**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, facility investigation, observation, and interview, facility staff failed to ensure an allegation of abuse was reported to Administration immediately for 1 of 6 (Resident #1) sampled residents reviewed for allegations of abuse and neglect. The findings include: 1. Review of the facility's policy titled, ABUSE PREVENTION POLICY, revised on 3/1/2018 revealed .resident has the right to be free from verbal, sexual, physical and mental abuse .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but no later than 2 hours after the allegation is made . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Diabetes, Human Immunodeficiency Virus Disease, Depression, and Encephalopathy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #1 was cognitively intact. Review of the progress notes dated 2/27/2025, revealed .This nurse and another nurse were walking down the A hall when this [Resident #1] motioned for us to come here. We entered his room and asked if he needed something he stated that someone stuck their finger in his butt last night. I asked what she looked like. [Named Resident #1] stated it was a he. I asked him if he could describe him, and he stated that he was tall and had curly hair. I asked him if he was his CNA [Certified Nursing Assistant]. He stated I guess so, I don't know. I Called the administrator immediately and reported what [Named Resident #1] had told me. Called for ambulance transport to .ER [emergency room] . During an observation and interview on 3/11/2025 at 8:59 AM, revealed Resident #1 lying in the bed with the head of the bed up approximately 45 degrees, a coffee cup on the overbed table, Quarter (¼) side tails x 2. Resident #1 was asked are you receiving good care. Resident #1 stated, .assume they are . Resident #1 was asked if he had had ever been abused or touched inappropriately here in the facility. Resident #1 stated, Touched inappropriately. Resident #1 was very difficult to understand and communicate with. During an interview on 3/4/2025 at 3:29 PM, Certified Nursing Assistant (CNA) R was asked about the alleged incident with Resident #1. CNA R stated, .short staffed .one of our CNAs had left early on C hall, can't work it by yourself .skilled people .that needs helps, too much for one person. This night [2/26/2025] our unit manager called and asked if I could help .on C hall .asked if anyone on my hall needed help. I told her I had .[Named Resident #1] .could [Named accused CNA F] help me with my people .as we were coming out [referring to another resident's room] [Named accused CNA F] said hey [Named Resident #1] is done, he [Resident #1] was cursing 'black son of a b**** [expletive],' he [Resident #1] was like ' .he raped me.' I was like that quick [happened that quick] and he was like yeah. I said give me a second .the new nurse .was [NAME] [missing in action] .he was nowhere to be found and so I told [what Named Resident #1 had reported] the next day .I had an Uber waiting on me, so I told the next day .I'm sorry .I know you have to tell right away .now I know to tell any nurse in charge. I feel bad I tried to tell my nurse, and he wasn't there [CNA R could not find him] .on my mind the whole night . During an interview on 3/5/2025 at 1:51 PM, Registered Nurse (RN) A stated, . he [Named Resident #1] sometimes will motion to me [to come in his room], so I didn't think anything about it until he told me that [the allegation of abuse]. He's with it. He said this is hard to talk about .Me and [Named RN P] were walking down the hall from medical records. We walked by and I said, hey, I waved, he waved and he [motioned with his hand] motioned me to come in .I said what's wrong because something was off .he said, Stuck his finger in my butt and tried to screw me with it. I said who, what does she look like. He said, It wasn't a she, it was a he .tall and curly hair. We only have 1 male CNA in the building .I said okay [Named Resident #1] he stuck his finger in he said 'yes' I said I've got to go report this .reported it then started calling the Nurse Practitioner .She said send him to the hospital . RN A was asked do your recall what day he told you. RN A stated, Thursday .2/27/2025 . RN A was asked did he tell you he had told anyone else. RN A stated, No .when she [Administrator] told me to start investigating and that's when I run up on [Named CNA R] and of course [Named accused CNA F] .I did skin checks on everybody in his [CNA F] section, and I didn ' t find anything. RN A confirmed she had talked to CNA [R] and stated, .got her to write her statement and of course I did an in-service afterwards .take it serious even if they ' re [the resident] confused, just go ahead and call [Named Administrator] . RN A was asked is that when you found out he (Resident #1) reported the same thing to CNA R the night before. RN A stated, Yeah she [CNA R] was in the room next [to Named Resident #1] and heard him yelling . During an interview on 3/20/2025 at 8:59 AM, the Chief Nursing Officer confirmed when an allegation of abuse is made it should be reported immediately and stated, .we have 2 hours to report it . During a telephone interview on 3/21/2025 at 12:13 PM, the Administrator stated, .He [Resident #1] reported to nurse supervisor that a staff member tried to put his finger in his rectum .we looked at the schedule .I think he described him to us .when we did the investigation suspended him [CNA F] .when we interviewed the male CNA [F] he denied it .[Named Resident #1] said he [CNA F] didn't do it .just tried to .we sent him [Resident #1] to the ER . The Administrator confirmed when an allegation of abuse is made it should be reported immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, American Heart Association website: www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure, medical record review, and interview, the facility failed to ensure residents were free of significant medication errors for 1 of 5 (Resident #13) sampled residents reviewed for medication administration. The findings include: 1. Review of the Administration of Drugs, policy dated April 2022, revealed . Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Directo .Drugs must be administered in accordance with the written orders of the attending physicia . 2. Review of the American Heart Association website: www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure revealed the following Blood Pressure Categories: a. Normal systolic (upper number) is less than 120 millimeters of mercury (mm Hg) and normal diastolic (lower number) is less than 80 mm Hg. b. Elevated blood pressure is 120-129 mm Hg systolic and elevated diastolic is less than 80 mm Hg. c. High Blood Pressure (Stage 1) is 130-139 mm Hg systolic or 80-89 mm Hg diastolic. d. High Blood Pressure (Stage 2) is 140 mm Hg or higher systolic or 90 mm Hg or higher diastolic. c. Hypertensive Crisis is higher than 180 mm Hg systolic and/or higher than 120 mm Hg diastolic. 3. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dependence on Renal Dialysis, Hypothyroidism, Anxiety, Bipolar Disorder, and Insomnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the Resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #13 was cognitively intact. Review of the Nurse's Note dated 1/29/2025 at 5:03 PM, revealed Resident #13 returned from dialysis with a prescription for Midodrine (Medication used to raise blood pressure) 5 mg by mouth on Monday, Wednesday, and Friday, 30 minutes before dialysis. Review of the physician's order for Resident #13 dated 1/29/2025, revealed an order for Midodrine Hydrochloride Oral Tablet 5 milligram (MG) by mouth every Monday, Wednesday, and Friday related to Dependence on Renal Dialysis, give 30 minutes prior to dialysis on Monday, Wednesday, and Friday. Review of the Black Box Warning for Midodrine revealed, midodrine can cause marked elevation of supine (lying down position) blood pressure . Review of the February 2025 Medication Administration Record (MAR) revealed Midodrine was administered two times a day on Monday, Wednesday, and Friday, instead of the ordered one time a day on Monday, Wednesday, and Friday. Review of the March 2025 Medication Administration Record (MAR) revealed Midodrine was administered two times a day on Monday, Wednesday, and Friday from 3/3/2025 through 3/24/2025. Review of the Vital Signs Summary on Friday, 3/7/2025 at 7:33 PM, revealed Resident #13's blood pressure was elevated at 177/95. There was no documentation to show the elevated blood pressure was re-checked. Review of the Medication Admin (Administration) Audit Report dated 3/7/2025, revealed Midodrine 5 mg was administered at 8:25 PM, less than an hour after Resident #13's blood pressure was 177/95. During an interview on 3/26/2025 at 3:32 PM, the Director of Nursing (DON) was asked to review Resident #13's medical record. The DON was asked when Midodrine should be administered. The DON stated 30 minutes prior to dialysis. The DON was asked if Midodrine should be administered twice a day on dialysis days. The DON stated, No. The DON confirmed the order for Midodrine was transcribed incorrectly and scheduled in error for two times a day instead of one time a day on dialysis days. During an interview on 3/27/2025 at 1:52 PM, Nurse Practitioner (NP) H confirmed she instructed Licensed Practical Nurse (LPN L) to enter an order for Midodrine but did not notice the order was entered incorrectly (twice a day on dialysis days). NP H stated, .I will take all the blame . NP H was asked if she would expect a blood pressure of 177/95 to be re-checked. NP H stated, I would.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, document review, medical record review, Law Enforcement Investigation review, observation, and interview, the Administration failed to assure the provision of appropriate fiscal resources and personnel to meet the needs of the residents. Administration failed to ensure residents' medications were timely and accurately reconciled and free of misappropriation, failed to ensure competent nursing staff documented controlled substances when administered and administered medications per the physician's order and the facility's medication schedule; and failed to ensure available medications weren't expired. The findings include: 1. Review of the undated policy titled, Administration revealed, .It is the policy of the facility to provide care and services related to Administration in accordance to state and Federal regulation .The Administration of the facility will ensure the following .1. Administration 2. License/Comply with Fed [Federal] /State/Local Law/Professional Standards .5. Staff Qualifications 6. Use of Outside Resources .Resident Records- Identifiable Information . Review of the facility policy titled, Abuse Prevention Policy, reviewed [DATE], revealed .The resident has the right to be free from .misappropriation of property .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 .Administrator will review investigational findings to determine appropriate corrective, remedial, or disciplinary actions to occur with accordance with applicable local, state or federal law. Administrator will review outcome in monthly continuous quality Improvement meeting .appropriate follow up and monitoring. Review of the facility policy titled, Controlled Substances revised 4/2019, .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications .Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on premises .The director of nursing services maintains a set of back-up keys for all medication storage areas including keys to controlled substance containers .Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift .Upon disposition .Medications returned to the pharmacy are recorded and signed by the director of nursing (or designee) and the receiving pharmacy .Policies and procedures for monitoring controlled medication to prevent loss, diversion .are periodically reviewed and updated by the director of nursing services and the consultant pharmacist . Review of the undated facility policy titled, Nursing Services, General, revealed .It is the policy of the facility to provide care and services related to Nursing Services in accordance to State and Federal regulation .This policy will include .Competent Nursing Staff . Review of the facility policy titled, Administration of Drugs, dated 4/2022, revealed .Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director .Unless otherwise specified by the resident's attending physician, routine drugs should be administered as scheduled . Review of the facility policy titled, Pharmacy Services DISCARDING AND DESTROYING MEDICATIONS, reviewed 11/2022, revealed .Medication will be disposed of in accordance with federal, state and local regulations governing management of .controlled substances . Review of the facility policy titled, Charting Errors and Omissions, revised 12/2022, revealed .Accurate medical records shall be maintained by this facility . 2. Review of the undated job description titled, Administrator, revealed .The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality of care can be provided to our residents at all times .Duties and Responsibilities .Plan, develop, organize, implement, evaluate and direct the facility's programs and activities in accordance with guidelines issued by the governing board. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility .Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed .Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services .Ensure that an adequate number of appropriately trained licensed professional and non-licensed personnel are on duty at all times to meet the needs of the residents .Review and check competence of work force and make necessary adjustments/corrections as required or that may become necessary . Review of the undated job description titled Director of Nursing Services, revealed .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that govern our facility .to ensure that the highest degree of quality care is maintained at all times As Director of Nursing Services, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Develop, implement, and maintain an ongoing quality assurance program for the nursing service's department .Assist the Quality Assessment & Assurance committee in developing and implementing appropriate plans of action to correct identified deficiencies .Assist the Pharmaceutical Services Committee in developing, maintaining, implementing, and periodically updating written policies and procedures for the administration, storage, and control of medications and supplies .Delegate to nursing service supervisory personnel the administrative authority, responsibility, and accountability necessary to perform their assigned duties . Make daily rounds of the nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Monitor medication passes and treatment schedules to ensure that medications are being administered as ordered and that treatments are provided as scheduled .Ensure that residents who are unable to call for help are checked frequently .Assist the Safety officer in developing safety standards for the nursing service department Ensure that a stock level of medications .is maintained on premises at all times to adequately meet the needs of the resident . Assist in the development of preliminary and comprehensive assessments of the nursing needs of each resident. Develop a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished, and which professional services is responsible for each element of care . Report suspected or known incidence of fraud .Report and investigate all allegations of resident abuse and/or misappropriation of resident property . 3. The facility Administration failed to ensure Residents #13, #14, #15, #18, #19, #20, #21, #22, #23, #25, #26, #28, and #30 were free from misappropriation of resident property when Licensed Practical Nurse (LPN) M, diverted resident medications from [DATE] through [DATE]. The facility Administration failed to identify the misappropriation until notified by Law Enforcement Officials on [DATE]. During an interview on [DATE] at 10:17 AM, the DON was asked how the facility was made aware of the allegation of the drug diversion by LPN M. The DON stated, When they came, I think the first to come in was the District Attorney's office of drug enforcement, they came in that morning [[DATE]]and that's how I was made aware. The DON confirmed the facility did not identify the residents' medications were missing prior to notification by the authorities. The DON was asked did you identify that the controlled drug record sheet was missing on any of the residents or medications prior to being notified by the authorities. The DON stated, No. The DON was asked who provided oversight to ensure drugs were not diverted. The DON stated, Me, I have to take responsibility . During an interview on [DATE] at 3:15 PM, the Medical Director (MD) confirmed he was made aware of the allegation of drug diversion by LPN M when the District Attorney came to the building, and they asked to speak to him. The MD was asked as the Medical Director, did he expect the facility to have systems and processes in place to track and reconcile controlled substances. The MD stated, Yes. Refer to F602 4. The facility Administration facility failed to ensure staff provided appropriate pain management consistent with professional standards of practice for Resident #9 and #17 and a safe environment to prevent accidents for Resident #17. a. Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Dementia, Anxiety, Periprosthetic Fracture Around Internal Prosthetic Hip Joint, and Pain in Right Knee. Resident #9's Minimum Data Set (MDS) assessment dated [DATE], revealed the Resident was rarely understood, exhibited short-term and long-term memory problems, and was assessed by staff with severe cognitive impairment. On [DATE] at 1:15 AM, Resident #9 sustained an unwitnessed fall, and later at 9:15 AM, Resident #9 began to exhibit verbal complaints and nonverbal cues of intense pain, hollering out when her right leg was moved, grimacing, and guarding her right hip and femur (thigh bone). The practitioner was not immediately notified of Resident #9's pain and the Resident did not receive pain medication. An x-ray was ordered at 11:31 AM and was obtained approximately 2 hours later at 1:32 PM. The x-ray revealed Resident #9 suffered a periprosthetic fracture (fracture that occurs around or near an orthopedic implant). Resident #9 was transferred to the hospital at approximately 3:40 PM. Resident #9 did not receive pain medication to address her pain prior to leaving the facility. b. Review of the medical record revealed Resident #17 was re-admitted to the facility on [DATE], following hospital discharge with diagnoses that included a right below the knee amputation on [DATE]. On [DATE], Resident #17's physician orders included Hydrocodone every 6 hours as needed for a moderate pain level of 4-7 and Ibuprofen 800 milligrams (mg) every 8 hours as needed for a mild pain level of 1-3. Review of the admission assessment dated [DATE] at 6:30 PM, revealed Resident #17 was experiencing pain rated as 5, which frequently caused difficulty sleeping and led to limitations of day-to-day activities. Resident #17 was severely cognitively impaired and dependent upon staff for assistance with all aspects of care. Resident #17 was experiencing uncontrolled pain as evidenced by the Resident's restlessness and trembling of the extremity. Resident #17 developed a new behavior of climbing out of bed on [DATE] and on [DATE]. Resident #17 sustained an unwitnessed fall with head injury, was transferred to the hospital and diagnosed with subarachnoid hemorrhage and a periorbital fracture. The facility failed to have a system in place to assess pain of residents with cognitive impairment and appropriately address the pain. c. During an interview on [DATE] at 9:41 AM, the DON confirmed Resident #17 did not receive Hydrocodone as ordered by the physician for pain rated 4 or greater. During an interview on [DATE] at 3:43 PM, the DON reviewed the orders from the hospital for Resident #17 that documented to pick up the ordered Hydrocodone at a local pharmacy in front of the facility. The DON stated, I would have said, whoa, I could have the family go get it and use it .she [LPN D] could have called me, and I could have given her direction .something would have happened, even if I called a Nurse Practitioner .she could have put in something [for pain]. They call me for a million things .night and day, but they didn't call me for this. The DON stated, I found out Monday when she went out. During an interview on [DATE] at 5:20 PM, when the Immediate Jeopardy template for Pain Management was presented to the Administrator and DON, the Administrator was asked was she aware of the issue with Resident #17 not receiving Hydrocodone for pain from [DATE]-[DATE]. The Administrator stated she had just been made aware when she returned from her trip (was not in the facility during the survey from [DATE] through [DATE] due to a pre-planned trip). During an interview on [DATE] at 1:33 PM, the DON confirmed Resident #9 experienced a fall with periprosthetic femur fracture, did not receive pain medication on [DATE], and the nursing staff should have called the