Autumn Care Of Cornelius

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility failed to honor a resident's food preferences for 1 of 1 resident reviewed for food preferences (Resident #88).Findings included:Resident #88 was admitted to the facility 03/08/23.Review of Resident #88's physician orders revealed an order dated 05/31/24 for a low concentrated sugar diet (a diet that reduces or eliminates foods with high amounts of sugar).Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was cognitively intact, was able to make herself understood, and was able to understand others. Resident #88's nutrition care plan, last edited 06/23/25, revealed she had increased nutrition/hydration risks related in part to diabetes and interventions included monitoring her dietary intake and respecting/honoring resident dietary choices.The Dietary Manager (DM) was observed to interview Resident #88 on 07/21/25 at 1:04 PM. During the interview Resident #88 informed the DM that she was taught not to waste food and it was upsetting to her when she received food like oatmeal or grits that she knew she would not eat. The DM stated she understood that Resident #88 did not want to receive oatmeal or grits on her meal trays. An observation of Resident #88's meal tray ticket on 07/22/25 at 8:30 AM revealed she was documented to receive scrambled eggs, sausage patties, toast, cereal of choice, and a banana. Resident #88's meal tray ticket documented she was to receive double portions. There was no documentation on her meal tray ticket reflecting her dislikes. An observation of Resident #88's breakfast meal tray at the same date and time revealed she received a bowl of grits, a scoop of eggs, 2 pieces of sausage patties, 2 pieces of toast, and no banana. An interview with Resident #88 on 07/22/25 at 8:32 AM revealed she would like to have her banana as requested. She stated having fresh fruit for breakfast was important to her and receiving the grits on her tray was frustrating to her because she had informed the dietary department numerous times she did not like grits.An interview with the Dietary Manager (DM) on 07/24/25 at 10:41 AM revealed residents should receive all items listed on their tray ticket, and she expected resident preferences to be honored. She stated residents should not receive items they had asked not to receive. An interview with the Administrator on 07/24/25 at 3:30 PM revealed he expected residents to receive the food preferences they communicated to staff.

Based on observations, record review, and dietary staff, Registered Dietitian (RD), and Regional Registered Dietitian interviews, the facility failed to provide food items as specified by the approved menu. This practice had the potential to affect 11 residents receiving a regular diet and 2 residents receiving a puree diet (consisting of foods with a pudding-like texture) on 1 of 4 units (700/800 hall). Findings included:A review of the approved menu for residents receiving a regular diet on 07/23/25 revealed the following foods were on the menu: chili and beans, garden salad with dressing, cornbread, and carrot cake. Alternate food items for the lunch meal included mixed vegetables and noodles. A review of the approved menu for residents receiving a puree diet revealed the following foods were on the menu: chili and beans, steamed squash, puree bread, and carrot cake. a. An observation of Dietary Aide #1 on the 700/800 hall on 07/23/25 from 12:10 PM through 12:19 PM revealed he checked the temperature of the garden salad, and the temperature was 43 degrees Fahrenheit. Dietary Aide #1 placed the pan of salad on ice and re-checked the temperature, which was 46.8 degrees Fahrenheit. Dietary Aide #1 was instructed by the Regional Registered Dietitian to serve mixed vegetables instead of garden salad to residents receiving a regular diet since the garden salad did not reach the correct temperature.An observation of Dietary Aide #1 revealed he began plating food on 07/23/25 at 12:20 PM. Residents receiving a regular diet received chili and beans, mixed vegetables, cornbread, and carrot cake. On 07/23/25 at 12:50 PM Dietary Aide #1 ran out of mixed vegetables and began serving chili and beans, noodles, cornbread, and carrot cake to residents receiving a regular diet. Dietary Aide #1 did not ask the Registered Dietitian (RD) or the Regional Registered Dietitian before substituting noodles for mixed vegetables.An interview with Dietary Aide #1 on 07/23/25 at 1:05 PM revealed he frequently ran out of food on the tray line, and he would plate whatever food he had left on the serving line. He stated he did not notify his supervisor when he ran out of food and did not ask for guidance to provide a nutritionally equivalent substitute. An interview with the Regional Registered Dietitian on 07/24/25 at 1:21 PM revealed Dietary Aide #1 should have stopped the meal tray line for the lunch meal on 07/23/25 when he ran out of mixed vegetables, notified his supervisor, and waited until a nutritionally equivalent substitute was available before sending regular trays to residents. She stated noodles were not an appropriate substitution for mixed vegetables. An interview with the Administrator on 07/24/25 at 3:22 PM revealed Dietary Aide #1 should have waited until an appropriate substitute was available for the lunch meal on 07/23/25 instead of substituting noodles for mixed vegetables. b. An observation of the meal tray line on 07/23/25 at 12:20 PM revealed Dietary Aide #1 began plating the food. Residents on a puree diet did not receive puree bread or a substitute for bread. In an interview with the RD on 07/23/25 at 12:30 PM she confirmed no puree bread was available for the lunch meal on 07/23/25. She stated residents receiving a puree diet should receive the same food or an appropriate substitution as residents receiving any other diet texture. An interview with Dietary Aide #1 on 07/23/25 at 1:05 PM revealed he did not have puree bread or a substitute to serve residents receiving a puree diet on 07/23/25 and he did not notify his supervisor that the puree bread was unavailable. An interview with [NAME] #1 on 07/24/25 at 1:21 PM revealed she did make puree bread for the lunch meal on 07/23/25, but it did not get sent to the 700/800 hall. An interview with the Administrator on 07/24/25 at 3:22 PM revealed puree bread did not get sent to the 700/800 hall for the lunch meal on 07/23/25. He stated residents receiving a puree diet on 07/23/25 did not receive bread and they should have received bread per the menu.