**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to perform daily wound care treatments on a sacral wound for 1 of 1 resident (Resident #4) observed for pressure ulcers. Findings included: Resident #4 was admitted to the facility on [DATE]. Diagnoses included, in part, pressure ulcer of sacral region and myoneural disorder (spinal compression with paralysis to lower extremities). The quarterly Minimum Data Set assessment dated [DATE] revealed resident was cognitively intact with no behaviors, had impairment on both sides to upper and lower extremities, utilzed a wheelchair for mobility, was always incontinent of bowel and bladder and was coded as having a pressure ulcer stage III. A review of Resident #4's care plan updated on 09/20/24 revealed a plan of care for actual impairment to skin integrity with pressure ulcer to sacrum. The goal was that the skin injury would improve by the next review date with interventions to include, in part, daily treatment to affected area to promote wound healing. A review of the physician orders revealed an order written on 10/29/24 to cleanse sacral area with normal saline, apply silver collagen matrix cut to fit wound, cover with an absorbent silicone dressing daily. Review of the weekly observation tool dated 10/29/24 revealed Resident #4 acquired a stage II pressure ulcer on 09/04/24 which had increased to a stage III pressure ulcer on 10/23/24. The overall impression indicated the wound was improving with epithelial tissue and granulation tissue present (healthy tissue). The assessment noted there was serosanguinous (bloody serum) draining with moderate amounts with no odor. The measurement of the wound was 1.5 centimeters (cm) X 0.7 cm X no depth. An observation of wound care was conducted on 11/06/24 at 9:30 AM with Nurse #1 and the Director of Nursing (DON). Resident #4 was informed that the two nurses were going to change her dressing to her sacrum. Resident #4 was turned to her left side. Nurse #1 proceeded to remove the existing dressing to Resident #4's sacrum which was dated 11/04/24. The wound was noted to be opened with small amount of bloody serum with redness surrounding the wound. Nurse #1 cleansed the pressure ulcer with wound cleanser, patted dry, and applied a small wound size piece of silver collagen to the wound and covered it with an absorbent silicone dressing. An interview with Nurse #1 on 11/06/24 at 9:40 AM was conducted. Nurse #1 was asked about the date on the dressing being 11/04/24. Nurse #1 stated she did not notice the date and proceeded to then remove the dressing from the trash bag. Nurse #1 read the date on the dressing and confirmed the date was 11/04/24. Nurse #1 did not know if the dressing was changed on 11/05/24 as ordered. A phone interview was conducted with Nurse #2 on 11/06/24 at 9:45 AM. Nurse #2 revealed she worked 12 hour shifts from 7:00 AM to 7:00 PM and she had changed the dressing on 11/04/24 and it was removed around 7:00 PM when Resident #4 got a bath and another dressing was reapplied after her bath on 11/04/24. Nurse #2 stated she did not change it on 11/05/24 since it was changed twice on 11/04/24. An interview was conducted with the Director of Nursing on 11/06/24 at 10:30 AM. The DON reported Resident #4's pressure ulcer was a stage II when it was identified on 09/04/24 and had recently increased to a stage III wound. The DON reported Resident #4 requests to get out of bed daily and sit up in her wheelchair for prolonged periods which she believed contributed to the wound worsening. She stated she would have expected Nurse #2 to follow the physician's order and change the dressing daily in order to aide in healing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews the facility failed to accurately document the completion of a wound treatment in the treatment administration record (TAR) for 1 of 1 residents (Resident #4) observed for pressure ulcers. Findings included: Resident #4 was admitted to the facility on [DATE]. Diagnoses included, in part, pressure ulcer of sacral region. A review of the physician orders revealed an order written on 10/29/24 to cleanse sacral area with normal saline, apply silver collagen matrix (antimicrobial barrier to prevent infections) cut to fit wound, cover with an absorbent silicone (a dressing that absorbs drainage) daily. Review of the Treatment Administration Record (TAR) revealed the wound treatment for Resident #4 was signed off on the TAR as evidenced by a check mark with Nurse #2's initials on 11/05/24. A phone interview was conducted