Nurse Practitioner (NP) to get an order for pain medication. Refer to F689 and F697 5. The facility Administration failed to ensure the facility had a system of recording, accurate reconciliation, and accounting for all controlled medications, failed to promptly identify diversion of controlled substances, failed to provide medications according to physician orders and the facility's medication schedule, and failed to ensure controlled substances were in date and no discrepancies were identified for Residents #8, #9, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27,# 28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #41, and #42 reviewed for drug diversion, controlled substance reconciliation, and administration of medications. During a telephone interview on [DATE] at 12:15 PM, the Administrator was asked how the facility reconciled controlled substances prior to [DATE], to ensure that all medications delivered to the facility were handled properly and accounted for. The Administrator was unable to answer the question and stated, That would be a DON [Director of Nursing] question . The Administrator was asked if she was aware that LPN M had unlimited access to controlled substances without having to have a second nurse to sign with her. The Administrator stated, .No, I was not .I thought it was always two nurses . The Administrator was asked if, as the Administrator, she expected that someone was tracking the controlled substances. The Administrator stated, .Yes, I just expect that to be the DON's responsibility to make sure those [controlled] substances are safe . During an interview on [DATE] at 3:43 PM, the DON was asked when the narcotic E-kit should be reconciled if a medication is taken out of it. The DON stated, When it's taken out. The DON confirmed she identified the narcotic E-kit on the C Hall Medication Cart was expired on [DATE] when she audited the cart at the time of the drug diversion by Licensed Practical Nurse (LPN) M. The DON stated, .I have since it expired been trying to get it in here . During an interview on [DATE] at 3:38 PM, the DON acknowledged the facility was having issues with medications being administered as ordered. The DON stated medication administration was being spotty, and they were trying to conduct additional training for agency staff. The DON acknowledged nursing staff failed to follow the education and training related to controlled substance documentation that was provided after the drug diversion was identified in [DATE], when the controlled substances were not signed out when administered on [DATE]. The DON acknowledged this was a staff performance issue, rather than an education issue. Refer to F726 and F755

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to maintain accurate medical records related to medication administration for 6 of 6 (Resident #6, 9, 13, 16, 24, and 38) sampled residents reviewed for medication administration. The findings included: 1. Review of the facility policy titled, Charting and Documentation, revised 7/2017, revealed .All services provided to the resident .or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .The following information is to be documented in the resident medical record .Medications administered . Review of the facility policy titled, Administration of Drugs, dated 4/2022, revealed .Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director .Unless otherwise specified by the resident's attending physician, routine drugs should be administered as scheduled .The nurse administering the drug must record such information on the residents eMAR [electronic Medication Administration Record] .must electronically sign the resident's eMAR immediately after administration . Review of the facility policy titled, Charting Errors and Omissions, revised 12/2022, revealed .Accurate medical records shall be maintained by this facility .Late entries in the medical record shall be dated at the time of entry and noted as a late entry . 2. Review of the medical record revealed Resident #6 was re-admitted on [DATE], with diagnoses of Parkinson's Disease, Contracture of ankle, and muscle spasms. Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #6 was cognitively intact and required use of a wheelchair for mobility. Review of the physician's orders dated 1/2/2025 for Resident #6 revealed Carbidopa Levodopa ER (extended release) oral tablet 25-100 milligram (mg) give 1 tablet by mouth every three hours for Parkinson's Disease, Entacapone 200 mg give 1 tablet by mouth every 3 hours for Parkinson's Disease, Ropinirole Hydrochloride (HCL) 0.5 mg give 1 tablet by mouth 3 times a day for Parkinson's, Tizanidine HCI 4mg give 1 tablet by mouth 3 times a day for Contracture, and Gabapentin 800 mg give 1 tablet by mouth 3 times a day for Parkinson's Disease. Review of the physician's orders dated 2/18/2025, Resident #6 Carvidopa 50-200 mg give 1 tablet by mouth four times a day for Parkinson's Disease, Diazepam 2mg give 1 tablet by mouth three times a day for Anxiety disorder and muscle spasms. Review of the Medication Admin (Administration) Audit Report, which indicated the actual time medications were documented as being administered, dated 3/14/2025 revealed the following medications were not documented as being administered accurately: The Ropinirole HCl 0.5 mg scheduled for 5:00 AM was documented as administered at 9:24 AM. The Tizanidine HCI 4 mg scheduled for 5:00 AM was documented as administered at 9:24 AM. The Gabapentin 800 mg scheduled for 6:00 AM was documented as administered at 9:24 AM. The Entacapone 200 mg give 1 tablet scheduled for 6:00 AM was documented as administered at 9:24 AM. The Carbidopa- Levodopa 25-100 mg dose scheduled for 6:00 AM was documented as administered at 9:24 AM. The Diazepam 2 mg scheduled for 6:00 AM was documented as administered at 9:24 AM. The Ropinirole HCI 0.5 mg scheduled for 9:00 PM was documented as administered at 11:34 PM. The Tizanidine HCI 4 mg scheduled for 9:00 PM was documented as administered at 11:33 PM. The Entacapone 200 mg scheduled for 9:00 PM was documented as administered at 11:33 PM. The Carbidopa-Levodopa 25-100 mg scheduled for 9:00 PM was documented as administered at 11:33 PM. During an interview on 3/18/2025 at 2:26 PM, Resident #6 stated on Friday night 3/14/2025, the nurse did not give him his Parkinson's medicine as scheduled. Resident #6 stated, This problem comes and goes, depending on the number of agency nurses working. During interview on 3/20/25 12:05 PM, the Director of Nursing (DON) confirmed the medication administration audit revealed Resident #6's medication was not administered as scheduled per the physician order and/or the medication administration was not documented timely and accurately. 3. Review of the medical records revealed Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Dementia, Diabetes, Anxiety, Periprosthetic Fracture Around Internal Prosthetic Hip Joint, and Pain in Right Knee. Review of a physician's order for Resident #9 dated 2/6/2025, revealed an order for Acetaminophen (for minor aches and pains) 325 mg, give 3 tablets by mouth two times a day. Review of the fall Incident Report dated 2/21/2025 at 1:15 AM, revealed Resident #9 sustained an unwitnessed fall. Review of the undated facility document titled MED (Medication) PASS TIME FRAMES revealed medications ordered two times a day should be administered from 7:00 AM-10:00 AM for the morning dose and 7:00 PM-10:00 PM for the evening dose. Review of the Medication Admin Record (MAR) for Resident #9 dated 2/21/2025, revealed a 6 (indicated the resident was hospitalized ) was documented in the box where the 7:00 AM to 10:00 AM dose of Acetaminophen should have been documented. Resident #9 was not transferred to the hospital until approximately 3:41 PM. Continued review revealed the MAR did not reflect documentation that Resident #9 received the Acetaminophen. Review of the E-INTERACT FORM dated 2/21/2025, revealed Resident #9 was transferred to the hospital at 3:41 PM. During a telephone interview on 3/27/2025 beginning at 2:10 PM, Licensed Praqctical Nurse (LPN) was asked about her documentation of Acetaminophen on the Medication Administration Record (MAR) that documented a 6 which indicated the resident was hospitalized , and asked did that mean the medication was not administered. LPN L stated, I guess not. LPN L stated she did not remember what time Resident #9 was transferred to the hospital. 4. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Diabetes, Dependence on Renal Dialysis, Hypothyroidism, Anxiety, Bipolar Disorder, and Insomnia. a. Review of the physician's order for Resident #13 dated 2/6/2025, revealed the following: Insulin Lispro (fast-acting insulin to lower blood glucose) 100 Units/ML, inject per sliding scale before meals for blood sugar (glucose) levels of: 71 - 150 mg/dL = 0 units 151 - 200 mg/dL = 2 units 201 - 250 mg/dL = 4 units 251 - 300 mg/dL = 6 units 301 - 350 mg/dL = 8 units 351 - 400 mg/dL= 10 units 401 mg/dL or above = 10 units recheck in one hour if blood sugar (glucose) has not gone down, notify the Nurse Practitioner (NP). Continued review revealed Norco (Hydrocodone-Acetaminophen) 7.5-325 mg, give 1 tablet by mouth four times a day for pain, Montelukast Sodium 10 mg, give 1 tablet by mouth one time a day for allergies, Ezetimibe 10 mg, give 1 tablet by mouth one time a day for Hyperlipidemia, Fluticasone Propionate Nasal Suspension 50 micrograms/actuation (mcg/act), 1 spray alternating nostrils two times a day for Allergic Rhinitis, and Sennosides-Docusate (Senna-S) 8.6-50 mg, give 2 tablets by mouth one time a say for Constipation. b. Review of the MAR for Resident #13 dated 2/1/2025-2/28/2025, revealed the following medications were documented as being administered timely: On 2/26/2025 at 7:30 AM, Resident #13's blood glucose (sugar) was 233 milligrams per deciliter (mg/dL) and LPN L documented she administered 4 units of Lispro Insulin at 7:30 AM. On 2/26/2025 at 12:00 PM, Resident #13's blood glucose was 264 mg/dL and LPN L documented she administered 6 units of Lispro Insulin at 12:00 PM. On 2/26/2025 at 11:00 AM, LPN L documented that she administered Resident #13's Norco. Review of the Medication Admin Audit Report, which indicated the actual time medications were documented as being administered, dated 2/25/2025-2/27/2025 revealed the following medications were not documented as being administered accurately: The Lispro Insulin scheduled on 2/26/2025 at 7:30 AM was documented as administered at 2:20 PM. The Norco 7.5-325 mg scheduled on 2/26/2025 at 11:00 AM was documented as administered at 2:20 PM. The Lispro Insulin scheduled on 2/26/2025 at 12:00 PM was documented as administered at 2:21 PM. The Buspirone 10 mg scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:51 AM. The Montelukast Sodium 10 mg scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:51 AM. The Ezetimibe 10 mg scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:52 AM. The Fluticasone Propionate Nasal Spray scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:52 AM. The Senna-S 8.6-50 mg scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:53 AM. Review of the MAR revealed the medications were administered timely, but review of the Medication Admin Audit Report revealed the medications were actually not accurately documented as administered timely. Observation and interview in the Resident's room on 3/13/2025 at 9:20 AM, revealed Resident #13 was in bed and wearing oxygen. Resident #13 stated a night nurse (Named LPN Q) said he gave her medications while she was asleep, but she told him she couldn't take medications while she slept. Resident #13 stated, .come to find out the next morning there was a lot of people that didn't get their medication so he's not coming back . During an interview on 3/26/2025 at 12:46 PM, LPN L stated medication should be administered within an hour before and an hour after the time it was scheduled. LPN L reviewed the Medication Admin Audit Report and stated she gave Resident #13's 7:30 AM dose of Lispro Insulin before breakfast. LPN L stated, I know because that's when I go down the hall and administer .sometimes there's just so much going on with that many patients it's hard to get it signed out. LPN L stated she administered Resident #13's 12:00 PM Lispro and Norco right before the Resident left for Dialysis which was around 11:00 AM. When asked about the documentation that showed Resident #13 received her 7:30 AM at 2:20 PM and 12:00 PM dose of Lispro Insulin at 2:21 PM, LPN L stated, That's probably just when I was able to chart it [Lispro Insulin and Norco] . 5. Review of the medical records revealed Resident #16 was admitted to the facility on [DATE], with diagnoses including Diabetes, Hypothyroidism, Gout and Cellulitis of Right Lower Limb. Review of the physician's orders for Resident #16 dated 3/6/2025 revealed Levothyroxine Sodium Tablet 137 micrograms (MCG) Give 1 tablet by mouth one time a day for Hypothyroidism and Furosemide Tablet 20 mg Give 1 tablet by mouth one time a day for edema. Review of the quarterly MDS assessment dated [DATE] revealed resident had a BIMS score of 15, which indicated Resident #16 was cognitively intact. Review of the Medication Admin Audit Report, which indicated the actual time medications were documented as being administered, dated 3/14/2025 revealed the following medications were not documented as being administered accurately: The Levothyroxine Sodium 137 MCG Give 1 tablet scheduled at 4:00 AM was documented as administered at 1:06 PM. The Furosemide 20 mg Give 1 tablet scheduled at 5:00 AM was documented as administered on 3/14/2025 at 1:06 PM. Observation and interview in the Resident's room on 3/13/2025 at 9:34 AM, revealed Resident #16 was in bed. Resident #16 stated there were times she did not receive her medications as scheduled especially on the night shift and she would get the medications when the day shift nurse arrived. During an interview on 3/26/2025 at 3:38 PM, the DON confirmed Resident #16's Levothyroxine that was due at 4:00 AM and the Furosemide that was due at 5:00 AM were documented as administered at 1:06 PM. The DON stated, [Named LPN C] comes at 7 [7:00] AM and gave the meds that were due at 4 [4:00] and 5 [5:00] am because they were not administered by either Agency [an agency nurse] or [Named LPN Q], a prn nurse. The DON stated, .it's [medication administration] being spotty and we're trying to get every agency person in here for additional training and the ones who are not performing I'm not letting them come back. 6. Review of the medical records revealed Resident #24 was admitted to the facility on [DATE], with diagnoses including Diabetes, Paraplegia, Schizophrenia, Narcolepsy, Insomnia, and Anxiety. Review of the quarterly MDS assessment dated [DATE], revealed resident had a BIMS score of 15, which indicated Resident #24 was cognitively intact. Review of the physician's orders for Resident #24 dated 3/6/2025, revealed Simethicone 125 mg give 1 tablet by mouth before meals and at bedtime for heartburn, Tamsulosin HCL 0.4 mg give 2 capsules by mouth at bedtime for enlarged prostate, Risperdal 1 mg give one tablet by mouth at bedtime for Schizophrenia, Gabapentin 600 mg give 1 tablet by mouth three times a day for Polyarthritis, Clonazepam 1 mg give 1.5 tablets by mouth at bedtime for Anxiety, and Mesalamine Rectal Suppository 1000 mg, insert 1 suppository rectally at bedtime for Constipation. Review of the Medication Admin Audit Report, which indicated the actual time medications were documented as being administered, dated 3/14/2025-3/16/2025 revealed the following medications were not documented as being administered accurately: The Simethicone 125 mg scheduled at 9:00 PM was documented as administered on 3/15/2025 at 12:01 AM. The Tamsulosin HCL 0.4 mg scheduled at 9:00 PM was documented as administered on 3/15/2025 at 12:01 AM. The Risperdal 1 mg scheduled at 9:00 PM was documented as administered on 3/15/2025 at 12:01 AM. The Gabapentin 600 mg scheduled at 9:00 PM was documented as administered on 3/15/2025 at 12:01 AM. The Clonazepam 1 mg scheduled at 9:00 PM was documented as administered on 3/15/2025 at 12:01 AM. The Mesalamine Suppository 1000 mg scheduled for 3/14/2025 at 9:00 PM, was documented as administered on 3/15/2025 at 12:01 AM. 7. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including Dementia, Diabetes, Bipolar Disorder, Schizophrenia, Osteoarthritis, and Depression. Review of the annual MDS assessment dated [DATE] revealed Resident #38 was cognitively intact. Review of the physician's orders for Resident 38 dated 3/6/2025, revealed Acetaminophen 650 MG give 2 tablets by mouth three times a day, Gabapentin (to treat seizures and nerve pain) 800 MG give 1 tablet by mouth three times a day, Ziprasidone (to treat Schizophrenia) 20 MG give 1 capsule by mouth at bedtime, Ziprasidone 80 MG, give 1 capsule by mouth at bedtime, and Lamictal (to treat seizures and bipolar disorder) 200 MG give one tablet by mouth at bedtime. Review of the Medication Admin Audit Report, which indicated the actual time medications were documented as being administered, dated 3/15/2025 revealed the following medications were not documented as being administered accurately: The Acetaminophen 650 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 1:44 AM. The Lamictal 200 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:13 AM. The Gabapentin 800 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:14 AM. The Ziprasidone 20 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:16 AM. The Ziprasidone 80 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:16 AM. Observation and interview on 3/17/2025 at 12:20 PM, revealed Resident #38 sitting in her wheelchair in her room and the Resident stated, .didn't get our meds last night till 2:30 the next morning .agency nurse she didn't know what she was doing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, personnel file review, medical record review, facility document review, Law Enforcement Investigation review, hospital order review, and interview, the facility failed to ensure the residents' rights to be free from misappropriation of residents' property for 13 of 13 (Resident #13, #14, #15, #18, #19, #20, #21, #22, #23, #25, #26, #28, and #30) sampled residents reviewed for misappropriation of resident property by means of diversion of resident medications including, but not limited to, controlled substances from [DATE] through [DATE]. On [DATE] facility Licensed Practical Nurse (LPN) M was arrested for drug diversion of the 13 residents' medications and controlled substances. The findings include: 1. Review of the facility policy titled, Abuse Prevention Policy with a facility review date of [DATE], revealed .The resident has the right to be free from .misappropriation of property .Facility has a zero-tolerance Abuse Standard regarding all proven allegations of .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 .Administrator will review investigational findings to determine appropriate corrective, remedial, or disciplinary actions to occur with accordance with applicable local, state or federal law. Administrator will review outcome in monthly continuous quality Improvement meeting. Department Manager(s) will be notified of investigation outcome for appropriate follow up and monitoring. Review of the facility policy titled, Controlled Substances revised 4/2019, .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications .Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on premises .The charge nurse on duty maintains the keys to controlled substance containers. The director of nursing services maintains a set of back-up keys for all medication storage areas including keys to controlled substance containers .Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift .Upon disposition .Medications returned to the pharmacy are recorded and signed by the director of nursing (or designee) and the receiving pharmacy .Policies and procedures for monitoring controlled medication to prevent loss, diversion .are periodically reviewed and updated by the director of nursing services and the consultant pharmacist . 2. Review of LPN M's personnel file revealed she worked in the facility from [DATE] through [DATE]. 