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to secure 3 bottles of medicated powder observed in a resident's room for 1 of 1 resident reviewed for medication storage (Resident #19).Findings included:Resident #19 was admitted to the facility 08/13/24 with diagnoses including obstructive uropathy (a condition that occurs when urine cannot drain out of the body) and macular degeneration (an eye disease that causes vision loss). The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was severely cognitively impaired and required partial/moderate assistance with bed to chair transfers. An observation of Resident #19's dresser on 07/21/25 at 3:10 PM revealed two 15 gram (gm) and one 60 gm bottles of Nystatin powder (antifungal medication) 100,000 units/gm sitting on top. Additional observations Of Resident #19's dresser on 07/22/25 at 1:55 PM, on 07/23/25 at 8:22 AM, on 07/24/25 at 8:42 AM, and on 07/25/25 at 10:32 AM revealed two 15 gm and one 60 gm bottles of Nystatin powder 100,000 units/gm sitting on top. An observation of Resident #19's dresser with Nurse #4 on 07/25/25 at 11:35 AM revealed two 15 gm and one 60 gm bottles of Nystatin powder 100,000 units/gm sitting on top. An interview with Nurse #7 on 07/25/25 at 11:35 AM revealed medicated powders should be stored in the treatment cart unless there was a physician's order to leave the medication in the resident's room. She stated she had not been all the way in Resident #19's room since beginning her shift at 7:00 AM on 07/25/25 and had not seen the bottles of medicated powder or she would have removed them. An interview with the Director of Nursing (DON) on 07/25/25 at 11:40 AM revealed Resident #19's medicated powder should have been stored in the treatment cart unless there was a physician's order to store the medication in the resident's room. The DON confirmed there was no physician order to leave Nystatin powder in Resident #19's room. An interview with the Administrator on 07/25/25 at 12:55 PM revealed he expected staff to follow the facility's policy for medication stored at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and Responsible Party and staff interviews, the facility failed to refund the balance of an expired resident's personal fund account within thirty days to the individual or probate jurisdiction administering the resident's estate (Resident #107) and failed to refund Social Security checks received after a resident transferred to another nursing facility (Resident #104) for 2 of 2 residents reviewed for personal funds.Findings included:1. Resident #107 was admitted to the facility on [DATE].A discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #107 passed away at the facility.The Resident Statement for Resident #107 with a billing date of [DATE] revealed a payment in the amount of $10,304.00 received on [DATE] was applied to room charges for the period [DATE] to [DATE] totaling $2,944.00 resulting in an overpayment in the amount of $7,360.00.Review of the refund requests for Resident #107 provided by the Business Office Manager on [DATE] at 1:00 PM revealed an initial request for a refund was submitted to the corporate office on [DATE] and a second refund request was submitted to the corporate office on [DATE].During a phone interview on [DATE] at 2:00 PM, Resident #107's Responsible Party (RP) revealed prior to Resident #107's passing, a payment was made to pay Resident #107's account in full. The RP explained after Resident #107 passed away, he had been corresponding frequently with the Business Office Manager to get a refund issued so that he would be able to close Resident #107's estate. The RP stated he wasn't sure why it took the facility 5 months to issue the refund but it was finally received approximately two weeks ago ([DATE]).During interviews on [DATE] at 2:30 PM and [DATE] at 1:00 PM, the Business Office Manager revealed Resident #107 passed away at the facility mid-month February 2025, however, resident accounts were not closed out until the following month to ensure there was no balance owed. If there was a refund due once the account was closed, she submitted a request to the corporate office to issue a refund that included the amount of the refund, name of the person to make the check payable to and the address to mail the refund. The Business Office Manger stated she was aware of the 30 day regulatory requirement for issuing refunds and explained it was hard to meet that requirement due to the facility's process of closing accounts the following month. The Business Office Manager stated one reason for the delay in issuing the refund was due to waiting on Resident #107's RP to send documentation that he was named as the executor of the estate which she received via email on [DATE]. She stated a refund check was then issued to Resident #107's RP. The Business Office Manager explained after receiving a call from Resident #107's RP on [DATE] stating he had not received the refund, she submitted a inquiry to the corporate office for a status. She discovered when the check was initially mailed to Resident #107's RP by the corporate office, it was sent to the incorrect address. She stated the refund was reissued and mailed to Resident #107's RP at the correct address on [DATE]. During interviews on [DATE] at 12:48 PM and 3:40 PM, the Administrator stated a refund should have been issued to Resident #107's RP within the 30 day regulatory timeframe following Resident #107's death. He explained with the facility's process on closing out resident accounts, it was difficult to get refunds processed timely. The Administrator stated a refund check was issued to Resident #107's RP and when it was discovered the refund was mailed to the wrong address, another refund check was reissued. 2. Resident #104 was admitted to the facility on [DATE].A discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 discharged to the community.The Resident Statement detail report for Resident #104 revealed checks were received from the Social Security Administration (SSA) on [DATE] in the amount of $2,094.00 and on [DATE] in the amount of $2,518.00. During a phone interview on [DATE] at 7:14 PM, Resident #104's Responsible Party (RP) revealed at her request, Resident #104 discharged from the facility on [DATE] to move out of state to an assisted living facility closer to her. The RP stated following Resident #107's discharge on [DATE], the facility received Resident #107's social security checks for [DATE] and [DATE]. The RP stated she contacted the SSA in both states and was told the money had not been returned. The RP explained Resident #104 owed a balance for [DATE] and [DATE] to the assisted living facility where she now resided and was fearful Resident #104 would be discharged due to non-payment