with Nurse #2 on 11/06/24 at 9:45 AM. Nurse #2 revealed she had changed the dressing on 11/04/24 and it was removed around 7:00 PM when Resident #4 got a bath and another dressing was reapplied after her bath on 11/04/24. Nurse #2 stated she did not change it on 11/05/24 since it was changed twice on 11/04/24. Nurse #2 stated she should not have signed off in the treatment administration record that she did the dressing change on 11/05/24 as that was inaccurate documentation. An interview was conducted with the Director of Nursing (DON) on 11/06/24 at 10:30 AM. The DON reported she expected her nursing staff to accurately document in the treatment administration record to reflect the care that was provided. The DON stated Nurse #2 should not have signed off on a treatment that she did not provide.

Based on observations and staff interviews, facility staff failed to implement infection control policy and procedures when Nurse Aide (NA) #1 and NA #2 did not don Protective Equipment (PPE) to include a gown when providing high-contact resident care activities for Resident #49 who had an indwelling medical device. Resident #49 had a lower back indwelling pleural catheter which was used for draining fluid from the pleural space (fluid filled space that surrounds the lungs) to help with breathing. The deficient practice was identified for 2 of 2 staff members reviewed for infection control practices (NA #1 and NA #2). The findings included: Review of the facility's the facility's Enhanced Barrier Precautions (EBP) signage for long term care facilities (LTCF) dated 07/26/22 read: All residents with any of the following: Wounds (skin opening that requires a dressing) and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of multi-drug-resistant-organism (MDRO) colonization status. All healthcare personnel must: wear gloves and gowns for the following high-contact resident care activities: Handling linen, transferring resident, and changing linen. During an observation on 11/06/24 at 11:25 AM a sign was posted by Resident #49's room door that read in part: Enhanced barrier precautions, and providers and staff must wear gloves and a gown for the following high-contact resident care activities: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs, device care or use of a central line, urinary catheters, feeding tubes, and wound care. During an observation from the hall on 11/06/24 at 11:30 AM Nurse Aide (NA #2) and NA #1 were observed in Resident #49's room changing the bed linens. Resident #49 was sitting at the bedside in her recliner. Nurse Aide #2 and Nurse Aide #1 had on gloves when changing the bed linens but were not wearing gowns. A hanging door bin with PPE (personal protective equipment) supplies was on the door, including one time use disposable gowns. An interview was conducted on 11/06/24 at 11:30 AM with Nurse Aide #1 and #2. They stated they did not put on gowns when they transferred Resident #49 to the recliner or when they changed the bed linens. They both knew Resident #49 was on Enhanced Barrier Precautions and acknowledged that they should have worn a gown and gloves when providing direct care, such as the transfer, and should have also worn a gown and gloves when changing bed linens. An interview was conducted on 11/07/24 at 8:55 AM with NA #1. She revealed on 11/06/24 at 11:30 AM when she was helping transfer Resident #49 from bed to Recliner, she went to put on a gown with her gloves, when NA #2 stated she didn't need to don a gown, so she didn't. NA #1 said looking back, she and NA #2 should have worn gowns. An interview was conducted on 11/07/24 at 9:05 AM with NA #2. She revealed she changed Resident #49's bed linens and was aware that the donning gown and gloves were required during high contact resident care activities. She stated they just got in a hurry when transferring Resident #49 and changing her linen. An interview was conducted on 11/07/24 at 9:20 AM with the Director of Nursing (DON). She stated staff should wear the appropriate personal protective equipment PPE when providing direct care to residents on enhanced barrier precautions. She also stated regardless, all the staff knew to abide by the different types of precautions posted on the residents' door and to follow the assigned personal protective equipment (PPE). She stated education would be provided to NA #1 and NA #2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff, Consultant Pharmacist, and Physician interviews the facility failed to protect a residents right to be free from misappropriation of a residents controlled medication (Oxycodone/Acetaminophen 5/325 milligrams (mg) , Hydrocodone/Acetaminophen 10/325 mg, Tramadol 50 mg, and Alprazolam 0.5 mg) which was prescribed by the physician for pain and anxiety. This resulted in a total of 42 doses of the medications that were not administered to 8 of 8 residents (Resident #51, #41, #2, #3,#4, #7, #8, #9) reviewed for misappropriation of medications. Findings included. 