3. On [DATE], LPN M was arrested for drug diversion of residents' medications. Review of Law Enforcement's investigation revealed Investigator #1 initiated a traffic stop of LPN M on [DATE] due to a potential window tint violation. Investigator #1 observed miscellaneous pills on the driver's side floorboard. The vehicle was searched and different kinds of scheduled and non-scheduled prescription medication pill blister packs (cards of medication that the medication can be pushed through the back of the card to dispense to residents) containing names of different people were observed. LPN M informed Investigator #1 that she worked at (Named the facility). Investigator #1 discovered prescription blister packs that dated back to 2020. Investigator #1 also found a green cloth bag in the car that contained over 15 small plastic baggies containing non-scheduled and scheduled prescription drugs all packaged separately, and .the schedule drugs ranged from Schedule II from Morphine and Hydrocodone, Schedule IV Lorazepam to Xanax and Schedule V Gabapentin and Pregabalin . LPN M was taken into custody at that time and charged with Unlawful Window Tint, Unlawful Possession without Prescription, and Possess Controlled Substance with Intent to Manufacture, Deliver, or Sell Controlled Substance for Schedule II (3 counts), Schedule IV (4 counts), and Schedule V (3 counts) drugs. Continued review of Law Enforcement's investigation revealed on [DATE] a search warrant was executed at LPN M's home. Investigators located multiple different kinds of pill blister packs containing names of different people. The Schedule drugs ranged from Schedule II Morphine and Hydrocodone, Schedule IV Lorazepam and Xanax, and Schedule V Gabapentin and Pregabalin and other non-scheduled drugs in various locations in the home. LPN M was additionally charged with Unlawful Possession without Prescription, and Possess Controlled Substance with Intent to Manufacture, Deliver, or Sell Controlled Substance for Schedule II (2 counts), IV (4 counts), and V (3 counts) drugs. Review of the pictures from the Law Enforcement's investigation and search of LPN M's car and home revealed the LPN was in possession of the following Residents' medications: 3a. One (1) of Resident #13's empty muscle relaxer blister pill packs. Four (4) of Resident #14's empty controlled substance blister pill packs. Three (3) of Resident #15's empty controlled substance blister pill packs. One (1) of Resident #18's empty controlled substance blister pill packs. One (1) of Resident #19's empty controlled substance blister pill packs. Two (2) of Resident #20's empty controlled substance blister pill packs. One (1) of Resident #21's empty controlled substance blister pill packs. One (1) of Resident #22's empty controlled substance blister pill packs. One (1) of Resident #23's empty controlled substance blister pill packs. Three (3) of Resident #25's empty controlled substance blister pill packs. One (1) of Resident #26's empty controlled substance blister pill packs. One (1) of Resident #28's empty antibiotic blister pill pack and 1 of Resident #28's empty blister pill packs. One (1) of Resident #30's empty controlled substance blister pill packs. 3b. One (1) of Resident #14's 60-count blister pill pack of Gabapentin 100 milligrams (mg) with 39 capsules remaining. One (1) of Resident #15's 45-count blister pill pack of Gabapentin 100 mg with 45 remaining. One (1) of Resident #19's 12-count blister pill pack of Hydrocodone-Acetaminophen 5-325 mg with 5 tablets remaining. One (1) of Resident #20's 60-count blister pack of Gabapentin 600 mg with 50 tablets remaining. One (1) of Resident #25's 30-count blister pack of Gabapentin 300 mg with 2 capsules remaining. One (1) of Resident #28's 14-count blister pack of Doxycycline 500 mg with 9 capsules remaining. One (1) of Resident #28's 60-count blister pack of Tramadol 50 mg with 50 tablets remaining. On [DATE], the surveyor met with Investigator #1 at the Sheriff's Department, and he provided a flash drive with over 400 pictures from the Law Enforcement investigation and a folder which contained their investigation and pictures of pill blister packs of several residents, pictures of vials of medication, and Controlled Drug Record forms that were found in the possession of LPN M. The Law Enforcement investigation revealed the following items were found in the search of LPN M's car and home: a. Schedule II-67 pills and 6 bottles of liquid. b. Schedule IV-266 pills and 2 bottles of liquid. c. Schedule V-130 pills. d. There were 704.5 total pills found in LPN M's car. e. There were 1,225 total pills found in LPN M's home. f. The total number of pills seized by law enforcement was 1,929.5. 4. Review of the medical records revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dependence on Renal Dialysis, Hypothyroidism, Anxiety, Bipolar Disorder, and Insomnia. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 scored a 15 on the Brief Interview for Mental Status (BIMS), which indicated Resident #13 was cognitively intact, and received antipsychotic, antianxiety, antidepressant and opioid medications. Review of the physician orders for Resident #13 dated [DATE], revealed Tizanidine Hydrochloride (HCL) (a muscle relaxer, non-scheduled medication) 2 mg, give 1 tablet by mouth four times a day. Review of the Medication Administration Record (MAR) dated [DATE] through [DATE], for Resident #13 revealed Tizanidine HCL 2 mg four times a day was discontinued on [DATE]. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1611) of Resident #13's blister pill pack of Tizanidine HCL 2 mg with a date issued of [DATE]. There were zero (0) of 60 Tizanidine tablets remaining in the blister pack. Continued review revealed a printed picture in the investigation of Resident #13's blister pill pack for Tizanidine HCL 2 mg, card 2 of 4, date issued [DATE]. There were 7 of 60 Tizanidine tablets remaining in the blister pack. Review of the quarterly MDS assessment dated [DATE], revealed Resident #13 scored a 15 on the BIMS score, which indicated Resident #13 was cognitively intact, and received antipsychotic, antianxiety, antidepressant and opioid medications. Observation and interview on [DATE] at 9:20 AM, revealed Resident #13 laying in bed, oxygen was being administered at 3 liters per minute by nasal cannula, and a grab bar was present on the left side of the bed. Resident #13 confirmed that she received scheduled medications for pain. Resident #13 stated, I remember a time or two when [Named LPN M] didn ' t give me [my] night meds .she's no longer here .for stealing drugs .I saw it on the news .Resident #13 confirmed that she reported the incident to another staff nurse . 5. Review of the closed medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Dementia, Diabetes, Osteoporosis, Insomnia, and Anxiety. Review of the quarterly MDS assessment dated [DATE], revealed Resident #14 scored a 01 on the BIMS score, which indicated Resident #14 was severely cognitively impaired, and received antianxiety, antidepressant and opioid medications. Review of the physician orders for Resident #14 dated [DATE], revealed Ativan (Lorazepam - a medication for anxiety) 0.5 mg every 12 hours as needed (PRN) for anxiety and agitation. Review of the physician orders for Resident #14 dated [DATE], revealed Percocet (Oxycodone-Acetaminophen medication for pain) 5-325 mg give 1 tablet by mouth two times a day every 6 hours as needed for pain and give 1 tablet by mouth two times a day for pain. Review of the physician orders for Resident #14 dated [DATE], revealed Gabapentin (medication for seizures and nerve pain) 100 mg give 1 capsule by mouth two times a day for diabetic neuropathy. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed pictures (#1620 and #1705) of Resident #14's blister pill pack of Lorazepam 0.5 mg, a Schedule IV controlled substance with an issue date of [DATE]. There were 0 of 50 Lorazepam tablets remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1678) of Resident #14's blister pill pack of Oxycodone-Acetaminophen 5-325 mg, a Schedule II controlled substance, date issued [DATE]. There were 0 of 60 Percocet tablets remaining in the blister pack. Review of the Pharmacy Electronic Shipping Manifest dated [DATE] at 2:16 PM, revealed 120 Oxycodone 5-325 mg tablets were delivered to the facility for Resident #14. The Manifest is the list of medications delivered to the facility from the pharmacy. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1539) of Resident #14's blister pill pack of Oxycodone-Acetaminophen 5-325 mg a Schedule II controlled substance with a date issued of [DATE]. There were 0 of 60 Percocet tablets remaining in the blister pack. Review of the Pharmacy Electronic Shipping Manifest dated [DATE] at 7:26 PM, revealed 90 Oxycodone 5-325 mg were delivered to the facility for Resident #14. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1708) of Resident #14's blister pill pack of Gabapentin 100 mg, a Schedule V controlled substance, with an issued date of [DATE]. There were 39 of 60 Gabapentin capsules remaining in the blister pack. The facility was unable to provide the Pharmacy Electronic Shipping Manifest for Resident #14's Gabapentin dated [DATE] or a Controlled Drug Record form for the Lorazepam dated [DATE], the Percocet dated [DATE] and [DATE], and the Gabapentin dated [DATE]. Review of the Nurse's Note dated [DATE], revealed Resident #14 expired in the facility. 6. Review of the closed medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Bipolar Disease, Anxiety and Insomnia. Review of the physician orders for Resident #15 dated [DATE], revealed the following: (a). Gabapentin 100 mg, give 1 capsule by mouth three times a day for neuropathy (weakness, numbness, and pain from nerve damage and pain). (b). Diazepam 5 mg, give 1 tablet by mouth every 12 hours as needed for anxiety for 14 days. (c). Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet by mouth every 6 hours as needed for pain for 14 days. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1623) of Resident #15's blister pill pack of Hydrocodone-Acetaminophen 10-325 mg, a Schedule II controlled substance, with an issued date of [DATE]. There were 0 of 12 Hydrocodone-Acetaminophen tablets remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1657) of Resident #15's blister pill pack of Diazepam 5 mg, a Schedule IV controlled substance, with an issued date of [DATE]. There were 0 of 12 Diazepam tablets remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1659) of Resident #15's blister pill pack of Gabapentin 100 mg, a Schedule V controlled substance, with an issued date of [DATE]. There were 45 of 45 Gabapentin capsules remaining in the blister pack. Review of the 5-day MDS assessment dated [DATE], revealed Resident #15 received antipsychotic and opioid medications. The facility was unable to provide a Pharmacy Electronic Shipping Manifest to show delivery of Resident #15's Gabapentin, Diazepam, and Hydrocodone-Acetaminophen dated [DATE], or a Controlled Drug Record for Gabapentin, Diazepam, and Hydrocodone-Acetaminophen. Review of the Nurses Note dated [DATE], revealed Resident #15 left the facility against medical advice. 7. Review of the closed medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including Diabetes, Chronic Pain Syndrome, and Anxiety. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1693) of Resident #18's blister pill pack of Alprazolam 0.25 mg, a Schedule IV controlled substance, with an issued date of [DATE]. There were 0 of 60 remaining in the blister pack. Review of the physician orders for Resident #18 dated [DATE], revealed Alprazolam (medication used to treat anxiety/depression) 0.5 mg, give 1 tablet by mouth three times a day. The facility was unable to provide a Pharmacy Electronic Shipping Manifest to show delivery of Resident #18's Alprazolam dated [DATE], or a Controlled Drug Record form for the Alprazolam. Review of the admission MDS assessment dated [DATE], revealed Resident #18 scored a 15 on the BIMS, which indicated the Resident was cognitively intact, and received antianxiety, antidepressant, and opioid medications. Review of the Nurse's Note dated [DATE], revealed Resident #18 was discharged home. 8. Review of the closed medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Prosthesis, Depression, Osteoarthritis, and Anxiety. Review of the physician orders from the Rehab Hospital for Resident #19 dated [DATE], revealed Norco 7.5-325 mg (Hydrocodone), give 1 tablet every 6 hours as needed for pain (pain scale 4-10). Review of the Resident #1's admission MDS assessment dated [DATE], revealed the Resident scored a 15 on the BIMS, which indicated the Resident was cognitively intact, and received antianxiety, antidepressant, and opioid medications. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1391) of Resident #19' s blister pill pack of Hydrocodone-Acetaminophen 7.5-325 mg, a Schedule II controlled substance, date issued not visible. There were 4 of 12 Hydrocodone-Acetaminophen tablets remaining in the blister pack. The facility was unable to provide a Pharmacy Electronic Shipping Manifest to show delivery of Resident #19' s Hydrocodone-Acetaminophen or a Controlled Drug Record for the Hydrocodone-Acetaminophen. Review of the Nurse's Note dated [DATE], revealed Resident #19 was discharged home. 9. Review of the closed medical record revealed Resident #20 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Sepsis, Diabetes, Hypothyroidism, Anxiety, Insomnia. Review of the physician's order for Resident #20 dated [DATE], revealed Gabapentin 300 mg, give 2 capsules by mouth three times a day for neuropathy. Review of the physician's order for Resident #20 dated [DATE] revealed, Gabapentin 100 MG, give 1 capsule by mouth three times a day. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1655) of Resident #20's Gabapentin 600 mg, a Schedule V controlled substance, card 1 of 6, dated [DATE]. There were 0 of 30 Gabapentin capsules remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1719) of Resident #20 ' s Gabapentin 600 mg, a Schedule V controlled substance, card 2 of 6, dated [DATE]. 50 of 60 Gabapentin capsules remained in the blister pack. The facility was unable to provide a Pharmacy Electronic Shipping Manifest to show delivery of Resident #20's Gabapentin dated [DATE] or a Controlled Substance Record for the Gabapentin. Review of the admission MDS assessment dated [DATE], revealed Resident #20 scored a 15 on the BIMS, which indicated she was cognitively intact, and received antipsychotic, antianxiety, antidepressant and opioid medications. Review of the Nurse's Note dated [DATE], revealed Resident #20 was discharged home. 10. Review of the closed medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses including Anxiety, Chronic Obstructive, Depression and Muscle Weakness. Review of the admission MDS assessment dated [DATE], revealed Resident #21 had a BIMS score of 15, which indicated Resident #21 was cognitively intact, received anxiety, antidepressant and opioid medications. Review of the physician orders for Resident #21 dated [DATE], revealed Lorazepam 0.5 mg, give 1 tablet by mouth every 8 hours as needed for anxiety for 14 days. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1590) of Resident #21's blister pack for Lorazepam 0.5 mg, a Schedule IV controlled substance, issued [DATE]. There were 0 of 20 Lorazepam tablets remaining in the blister pack. The facility was unable to provide a Pharmacy Electronic Shipping Manifest to show delivery of Resident #21's Lorazepam dated [DATE] or a Controlled Drug Record form for the Lorazepam. Review of the Nurse's Note dated [DATE], revealed Resident #21 was transferred to the hospital, the resident did not return to the facility. 11. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dementia, Anxiety, and Chronic Kidney Disease Stage 4. Review of the physician orders for Resident #22 dated [DATE], revealed Clonazepam 0.5 mg, give 1 tablet by mouth every 24 hours for anxiety. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1625) of Resident #22's blister pack for Clonazepam 0.5 mg, a Schedule IV controlled substance, issued [DATE]. There were 0 of 14 Clonazepam tablets remaining in the blister pack. The facility was unable to provide a Pharmacy Electronic Shipping Manifest to show delivery of Resident #22's Clonazepam dated [DATE] or a Controlled Drug Record form for the Clonazepam. Review of the quarterly MDS assessment dated [DATE], revealed Resident #22 scored a 03 on the BIMS, which indicated Resident #22 was severely cognitively impaired, and received antidepressant and opioid medications. Observation in the resident's room on [DATE] 1:25 PM, revealed a sign for contact precautions on the hall wall to the right of the door, Resident #22 lay in bed on her back, her eyes were closed, and she appeared to be asleep. The call light was in reach and the bed in low position. 12. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Acquired Absence of Right Leg Above Knee (above the knee amputation), Anxiety, Personal History of Malignant Neoplasm of Uterus, and Diabetes. Review of the admission MDS assessment dated [DATE], revealed Resident #23 scored a 14 on the BIMS, which indicated Resident #23 was cognitively intact, and received opioids medications. Review of the physician orders dated [DATE], revealed Ativan (Lorazepam medication given for anxiety) 0.5 mg, give 1 tablet by mouth 3 times every week every Monday, Wednesday, and Friday for anxiety disorder. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1711) of Resident #23 ' s blister pack for Lorazepam 0.5 mg, a Schedule IV controlled substance, issued [DATE]. 0 of 12 Lorazepam tablets remained in the blister pack. The facility was unable to provide a Pharmacy Electronic Shipping Manifest to show delivery of Resident #23's Lorazepam dated [DATE] or a Controlled Drug Record form for the Lorazepam. 13. Review of the closed medical records revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Diabetes, Cirrhosis of Liver, Anxiety, Insomnia, and Gout. Review of the admission MDS assessment dated [DATE] revealed Resident #25 scored a 13 on the BIMS, which indicated Resident #25 was cognitively intact, and received antidepressant medications. Review of the physician orders for Resident #25 dated [DATE], revealed Gabapentin 300 mg, give 1 capsule by mouth two times a day for seizures. Review of the MAR dated [DATE]-[DATE], revealed Resident #25 received 20 doses of Gabapentin 300 mg. Review of the Law Enforcement investigation revealed a Controlled Drug Record for Resident #25's Gabapentin 300 mg that was seized in the search of LPN M's car and home. The form revealed there should have been 2 Gabapentin on the pill blister pack that LPN M diverted from the facility. Review of the Law Enforcement investigation for the drug diversion by LPN M, revealed a picture (#1694) of Resident #25's blister pack for Gabapentin 300 mg, a Schedule IV controlled substance, issued [DATE]. 2 of 30 Gabapentin capsules remained in the blister pack. Review of the Pharmacy Electronic Shipping Manifest dated [DATE], revealed 30 Gabapentin 300 mg and 28 Lorazepam 0.5 mg were delivered for Resident #25. Review of the Medication Administration Record (MAR) for Resident #25 dated [DATE]-[DATE], revealed Alprazolam 0.5 mg, give 1 tablet every 12 hours as needed for anxiety for 14 days, was ordered on [DATE]. Resident #25 received 1 dose of Alprazolam on [DATE] at 11:31 AM. On [DATE], the frequency of the order was changed to give 1 tablet of Alprazolam every 8 hours as needed for anxiety for 14 days. Resident #25 received 1 dose of Alprazolam on [DATE] at 9:00 PM. Review of the physician's order for Resident #25 dated [DATE], revealed Alprazolam 0.5 mg, give 1 tablet by mouth every 8 hours as needed for anxious behavior. Review of the Law Enforcement investigation revealed a Controlled Drug Record form for Resident #25's Alprazolam 0.5 mg dated [DATE], that was seized in the search of LPN M's car and home. The form revealed there should have been 8 of 28 Lorazepam 0.5 mg on the pill blister pack that LPN M diverted from the facility. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1645) of Resident #25's s blister pack for Alprazolam 0.5 mg, a Schedule IV controlled substance, issued [DATE]. 0 of 28 Lorazepam tablets remained in the blister pack. Continued review of the Law Enforcement investigation revealed a Controlled Drug Record form for Resident #25's Alprazolam 0.5 mg dated [DATE], that was seized in the search of LPN M ' s car and home. The form revealed there should have been 42 of 42 Lorazepam 0.5 mg in the pill blister pack that LPN M diverted from the facility. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1686) of Resident #25's blister pack for Alprazolam 0.5 mg, a Schedule IV controlled substance, issued [DATE]. 0 of 42 Lorazepam tablets remained in the blister pack. The facility was unable to provide a Controlled Drug Record form for Resident #25's Lorazepam dated [DATE] and [DATE]. Review of the Nurses' Note dated [DATE] revealed Resident #25 expired in the facility. 14. Review of the closed medical records revealed Resident #26 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Depression, Dementia, and Senile Degeneration of Brain. Review of the quarterly MDS assessment dated [DATE], revealed Resident had a BIMS score of 2, which indicated Resident #26 was severely cognitively impaired, and received antidepressant and opioid medications. Review of the physician's order For Resident #26 dated [DATE], revealed Lorazepam 0.5 mg, give 1 tablet by mouth four times a day for seizures. Review of the Pharmacy Electronic Shipping Manifest dated [DATE] at 8:43 PM, revealed 30 Lorazepam 0.5 mg tablets were delivered for Resident #26. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1519) of Resident #26's blister pack for Lorazepam 0.5 mg, a Schedule IV controlled substance, issued [DATE]. 0 of 30 Lorazepam tablets remained in the blister pack. The facility was unable to provide a Controlled Drug Record form for Resident #26 ' s Lorazepam dated [DATE]. Review of the Nurse's Note dated [DATE] at 7:13 PM, revealed Resident #26 expired in the facility. 