since the facility had not refunded the money to SSA nor sent the refund to the assisted living facility.During an interview on [DATE] at 2:30 PM, the Business Office Manager revealed when Resident #104 first admitted to the facility (2021) she received a pension check in addition to her social security check. She explained Resident #104's social security check was sent directly to the facility but the pension check was not which resulted in her accumulating a balance owed at the facility. The Business Office Manager stated at one point she noticed that Resident #104's social security payments were short and when she called the SSA to inquire, she found out Resident #104's checks were being garnished due to back taxes. She stated she filled out a form to have the garnishment refunded which was applied to the balance Resident #104 owed at the facility. The Business Office Manager explained when Resident #104 discharged from the facility ([DATE]) the remaining amount of her [DATE] social security check was also applied to her balance owed. She explained on [DATE] a refund check was issued to Resident #104 in the amount of $2,254.62 for the remainder of the [DATE] social security check the facility received but still showed as outstanding (not cashed). The Business Office Manager explained she wasn't aware the facility had also received Resident #104's [DATE] social security check in the amount of $2,448.00 because a credit did not generate on her account due to the system automatically applying the payment to her balance owed. The Business Office Manager stated she submitted a request for an expedited refund in the amount of $2,448.00 that was being sent to Resident #104 at the assisted living facility she now resided and she would be contacting the corporate office to inquire about having the refund in the amount of $2,254.62 reissued and sent to Resident #104. During an interview on [DATE] at 1:00 PM, the Administrator stated they had overlooked the refund owed to Resident #104 and a refund should have been issued within the regulatory timeframe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 25 opportunities, resulting in a medication error rate of 12% for 3 of 5 residents observed during the medication administration (Resident #79, Resident #84 and Resident #26).The findings included:The manufacturer's instructions for a prefilled insulin pen indicated that priming the insulin pen each time was an important step to ensure there were no air bubbles in the insulin and the full dose of insulin was given. Priming the insulin pen: 1. Dial up 2 units: turn the dose selector dial to 2 units, 2. Prime the pen: Press the injection button to let out any air bubbles and ensure the insulin is flowing correctly, 3. Check for a drop of insulin: you should see a drop of insulin on the tip of the needle, 4. Repeat if necessary.1. Resident #79 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus.Review of Resident #79's physician orders dated 04/29/25 for Lantus insulin give 10 units subcutaneously every day.On 07/23/25 at 8:55 AM an observation was made of Nurse #3 preparing to administer insulin to Resident #79 via an insulin pen. The Nurse removed the Lantus insulin pen from the medication cart and set the counter to 10 units. Nurse #3 administered the 10 units of insulin without priming the insulin pen as advised by the manufacturer's instructions.An interview was conducted with Nurse #3 on 07/23/25 at 2:51 PM. The Nurse was asked to review the steps of giving insulin via an insulin pen. Nurse #3 repeated the steps she had taken when administering insulin to Resident #79 but did not include priming the insulin pen. The Nurse was asked if she knew about priming the insulin and she indicated she knew but thought it was only for the first time the insulin pen was used.During an interview with the Pharmacist on 07/24/25 at 2:30 PM the Pharmacist explained it was important to prime the insulin every time it was used in order to remove any air bubbles that may be present in order to inject the full amount of insulin prescribed for the Resident. During an interview with the Director of Nursing (DON) on 07/24/25/25 at 2:30 PM the DON indicated that she expected Nurse #3 to follow the manufacture's recommendations when given insulin using an insulin pen.2. Resident #84 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus.Review of Resident #84's physician orders revealed an order dated 01/18/25 for Lispro insulin 2 units subcutaneously before meals.On 07/22/25 at 4:10 PM an observation was made of Nurse #2 preparing to administer insulin to Resident #84 via an insulin pen. The Nurse removed the Lispro insulin pen from the medication cart and set the counter to 2 units. Nurse #2 administered the 2 units of insulin without priming the insulin pen as advised by the manufacturer's instructions.An interview was conducted with Nurse #2 on 07/23/25 at 2:35 PM. The Nurse was asked to review the steps when giving insulin using an insulin pen and Nurse #2 repeated how he administered the insulin the day before. When the Nurse was asked about priming the insulin pen the Nurse reported that he was not aware that the insulin pen needed to be primed before giving the insulin and stated he would remember to do that going forward.During an interview with the Pharmacist on 07/24/25 at 2:30 PM the Pharmacist explained it was important to prime the insulin every time it was used in order to remove any air bubbles that may be present in order to inject the full amount of insulin prescribed for the Resident. During an interview with the Director of Nursing (DON) on 07/24/25/25 at 2:30 PM the DON indicated that she expected Nurse #2 to follow the manufacture's recommendations when given insulin using an insulin pen.3. Resident #26 was admitted to the facility on [DATE] with diagnoses that included neuralgia (nerve pain caused by damage or irritation).Review of Resident #26's physician orders dated 03/22/25 revealed Vitamin B-12, 2,500 micrograms (mcg) by mouth once a day for neuralgia.An observation was made of Nurse #3 on 07/23/25 at 9:00 AM during a medication administration of Resident #26. The Nurse prepared Resident #26's medications which included Vitamin B-12. The Vitamin B-12 was supplied in a bottle of 1,000 mcg per tablet. The Nurse picked up the bottle of B-12 and stated she would have to cut one of the tablets in half in order to give the correct dose then proceeded to cut one tablet in half and put the half tablet in the medicine cup along with a whole tablet and administered 1,500 mcgs to Resident #26 instead of 2.5 tablets which would equal 2,500 micrograms.An interview was conducted