., some residents were already seated at tables in the dining room. There was one pack of hand sanitizing wipes at the largest table in the dining room. Three additional residents entered the dining area. Residents were helped with clothing protectors however there was no observation of staff offering residents the opportunity to sanitize their hand prior to eating. Staff sanitized their own hands at the sink appropriately between residents and tasks. During an interview on 5/15/24 at 12:51 p.m., nursing assistant (NA)-A stated they always offered residents hand hygiene when they were in the resident's room but indicated they had not been offering hand hygiene to residents in the dining room prior to meals. NA-A confirmed they had not offered hand hygiene at the breakfast or lunch meals on 5/15/24. This should be done for infection prevention reasons. During an interview on 5/15/24 at 1:13 p.m., NA-B stated the dining room tables normally had hand sanitizer wipes on them, but there wasn't any, and they were not sure what had happened to them. NA-B stated when they brought a resident to the dining room from their room, they usually asked the resident if they wanted to wash their hands at their sink in their room. NA-E confirmed they had not offered hand sanitization to any of the residents in the dining room prior to meals being served on 5/15/24, and indicated it was important to offer residents hand sanitization prior to meals to prevent germs and infection. During an interview on 5/15/24 12:42 p.m., family member (FM)-A stated they had never seen their family member or other residents offered hand sanitization in the dining room prior to meals. FM-C stated they visited over mealtime about three times a week. During an interview on 5/15/24 at 1:23 p.m., the infection preventionist (IP) stated it was their expectation that residents were offered the opportunity for hand sanitization prior to meals. Resident's hands could be contaminated just from touching surfaces and or from missed handwashing after bathroom use. The IP stated they needed to make sure resident's hands were sanitized prior to food consumption to help prevent the spread of infection and or illness. During an interview on 5/15/24 at 1:41 p.m., the director of nursing (DON) stated they expected staff to give all residents the opportunity for hand sanitization prior to meals either at the sink or with the hand sanitizing wipes that are normally on the dining tables. The DON stated sanitizing wipes should be on all the dining tables and indicated wipes had been requested earlier that day. Proper hand sanitization for residents was needed to prevent the spread of infection and illness. The facility Stand Work: Activates of Daily Living (ADL's) Standards of Care dated 4/12/24, line item 15. Instructed all residents were to be offered hand hygiene prior to meals.