15. Review of the medical records revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Diabetes, Cellulitis Right Lower Limb, and Cellulitis of Left Lower Limb. Resident #28 was discharged [DATE]. Review of the admission MDS assessment dated [DATE], revealed Resident scored a 13 on the BIMS, which indicated Resident # was cognitively intact, and received opioid medications. Review of the physician order for Resident #28 dated [DATE], revealed Tramadol (opioid medication given for pain) 50mg, give 1 tablet by mouth every 6 hours as needed for pain. Review of the Medication Administration Record (MAR) dated [DATE]-[DATE], revealed .DOXYCYCLINE MONO (monohydrate a non-scheduled medication given to treat bacterial infections)100 MG .Give .by mouth two times a day related to CELLULITIS OF RIGHT LOWER LIMB .CELLULITIS OF LEFT LOWER LIMB .for 3 days .Order dated XXX[DATE] . Continued review of the MAR revealed Resident #28 received 5 doses of Doxycycline. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1564) of Resident #28 ' s blister pack for Doxycycline 100mg, an antibiotic, date issued [DATE]. 9 of 14 Doxycycline remained in the blister pack. Review of the MAR for Resident #28 dated [DATE]-[DATE], revealed Resident #28 received 1 dose of Tramadol 50 mg. Review of the Pharmacy Electronic Shipping Manifest dated [DATE] at 8:25 PM, revealed 60 Tramadol Hydrochloride 50 mg tablets were delivered for Resident #28. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1561) of Resident #28's blister pack for Tramadol 50 mg, a Schedule IV controlled substance, date issued [DATE]. 50 of 60 Tramadol tablets remained in the blister pack. The facility was unable to provide a Controlled Drug Form for Resident #28's Tramadol dated [DATE]. Review of the Nurse's Note dated [DATE], revealed Resident #28 discharged home with family. 16. Review of the closed medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Fracture of Left Femur, Dementia, Anxiety, and Dementia. Review of the admission MDS assessment dated [DATE], revealed Resident scored a 03 on the BIMS, which indicated Resident #30 was severely cognitively impaired, and received anticoagulant and diuretic medications. Review of the physician's order for Resident #30 dated [DATE], revealed Lorazepam 0.5 mg, give 1 tablet by mouth every 12 hours as needed for agitation and anxious behavior for 2 days. Do not give within 2 hours of scheduled Oxycodone. Review of the Pharmacy Electronic Shipping Manifest dated [DATE] at 3:18 PM, revealed 4 Lorazepam 0.5 mg tablets were delivered for Resident #30. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed a picture (#1520) of Resident #30's blister pack for Lorazepam 0.5 mg, a Schedule IV controlled substance, date issued [DATE]. 0 of 4 Lorazepam tablets remained in the blister pack. The facility was unable to provide a Controlled Drug Record of Resident #30's Lorazepam dated [DATE]. Review of the Nurse's Note dated [DATE], revealed Resident #30 was discharged home with her daughter. 17. During an interview on [DATE] at 9:55 AM, the Director of Nursing (DON) stated, .when a card [pill blister pack] is emptied it is pulled from the cart as well as the narcotic sheet and put in a basket that comes to me .when a narcotic is discontinued and still some left on the [medication (med)] cart the nurses and I pull that, we log it on a sheet, the number of pills the resident's name, what it [medication] is and it's locked into this double locked cabinet until pharmacy comes and then pharmacy and I will destroy those narcs .I use Rx Destroyer, chemical based that you dump [medications to be destroyed] in there .so much of the diversion part we don't have because they [Law Enforcement] took it. The DON was asked were they able to substantiate the nurse [LPN M] took any medications. The DON stated, Our investigation was limited with having enough paperwork .I would have to say yeah she did [divert resident's medications] .they brought in some sheets and I reviewed them .they were all deceased residents .she [LPN M] was delegated with removing narcotics from the cart .they [residents] would expire, she took the narcotic sheet and the narcotic and I don't know how she was able to do it without getting caught .I was floored, devasted and a[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, job description review, personnel record review, facility investigation review, in-service record review, medical record review, observation, and interview, the facility failed to provide sufficient nursing staff with appropriate competencies and skill sets to ensure residents attain or maintain the highest level of practicable physical well-being. The facility failed to ensure competent nursing staff (Certified Nursing Assistant (CNA) R) who immediately reported an allegation of abuse to Administration for 1 of 6 (Resident #1) sampled residents reviewed for allegations of abuse, failed to ensure competent nursing staff (Licensed Practical Nurse (LPN) B and LPN C) who documented controlled substances when administered for 14 of 57 (Resident #7, 8, 13, 22, 27, 29, 31, 32, 33, 34, 35, 36, 41, and 42) sampled residents reviewed for narcotic reconciliation, failed to ensure competent nursing staff (LPN L and LPN Q) who administered medications per the physician's order and as scheduled for 5 of 5 (Resident #6, 13, 16, 24, and 38) residents reviewed for administration of medications, and failed to ensure competent nursing staff (LPN D and LPN L) who appropriately assessed and implemented interventions to address pain and the new onset behavior of attempting to get up unassisted for cognitively impaired residents for 2 of 6 (Resident #17 and 9) sampled residents reviewed for pain assessments and implementation of pain management in cognitively impaired residents with non-verbal pain cues. The findings include: 1. Review of the policy titled, Staffing Guidelines, dated 8/22/2022, revealed It is the policy of the center [facility] to abide by the Federal and Sate staffing guidelines .The center adopts the Federal regulations from the Centers for Medicare and Medicaid Services (CMS) as well as the state regulations for which the center resides as our policies. The staffing and ratios outlined in the regulations will be followed by the Center. Review of the undated facility policy titled, Nursing Services, General, revealed .It is the policy of the facility to provide care and services related to Nursing Services in accordance to State and Federal regulation .This policy will include .Competent Nursing Staff . Review of the facility policy titled, Charting and Documentation, revised 7/2017, revealed .All services provided to the resident .or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .The following information is to be documented in the resident medical record .Medications administered .Treatment or services performed . Review of the facility policy titled, Charting Errors and Omissions, revised 12/2022, revealed .Accurate medical records shall be maintained by this facility .Late entries in the medical record shall be dated at the time of entry and noted as a late entry . Review of the facility policy titled, Administration of Drugs, dated 4/2022, revealed .Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director .Unless otherwise specified by the resident's attending physician, routine drugs should be administered as scheduled .The nurse administering the drug must record such information on the residents eMAR [electronic Medication Administration Record] .must electronically sign the resident's eMAR immediately after administration . Review of the undated facility policy titled, Pain Managment, revealed .The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice . 2. Review of the facility Job Description titled, Charge Nurse, revealed .The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility .to ensure that the highest degree of quality care is maintained at all times .delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Transcribe physician's orders to resident charts .medication cards .Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care .Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures .Prepare and administer medications as ordered by the physician .Ensure that an adequate supply of floor stock medications .is on hand to meet the nursing needs of the residents .Notify the Nurse Supervisor of all drugs and narcotic discrepancies noted on your shift .Review medication cards for completeness of information, accuracy in the transcription of the physician ' s order .Dispose of drugs and narcotics as required, and in accordance with established procedures .Notify the resident's attending physician .when there is a change in the resident's condition . 3. Review of the personnel record for Licensed Practical Nurse (LPN) B revealed the LPN Job Description was signed on 4/26/2016. Continued review revealed, .Provide direct nursing care to the residents and supervise the day-to-day nursing activities performed by nursing assistants .in accordance with Federal, State, and Local standards, guidelines and regulations .to maintain the highest degree of quality care at all times .Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures .Prepare and administer medication as ordered by the physician .Verify that narcotic records are accurate for your shift . Review of the personnel record for LPN C revealed the Charge Nurse Job Description was signed and dated on 6/1/2023. Review of the personnel record for LPN L revealed the Charge Nurse Job Description was signed and dated on 5/21/2024. Review of the Nurse Competency Assessment Form in LPN's personnel record dated 5/22/2024, revealed .Demonstrates ability to apply knowledge and skills in a healthcare setting .Demonstrates effective communication .Monitor, document and report all changes in condition appropriately .Understands specific facility client population .Demonstrates proper documentation of medication administration .Consistently, appropriately and correctly documents in EMR [Electronic Medical Record] . Review of the personnel record for LPN D revealed the Charge Nurse Job Description was signed and dated on 10/10/2024. Continued review of the Nurse Competency Assessment Form dated 10/24/2024, revealed .Demonstrates ability to apply knowledge and skills in a healthcare setting .Demonstrates effective communication .Monitor, document and report all changes in condition appropriately .Understands specific facility client population .Demonstrates proper documentation of medication administration .Consistently, appropriately and correctly documents in EMR . Review of the personnel record for Certified Nursing Assistant (CNA) R revealed the CNA Job Description was signed and dated 1/2/2025. Continued review revealed .Report all allegations of resident abuse . 4. The facility failed to ensure competent staff who immediately reported allegations of abuse. a. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Diabetes, Human Immunodeficiency Virus Disease, Depression, and Encephalopathy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14. Review of the progress notes dated 2/27/2025, revealed Resident #1 reported to RN A that a male staff member had sexually abused him by digital penetration of the rectum. RN A called the Administrator immediately and reported the allegation and Resident #1 was transported to the emergency room (ER). During an interview on 3/4/2025 at 3:29 PM, Certified Nursing Assistant (CNA) R stated she was told by Resident #1 on 2/26/2025 that a male staff member raped him. CNA R stated .the new nurse .was [NAME] [missing in action] .he was nowhere to be found .I had an Uber waiting on me . CNA R stated she reported the allegation of abuse to facility staff the following day (2/27/2025). CNA R stated, .I'm sorry .I know you have to tell right away .now I know to tell any nurse in charge. I feel bad . b. CNA R had previously attended an Abuse inservice on 2/5/2025, but did not report the abuse on 2/26/2025, when the resident reported the allegation. 5. The facility failed to ensure competent nursing staff documented controlled substances when administered: a. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Review of the Medication Administration Audit Report for Resident #7 dated 3/4/2025 at 9:07 AM, revealed Lacosamide (medication to control seizures) 50 mg tablet was administered to Resident #7. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, with LPN C, revealed a discrepancy of Resident #7's Lacosamide 50 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 6 Lacosamide tablets and the Controlled Drug Record documented there should be 7 Lacosamide tablets presents. LPN C confirmed the discrepancy. b. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Review of Resident #8's physician's orders dated 2/6/2025, revealed an order for Percocet (Oxycodone-Acetaminophen) 5-325 mg one time a day. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #8's Oxycodone-Acetaminophen 5-325 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 28 Oxycodone-Acetaminophen tablets. and the Controlled Drug Record documented there should be 29 Oxycodone-Acetaminophen tablets present. LPN C confirmed the discrepancy. c. Review of the medical records revealed Resident #13 was admitted to the facility on [DATE]. Review of Resident #13's physician's orders dated 3/6/2025, revealed Norco (Hydrocodone-Acetaminophen) 7.5-325 mg 4 times a day. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #13's Hydrocodone-Acetaminophen 7.5-325 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 9 Hydrocodone-Acetaminophen tablets, and the Controlled Drug Record documented 10 Hydrocodone-Acetaminophen tablets should be present. LPN C confirmed the discrepancy. d. Review of the medical records revealed Resident #22 was admitted to the facility on [DATE]. Review of Resident #22's physician's orders dated 2/6/2025, revealed an order for Lorazepam 0.5 mg twice a day for anxiety. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #22's Lorazepam tablets between the medication card and the Controlled Drug Record. The medication card contained 17 Lorazepam tablets, and the Controlled Drug Record documented there should be 18. LPN C confirmed the discrepancy. e. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Review of Resident #27's physician's orders dated 2/14/2025, revealed an order for Hydrocodone-Acetaminophen 5-325 mg every 6 hours as needed (PRN) for pain. Observation and interview at the C Hall Medication Cart with LPN B on 3/4/2025 beginning at 11:23 AM, revealed a discrepancy of Resident #27's Hydrocodone-Acetaminophen 5-325 milligrams (mg) tablets between the medication card and the Controlled Drug Record. The medication card contained 39 Hydrocodone-Acetaminophen tablets, and the Controlled Drug Record documented there should be 40 Hydrocodone-Acetaminophen tablets present. LPN B acknowledged she administered the Hydrocodone-Acetaminophen and failed to sign it out when it was administered. f. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Review of Resident #29's physician's orders dated 2/6/2025, revealed an order for Tramadol Hydrochloride (HCL) 50 mg two times a day for pain and every 6 hours PRN for pain. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #29's Tramadol HCL 50 mg tablets between the medication card and the Controlled Drug Record. The medication card contained no Tramadol tablets, and the Controlled Drug Record documented there should be 1 tablet present. LPN C confirmed the discrepancy. g. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #31's physician ' s orders dated 2/6/2025, revealed an order for Xanax (Alprazolam) 0.25 mg two times a day. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #31's Alprazolam 0.25 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 32 Alprazolam tablets, and the Controlled Drug Record documented there should be 33 Alprazolam tablets present. LPN C confirmed the discrepancy. h. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Review of Resident #32's physician's orders dated 2/6/2025, revealed an order for Lacosamide 150 mg two times a day for seizures. Observation and interview at the B Hall medication cart with LPN C beginning at 11:31 AM, revealed a discrepancy of Resident #32's Lacosamide 150 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 8 Lacosamide tablets and the Controlled Drug Record documented there should be 9 Lacosamide tablets present. LPN C confirmed the discrepancy. i. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #33's physician's orders dated 2/6/2025, revealed an order for Pregabalin 75 mg, 2 capsules one time a day related to Chronic Pain Syndrome and give 1 capsule one time a day for Chronic Pain Syndrome. 2 capsules were scheduled to be administered at bedtime and 1 capsule in the morning. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident 33's Pregabalin 75 mg capsules between the medication card and the Controlled Drug Record. The medication card contained 25 Pregabalin capsules and the Controlled Drug Record documented there should be 26 Pregabalin present. LPN C confirmed the discrepancy. j. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE]. Review of Resident #34's physician's orders dated 2/21/2025, revealed an order Alprazolam 0.25 mg three times a day related to Anxiety Disorder. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #34's Alprazolam 0.25 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 18 Alprazolam tablets and the Controlled Drug Rcord documented there should be 19 Alprazolam tablets present. k. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. Review of Resident #35's physician's orders dated 2/6/2025, revealed Xanax 0.25 mg four times a day for Anxiety Disorder. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #35's Alprazolam (Xanax) 0.25 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 20 Alprazolam tablets, and the Controlled drug Record documented there should be 21 Alprazolam tablets present. During an interview on 3/4/2025 at 11:45 AM, LPN C acknowledged the facility's policy was to sign off the controlled substances when they were administered and stated, .but you caught us on a busy day. During an interview on 3/5/2025 at 9:55 AM, the DON stated controlled substances should be signed out on the Controlled Drug Record when they were pulled from the medication cart. l. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Review of Resident #36's physician's orders dated 2/13/2025, revealed Hydrocodone-Acetaminophen 5-325 mg three times daily. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #36's Hydrocodone-Acetaminophen 5-325 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 26 Hydrocodone-Acetaminophen tablets and the Controlled Drug Record documented there should be 27 Hydrocodone-Acetaminophen tablets present. LPN C confirmed the discrepancy. m. Review of the medical records revealed Resident #41 was admitted to the facility on [DATE]. Review of Resident #41's physician's order dated 2/6/2025, revealed an order for Alprazolam 0.5 mg two times a day for anxiety and Norco 7.5-325 mg (Hydrocodone-Acetaminophen) 4 times a day for Phantom Limb Pain. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #41's Alprazolam 0.5 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 28 Alprazolam tablets, and the Controlled Drug Record documented there should be 29 Alprazolam tablets present. Continued observation revealed a discrepancy of Resident #41's Hydrocodone-Acetaminophen 7.5-325 mg tablets between the medication card and the Controlled Drug Record. The medication card contained 31 Hydrocodone-Acetaminophen tablets, and the Controlled Drug Record documented there should be 32 Hydrocodone-Acetaminophen tablets present. LPN C confirmed the discrepancy. n. Review of the medical records revealed Resident #42 was admitted to the facility on [DATE]. Review of Resident #42's physician's orders dated 2/6/2025, revealed an order for Gabapentin 400 mg two times a day for diabetes with polyneuropathy. Observation and interview at the B Hall medication cart with LPN C on 3/4/2025 beginning at 11:31 AM, revealed a discrepancy of Resident #42's Gabapentin 400 mg capsules between the medication card and the Controlled Drug Record. The medication card contained 33 Gabapentin capsules, and the Controlled Drug Record documented there should be 34 Gabapentin capsules present. LPN C confirmed the discrepancy. 6. The facility failed to ensure competent nursing staff who administered medications per the physician's order and as scheduled: Review of the undated facility document titled, MED [Medication] PASS TIME FRAMES, revealed .One time a day = [equals .7-10a [7:00-10:00 AM] or 7-10p [7:00-10:00 PM] .TID [three times a day] .enter 0500 [5:00 AM], 1300 [1:00 PM], 2100 [9:00 PM] .QID [four times a day] & [and] q6 [every 6 hours] .enter 0500 [5:00 AM], 1100 [11:00 AM], 1700 [5:00 PM], 23:00 [11:00 PM . a. Review of the medical record revealed Resident #6 was re-admitted on [DATE], with diagnoses of Parkinson's Disease, Contracture of ankle, and muscle spasms. Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #6 was cognitively intact and required use of a wheelchair for mobility. Review of the physician's orders dated 1/2/2025 for Resident #6 revealed Carbidopa Levodopa ER (extended release) oral tablet 25-100 milligram (mg) give 1 tablet by mouth every three hours for Parkinson's Disease, Entacapone 200 mg give 1 tablet by mouth every 3 hours for Parkinson's Disease, Ropinirole Hydrochloride (HCL) 0.5 mg give 1 tablet by mouth 3 times a day for Parkinson's, Tizanidine HCI 4mg give 1 tablet by mouth 3 times a day for Contracture, and Gabapentin 800 mg give 1 tablet by mouth 3 times a day for Parkinson's Disease. Review of the physician's orders dated 2/18/2025, Resident #6 Carvidopa 50-200 mg give 1 tablet by mouth four times a day for Parkinson's Disease, Diazepam 2mg give 1 tablet by mouth three times a day for Anxiety disorder and muscle spasms. Review of the Medication Admin (Administration) Audit Report, which indicated the actual time medications were documented as being administered, dated 3/14/2025 revealed the following medications were not documented as being administered accurately: The Ropinirole HCl 0.5 mg scheduled for 5:00 AM was documented as administered at 9:24 AM. The Tizanidine HCI 4 mg scheduled for 5:00 AM was documented as administered at 9:24 AM. The Gabapentin 800 mg scheduled for 6:00 AM was documented as administered at 9:24 AM. The Entacapone 200 mg give 1 tablet scheduled for 6:00 AM was documented as administered at 9:24 AM. The Carbidopa- Levodopa 25-100 mg dose scheduled for 6:00 AM was documented as administered at 9:24 AM. The Diazepam 2 mg scheduled for 6:00 AM was documented as administered at 9:24 AM. The Ropinirole HCI 0.5 mg scheduled for 9:00 PM was documented as administered at 11:34 PM. The Tizanidine HCI 4 mg scheduled for 9:00 PM was documented as administered at 11:33 PM. The Entacapone 200 mg scheduled for 9:00 PM was documented as administered at 11:33 PM. The Carbidopa-Levodopa 25-100 mg was scheduled for 9:00 PM was documented as administered at 11:33 PM. During an interview on 3/18/2025 at 2:26 PM, Resident #6 stated on 3/14/2025, the night nurse did not administer his medicine as scheduled. Resident #6 stated, this problem comes and goes, depending on the number of agency nurses working. During interview on 3/20/25 12:05 PM, the DON acknowledged the medication administration audit form revealed Resident #6's medication was not administered as scheduled per the physician order and the medication administration was not documented timely and accurately. b. Review of the medical records revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dependence on Renal Dialysis, Hypothyroidism, Anxiety, Bipolar Disorder, and Insomnia. Review of Resident #13's physician's orders dated 2/6/2025, revealed the following: Insulin Lispro (fast-acting insulin to lower blood glucose) 100 Unit/ML inject per sliding scale before meals: for a blood glucose of 71-150 mg/dL give 0 units, for a blood glucose of 151 - 200 mg/dL give 2 units, for a blood glucose of 201-250 mg/dL give 4 units, for a blood glucose of 251-300 mg/dL give 6 units, for a blood glucose of 301-350 mg/dL give 8 units, for a blood glucose of 351-400 mg/dL give 10 units, and for a blood glucose of 401 mg/dL or higher give 10 units and recheck in one hour, if blood sugar (glucose) has not gone down, notify the Nurse Practitioner (NP). Norco (Hydrocodone-Acetaminophen) 7.5-325 mg, give 1 tablet by mouth four times a day for pain. Buspirone Hydrochloride (HCL) 10 mg, give 1 tablet by mouth two times a day for depression. Montelukast Sodium 10 mg, give 1 tablet by mouth one time a day for allergies. Ezetimibe 10 mg, give 1 tablet by mouth one time a day for Hyperlipidemia. Fluticasone Propionate Nasal Suspension 50 micrograms/actuation (mcg/act), 1 spray alternating nostrils two times a day for Allergic Rhinitis. Sennosides-Docusate (Senna-S) 8.6-50 mg, give 2 tablets by mouth one time a say for Constipation. Review of the MAR for Resident #13 dated 2/1/2025-2/28/2025, revealed Resident #13's blood glucose was 233 mg/dl on 2/26/2025 at 7:30 AM and 4 units of Lispro Insulin was administered. Continued review revealed Resident #13's blood glucose was 264 mg/dL on 2/26/2025 at 12:00 PM and 6 units of Lispro Insulin were administered. Review of the Medication Admin (Administration) Audit Report (report which indicated the actual time medications were documented as given) for Resident #13 dated 2/25/2025-2/27/2025, revealed the following: Lispro Insulin scheduled to be administered per sliding scale on 2/26/2025 at 7:30 AM, before breakfast, was documented as administered at 2:20 PM, 6 hours and 50 minutes late. Lispro Insulin scheduled to be administered per sliding scale on 2/26/2025 at 12:00 PM, before lunch, was documented as administered at 2:21 PM, 2 hours and 21 minutes late. Resident #13's 7:30 AM dose of Insulin and her 12:00 PM dose of Insulin were documented as administered 1 minute apart. Norco scheduled to be administered on 2/26/2025 at 11:00 AM, was documented as administered at 2:20 PM, 3 hours and 20 minutes late. Buspirone 10 mg tablet scheduled for 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:51 AM, 3 hours and 51 minutes late. Montelukast Sodium 10 mg tablet scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:51 AM, 3 hours and 51 minutes late. Ezetimibe 10 mg tablet scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:52 AM, 3 hours and 52 minutes late. Fluticasone Propionate Nasal spray scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:52 AM, 3 hours and 52 minutes late. Senna-S 8.6-50 mg scheduled on 2/27/2025 at 7:00 PM-10:00 PM was documented as administered on 2/28/2025 at 1:53 AM, 3 hours and 53 minutes late. Review of the working schedule dated 2/27/2025, revealed LPN Q worked the B Hall where Resident #13 resided on 2/27/2025. Observation and interview in the Resident's room on 3/13/2025 at 9:20 AM, revealed Resident #13 lay in bed, oxygen was administered by nasal cannula at 3 liters per minute. Resident #13 confirmed she had been in the facility about 4 years. Resident #13 stated, One day .they had a nurse in, I didn't get my night medicine I asked him about it and he said no I gave it to you, you were asleep, come to find out the next morning there was a lot of people that didn't get their medication so he's not coming back .[Named LPN Q] . During an interview on 3/26/2025 at 12:46 PM, LPN L reviewed Resident #13's Medication Admin Audit Report. LPN L stated Resident #13 was not even in the facility at 2:20 PM and 2:21 PM on 2/26/2025 (2/26/2025 was a dialysis day for Resident #13 and she left the facility at approximately 11:00 AM). LPN L stated the 7:30 Lispro Insulin was given before breakfast and the 11:00 AM dose of Norco and the 12:00 PM dose of Lispro and were given right before the resident left for dialysis. LPN L stated, That ' s probably just when I was able to chart it [Lispro Insulin and Norco] . c. Review of the medical records revealed Resident #16 was admitted to the facility on [DATE]. Review of Resident #16's physician's orders dated 3/6/2025, revealed Levothyroxine Sodium 137 micrograms [MCG], give 1 tablet by mouth one time a day related to Hypothyroidism (where the thyroid gland does not produce enough thyroid hormone) and Furosemide 20 mg, give 1 tablet by mouth one time a day for edema. Review of the Medication Admin Audit Report for Resident #16 dated 3/14/2025, revealed the Levothyroxine Sodium 137 MCG [micrograms] scheduled at 4:00 AM, was documented as administered at 1:06 PM, 9 hours late. Continued review revealed the Furosemide 20 mg scheduled at 5:00 AM, was documented as administered at 1:06 PM, 8 hours late. d. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Review of Resident #24 physician's order dated 3/6/2025, revealed Simethicone 125 mg by mouth before meals and at bedtime for heartburn and indigestion; Tamsulosin Hydrochloride (HCL) 0.4 mg, 2 capsules at bedtime for an enlarged prostate; Risperdal 1 mg at bedtime related to Schizophrenia; Gabapentin 600 mg, give 1 tablet three times a day for polyarthritis (arthritis in five or more joints simultaneously); Clonazepam 1 mg, 1.5 tablets at bedtime related to Generalized Anxiety Disorder; and Mesalamine Rectal Suppository, 1000 mg at bedtime related to Constipation. Review of the Medication Admin Audit Report for Resident #24 dated 3/14/2025-3/16/2025, revealed the following medications were scheduled for 3/14/2025 at 9:00 PM, and were documented as administered on 3/15/2025 at 12:01 AM, 3 hours late: Simethicone 125 mg Tamsulosin HCL 0.4 mg Risperdal 1 mg Gabapentin 600 mg, Clonazepam 1 mg Mesalamine Rectal Suppository 1000 mg. e. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses including Dementia, Diabetes, Bipolar Disorder, Schizophrenia, Insomnia, Osteoarthritis, and Depression. Review of the Resident #38's physician's orders dated 3/6/2025, revealed Acetaminophen 650 mg, 2 tablets by mouth three times a day; Gabapentin 800 mg, three times a day; Ziprasidone (medication to treat psychosis) 20 mg at bedtime; Ziprasidone 80 MG at bedtime; Lamictal (a medication to treat seizures and bipolar disorder) 100 MG at bedtime. Review of the Medication Admin Audit Report for Resident #38 dated 3/15/2025, revealed the following: Acetaminophen 650 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 1:44 AM, 3 hours and 44 minutes late. Lamictal 200 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:13 AM, 4 hours and 13 minutes hours late. Gabapentin 800 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:14 AM, 4 hours and 14 minutes hours late. Ziprasidone 20 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:16 AM, 4 hours and 16 minutes hours late Ziprasidone 80 mg scheduled at 9:00 PM was documented as administered on 3/16/2025 at 2:16 AM, 4 hours and 16 minutes hours late. Observation and interview on 3/17/2025 at 12:20 PM, revealed Resident #38 sitting in her wheelchair in her room and the Resident stated, .didn ' t get our meds last night till 2:30 the next morning .agency nurse she didn't know what she was doing . During an interview on 3/26/2025 at 3:38 PM, the DON acknowledged the facility was having issues with medications being administered as ordered. The DON stated, .it's [medication administration] being spotty and we ' re trying to get every agency person in here for additional training .the ones who are not performing, I'm not letting them come back. The DON was asked would you say staff are following the instructions and the in-services provided following the drug diversion (in October 2024) and signing out narcotics when administered. The DON stated, No. I went as far as demonstrating when you pull your pills, I walked them through each step of administration . The DON was asked would you say this is not an education issue because the staff were educated, but rather this is a staff performance issue. The DON stated, Yes, ma'am and I walk around and say be sure you're signing as soon as it [[NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, Pharmacy Services Agreement, Law Enforcement Investigation, facility investigation, medication reconciliation document review, medical record review, facility document review, observation, and interview, the facility failed to have a system of recording, accurate reconciliation, and accounting for all controlled medication, failed to promptly identify diversion of controlled substances, failed to provide medications according to physician orders and per facility policy, and failed to ensure controlled substances were in date and no discrepancies were identified for 31 of 57 (Residents #6, 7, 8, 9, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 38, 41, and 42) sampled residents reviewed for controlled substance reconciliation, drug diversion, and medication administration. The findings include: 1. Review of the Pharmacy Services Overview Policy, revised [DATE], revealed, .the facility shall accurately and safely provide or obtain pharmacological services, including the provision of routine and emergency medications .Policy interpretation and implementation .Pharmaceutical services consist of .a. the process of receiving and interpreting prescribers' orders; acquiring, receiving, storing, controlling, reconciling, compounding, dispensing, packaging, labeling, distributing, administering, monitoring responses to, using and or disposing of all medications .b. the provision of medication- related information to health care professionals and residents .c. the process of identifying, evaluating and addressing medication - related issues including the prevention and reporting of medication errors .d. The provision, monitoring and/or the use of medication-related devices .Pharmacy services are available to residents 24 hours a day, seven days a week .Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner .Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting pharmacy if a resident's medication is not available for administration .Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice .The consultant pharmacist, in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services including (but not limited to) .acquisition and availability of medications .receipt, labeling and storage of medications .reconciliation of medications from the pharmacy .control of medications from point of receipt to secured storage areas .facility staff roles and responsibilities during the receipt and storage of medication .administration of medications, disposition of medications . Review of the facility policy titled, Medication Ordering and Receiving From Pharmacy Provider Emergency .Emergency Kits (E-Kits), dated 1/2024, revealed .Emergency pharmaceutical service is available on a 24-hour basis. Emergency needs for medication are met by using the nursing care center ' s approved emergency medication supply or by special order from the provider pharmacy. Emergency medications and supplies are provided by the pharmacy in compliance with applicable state and federal regulations .The provider pharmacy supplies emergency or stat [immediate or urgent] medications/items according to the provider pharmacy agreement. Emergency medications and supplies are .checked periodically for integrity and dating and stored in accordance with .federal regulations .When an emergency or stat medication is needed, the nurse first verifies and reviews the prescriber's orders for appropriateness, checks the resident ' s allergies, and removes the required non-controlled medication from the emergency kit .Upon removal of any medication or supply item from the emergency kit, the nurse documents the medication .used on an emergency kit log .One copy of this information should be immediately faxed to the pharmacy or placed within the resealed emergency kit until it is scheduled for exchange .Items to be documented on the log include .Resident's name .Medication name, strength and quantity .Date and time of medication removal .Prescriber's name .Date and time pharmacy notified .Signature of nurse removing and administering dose .The nursing staff, consultant pharmacist and provider pharmacy designee checks the emergency kits regularly for expiration dating of the contents. The date of expiration is noted on the outside of the kit .If hard copy Prescriber signed prescription is available .Nurse will contact pharmacist to communicate need to access E-kit .Nurse will fax hard copy prescription to pharmacist .Once the pharmacist confirms receipt of a valid prescription, the pharmacist will contact facility nurse to communicate .Authorization to access emergency kit .Specific prescription details .Number of authorized entries to E-kit .Number of doses per entry to E-kit . Review of the facility policy titled, Controlled Substances, revised 4/2019, revealed .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications . Review of the facility policy titled, Pharmacy Services, reviewed 11/2022, DISCARDING AND DESTROYING MEDICATIONS .medications will be disposed of in accordance with federal, state and local regulations governing management of .controlled substances .All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of .Schedule V (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines .Schedule II .and IV (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines .If a resident is transferred to another facility, or dies while he or she is in lawful possession of controlled substance(s) by depositing in the authorized on-site collection receptacle .must take place immediately (no longer than three days after discontinuation of use by the resident .Completed medication disposal records shall be kept on file in the facility for at least two (2) years, or as mandated by state law governing the retention and storage of such records . Review of the facility policy titled, Administration of Drugs, dated 4/2022, revealed .Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's [facility's] Medical Director .Drugs may not be set up in advance and must be administered within one (1) hour before or after their prescribed time .Unless otherwise specified by the resident's attending physician, routine drugs should be administered as scheduled .The nurse administering the drug must record such information on the residents eMAR [electronic Medication Administration Record] .The nurse administering the drugs must electronically sign the resident's eMAR immediately after administration . Review of the facility policy titled, Person-Centered Medication Administration Schedule, revised [DATE], revealed .Medications shall be administered according to established durations to allow for a more relaxed, person-centered schedule . Review of the PHARMACY SERVICES AGREEMENT, dated and signed on [DATE], revealed Pharmacy Services Agreement .is made between Pharmacy Corporation of America .and [Named Facility Management Company] .The parties agree as follows .Pharmacy shall provide services set forth in this Agreement to Client and persons in care of the Customer (the Residents .) in accordance with terms and conditions of this Agreement, and any Schedules .or policies and procedures of the Manual .which are incorporated into this agreement .3. OBLIGATIONS OF THE PHARMACY .Pharmacy shall provide to Client and deliver to the Customer prescription and non-prescription drugs, biologicals .and Services as set forth in this Agreement, in accordance with the orders of the Residents ' licensed prescribers as provided to the Pharmacy by Customer, and the Customer ' s own orders .B. Pharmacy shall provide, maintain and replenish emergency drug supply kits (the Emergency Kits) as permitted by Applicable Law .F. The parties anticipate that Customer shall use best efforts to provide Medications to Resident at time of discharge or return Products to Pharmacy. Pharmacy shall manage Product returns in accordance with its then current return policy as specified in the Manual .4. Obligations of the Client [facility] .Comply with .Drug Enforcement Agency (DEA) requirements relating to the submission of prescriptions for controlled substances, including, but not limited to, promptly providing Pharmacy with copies of prescriptions for Medications .properly execute physician prescription for all controlled substance Medication orders .Document usage of Emergency Kits .H. Store and handle all medications in accordance with Applicable Law .Nurse Consulting Services .[Named Pharmacy Company] employs a Nurse Consulting Services organization intended to satisfy specific service needs of the Customer .employs qualified pharmacy technicians and nurses who upon request can be called upon to perform the following .Perform medication cart audits .check of all Medications for .date opened and expiration dates .removal of all discontinued Medications .Perform a Narcotics Review with documentation review for the protection of facility staff and residents .Perform a Root Cause Analysis to determine process gaps and provide written solutions for both Pharmacy and Client Issues . 2. Review of the Law Enforcement investigation dated [DATE], revealed Investigator #1 conducted a traffic stop of Licensed Practical Nurse (LPN) M for a window tint violation on [DATE]. LPN M was found with miscellaneous pills in the floorboard of her car and a probable cause search warrant was conducted of the vehicle. Investigators found multiple pill blister packs (a card of medication with the pills showing in clear windows on the front and the ability to pop the pills out on the back of the card) of non-scheduled and scheduled prescription medications containing names of different people. [Named LPN M] advised on scene that the prescription pill blister packets were from deceased patients that she had worked with .advised that she worked with patients at a long term care facility. Some of the prescription pill blister packets dated back to the year 2020. Also located inside of [Named LPN M] vehicle was a green cloth bag that contained over 15 small plastic baggies containing non scheduled prescription drugs and scheduled prescription drugs all packaged separately for resale, the schedule drugs ranged from Schedule II Morphine and Hydrocodone, Schedule IV Lorazepam to Xanax and Schedule V Gabapentin and Pregabalinand [Pregabalin] . Continued review of the Law Enforcement Investigation revealed LPN M ' s home was also searched and Investigators found a total of 704.5 pills in her car and 1,225 pills in her home for a total of 1,929.5 pills seized by authorities. LPN M was taken into custody and formally charged with Unlawful Window Tint, Unlawful Possession without Prescription, and Possess Controlled Substance with Intent to Manufacture, Deliver, or Sell Controlled Substance for Schedule II (3 counts), Schedule IV (4 counts), and Schedule V (3 counts) drugs. 