with Nurse #3 at 2:51 PM on 07/23/25. The Nurse was asked to review the calculation of Resident #26's Vitamin B-12 tablets. The Nurse stated the total dose to be given was 2,500 and she cut one tablet in half and thought she gave the Resident 2.5 tablets. The Nurse was informed that she only gave 1.5 pills which was not enough to equal the 2,500 dose of Vitamin B-12 and the Nurse stated she should have gotten the 500-microgram stock bottle from the medication room and used it instead of cutting one of the pills in half. Nurse #3 stated she was nervous during the medication pass.On 07/24/25 at 2:30 PM an interview was conducted with the Pharmacist who explained that the correct dose of Vitamin B-12 should have been administered to Resident #26.An interview was conducted with the Director of Nursing (DON) on 07/24/25 at 2:30 PM. The DON stated Nurse #3 should have retrieved the bottle of Vitamin B-12 from the medication room to help prevent making the medication error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure accurate accounting for the receipt of nine (9) tablets of controlled medications. This was for 1 of 1 facility emergency-controlled medication storage areas.The findings included:Review of a pharmacy order sheet for scheduled I and II controlled medications revealed one (1) oxycodone immediate release (IR) 5 milligrams (mg) was ordered on 08/07/24.Review of a pharmacy order sheet for scheduled IV controlled medications revealed four (4) lorazepam 0.5 mg tablets and four (4) tramadol 50 mg tablets were ordered on 08/07/24.Review of a pharmacy delivery sheet for controlled medications revealed the following controlled medications were delivered to the facility on [DATE]: (1) oxycodone IR 5 mg tablet, (4) tramadol 50 mg tablets and (4) lorazepam 0.5 mg tablets. The delivery sheet was signed by the delivery driver and Nurse #5.On 07/22/2025 at 3:03 PM an interview was conducted with the Director of Nursing (DON) who explained that on 08/09/24 she reviewed the pharmacy delivery sheet for the controlled medications and found that the controlled medications were signed for by Nurse #5. The DON went to the medication cart that Nurse #5 worked on 08/08/24 to obtain the controlled medications but the medications were not on the medication cart. Nurse #6 who was assigned to the medication cart on 08/09/24, reported that she did not count controlled medications from the pharmacy with Nurse #5 during shift change that morning on 08/09/24. The DON continued to explain that she and Nurse #6 completed a review of all medication carts and could not find the controlled medications. The DON called Nurse #5 to inquire about the controlled medications and Nurse #5 reported that she received controlled medications for a resident but not for the facility's emergency controlled medication storage. Nurse #5 explained to the DON that she signed the delivery sheet but admitted ly she did not count the controlled medications in the package with the delivery driver before she signed the delivery sheet. The DON explained that she notified the Administrator who called the pharmacy to report the missing controlled medications and inquire about the delivery driver.An interview was conducted with Nurse #5 on 07/22/25 at 7:46 PM who confirmed that she worked on the night of 08/08/24. The Nurse explained that she received the pharmacy delivery of controlled medications for a resident but did not receive the controlled medications for the emergency controlled storage. Nurse #5 reported she did not count the controlled medications with the delivery driver but did sign the delivery sheet. The Nurse was insistent that there were no other medications in the package except for the resident's controlled medications. The Nurse continued to explain that she was asked to come to the facility on [DATE] to provide a statement and adhere to a drug test for reasonable suspicion which she complied, and the result was negative on 08/09/24. Nurse #5 reported that she was suspended on 08/09/24 pending investigation of the missing controlled medications which lasted ten (10) days. The Nurse stated she was reported to the Board of Nursing (BON) and the BON informed the Nurse that there would be no formal disciplinary action. The Nurse explained that she was called to the facility on [DATE] and was given a written warning on not following the proper procedure of obtaining controlled medications and was educated on the proper procedure of obtaining controlled medications. The Nurse reported that now the new procedure was for two (2) nurses to verify the controlled medication count when delivered from the pharmacy.During an interview with Nurse #6 on 07/22/25 at 8:00 PM the Nurse explained that she was approached by the DON on 08/09/24 and asked if she counted the emergency controlled medications during shift change with Nurse #5 and the Nurse reported that she had not counted any emergency storage medications with Nurse #5. Nurse #6 continued to explain that she helped the DON search for missing controlled medications and could not find them and she helped count all the controlled medications on all the medication carts in the facility and the counts were all reconciled.On 07/22/25 at 4:50 PM an interview was conducted with the Administrator who reported that he was notified on 08/09/24 of the missing emergency controlled medications ordered by the DON on 08/07/24. The Administrator explained that all the medication carts and medication rooms were searched but the missing controlled medications were not found. The Administrator stated that they brought Nurse #5 in on 08/09/24 for a written statement and a drug test which was negative and suspended her pending the completion of the investigation. He continued to explain that he reported the missing controlled medications to the local law enforcement who investigated the situation and there were no charges related to the investigation. He stated he reported the missing controlled medications to Adult Protective Services (APS) and there was no report taken by APS citing there was no resident involved in the missing controlled medications therefore, there was no abuse, neglect or exploitation. The Administrator explained that he called the pharmacy manager to inform them of the situation and asked that the delivery driver provide a written statement and adhere to a drug test, but the driver refused, and the pharmacy manager stated it was not a part of their policy to provide it. The facility provided the following correction action plan:Address how corrective actions will be accomplished for those residents to have been affected by the deficient practices. On 