1a.)Resident #51 was admitted to the facility on [DATE] with diagnoses including fractured vertebra and sacrum, and Arthritis. A physicians order dated [DATE] for Resident #51 revealed Oxycodone/Acetaminophen 5/325 mgs. Take one tablet every 8 hours as needed for pain. Review of Resident #51's Controlled Drug Record initiated [DATE] revealed Oxycodone/Acetaminophen 5/325 mgs was signed out of the narcotic count by Nurse #1 on 04/11, 04/25, 04/27, and [DATE]. Review of Resident #51's Medication Administration Record (MAR) dated [DATE] revealed no documentation by Nurse #1 on 04/11, 04/25, 04/27, or 04/28 that the Oxycodone/Acetaminophen 5/325 mgs was administered to Resident #51. Review of the nursing progress notes from [DATE] through [DATE] revealed no documentation by Nurse #1 that Oxycodone/Acetaminophen 5/325 mgs was administered to Resident #51. During an interview on [DATE] at 11:30 AM Resident #51 was observed sitting in a wheelchair in his room. He was alert and oriented. He stated he did not take any pain medication at this time. He stated he did not have complaints of pain and had never really had much pain. He stated he did not recall getting pain medication regularly or needing pain medication on a regular basis at any time since his admission to the facility. b.) Resident #41 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, and depression. A physicians order dated [DATE] for Resident #41 revealed Alprazolam 0.5 mg. take one tablet by mouth as needed for anxiety. Review of Resident #41's Controlled Drug Record initiated [DATE] revealed Alprazolam 0.5 mg was signed out of the narcotic count by Nurse #1 on [DATE] and [DATE]. Review of Resident #41's Medication Administration Record (MAR) dated [DATE] revealed no documentation by Nurse #1 on 05/11 or [DATE] that Alprazolam 0.5 mgs was administered. Review of the nursing progress notes from [DATE] through [DATE] revealed no documentation by Nurse #1 that Alprazolam 0.5 mgs was administered to Resident #41. During an observation on [DATE] at 11:00 AM Resident #41 was observed sitting in the locked memory unit dining area. She was calm with no signs of increased anxiety. c.) Resident #2 was admitted to the facility on [DATE] with diagnoses including Respiratory failure and chronic pain. A physicians order dated [DATE] for Resident #2 revealed Oxycodone/Acetaminophen 10/325 mgs. Take one tablet every 6 to 8 hours as needed for pain control. Review of Resident #2's Controlled Drug Record initiated [DATE] revealed Oxycodone/Acetaminophen 10/325 mgs was signed out of the narcotic count by Nurse #1 on 04/07, 04/08, 04/09, 04/12, 04/13 at 8:30 AM and 2:00 PM and [DATE]. Review of Resident #2's Medication Administration Record (MAR) dated [DATE] revealed no documentation by Nurse #1 that Oxycodone/Acetaminophen 10/325 mgs was administered to Resident #2 on 04/07, 04/08, 04/09, 04/12, 04/13 at 8:30 AM and 2:00 PM and [DATE]. Review of the nursing progress notes from [DATE] through [DATE] revealed no documentation by Nurse #1 that Oxycodone/Acetaminophen 10/325 mgs was administered to Resident #2. During an interview on [DATE] at 1:00 PM the Director of Nursing stated Resident #2 expired on [DATE] due to respiratory disease. d.) Resident #3 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Quadriplegia, and Non-Alzheimer's dementia. A physicians order dated [DATE] for Resident #3 revealed Hydrocodone/Acetaminophen 10/325 mgs. Take one tablet every 6 hours as needed for pain control. Review of Resident #3's Controlled Drug Record initiated [DATE] revealed Hydrocodone /acetaminophen 10/325 mgs was signed out of the narcotic count by Nurse #1 on 04/07, 04/08 at 7:45 AM and 6:22 PM, 04/09, 04/13, 04/18, 04/21 at 7:15 AM and 1:15 PM, 04/22 at 7:15 AM, and 1:30 PM, 04/23, 04/25 at 2:00 PM, 04/26, 04/27 at 7:15 AM and 5:30 PM, 04/28, 05/01 at 8:00 AM, 05/02 at 8:00 AM and 5:30 PM, 05/05, 05/06 at 7:25 AM and 6:26 PM, 05/07 at 7:30 AM and 6:00 PM, and [DATE]. Review of Resident #3's Medication Administration Record (MAR) dated [DATE] and [DATE] revealed no documentation by Nurse #1 that Hydrocodone/Acetaminophen 