3. Review of the facility investigation revealed the facility was provided a list of 109 residents' names affected by the drug diversion of LPN M on [DATE]. Review of a typewritten statement by the Administrator dated [DATE], revealed she was notified on [DATE] that (LPN M) was detained on drug charges. On [DATE], the Drug Enforcement Agency (DEA) served the facility with a search warrant on the drug diversion. The residents identified were discharged , deceased , or the medications were expired .No adverse effects have been identified .I [Administrator] had no prior knowledge of any incidents regarding the missing medications .The investigation concluded that (LPN M) removed various types of medications from the facility .The employee was termed on [DATE], due to employee failing to return to work .The root cause is the drug destruction process was not followed properly by the nurse . Review of the typewritten statement by the Director of Nursing (DON) signed and dated [DATE], revealed the DON was notified on [DATE] by the day shift nurse on A Hall that the Unit Manager (LPN M) would be late because of a traffic stop. After an hour had passed LPN M had still not arrived at work. The DON made multiple attempts through the night to reach LPN M by phone without success. The DON and the Administrator met with 2 investigators from the District Attorney's Office of Drug Enforcement in the facility lobby on [DATE] and were notified that LPN M was in custody for drug related charges, she had narcotics (controlled substances) from the facility and narcotic tracking sheets with residents' information, in addition to miscellaneous (non-scheduled) medications. The DON and the Administrator met with DA Drug Enforcement, DEA, and the [Named City where facility was located] Police Department at different times.Because all evidence is in the possession of law Enforcement I [DON] was unable to perform a thorough investigation. However, I do know I delegated to [Named LPN M] to assist with pulling of narcotics from the medication carts for destruction. She was part of a trusted management team. I am unaware exactly how she accomplished this without my knowledge. Upon becoming aware of the situation narcotic audits were completed, reviewed policies and procedures with nursing staff and conducted interviews. The Narcotic audits did not find any discrepancies . 4a. Review of the medical records revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dependence on Renal Dialysis, Hypothyroidism, Anxiety, Bipolar Disorder, and Insomnia. Review of the physician orders for Resident #13 dated [DATE], revealed Tizanidine Hydrochloride (HCL) (a muscle relaxer, non-scheduled medication) 2 mg was ordered four times a day. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #13's pill blister pack of Tizanidine HCL 2 mg, card 1 of 4, dated [DATE] was found in LPN M's possession. There were zero (0) of 60 Tizanidine tablets remaining in the blister pack. Continued review revealed Resident #13's blister pill pack for Tizanidine HCL 2 mg, card 2 of 4, dated [DATE] was found in LPN M's possession. There were 7 of 60 Tizanidine tablets remaining in the blister pack. b. Review of the closed medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dependence on Renal Dialysis, Hypothyroidism, Anxiety, Bipolar Disorder, and Insomnia. Review of the physician orders for Resident #14 dated [DATE], revealed Ativan (Lorazepam - a medication for anxiety) 0.5 mg was ordered every 12 hours as needed (PRN) for anxiety and agitation and Percocet (medication for pain) 5-325 mg was ordered mouth two times a day every 6 hours as needed for pain and two times a day for pain. Review of the physician orders for Resident #14 dated [DATE], revealed Gabapentin (medication for seizures and nerve pain) 100 mg was ordered two times a day for diabetic neuropathy. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #14's blister pill pack of Lorazepam 0.5 mg, a Schedule IV controlled substance dated [DATE] was found in LPN M's possession. There were 0 of 50 Lorazepam tablets remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #14's blister pill pack of Percocet (Oxycodone-Acetaminophen) 5-325 mg, a Schedule II controlled substance, dated [DATE] was found in LPN M's possession. There were 0 of 60 Percocet tablets remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #14's blister pill pack of Percocet 5-325 mg a Schedule II controlled substance dated [DATE] was found in LPN M's possession. There were 0 of 60 Percocet tablets remaining in the blister pack. c. Review of the closed medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Bipolar Disease, Anxiety and Insomnia Review of the physician's orders for Resident #15 dated [DATE], revealed Gabapentin 100 mg was ordered three times a day for neuropathy (weakness, numbness, and pain from nerve damage and pain), Diazepam 5 mg was ordered every 12 hours as needed for anxiety for 14 days, and Hydrocodone-Acetaminophen 10-325 mg was ordered every 6 hours as needed for pain for 14 days. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #15's blister pill pack of Hydrocodone-Acetaminophen 10-325 mg, a Schedule II controlled substance, dated [DATE] was found in LPN M's possession. There were 0 of 12 Hydrocodone-Acetaminophen tablets remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #15's blister pill pack of Diazepam 5 mg, a Schedule IV controlled substance, dated [DATE] was found in LPN M's possession. There were 0 of 12 Diazepam tablets remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #15's blister pill pack of Gabapentin 100 mg, a Schedule V controlled substance, dated [DATE] was found in LPN M's possession. There were 45 of 45 Gabapentin capsules remaining in the blister pack. d. Review of the closed medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including Diabetes, Chronic Pain Syndrome, and Anxiety. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #18's blister pill pack of Alprazolam 0.25 mg, a Schedule IV controlled substance, dated [DATE] was found in LPN M's possession. There were 0 of 60 remaining in the blister pack. Review of the physician orders for Resident #18 dated [DATE], revealed Alprazolam (medication used to treat anxiety/depression) 0.5 mg was ordered by mouth three times a day. e. Review of the closed medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Prosthesis, Depression, Osteoarthritis, and Anxiety. Review of the physician orders from a Rehab Hospital for Resident #19 dated [DATE], revealed Norco 7.5-325 mg (Hydrocodone) was ordered every 6 hours as needed for pain (pain scale 4-10). Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #19's blister pill pack of Hydrocodone-Acetaminophen 7.5/325 mg, a Schedule II controlled substance, with date not visible, was found in LPN M's possession. There were 4 of 12 Hydrocodone-Acetaminophen tablets remaining in the blister pack. f. Review of the closed medical record revealed Resident #20 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Sepsis, Diabetes, Hypothyroidism, Anxiety, Insomnia. Review of the physician's order for Resident #20 dated [DATE], revealed two capsules of Gabapentin 300 mg (for a total of 600 mg) were ordered three times a day for neuropathy. The order was discontinued [DATE]. Review of the physician's order for Resident #20 dated [DATE], revealed Gabapentin 100 MG three times a day. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #20's Gabapentin 600 mg, a Schedule V controlled substance, card 1 of 6, dated [DATE], was found in LPN M's possession. There were 0 of 30 Gabapentin capsules remaining in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #20 ' s Gabapentin 600 mg, a Schedule V controlled substance, card 2 of 6, dated [DATE], was found in LPN M's possession. 50 of 60 Gabapentin capsules remained in the blister pack. g. Review of the closed medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses including Anxiety, Chronic Obstructive, Depression and Muscle Weakness. Review of the physician orders for Resident #21 dated [DATE], revealed Lorazepam 0.5 mg was ordered every 8 hours as needed for anxiety for 14 days. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #21's blister pack for Lorazepam 0.5 mg, a Schedule IV controlled substance, dated [DATE], was found in LPN M's possession. There were 0 of 20 Lorazepam tablets remaining in the blister pack. h. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dementia, Anxiety, and Chronic Kidney Disease Stage 4. Review of the physician orders for Resident #22 dated [DATE], revealed Clonazepam 0.5 mg was ordered every 24 hours for anxiety. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #22's blister pack for Clonazepam 0.5 mg, a Schedule IV controlled substance, dated [DATE], was found in LPN M's possession. There were 0 of 14 Clonazepam tablets remaining in the blister pack. i. Review of the closed medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Acquired Absence of Right Leg Above Knee (above the knee amputation), Anxiety, Personal History of Malignant Neoplasm of Uterus, and Diabetes. Review of the physician's orders dated [DATE], revealed Ativan (Lorazepam medication given for anxiety) 0.5 mg was ordered 3 times every week on Monday, Wednesday, and Friday for anxiety disorder. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #23' s blister pack for Lorazepam 0.5 mg, a Schedule IV controlled substance, dated [DATE], was found in LPN M's possession. 0 of 12 Lorazepam tablets remained in the blister pack. j. Review of the closed medical records revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Diabetes, Cirrhosis of Liver, Anxiety, Insomnia, and Gout. Review of the physician orders for Resident #25 dated [DATE], revealed Gabapentin 300 mg was ordered two times a day for seizures. Review of the Law Enforcement investigation of the drug diversion by LPN M, revealed Resident #25's blister pack for Gabapentin 300 mg, a Schedule IV controlled substance, dated [DATE], was found in LPN M's possession. 2 of 30 Gabapentin capsules remained in the blister pack. Review of the physician s order for Resident #25 dated [DATE], revealed Alprazolam 0.5 mg was ordered every 8 hours as needed for anxious behavior. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #25's blister pack for Alprazolam 0.5 mg, a Schedule IV controlled substance, dated [DATE], was found in LPN M's possession. 0 of 28 Lorazepam tablets remained in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #25's blister pack for Alprazolam 0.5 mg, a Schedule IV controlled substance, dated [DATE], was found in LPN M's possession. 0 of 42 Lorazepam tablets remained in the blister pack. k. Review of the closed medical records revealed Resident #26 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Depression, Dementia, and Senile Degeneration of Brain. Review of the physician's order for Resident #26 dated [DATE], revealed Lorazepam 0.5 mg was ordered four times a day for seizures. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #26's blister pack for Lorazepam 0.5 mg, a Schedule IV controlled substance, dated [DATE], was found in LPN M's possession. 0 of 30 Lorazepam tablets remained in the blister pack. l. Review of the medical records revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Diabetes, Cellulitis Right Lower Limb, and Cellulitis of Left Lower Limb. Review of the physician's order for Resident #28 dated [DATE], revealed Tramadol (opioid medication given for pain) 50 mg was ordered every 6 hours PRN for pain. Review of the Medication Administration Record (MAR) dated [DATE]-[DATE], revealed Resident #28 received five doses of Doxycycline (a medication given to treat bacterial infections) 100 mg. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #28's blister pack for Doxycycline 100 mg, dated [DATE], was found in LPN M ' s possession. 9 of 14 Doxycycline remained in the blister pack. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #28's blister pack for Tramadol 50 mg, a Schedule IV controlled substance, date [DATE], was found in LPN M's possession. 50 of 60 Tramadol tablets remained in the blister pack. m. Review of the closed medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Fracture of Left Femur, Dementia, Anxiety, and Dementia. Review of the physician's order for Resident #30 dated [DATE], revealed Lorazepam 0.5 mg was ordered every 12 hours as needed for agitation and anxious behavior for 2 days. Review of the Law Enforcement investigation of the drug diversion by LPN M revealed Resident #30's blister pack for Lorazepam 0.5 mg, a Schedule IV controlled substance, dated [DATE], was found in LPN M's possession. 0 of 4 Lorazepam tablets remained in the blister pack. 5. During an interview on [DATE] at 9:55 AM, the Director of Nursing (DON) stated, Our investigation was limited with having enough paperwork .I would have to say, yeah, she [LPN M] did [divert residents' medications] .they brought in some sheets and I reviewed them .they were all deceased residents .she [LPN M] was delegated with removing narcotics from the cart .they [residents] would expire, she took the narcotic sheet and the narcotic and I don ' t know how she was able to do it without getting caught .I was floored, devasted and angry .there was no hint of anything. The DON stated, .I delegated to a criminal unknowingly. During an observation and interview at the [Named County] Sheriff's Department on [DATE] 9:30 AM, Investigator #1 provided the Law Enforcement investigation of the drug diversion by LPN M. Investigator #1 stated that while he was talking to (Named LPN M) she told him she was on her way to work at the facility where she was a charge nurse, he observed loose pills in the floorboard of the LPN's car and initiated a search warrant, which revealed Scheduled and non-scheduled pill blister packs, some bottles of liquid medication with resident's names on them, and the Controlled Drug (substance) Record form for several residents during the search. Continued interview revealed investigators also found a bluish-green handbag inside her (LPN M's) purse with several little baggies which contained various medications, that appeared to be ready for resale. LPN M was arrested and taken into custody at that time. Investigator #1 stated a search of LPN M's home was initiated, which also revealed many more Scheduled and non-scheduled medications with names of residents from the facility. 6a. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-dominant side, Vascular Dementia, Epilepsy, Depressive Disorder, Anxiety Disorder, Mood Disorder, Pseudobulbar Effect, and Psychotic Disorder with Delusions. Review of the Medication Administration Audit Report for Resident #7 dated [DATE], revealed Lacosamide (medication to control seizures) Oral Tablet 50 mg was administered to Resident #7 at 9:07 AM. Observation and interview at the B Hall medication cart on [DATE] beginning at 11:31 AM, with LPN C, revealed the CONTROLLED DRUG RECORD for Resident #7 dated 21/ (the date was not correctly filled out), revealed 7 tablets of Lacosamide were present. Review of the Lacosamide medication card for Resident #7 revealed 6 Lacosamide tablets were present, a discrepancy of 1 tablet. LPN C confirmed the discrepancy. Review of the Alprazolam medication card for Resident #7 revealed 32 Alprazolam tablets were present, a discrepancy of 1 tablet. LPN C confirmed the discrepancy. b. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Nondisplaced Intertrochanteric Fracture of Right Femur, Osteoporosis, Falls, Dementia, and Anxiety Disorder. Review of a physician's order dated [DATE], revealed an order for Percocet (Oxycodone-Acetaminophen) 5-325 mg, give 1 tablet by mouth one time a day. Observation and interview at the B Hall medication cart on [DATE] beginning at 11:31 AM, with LPN C, revealed the CONTROLLED DRUG RECORD for Resident #8 dated [DATE], revealed 29 tablets of Oxycodone-Acetaminophen 5-325 mg were present. Review of the medication card for Resident #8's Oxycodone-Acetaminophen, revealed 28 Oxycodone-Acetaminophen tablets were present, a discrepancy of 1 tablet. LPN C confirmed the discrepancy. c. Review of the medical records revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dependence on Renal Dialysis, Hypothyroidism, Anxiety, Bipolar Disorder, and Insomnia. Review of the physician s order for Resident #13 dated [DATE], revealed Norco (Hydrocodone-Acetaminophen) 7.5-325 mg, give 1 tablet by mouth 4 times a day. Observation and interview at the B Hall medication cart on [DATE] beginning at 11:31 AM, with LPN C, revealed the CONTROLLED DRUG RECORD for Resident #13 dated [DATE], revealed 10 Hydrocodone-Acetaminophen 7.5-325 mg tablets were present. Review of the Hydrocodone-Acetaminophen medication card for Resident #13 revealed 9 Hydrocodone-Acetaminophen tablets were present, a discrepancy of 1 tablet. LPN C confirmed the discrepancy. d. Review of the medical records revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Diabetes, Dementia, Anxiety, and Chronic Kidney Disease Stage 4. Review of the physician's order for Resident #22 dated [DATE], revealed Lorazepam 0.5 mg, give 1 tablet by mouth two times a day for anxiety. Observation and interview at the B Hall medication cart on [DATE] beginning at 11:31 AM, with LPN C, revealed the CONTROLLED DRUG RECORD for Resident #22 dated [DATE], revealed 18 Lorazepam 0.5 mg tablets were present. Review of the Lorazepam medication card for Resident #22 revealed 17 Lorazepam tablets were present, a discrepancy of 1 tablet. LPN C confirmed the discrepancy. e. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Traumatic Spinal Cord Dysfunction, Quadriplegia, Anxiety, and Depression. Review of the physician's order for Resident #27 dated [DATE], revealed an order for Hydrocodone-Acetaminophen 5-325 mg by mouth every 6 hours as needed for pain. [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to implement a comprehensive care plan for 2 of 18 (Resident #21 and #70) sampled residents reviewed for care planning. The findings include: 1. Review of the facility's policy titled, CARE PLAN POLICY ., dated 10/25/2022, revealed .Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .facility must provide the resident .a written summary of the baseline care plan by the completion of the comprehensive care plan .summary must include .summary of the resident's medications . 2. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses of Hemiplegia and Hemiparesis, Cerebrovascular Disease, Gastrostomy, Pneumonia, Diabetes, End Stage Renal Disease, and Dysphagia. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Resident #21 required moderate assistance for activities of daily living (ADLs), received dialysis [process that removes waste products and excess fluid from the blood], received antiplatelets [used to treat and prevent blood clots], and insulin [medication to lower blood glucose]. Review of the Medication Administration Record (MAR) dated 2/1/2024- 2/29/2024, revealed Heparin Sodium [blood thinner] .5000 UNIT/0.5 ML [milliliter] .Inject 5000 unit subcutaneously two times a day . The MAR revealed the Heparin was administered on 2/26/2024 through 2/29/2024. Review of the Care Plan dated 2/20/2024, revealed the medications, including Heparin, used for a blood thinner, were not included in the care plan. 3. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE], with diagnoses of Multiple Fractures of Ribs, Right Tibia, and Compression Fracture of T11-T12 Vertebra, Anxiety, and Urinary Retention. Review of the admission MDS dated [DATE], revealed Resident #70 had a BIMS score of 15, which indicated she was cognitively intact. Medications received included antianxiety, antidepressant, anticoagulant, and opioid. Review of the Physician Order dated 2/15/2024 revealed DULoxetine HCl [antidepressant medication] Oral Capsule Delayed Release Particles 60 MG [milligram] [Duloxetine] .Give 1 capsule by mouth one time a day related to ANXIETY DISORDER . Review of the Physician Order dated 2/1/2024 revealed oxyCODONE HCl [pain medication] Oral Tablet 5 MG [Oxycodone] *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for Pain. Review of the Physician Order dated 2/15/2024 revealed busPIRone HCl [medication to treat anxiety] Oral Tablet 5 MG [Buspirone HCl] Give 1 tablet by mouth two times a day related to ANXIETY DISORDER . Rivaroxaban [medication to prevent blood clots] Oral Tablet 10 MG [Rivaroxaban] Give 1 tablet by mouth one time a day related to OTHER PRIMARY THROMBOPHILIA . Review of the Care Plan dated 2/26/2024, revealed the medications of Duloxetine, Oxycodone, Buspirone, and Rivaroxaban were not included in the care plan. During an interview on 3/7/2024 at 10:01 AM, the MDS Coordinator was asked should the comprehensive care plan include the current medications. The MDS Coordinator stated, Yes, they should . The MDS Coordinator was asked, do you see the medications on the care plan for Resident #70. MDS Coordinator stated, I don't . During an interview on 3/7/2024 at 11:15 AM, the Director of Nursing (DON) was asked should Heparin be documented on the care plan. The DON stated, Yes .