08/08/24 Nurse #5 signed a narcotics delivery sheet which states that 4 house stock Ativan 0.5 mg tablets, 1 house stock oxycodone 5 mg tablet, 4 house stock tramadol 50 mg tablets and 2 bottles of lorazepam 60 milliliters for a resident were delivered. Nurse #5 states that she did not verify and count the narcotics with the delivery driver but did sign the delivery sheet. Nurse #5 stated she acknowledges receiving 2 bottles of liquid lorazepam for the resident which she secured in the refrigerator. Nurse #5 does not recall seeing the house stock narcotics in the delivery. On 08/09/24 the Director of Nursing became aware that the house stock narcotics were missing. Nurse #5 was suspended on 08/09/24. The Director of Nursing or designee searched Nurse #5's medication cart and medication room and was unable to locate the missing house stock narcotics on 08/09/24. The Administrator submitted a 24-hour report to the Division of Health Services Regulation to report the missing narcotics on 08/09/24. The Administrator reported the missing medications to Adult Protective Services and the police department on 08/14/24. Nurse #5 was drug tested on [DATE]. Results of the drug test were negative. Human resources completed a review of Nurse #5's employee file on 08/16/24 and verified she had a valid nurse license, had no disciplinary action against her license, had no exclusions from government programs, and had nothing on her background check that would preclude her from employment in a nursing home. Nurse #5 was drug tested on hire 01/06/21, and the results were negative. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 08/09/24 the Director of Nursing or designee completed a search of all other medication carts and medication rooms in the building. An audit was completed of the narcotics in the Omnicell, and an audit was completed of all resident narcotics on the medication carts. All other narcotics were accounted for. Human resources reviewed the employee files of five other employees on 08/14/24 and verified they had a valid license, and had no disciplinary action against their license, had no exclusions from government programs, and had nothing in their background checks that would preclude them from employment in a nursing home. All five employees were drug tested on hire and were negative. The 4-house stock Ativan, 1 house stock oxycodone, and 4 house stock tramadol were unable to be located. No other residents were affected by the missing house stock narcotics. The facility never ran out of any of the house stock narcotics. Narcotics were continually available to all residents. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 08/09/24 the Director of Nursing or Designee educated all licensed nurses and medication aides on the facility policy for narcotics handling to include reviewing the delivery manifest with the driver and completing a count of each narcotic listed on the manifest with the driver ensuring the accuracy of what medication was delivered and the quantity of each medication was delivered prior to two nurses signing the delivery form. Immediately after receiving the medication the nurse will secure the narcotics into the medication cart or the narcotics refrigerator. If the medication delivered is not correct the nurse is to decline the delivery and immediately inform the Director of Nursing. The Director of nursing or designee will ensure that all licensed nurses receive this education prior to working their next shift. The Director of Nursing will ensure all newly hired licensed nurses will receive this education during their orientation. No nurse will work prior to receiving this education. Indicate how the facility plans to monitor its performance to make sure that solutions are sustainedOn 08/09/24 the Administrator and Director of Nursing discussed the plan of correction and determined to have an ADHOC Quality Assurance Process Improvement (QAPI) meeting. A verbal ADHOC QAPI was held on 08/09/24 with the Interdisciplinary team and educated the team on the interventions that were put into place to prevent narcotic medication discrepancies. The Medical Director was notified by the Director of Nursing via phone on 08/09/25 regarding narcotics discrepancy and what interventions that were put in place. The Director of Nursing implemented the plan of correction 08/09/24. During the QAPI meeting on 08/09/24 the decision was made to audit the plan of correction, and the Administrator informed the Director of Nursing or designee beginning the week of 08/19/24 she will audit the delivery slips with for house stock narcotics to ensure the delivery was reviewed by two nurses. Audits will continue for 8 weeks. The Interdisciplinary team will review and provide recommendations on the audit results provided by the Director of Nursing and or Designee during the QAPI meeting for the next 3 months to ensure sustained compliance. Changes to the plan of correction will be made as needed. The Administrator and Director of Nursing will ensure the corrective action plan is implemented. Date of Compliance: 08/19/24The Plan of Correction was validated on 07/25/25 which included reviewing the facility's weekly audits of the pharmacy emergency controlled delivery sheets that ensured two (2) nurses signed the delivery sheets. The education provided to the nurses was evident by the signatures on the education sign in sheets and through verbal affirmation by the nurses that they received the education. The audits were presented to QA for three (3) consecutive months. The facility's compliance date of 08/19/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff and resident interview, the facility failed to reassess for the ability to self-administer medications for a resident who was self-administering a medication for 1 of 1 resident reviewed for self-administering medications (Resident #10).The findings included:Resident #10 was admitted to the facility on [DATE] with diagnoses that included gastroesophageal reflux disease (GERD).Review of Resident #10's physician orders dated 08/06/24 for calcium carbonate chewable tablets 500 milligrams, take two tablets every eight hours as needed for GERD.Review of Resident #10's Self-Administration assessment dated [DATE] indicated the Resident did not want to self-administer medications.Review of Resident #10's annual Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact.On 07/22/25 at 1:05 PM during an interview and observation of Resident #10 it was noted that there was a bottle of antiacid tablets approximately 1/4 full of tablets of various colors sitting on her over bed table in her room. When Resident #10 was