10/325 mgs was administered to Resident #3 on 04/07, 04/08 at 7:45 AM and 6:22 PM, 04/09, 04/13, 04/18, 04/21 at 7:15 AM and 1:15 PM, 04/22 at 7:15 AM, and 1:30 PM, 04/23, 04/25 at 2:00 PM, 04/26, 04/27 at 7:15 AM and 5:30 PM, 04/28, 05/01 at 8:00 AM, 05/02 at 8:00 AM and 5:30 PM, 05/05, 05/06 at 7:25 AM and 6:26 PM, 05/07 at 7:30 AM and 6:00 PM, and on [DATE]. Review of the nursing progress notes from [DATE] through [DATE] revealed no documentation by Nurse #1 that Hydrocodone/Acetaminophen 10/325 mgs was administered to Resident #3. e.) Resident #4 was admitted to the facility on [DATE] with diagnoses including Diabetes and left below knee amputation. A physicians order dated [DATE] for Resident #4 revealed Oxycodone/Acetaminophen 5/325 mgs. Take one tablet every 4 hours as needed for pain. Review of Resident #4's Controlled Drug Record initiated [DATE] revealed Oxycodone/Acetaminophen 5/325 mgs was signed out of the narcotic count by Nurse #1 on [DATE]. Review of Resident #4's Medication Administration Record (MAR) dated [DATE] revealed no documentation by Nurse #1 on [DATE] that the Oxycodone/Acetaminophen 5/325 mgs was administered to Resident #4. Review of the nursing progress notes on [DATE] revealed no documentation by Nurse #1 that Oxycodone/Acetaminophen 5/325 mgs was administered to Resident #4. Resident #4 was discharged from the facility on [DATE]. f.) Resident #7 was admitted to the facility on [DATE] with diagnoses including Congestive heart failure, Non-Alzheimer's dementia, and pain. A physicians order dated [DATE] for Resident #7 revealed Tramadol 50 mgs. Take one tablet by mouth three times a day as needed for pain. Review of Resident #7's Controlled Drug Record initiated [DATE] revealed Tramadol 50 mgs was signed out of the narcotic count by Nurse #1 on [DATE]. Review of Resident #7's Medication Administration Record (MAR) dated [DATE] revealed no documentation by Nurse #1 on [DATE] that Tramadol 50 mgs was administered to Resident #7. Review of the nursing progress notes on [DATE] revealed no documentation by Nurse #1 that Tramadol 50 mgs was administered to Resident #7. Resident #7 was discharged from the facility on [DATE]. g.) Resident #8 was admitted to the facility on [DATE] with diagnoses including Diabetes, and hip and knee replacement. A physicians order dated [DATE] for Resident #8 revealed Tramadol 50 mgs. Take one tablet by mouth every 6 hours as needed for pain. Review of Resident #8's Controlled Drug Record initiated [DATE] revealed Tramadol 50 mgs was signed out of the narcotic count by Nurse #1 on [DATE]. Review of Resident #8's Medication Administration Record (MAR) dated [DATE] revealed no documentation by Nurse #1 on [DATE] that Tramadol 50 mgs was administered to Resident #8. Review of the nursing progress notes on [DATE] revealed no documentation by Nurse #1 that Tramadol 50 mgs was administered to Resident #8. Resident #7 was discharged from the facility on [DATE]. h.) Resident #9 was admitted to the facility on [DATE] with diagnoses including right femur fracture, dementia, and chronic pain. A physicians order dated [DATE] for Resident #9 revealed Hydrocodone/Acetaminophen 10/325 mgs. Take one tablet every 12 hours as needed for pain control. Review of Resident #9's Controlled Drug Record initiated [DATE] revealed Hydrocodone/acetaminophen 10/325 mgs was signed out of the narcotic count by Nurse #1 on [DATE], [DATE] at 12:31 PM, and [DATE]. Review of Resident #9's Medication Administration Record (MAR) dated [DATE] revealed no documentation by Nurse #1 on [DATE], [DATE] at 12:31 PM, and [DATE] that Hydrocodone/Acetaminophen 10/325 mgs was administered to Resident #9. Review of the nursing progress notes from [DATE] through [DATE] revealed no documentation by Nurse #1 that Hydrocodone/Acetaminophen 10/325 mgs was administered to Resident #9. Resident #9 was discharged from the facility on [DATE]. Review of the facility investigation initiated on [DATE] revealed: On [DATE] at approximately 11:30 AM Nurse #2 reported that Nurse #3 had suspicions that Nurse #1 was taking resident's medications and not administering the medications to the residents. She stated that one specific resident had an order for a narcotic as needed pain medication, but the resident never complained of pain. She stated that Nurse #1 was the only nurse signing out this narcotic for this specific resident. She stated that over a month ago another resident complained that Nurse #1 crushed her medications although there was no indication or need for the medications