Based on policy review, observations, and interview, the facility failed to ensure food was handled, prepared, and served under sanitary conditions when 2 of 6 dietary staff (Dietary Aide #1 and Dietary Aide #3) failed to remove their gloves and perform hand hygiene after leaving the dirty side of the dishwasher and before removing clean dishes from the clean side of the dishwasher, when 1 of 6 dietary staff (Dietary Aide #2) failed to cover food when transporting food through the hallway, and when the facility failed to test the sanitizing solution level of the low temperature dishwasher daily. The facility had a census of 66 with 63 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility's undated policy titled, Policy: Cleaning of Dish Machine, revealed All flatware, servicing dishes, and cookware will be washed, rinsed, and sanitized after each use. Dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitation .The person loading dirty dishes should not handle the clean dishes unless they change their apron and wash their hands thoroughly before moving from dirty to clean dishes FOLLOW MANUFACTURES SPECIFICATIONS .Low Temperature Dishwasher Spray Type Dish Machines Using Chemicals to Sanitize .Wash Temperature 120 [degrees Fahrenheit] 50 PPM [Parts per Million] Hypochlorite . Review of the facility's undated policy titled GENERAL FOOD PREPARATION AND HANDLING, revealed .Prepared food will be transported to other areas in covered containers . 2. Observation in the Dining Room on 3/5/2024 from 11:20 AM to 11:30 AM, revealed Dietary Aide #2 transported uncovered metal pans of Salisbury Fried Steak, Puree Meat, and Puree Vegetables the dining room steam table to the kitchen to reheat. 3. Observation in the Dishwashing Area on 3/4/2024 at 1:03 PM, revealed Dietary Aide #1 failed to remove his gloves and perform hand hygiene after working on the dirty side of the dishwasher, then walked to the clean side of the dishwasher and removed clean dishes, picked up and stacked clean dishes while wearing the same dirty gloves. Observation in the Dishwashing Area on 3/7/2024 at 8:51 AM to 9:19 AM, revealed Dietary Aide #1 failed to remove his gloves and perform hand hygiene after dumping food from dirty dishes, and stacking dirty dishes from the dirty side of the dishwasher then he went to the clean side of the dishwasher, removed, and stacked clean dishes from the clean side of the dishwasher with the same dirty gloves. Observation in the Dishwashing Area on 3/7/2024 at 10:04 AM, Dietary Aide #1 failed to remove his gloves and perform hand hygiene after working on the dirty side of the dishwasher, then walked to the clean side of the dishwasher and removed clean dishes and stacked clean dishes, wearing the same dirty gloves. Observation in the Dishwashing Room on 3/7/2024 at 1:28 PM, revealed Dietary Aide #3 failed to remove his gloves and perform hand hygiene after working on the dirty side of the dishwasher, then walked to the clean side of the dishwasher and removed clean dishes and stacked clean dishes, wearing the same dirty gloves. 4. Review of the facility's Dish Machine Log dated 2/2024 and 3/2024, revealed there were no sanitizing chemical levels documented on the log. The facility failed to perform a daily test of the low temperature dishwasher's sanitizing chemical level. During an interview on 3/7/2024 at 9:41 AM, Dietary Aide #1 confirmed there is no documentation of the sanitizing solution level for the low temperature dishwashing machine. During an interview on 3/7/2024 at 11:36 AM, the Certified Dietary Manager (CDM) confirmed the facility's dishwasher is a low temperature dishwasher and the level of the sanitizing chemical for the low temperature dishwasher should be tested daily and documented on a log (a sheet of paper with results of findings). The CDM was asked to explain the process when the same person moves from working on the dirty side of the dishwasher to the clean side of the dishwasher. The CDM stated, .gloves off, wash hands, and new gloves to catch the clean plates or whatever it is .always change gloves once changing a task and always wash hands before putting on gloves . The CDM was asked to explain the process when transporting food from one area of the building to another area. The CDM stated, .all food has to be covered .debris floating in the air and hallway is unsanitized bacteria in the air can't see it [bacteria] but they [bacteria] are there or something could fall in it [food]. It [food] has to be wrapped . The CDM confirmed the facility had no documented test results of the sanitizing solution for the low temperature dishwasher. During an interview and observation on 3/7/2024 at 11:37 AM, revealed one bottle of chlorine sanitizing test strips were expired dated 2/2023 and two bottles were dated 6/2023. The CDM confirmed the chlorine sanitizing test strip were expired. During an interview on 3/7/2024 at 2:09 PM, the Service Representative from (Named Company) and the CDM was asked, per manufacturers recommendation, how often should the sanitizing solution for the low temperature dishwasher be tested to make sure it is at the correct range. The CDM stated, It [manufacturer recommendation] is on the dishwasher to test the sanitizing solution every day. The Service Representative stated, .Always want to make sure the sanitizer level is at correct level with a low temp dishwasher .It [sanitizing solution] is what sanitizes the dishes. During an interview on 3/7/2024 at 5:13 PM, the CDM confirmed there was no documentation of the sanitizer level for the dishwasher and it should have been on the Dish Machine Log sheet. The facility failed to ensure staff removed gloves and performed hand hygiene after working from the dirty side of the dishwasher and proceeded to the clean side of the dishwasher to work, failed to ensure food was covered during transport from one area of the facility to another area, and failed to ensure staff tested the dishwasher's sanitizing solution level daily.

Based on policy review, Nursing Home Licensure Checklist review, work schedules, and interview, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day 7 days a week. The findings include: Review of the facility's policy titled Payroll Based Journaling dated October 25, 2022 revealed, .Facility shall use the services of a Registered Professional nurse for at least 8 consecutive hours a day, 7 days a week .Facility shall permit the CCO [Chief Clinical Operations]/DON [Director of Nursing] to serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents . Review of the Nursing Home Licensure Checklist dated 2/11/2023 through 2/24/2023 revealed there were not 8 consecutive hours of RN services on the following dates and the average daily censuse was 66 residents: a. 2/14/2023 b. 2/21/2023 c. 2/24/2023 Review of the working schedule for February 2023 revealed there was not 8 consecutive hours of RN services on the following dates: a. 2/7/2023 b. 2/14/2023 c. 2/21/2023 d. 2/24/2023 During an interview on 2/28/2023 at 12:51 PM, the DON confirmed there was no Registered Nurse (RN) coverage for the dates listed above. The DON stated, I didn't have an RN on those days .Didn't have anyone that would fill the position. I'm supposed to have an RN for 8 consecutive hours a day; on those days I didn't . During an interview on 3/2/2023 at 1:20 PM, when asked if the facility provided 8 hours of RN coverage 7 days a week, the [NAME] President of Clinical Operations stated, I'm aware the RN coverage was not filled. We are aware an RN should provide coverage 8 consecutive hours and the DON hours do not count for the hours of coverage .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance related to nail care was provided for 1 of 3 sampled residents (Resident #1) reviewed for ADL care. The findings included: Review of the facility's policy titled, A.M. [morning] CARE dated 5/2018, with a review date of 11/2022, revealed .A.M. Care will be given to all residents daily .Assist to allowed position of comfort .Provide nail care . Review of the facility's policy titled, admission OF THE RESIDENT -LICENSED NURSE dated 11/28/2017, with a review date of 12/2022, revealed .When a resident is admitted to the facility all required information will be obtained to complete a comprehensive assessment and baseline of the resident .Establish lines of communication between the facility, the resident .Reconcile Physician Orders . Review of the facility's policy titled, NAIL CARE (FINGER AND TOE) dated 4/25/2018, with a review date of 11/15/2022, revealed .The purpose is to clean the nail bed, prevent infection and comfort the resident .Nail care includes daily cleaning and regular trimming. Stop and report any evidence of .infection, pain, or if nails are too hard or thick to cut .Wash hands .Explain .to the resident .Soak hands, Scrub nails gently .Trim nails .Report the condition of the resident's nails .Complaints or problems with hands .Pain .Any difficulty or complaints made by the resident related to the procedure . Review of the facility's policy titled, NOTIFICATION OF RESIDENT'S CHANGE OF CONDITION dated 9/1/2018, with a review date of 10/19/2021, revealed .This facility will promptly notify the resident .Physician and Responsible Party of changes .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician when there has been .Refusal of treatment or medications ( .(2) or more consecutive times [without breaks or gaps]) .the Nurse Supervisor/Charge Nurse will inform the resident, family, or responsible party of any changes in .medical care or nursing treatments . Review of the facility's policy titled, REQUESTING, REFUSING AND/OR DISCONTINUING CARE OF TREATMENT POLICY dated 11/28/2017, revealed .Residents have the right to request, refuse and/or discontinue treatment prescribed .as well as care routines outlined on the resident's assessment and plan of care .If a resident .refuses care or treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will meet with the resident to a. determine why .try to address the resident's concerns and discuss alternative options .discuss the potential .consequences .of the resident's decision .Detailed information relating to the .refusal .of care or treatment will be documented in the resident's medical record .shall include .date and time .treatment was attempted .type of treatment .reason for .refusal .That the resident was informed .purpose of .and potential outcome of not receiving .The resident's condition .date and time the practitioner was notified .response . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, Liver Disease (Cirrhosis of the Liver), Depression, Cerebral Infarction, Osteoarthritis, and Hypertension. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15 and required extensive assistance from staff for personal hygiene. Review of the quarterly MDS dated [DATE], revealed Resident #1 had moderately impaired cognition as indicated by a BIMS score of 8 and required limited assistance for personal hygiene. Review of the Care Plan dated 6/15/2021, and reviewed 11/29/2022, revealed .has an ADL Self Care Performance Deficit .Check nail length and clean on bath day and as necessary. Report any changes or necessity for trimming to the nurse . Review of the Physician's orders dated 5/5/2022, and discontinued on 12/20/2022, revealed .Dilute ¼ [one fourth] cup of white vinegar with 4 cups of water and have patient soak both hands for 15 minutes every Monday and Thursday. Nails are to be trimmed and /or filed every Thursday. Instruments are to be sanitized after each use .PLEASE DOCUMENT IF PATIENT REFUSES . Review of signed Physician orders dated 12/08/2022, revealed .All orders initiated between recerts [recertification] will continue until the next recert unless otherwise indicated .Next Review Date: 01/08/2023 . Review of the Medication Administration Record (MAR) dated 10/2022, revealed Resident #1 did not receive the ordered nail care 2 out of 9 scheduled days. The MAR was blank on 10/3/2022 and 10/27/2022. Review of the MAR dated 11/2022 revealed Resident #1 did not receive the ordered nailcare 8 out of 8 scheduled days on 11/3/2022, 11/7/2022, 11/10/2022, 11/14/2022, 11/17/2022, 11/21/2022, 11/24/2022, and 11/28/2022. Review of the MAR dated 12/2022, revealed Resident #1 did not receive the ordered nailcare 6 scheduled days on 12/1/2022, 12/5/2022, 12/8/2022, 12/12/2022, 12/15/2022, and 12/19/2022. Observation in Resident #1's room on 12/28/2022 at 11:48 PM, revealed Resident #1 had long, curved fingernails on both hands. Observation in resident's room on 12/29/2022 at 5:21 PM, revealed Resident #1 had long, curved fingernails with a thick tan-colored buildup underneath them. During an interview on 12/29/2022 at 6:17 PM, the Director of Nursing (DON) confirmed Resident #1 had long, curved fingernails on both hands with a buildup underneath them. The DON confirmed Resident #1's nails should be short and clean. During an interview on 12/29/2022 at 4:36 PM, the Administrator confirmed all residents' nails should be clean and trimmed; and if nurses cannot clean and trim a resident's fingernails, they should document in the resident's progress notes and notify the provider to see if the resident needs to be sent to a specialist. During an interview on 12/29/2022 at 5:26 PM, the DON confirmed the physician's order for Resident #1's fingernails to be soaked in vinegar and water two times per week and trimmed and/or filed once a week was not reconciled after Resident #1's return from the hospital on [DATE], and that the order should have continued after Resident #1's return from a 4 day stay at the hospital. The DON confirmed she had spoken with the provider, and the order should have continued. The DON confirmed it was the floor nurses' responsibility to follow the order to soak and cut Resident #1's nails on Mondays and Thursdays, any unsuccessful attempts should have been documented, and the provider should have been notified. The DON confirmed, If it is not documented it is not done. During a telephone Interview on 1/3/2023 at 12:23 PM, Licensed Practical Nurse (LPN #2) confirmed she provided care to Resident #1 from 12/25/2022 to 12/29/2022. LPN #2 confirmed she did not soak and trim Resident #1's fingernails from 12/25/2022 to 12/29/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to develop a comprehensive Care Plan for wandering and elopement for 2 of 5 (Resident #8 and #10) sampled residents reviewed for wandering. The findings include: 1. Review of the facility's policy titled, CARE PLAN, reviewed November 15, 2022, revealed .Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services and attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The plan of care will address the resident's status in triggered .areas . 2. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE], with diagnoses of Diabetes, Chronic Kidney Disease, Overactive Bladder, Hypertension and Anxiety Disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment and was not coded for wandering. Review of the Physician's Orders dated 12/16/2022, revealed .Monitor for exit seeking behaviors and location of resident r/t [related to] wandering . Review of the Elopement Assessments dated 12/6/2021, 3/6/2022, 5/25/2022, 8/25/2022, 9/7/2022 and 12/7/2022 revealed Resident #8 was at risk for elopement. Review of the care plan dated 12/5/2022 revealed no documentation related to Resident #8's wandering/elopement risk. 3. Review of the medical record, revealed Resident #10 was admitted to the facility on [DATE], with diagnoses of Diabetes, Dementia, Hypertension, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed Resident #10 had a BIMS score of 4, which indicated severe cognition impairment and was not coded for wandering. Review of the Physician's Orders dated 12/16/2022, revealed .Monitor for exit seeking behaviors and location of resident r/t wandering . Review of the Elopement Assessments dated 4/19/2022, 7/19/2022, 10/19/2022 and 12/13/2022 revealed Resident #10 was at risk for elopement. Review of the care plan dated 9/19/2022 revealed no documentation related to Resident #10's wandering/elopement risk. During an interview on 12/13/2022 at 4:10 PM, the Director of Nursing (DON) confirmed the residents at risk for wandering and elopement should be care planned for wandering and elopement risk. During an interview on 12/14/2022 at 9:09 AM, MDS Coordinator #1 confirmed Resident #8, and #10 should be care-planned for their wandering and elopement risks.