asked about the medication the Resident explained that a family member brought the medication to her because she had gastric reflux and heart burn mostly at night and she took the medication when she needed them. The Resident stated she did not have heartburn every night, but she wanted them close by when she needed them. Subsequent observations were made on 07/23/25 at 2:23 PM, 07/24/25 at 8:42 AM and 07/25/25 at 8:51 AM and the bottle of antiacid tablets remained at Resident #10's bedside.An interview was conducted with Nurse #4 on 07/25/25 from 11:25 AM. The Nurse explained that Resident #10 did not have an order to self-medicate and she did not think she would be able to administer her own medications. The Nurse was notified of the bottle of antiacids on the Resident's over bed table and the Nurse retrieved the medication and stated she would address it with the Director of Nursing. The Nurse stated she had not noticed the medication in the Resident's room.During an interview with the Director of Nursing (DON) on 07/25/25 at 11:54 AM, the DON explained that residents had to be assessed to be able to keep their medications at bedside and had to be assessed to be able to medicate themselves according to the physician orders. She indicated that Resident #10 could possibly self-administer her antiacid medication but first she would have to be assessed in order to do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to ensure Nurse #7 suctioned a resident's tracheostomy (a surgical opening in the neck to allow breathing) using sterile technique (a way of providing care that attempts to eliminate germs to prevent infection) for 1 of 1 resident reviewed for tracheostomy care (Resident #1).Findings included:Resident #1 was admitted to the facility 07/07/25 with diagnoses including pneumonia and respiratory failure (when the lungs can't properly exchange oxygen and carbon dioxide). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and received tracheostomy care and suctioning. Review of a respiratory care plan initiated 07/07/25 revealed Resident #1 had a tracheostomy and interventions included providing oxygen as ordered and suctioning her tracheostomy as needed. A continuous observation of Nurse #7 on 07/25/25 from 10:50 AM to 11:20 AM revealed she was providing tracheostomy care for Resident #1. During tracheostomy care, Resident #1 indicated she needed to be suctioned. Nurse #7 immediately discontinued tracheostomy care, removed her gloves, washed her hands, applied clean gloves, opened the package containing the sterile suction catheter (tube), connected the suction catheter to the suction machine, turned on the suction machine, and inserted the suction catheter into Resident #1's tracheostomy, applied suction for approximately 15 seconds, removed the suction catheter from the tracheostomy, waited approximately 30 seconds, reinserted the suction catheter, applied suction for approximately 15 seconds, removed the suction catheter from Resident #1's tracheostomy, removed the suction catheter from the suction machine, discarded the suction catheter in the trash, removed her clean gloves, discarded the gloves in the trash, and washed her hands. Nurse #7 did not don sterile gloves or use sterile technique while suctioning Resident #1.In an interview with Nurse #7 on 07/25/25 at 11:24 AM she confirmed she did not use sterile gloves or sterile technique to suction Resident #1's tracheostomy. She stated she was aware there were tracheostomy suction kits which contained sterile gloves and sterile water that she was supposed to use, but she was nervous and forgot. An interview with the Director of Nursing (DON) on 07/25/25 at 11:48 AM revealed she expected sterile technique to be used when suctioning a tracheostomy tube. An interview with the Administrator on 07/25/25 at 12:55 PM revealed he expected nursing staff to follow facility policy for suctioning a tracheostomy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and Law Enforcement Detective and staff interviews, the facility failed to assure residents' property was safeguarded and staff did not misappropriate the residents' property for personal gain. Nurse Aide #1 used Resident #118's credit card to make unauthorized purchases totaling $757.73 without Resident #118's permission or knowledge and Housekeeper #1 used Resident #119's credit card to make an unauthorized purchase totaling $152.13 without Resident #119's permission or knowledge for 2 of 3 residents reviewed for misappropriation of resident property (Resident #118 and Resident #119).Findings included:The facility's Resident Abuse policy, last revised on 08/30/23, revealed in part, the facility would ensure all residents were free from misappropriation of property.1. Resident #118 was admitted to the facility on [DATE].The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #118 with intact cognition.Review of the facility's investigation revealed on 12/12/24 at 3:30 PM the facility became aware of an allegation of misappropriation of property when Resident #118 reported her credit card was missing and an investigation was initiated. Resident #118 was notified by a family member that there were charges made using her credit card and when Resident #118 looked, she was unable to locate the credit card. Resident #118's credit card was frozen by the bank, the charges were disputed and law enforcement was notified. Continued review of the facility's investigation included an undated statement signed by the Administrator that revealed in part, the Law Enforcement Detective contacted the Administrator on 12/23/24 at 1:00 PM stating they had identified Nurse Aide (NA) #1 through video surveillance as the person who made the unauthorized purchases using Resident #118's credit card. NA #1 was working at the facility on 12/23/24 and was on break until 2:00 PM. Immediately upon returning from break, NA #1 was escorted to the Director of Nursing's (DON) office by the Administrator and interviewed. At first, NA #1 denied the accusation but when NA #1 was informed that law enforcement had video evidence of her making the purchases using Resident #118's credit card, NA #1 admitted to the Administrator and DON that she had taken Resident #118's credit card without authorization. NA #1 was terminated from employment and escorted out of the facility.A review of Resident #118's bank account records from 12/07/24 to 12/12/24 revealed four separate purchases were made to restaurants on 12/07/24 totaling $92.92; five separate purchases were made to restaurants and department stores on 12/10/24 totaling $489.38; and three separate purchases were made to restaurants and a grocery