to be crushed. Nurse #3 stated that the resident complained and she didn't think the nurse was giving her pain medication. She stated she felt that it was also suspicious that Nurse #1 picked up additional shifts on households that she generally did not work and thought this could be to gain access to medications. Nurse #3 reported that other nurses were suspicious as well and provided a list of nurses and medication aides with concerns. An interview was conducted on [DATE] at 10:00 AM with the Director of Nursing (DON) along with the Administrator. The DON stated she was made aware of the allegation of possible drug diversion regarding Nurse #1 on [DATE] and a full investigation was initiated. She stated she reviewed the narcotic book containing all controlled drug records from the household that Nurse #1 worked on and identified a Resident ( #51) that had an order for Oxycodone/Acetaminophen 5/325mg as needed every 8 hours for pain. The order stood out to her because Nurse #1 was the only nurse that signed out this medication for Resident #51 since [DATE]. She stated from [DATE] through [DATE] Nurse #1 signed out the medication 13 times. She stated she reviewed Resident #51's MAR to reconcile with the Controlled Drug Record and found where Nurse #1 failed to document that she administered the medication on the medication administration record on several occasions. She stated Resident #51 rarely complained of pain. She reviewed more resident records and found several other residents that had controlled medication orders and Nurse #1 signed them out on the Controlled Drug Record but didn't sign them out on the MAR as being administered to the residents. She stated she then notified the Administrator, and they interviewed Nurse #1 who denied taking any of the residents medications. The DON stated Nurse #1 stated she always documented on the MAR and didn't understand why the documentation on the MAR didn't show up and she probably just forgot to sign them out on the MAR. The Administrator added that the audits conducted and the interviews with other nurses indicated drug diversion. He stated Nurse #1 had been employed with the facility for 18 years and was terminated at that time. The DON added that she informed Nurse #1 that she would be reported to the Board of Nursing. She stated Nurse #1 did not want to review the audits that were done. The DON stated the Board of Nursing submitted their findings to the facility following their investigation. The Board of Nursing findings revealed Nurse #1 admitted that she had been diverting controlled medications from the facility for a period of time. Her nursing license was suspended. During an interview on [DATE] at 11:00 AM Nurse #4 stated she was aware of the allegations of drug diversion and was one of the nurses interviewed during the investigation of Nurse #1. She stated Nurse #1 was suspected of not giving certain residents their pain medications. She stated for example Resident #51 never complained of pain, but Nurse #1 signed out pain medications for him on many occasions. She stated there were other residents identified during the investigation that were affected. She stated she received in-service training during that time regarding drug diversion. During a phone interview on [DATE] at 4:10 PM the Consultant Pharmacist stated she conducted monthly record reviews at the facility. She stated she was made aware of the allegation of diversion in [DATE] regarding Nurse #1. She stated she was not aware until that time of any problems with narcotic medications at the facility. She stated during the monthly record reviews she reviewed prn (as needed) use of medications and did not see on the residents MAR that the medications were being administered or used frequently. She stated she had no concerns since that time with medication administration at the facility. During a phone interview on [DATE] at 4:31 PM the Medical Director stated he was made aware of the medication diversion. He stated he was at the facility on the day the facility was made aware. He stated he made rounds with the nurses weekly at the facility and there was no harm to any of the residents. He stated he had evaluated all of the affected residents during that time and found no negative outcome. He stated he had no concerns with the facility staff. During a follow up interview on [DATE] at 3:00 PM the DON stated a full plan of correction was implemented to include in-service training, audits, and audit results were discussed in the last QA meeting which was held on [DATE]. She stated the audits were completed in [DATE] and the next QA meeting would be held the week of [DATE]. The corrective action for the noncompliance dated [DATE] was as follows: On [DATE] the Director of Nursing and the Administrator were made aware of the allegation and conducted an initial investigation. On [DATE] the State Agency was notified. On [DATE] the DON initiated a 100% audit of the Medication Administration Records (MARs) and Controlled Drug Records of all residents who received Controlled medications and compared to the residents corresponding MAR to identify discrepancies. The audit was to ensure the medication was signed out on the residents Controlled Drug Record and to ensure staff signed the MAR that the narcotic was administered. The outcome of the audit revealed 10 residents identified as being affected. On [DATE] Nurse #1 was terminated. On [DATE] the Medical Director was made aware of the possible drug diversion. On [DATE] the Police Department was notified of the possible drug diversion. On [DATE] affected residents that still remained in the facility were assessed for changes in clinical condition. Interviews were conducted with affected residents or their Responsible Party (RP) to identify any concerns with residents not receiving as needed medications upon request. There were no issues identified. On [DATE] residents with the potential to be affected were assessed to identify any concerns with as needed medications being administered. Interviews were conducted with the residents or their Responsible Party (RP). There were no issues identified. On [DATE], 100% in-service training was initiated with all nurses and medication aides by the Staff Development Coordinator (SDC) regarding signs of narcotic diversion and prevention, reporting requirements of suspected diversion, and medication policy and procedures ensuring that controlled drug records matched the MAR. In-services were to be completed by [DATE]. After [DATE], any staff who had not received the in-service training would not be allowed to work until they completed the in-service training. All newly hired nurses and medication aides would be in-serviced during orientation. Beginning [DATE], the nurse mentors will review all residents with prescribed as needed narcotics to ensure that each narcotic is signed out on the controlled drug record with a corresponding administration record once weekly x 4 weeks, then once every 2 weeks x 1 month, then monthly x 1. The Director of Nursing will forward the results of the audits to the Quality Assurance (QA) Committee Meeting monthly until resolved. The quarterly QA meeting was held [DATE] where the results of the investigation and audits were discussed. Validation of the corrective action was completed on [DATE]. This included staff interviews regarding the incident, and in-service training that was received to ensure understanding and knowledge of the training provided. Observations were conducted of the medication carts; controlled substance counts were conducted with nursing staff of narcotics stored on the medication carts. Controlled Substance Count Records were reviewed. Audits were verified. A QA meeting was held on [DATE] where audit results were discussed. The facility alleged compliance with the corrective action plan on [DATE].

Based on observations and staff interviews, the facility failed to label/date leftover frozen food items stored available for use and store frozen food items covered in 1 of 1 walk-in freezer and failed to discard expired food in 1 of 1 reach-in cooler in the main kitchen. This had the potential to affect food served to residents. Findings included: The initial tour of the kitchen was conducted on 5/23/22 at 11:35 AM with the Director of Dining Services (DDS). An observation of the walk-in freezer revealed a leftover bag of sea scallops with no label with date opened, a leftover bag of onions with no label with date opened, and a leftover bag of mixed vegetables with no label with date opened, and a roast with an open plastic wrap cover. Observation of the reach-in cooler revealed a container of cranberry sauce with the expiration date of 5/20/22. An interview was conducted on 5/23/22 at 11:45 AM with the DDS. He stated all leftover food items in the walk-in freezer should be covered and labeled with the expiration date. He further stated that expired food should not be in the reach-in cooler. The DDS indicated the walk-in freezer and the reach-in cooler were checked every day for unlabeled and expired food items.