Based on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect when staff failed to provide privacy for 2 of 4 sampled residents (Resident #56 and #59) reviewed during wound care. The findings include: Review of the facility's policy titled, Abuse Prevention Policy, revised 3/1/2018, revealed .The facility staff will provide resident with personal care and services away from public view and provide clothing or draping to prevent unnecessary exposure of body parts . Observation in the resident's room on 4/25/2022 at 2:07 PM, revealed the Treatment Nurse assisted Resident #59 with personal care, a brief change, and a dressing change to the sacrum (the triangular bone in the lower back that forms part of the pelvis). The window blinds were left open and the privacy curtain was not pulled. The roommate attempted to enter the room before the dressing change was completed. During an interview on 4/25/2022 at 2:30 PM, the Treatment Nurse was asked if she should have closed the blinds. The Treatment Nurse stated, Yes, ma'am. The Treatment Nurse stated, .his roommate was not in the room, so I didn't need to [pull the privacy curtain] . During this treatment the roommate attempted to enter the room before the wound care was completed. The Treatment Nurse was asked if the privacy curtain should have been pulled. The Treatment Nurse stated, Yes, ma'am . Observation in the resident's room on 4/26/2022 at 11:10 AM, revealed Certified Nursing Assistant (CNA) #1 provided personal care after an incontinent episode for Resident #56, prior to the nurse performing wound care. The window blinds were opened and the privacy curtain was not pulled. During an interview on 4/26/2022 at 11:25 AM, CNA #1 was asked if she should have closed the blinds prior to providing personal care. CNA #1 stated, .I thought they were closed . During an interview on 4/26/2022 at 12:05 PM, the Director of Nursing (DON) was asked if the window blinds should be closed and the privacy curtain should be pulled prior to providing personal care or wound care. The DON stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide reasonable accommodations to meet the residents' needs for the use of a call light for 3 of 70 sampled residents (Resident #46, #57, and #69) reviewed. The findings include: Review of the facility's Call Light Policy, revised 10/2/2017, revealed .The purpose of the call light is to provide a system for the resident to call for assistance .Ensure that all residents (even those that are confused) have access to the call light .Report any defective call lights to charge nurse and the maintenance department immediately . Review of the medical record, revealed Resident #46 was admitted to the facility on [DATE] with diagnoses of Osteoarthritis, Chronic Obstructive Pulmonary Disease, Bipolar Disorder, Alzheimer's Disease, and Right Foot Drop. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive deficits, and required extensive assistance with her activities of daily living. Observations in the resident's room on 4/24/2022 at 9:05 AM and 2:51 PM, revealed Resident #46 lying in bed watching television. Her call light was observed on the floor behind her bed. Review of the medical record, revealed Resident #57 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis, Diabetes Mellitus, Pressure Ulcer of the Sacrum, and Glaucoma. Review of the 5-day MDS dated [DATE], revealed Resident #57 had a BIMS score of 14, which indicated she was cognitively intact, and required total dependence of bathing with one person assist. Observation in the resident's room on 4/25/2022 at 11:21 AM, revealed Resident #57 lying in bed and the call light hanging off the left side of the bed, out of the resident's reach. During an interview in the resident's room on 4/25/2022 at 11:23 AM, Licensed Practical Nurse (LPN) #1 was asked if Resident #57's call light was within reach. LPN #1 stated, .can't reach it [call light] way down there .we tell them [staff] not to do that [referring to the cord being wrapped around the siderail] . Review of the medical record, revealed Resident #69 was admitted to the facility on [DATE] with diagnoses of Stage 3 Kidney Disease, Depression, and Hypertension. Review of the annual MDS dated [DATE], revealed Resident #69 had a BIMS score of 7, which indicated he had severe cognitive deficits, and required limited assistance with most of his activities of daily living. Observation in the resident's room on 4/24/2022 at 11:04 AM, revealed Resident #69 lying in bed and his call light was not completely pushed into the receptacle. Resident #69 was asked to access his call light. The light on the receptacle did not light up and the light above the door outside the room in the hallway did not light up, indicating the call light had been accessed. During an interview on 4/24/2022 at 11:43 AM, Certified Nursing Assistant (CNA) #2 attempted to access the call light in Resident #69's room and confirmed Resident #69's call light did not work. During an interview on 4/24/2022 at 2:09 PM, the Maintenance Director confirmed he had not received a report the call light was not working. During an interview on 4/25/2022 at 11:45 AM, the Director of Nursing (DON) was asked if residents' call lights should be kept within the residents' reach. The DON stated, Yes . The DON confirmed all call lights should be functioning and within reach. During an interview on 4/26/2022 at 3:39 PM, the DON was asked what she expected the staff to do when a call light was not working. The DON stated, .She reports it to the nurse as soon as possible .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to perform complete neurological (neuro) checks for residents that had unwitnessed falls for 1 of 8 sampled residents (Resident #27) reviewed for falls. The findings include: Review of the facility's FALL PREVENTION PROTOCOL POLICY, with a revised date of 10/18/2021, revealed .Fall refers to unintentionally coming to a rest on the ground, floor, or other lower level .a fall without injury is still a fall .After an incident of a fall .Start Neuro checks if there is a suspected head injury or for an unwitnessed fall as per facility protocol .Standard of Practice sequence for Vital Signs and Neuro Checks .Every 15 minutes X [times] (1) hour .Every 30 minutes X (1) hour .Every 1-hour x (4) hours .Every 4 hours X (24) hours . Review of the medical record, revealed Resident #27 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Psychosis, and Left Leg Above Knee Amputation. Review of the Care Plan dated 6/25/2021, revealed .At risk for falls r/t [related to] (L) [left] hemiplegia [Paralysis of one side of the body] with (L) AKA [above knee amputation] .Resident resistive to interventions, knows how to use call light .call light in reach .impulsive .will self transfer with poor safety awareness . Review of the Incident Report dated 3/6/2022 at 4:00 PM, revealed .called to resident's room to assist resident after experiencing a fall .Resident stated that he was attempting to get his other shoe off the floor and went head first off the bed and hit his eyebrow on his bedside table .was assessed and assisted back into his wheelchair .Vitals were taken and neuro checks were initiated . Review of the Neurologic Focused Evaluation revealed neuro checks were initiated on 3/6/2022 at 4:00 PM, the second neuro check was performed 3 hours and 45 minutes later, at 7:45 PM, the third neuro check was performed 1 hour later at 10:45 PM, and the last neuro check was performed 2 hours and 45 minutes later at 12:45 AM. Review of the Incident Report dated 4/17/2022, revealed .notified by tx [treatment] nurse .that another resident [Resident #27] found on the floor. Resident stated 'I was trying to transfer to my chair to get someone to take me out to smoke, and somehow slid down to the floor' . Review of the Nurses' Notes dated 4/17/2022, revealed .14:00 [2:00 PM] .alerted that resident experienced an unwitnessed fall. No injuries noted. Neuro checks initiated . The facility was unable to provide documentation that neuro checks were performed every 15 minutes for 1 hour, every 30 minutes for 1 hour, every hour for 4 hours, and every 4 hours for 24 hours after the fall on 4/17/2022. During an interview on 4/26/2022 at 3:47 PM, the Director of Nursing (DON) confirmed neuro checks were not performed per facility protocol on both falls for Resident #27 on 3/6/2022 and 4/17/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to obtain orders for oxygen for 1 of 6 sampled residents (Resident #68) reviewed for oxygen. The findings include: Review of the facility's Oxygen Therapy Policy, revised on 11/2/2017, revealed .Oxygen therapy is to be used with a written order by a physician. A physician's order for O2 [oxygen] therapy is to contain liter flow per minute via [by way of] mask or cannula . Review of the medical record, revealed Resident #68 was admitted to the facility on [DATE] with diagnoses of Displaced Fracture of the Second Metatarsal Bone, Left Foot, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Anxiety and Hypertension. Review of the Order Summary Report dated 4/25/2022, revealed .CHANGE AND DATE ALL RESPIRATORY SUPPLIES AND TUBING WEEKLY . There was no order for oxygen therapy, for a flow rate, or frequency of oxygen. Review of the Medication Administration Record (MAR) dated 4/2022, revealed respiratory supplies and O2 tubing were documented as being changed on 4/7/2022, 4/14/2022 and 4/21/2022. Observation in the resident's room on 4/24/2022 at 9:23 AM and 2:41 PM, and on 4/25/2022 at 9:35 AM, revealed Resident #68 was receiving Oxygen at 4 liters per minute via bi-nasal cannula. During an interview on 4/25/2022 at 9:38 AM, Licensed Practical Nurse (LPN) #1 was asked if Resident #68 had an order for oxygen. LPN #1 stated, I don't see one, but I have seen it .It's supposed to be running at 2 [liters per minute] . During an interview on 4/26/2022 at 8:10 AM, the Director of Nursing confirmed Resident #68 did not have an order for oxygen.

Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, review of Employee and Essential Healthcare Personnel Screening Logs, Employee Schedules, assignment sheets, and interview, the facility failed to follow CDC infection control guidelines to ensure practices to prevent the potential spread of COVID-19 when 8 of 71 staff members (Dietary Aide #1, Dishwasher #1, [NAME] #1 and #2, Dietary Helper #1, the Assistant Dietary Manager, Housekeeper #1 and Physical Therapy Assistant (PTA) #1) failed to complete screenings for the detection of COVID-19 prior to working on 4 of 4 days (4/15/2022, 4/16/2022, 4/17/2022 and 4/19/2022) reviewed for screenings. This had the potential to affect the 70 residents residing in the facility. The findings include: Review of the CDC document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/2022, revealed .Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Establish a process to identify anyone entering the facility, regardless of their vaccination status .options could include (but are not limited to) : individual screening on arrival at the facility . Review of the facility's policy titled, Pandemic Event Emergency Procedure Coronavirus (COVID-19) Respiratory Disease Infection, revised 3/5/2020, revealed .All Employees-Screen all Employees by obtaining temperatures and assessing for coughing, and sore throat symptoms, chest discomfort or shortness of breath. If temperature is greater than 100 degrees Fahrenheit, and/or employee reports respiratory type symptoms the employee will not be allowed to start work . Review of the Employee and Essential Healthcare Personnel Screening Logs, Employee Schedules, and assignment sheets revealed the following employees worked on the following days and did not screen for signs and symptoms of COVID-19 prior to working: a. 4/15/2022 - Dietary Aide #1, Dishwasher #1, [NAME] #1 and Dietary Helper #1. b. 4/16/2022 - Dietary Aide #1, Dishwasher #1, Dietary Helper #1, [NAME] #2 and the Assistant Dietary Manager. c. 4/17/2022 - Dietary Helper #1 and Housekeeper #1. d. 4/19/2022 - PTA #1. During an interview on 4/26/2022 at 3:20 PM, the Receptionist confirmed Dietary Aide #1, Dishwasher #1, [NAME] #1 and #2, Dietary Helper #1, the Assistant Dietary Manager, Housekeeper #1 and PTA #1 did not screen prior to working their scheduled shift listed above, on 4/15/2022, 4/16/2022, 4/17/2022 and 4/19/2022. During an interview on 4/26/2022 at 6:02 PM, the Administrator confirmed staff should screen for signs and symptoms of COVID-19 prior to starting their shift.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a comprehensive care plan was developed for an indwelling urinary catheter for 1 of 21 sampled residents (Resident #53) reviewed. The findings include: Review of the facility's policy titled, CARE PLAN POLICY, revised 12/12/2017, showed that areas of concern will be addressed with specific person centered approaches to promote attainment or maintenance of goals. Review of Physician Orders dated 12/31/2020 showed an order to .Maintain .catheter R/T [related to] Urinary Retention .Change .catheter as needed Bulb 30 cc [cubic centimeter] Size 14F [French] as needed . Review of the medical record showed that there was no comprehensive care plan for an indwelling urinary catheter. Observation in the resident's room on 2/9/2020 at 9:53 AM, 11:53 AM, and 3:26 PM, 2/10/2020 at 7:56 AM and 5:47 PM, 2/11/2020 at 8:27 AM and 3:55 PM, and 2/12/2020 at 8:06 AM, showed Resident #53 was lying in his bed with an indwelling urinary catheter draining urine into a bed side drainage bag. During an interview conducted on 2/11/2020 at 1:48 PM, the Minimum Data Set (MDS) Coordinator confirmed the indwelling urinary catheter should have been on the comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Certified Nursing Assistant (CNA) job description, observation, and interview, the facility failed to ensure the availability of water at the bedside for 1 of 7 sampled residents (Resident #23) reviewed for nutrition. The findings include: Review of the Certified Nursing Assistant job description, showed, .Keep residents' water pitchers clean and filled with fresh water (on each shift), and within easy reach of the resident . Review of the medical record, showed Resident #23 was admitted to the facility on [DATE] with diagnoses of Dementia, Dysphasia, Retention of Urine, and Osteoarthritis. Observation in the resident's room on 2/9/2020 at 2:55 PM, showed Resident #23 was lying on the bed with a small cup of water on the overbed table out of her reach. Observation in the dining room on 2/10/2020 at 7:49 AM, showed Resident #23 seated in a wheelchair at a dining table drinking a cup of coffee. Observation in the resident's room on 2/10/2020 at 10:10 AM and 5:41 PM, and 2/11/2020 at 7:52 AM, showed there was no water pitcher or cup in her room. During an interview conducted on 2/11/2020 at 8:31 AM, CNA #1 confirmed there was no water pitcher or cup in Resident #23's room. During an interview conducted on 2/11/2020 at 10:43 AM, the Nurse Practitioner confirmed Resident #23 was not on a fluid restriction and stated, .she definitely needs a water pitcher .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a bedrail was maintained in good working order for 1 of 76 residents (Resident #1) reviewed with bedrails. The findings include: Review of the facility's policy titled, BED INSPECTION SAFETY POLICY, revised 9/21/2017, showed, .The Maintenance Department will conduct quarterly inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment or other safety hazards . Review of the Director of Maintenance job description, showed, .Ensure that supplies, equipment .are maintained to provide a safe and comfortable environment . Review of the medical record, showed Resident #1 had diagnoses of Dementia, Hallucinations, Cerebella Ataxia, and Autonomic Neuropathy. Observation in Resident#1's room on 2/9/2020 at 10:05 AM, 11:47 AM, and 2:25 PM, and on 2/10/2020 at 7:54 AM, 11:44 AM, and 2:50 PM, showed the upper right quarter bedrail was hanging on the bed by one screw with the rail lying on the floor. During an interview conducted on 2/11/2020 at 4:55 PM, the Director of Maintenance confirmed that the upper right quarter bedrail was broken. The Administrator confirmed Resident #1 should be in a different bed with properly functioning bedrails.

Based on policy review, observation, and interview, the facility failed to ensure pureed food was prepared and served under sanitary conditions as evidenced by an unclean deep fryer, ice build-up in freezers, carbon build-up on skillets, pureed foods not served at an appropriate temperature, no temperature logs for 1 of 2 nutrition freezers (A/B Nutrition Room), and a black substance in 1 of 3 ice machines (A/B Nutrition Room). The facility had a census of 75 residents with 75 of those residents receiving a tray from the kitchen. The findings include: Review of the facility's policy titled, Food: Preparation, dated 9/2017, showed, .The Cook(s) will prepare all cooked food items will be cooked to a minimum internal temperature for 15 seconds, as follows .ground meat-155 degrees .when hot pureed .food drop into the danger zone (below 135 degrees), the mechanically altered food must be reheated to 165 degrees for 15 seconds . Observation in the Kitchen on 2/9/2020 at 9:15 AM, showed the deep fryer with brown sediment floating on top of the grease. During an interview conducted on 2/9/2020 at 9:15 AM, the CDM confirmed the brown sediment floating on top of the grease in the deep fryer should not be there. Observation in the Kitchen on 2/9/2020 at 9:25 AM, showed ice build-up on all three chest freezers and one upright freezer. During an interview conducted on 2/12/2020 at 10:15 AM, the CDM and Regional CDM confirmed the freezers should have been cleaned. Observation in the Kitchen on 2/10/2020 at 11:15 AM, showed two large skillets with black thick carbon residue around the inside of the skillets. During an interview on 2/12/2020 at 11:15 AM, the CDM confirmed the black thick residue was carbon and should not be there. Observation in the Main Dining Room on 2/10/2020 at 12:00 PM, the [NAME] checked the temperature of the pureed meat and the temperature was 130 degrees. Three pureed trays had been served. During an interview conducted on 2/10/2020 at 12:00 PM, the Certified Dietary Manager (CDM) confirmed the pureed meat temperature was too low. Observation in the A/B Nutrition Room on 2/11/2020 at 4:00 PM, showed that there were no freezer temperatures documented and there was black residue inside the ice machine. During an interview conducted on 2/12/2020 at 10:15 AM, the CDM and Regional CDM confirmed the black residue should not be inside the ice machine. During an interview conducted on 2/12/2020 at 11:15 AM, the CDM and Regional CDM confirmed the freezer temperatures should have been documented.