store on 12/12/24 totaling $175.43. Resident #118 discharged from the facility on 12/20/24 and was unable to be interviewed during this investigation.During a phone interview on 07/23/25 at 2:55 PM, NA #1 stated she did not take Resident #118's credit card and did not make the unauthorized credit card purchases. NA #1 expressed she never provided care to Resident #118 and was not working the day the credit card was allegedly lost. When asked if she was informed that law enforcement was able to positively identify her through video surveillance as the person making the unauthorized purchases, she replied no. NA #1 restated she did not do what she was being accused of and voiced she felt the facility administration singled her out for one reason or another. Review of the time clock report and corresponding staff schedule for 12/06/24 revealed NA #1 worked 7:00 PM to 7:00 AM and was assigned to Resident #118's hall.During a phone interview on 07/25/25 at 9:40 AM, the Law Enforcement Detective revealed he went to the grocery store and one of the department stores where purchases were made, told store employees what he was looking for and they were able to provide him with video security footage. He explained he was able to get still shots (photographs) from the video security footage, ran the images through facial recognition software and NA #1 was positively identified when a match was made to her driver's license photo. In addition, the loss prevention employee at the department store was able to confirm NA #1 used her membership number when making the purchase. The Law Enforcement Detective stated he never interviewed NA #1 as he had all the information needed and charges were filed.During an interview on 07/24/25 at 1:55 PM, the DON confirmed she was present on 12/23/24 when the Administrator interviewed NA #1 about Resident #118's credit card. The DON stated once the Administrator informed NA #1 that law enforcement had video evidence, NA #1 admitted that she took Resident #118's credit card without her knowledge and made the purchases. The DON stated NA #1 never provided any explanation as to why she took Resident #118's credit card.During interviews on 07/23/25 at 10:21 AM and 07/25/25 at 7:50 AM, the Administrator revealed at the time of Resident #118's admission to the facility (12/06/24), her family was managing her finances, noticed the charges made on her credit card and when they called Resident #118 about the charges, she denied spending any money. He stated he was informed by Resident #118's family they had notified her bank to freeze her account and they provided him with copies of the detailed transactions from her account. The Administrator stated when he spoke with Resident #118 she displayed no emotional distress, just appeared annoyed over the situation, and had no idea who would have taken her credit card. The Administrator stated at the time the allegation was made, he initially suspected another staff member who was involved in a similar situation a few weeks prior; however, she had resigned her position on 12/02/24 which was prior to this incident. He explained at the conclusion of the facility's investigation they were unable to determine what had happened to Resident #118's credit card or if it had been taken by an employee at the facility. The Administrator stated NA #1 was never a suspect until he was notified by law enforcement on 12/23/24 that they had video evidence of NA #1 making the unauthorized purchases and were able to make a positive identification by comparing pictures from the video to NA #1's driver's license photo. The Administrator stated after speaking to law enforcement, he brought NA #1 to the DON's office for an interview. He stated at first, NA #1 denied taking Resident #118's credit card and making unauthorized purchases but when she was told law enforcement stated they had video footage of her using the credit card, she told him well you got me, there is no way around it and finally admitted to taking and using Resident #118's credit card without her knowledge. The Administrator stated NA #1 never provided an explanation as to why she took Resident #118's credit card and basically stopped talking. The Administrator stated NA #1's employment was terminated and she was escorted out of the building. The Administrator stated he was informed by Resident #118 that her bank had refunded the money from the unauthorized purchases.2. Resident #119 was admitted to the facility on [DATE].The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #119 with intact cognition.Review of the facility's investigation revealed on 12/06/24 at 2:15 PM the facility became aware of an allegation of misappropriation of property for Resident #119 and an investigation was initiated. Resident #119 reported an unauthorized purchase was made to a department store in the amount of $152.13 and her credit card was missing from her wallet. Resident #119 also alleged she thought Housekeeper #1 was the person who had taken her credit card. Resident #119 contacted her bank to freeze the card, reissue a new card and disputed the charges. The accused employee resigned employment around the same time the purchase was made using Resident #119's credit card. Resident #119 reported the bank refunded the money from the unauthorized purchase and issued her a new credit card. Law enforcement, Health Care Personnel Registry and Adult Protective Services were all notified of the incident.Resident #119 discharged from the facility on 12/23/24 and was unable to be interviewed during this investigation.Unsuccessful telephone attempts for an interview with Housekeeper #1 were made on 07/23/25 at 9:09 AM and 07/24/25 at 12:06 PM with no return phone call.During interviews on 07/23/25 at 10:21 AM and 07/25/25 at 7:50 AM, the Administrator revealed when Resident #119 reported her credit card was missing on 12/06/24, she alleged it was a housekeeper who took the credit card without her permission and he knew by the process of elimination that Housekeeper #1 was assigned to Resident #119's hall. The Administrator stated when he spoke with Resident #119 she displayed no emotional distress, just appeared annoyed over the situation. He explained an investigation was initiated, including reporting the incident to law enforcement, Adult Protective Services and the State Agency, and Housekeeper #1 had already resigned her position on 12/02/24 prior to the incident being reported. He stated he tried calling Housekeeper #1 but she never returned any of his phone calls. The Administrator stated Resident #119 reported that her bank had refunded the money from the unauthorized purchase.

Based on observations, record review, and staff interviews, the facility failed to ensure staff implemented their infection control policy for hand hygiene when a nurse aide failed to remove dirty gloves and perform hand hygiene during incontinence care for Resident #1. This deficient practice was identified for 1 of 7 staff members observed for infection control practices (Nurse Aide #4). Findings included:Review of the facility's policy titled Hand Hygiene/Handwashing Policy last revised 02/28/25 read in part as follows: Hand hygiene is the most important component for preventing the spread of infection. Use of gloves does not replace the need for hand cleaning by handwashing. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: before moving from work on a soiled body site to a clean body site on the same patient, after contact with bodily fluids, and immediately after glove removal.A continuous observation of Nurse Aide (NA) #3 on 07/23/25 from 8:41 AM through 9:05 AM revealed NA #3 provided incontinence care to Resident #1. With gloved hands NA #3 cleaned urine with resident care wipes, placed the wipe in the trash can, assisted Resident #1 with rolling onto her left side, cleaned urine with resident care wipes, placed the wipe in the trash can, applied skin barrier ointment to Resident #1's right buttock, rolled a clean brief and bed pad under Resident #1, assisted Resident #1 with rolling onto her right side, cleaned urine with resident care wipe, placed the wipe in the trash can, pulled the clean brief and bed pad under resident, applied skin barrier ointment to Resident #1's left buttock, assisted Resident #1 with rolling onto her back, pulled up the brief and fastened it, pulled Resident #1's gown down, removed the pillow under Resident #1's head and pulled her up in the bed using the bed pad, assisted Resident #1 with rolling on her left side, placed a pillow under her left side, assisted Resident #1 with rolling onto her right side, placed a pillow under her right side, placed a pillow under Resident #1's head, pulled up her bed sheet and cover, used the bed control to raise Resident #1's head, placed the call light on Resident #1's bed and within her reach, pulled her overbed table across her bed and lowered the table, removed his gloves and placed them in a trash bag, picked up the trash bag, and exited the room. NA #3 did not remove his gloves and perform hand hygiene after removing urine, after applying ointment to Resident #1's buttocks, and before touching other items in Resident #1's environment. NA #3 did not perform hand hygiene after removing his gloves at the completion of care and before exiting Resident #1's room. An interview with NA #3 on 07/23/25 at 9:08 AM revealed he usually changed his gloves during incontinence care only if they were visibly soiled and he performed hand hygiene when he was ready to exit the resident's room. He stated he was nervous and that was why he did not perform hand hygiene after removing his gloves when he finished providing care and before exiting Resident #1's room. An interview with the Director of Nursing (DON) on 07/23/25 at 10:40 AM revealed she expected staff to remove gloves and perform hand hygiene when moving from dirty to clean tasks. An interview with the Administrator on 07/24/25 at 4:20 PM revealed he expected staff to remove their gloves and perform hand hygiene after performing incontinence care and before performing the next task. An interview with the Infection Preventionist on 07/25/25 at 10:11 AM revealed when staff performed incontinence care they should remove their gloves after cleaning the resident, perform hand hygiene, and then continue care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to ensure a controlled substance medication ordered for a resident was safely stored and secured using a double lock feature for 1 of 4 medication storage refrigerators observed (Resident #65). A controlled substance has an accepted medical use, a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. The facility also failed to date an open vial of insulin on 1 of 2 medication carts reviewed (300/400 hall medication cart) and failed to date a vial of Tuberculin Serum (used to conduct tuberculosis screening) and failed discard the Tuberculin serum after 30 days in 2 of 4 medication rooms reviewed 300/400 hall medication cart and 500/600 hall medication cart).
The findings included:
Review of a facility policy titled Storage and Expiration Dating of Medications, Biologicals revised last on 08/07/23 read in part, facility should store Schedule II-V controlled substances in a separate compartment within the locked medication carts and should have a different key or access device. Store all drugs and biologicals in locked compartments, including the storage of scheduled II-V medications in separately locked, permanently affixed compartments permitting only authorized personnel to have access.
1.
Resident #65 was admitted to the facility on [DATE].
Review of a physician order dated 04/03/24, Lorazepam (schedule IV antianxiety) 2 milligrams (mg)/1 milliliter (ml), give 0.5 mg by mouth at bedtime for anxiety.
An observation of the 700/800 hall medication room refrigerator was made on 04/30/24 at 3:29 PM along with Nurse #1 revealed the small medication room refrigerator did not have a lock device on it. Once opened the refrigerator had a small permanently affixed container but the lock was not present and only contained a small hole where the lock used to be. The permanently affixed container was opened by inserting a finger into the lock hole and opening the container. Inside the container was a box labelled with Resident #65's name and directions. The medication was Lorazepam 2mg/1ml that contained approximately 12 ml of medication in it.
The Director of Nursing (DON) was interviewed on 04/30/24 at 3:57 PM. The DON was asked to observe the 700/800 hall medication room refrigerator. She stated that she was unaware that the lock was broken on the refrigerator and on the small permanently affixed container. She stated she was aware that the Lorazepam needed to be secured and she would get a lock installed immediately.
Nurse #1 was interviewed on 04/30/24 at 4:10 PM who stated the lock on the medication room refrigerator in the medication room had been broken for months and she had reported it several people but could not recall who all she had reported to. Nurse #1 explained that the lock on the refrigerator had been broken since last week and she had not report that to anyone. She added that the lock that was on the refrigerator was so flimsy and was hanging on by a thread and then eventually just fell off sometime last week.
2.
Review of a facility policy titles Storage and Expiration Dating of Medications, Biologicals revised last on 08/07/23 read in part, facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened.
An observation of the 300/400 hall medication cart was made on 05/01/24 at 10:00 AM along with Nurse #2. The observation revealed an opened via of Humalog insulin that contained no date of when it was opened.
Nurse #2 was interviewed on 05/01/24 at 10:10 AM, she stated she was not sure when the vial had been opened as she only worked one day a week. She indicated that she would discard the vial of insulin.
The Director of Nursing (DON) was interviewed on 04/30/24 at 3:49 PM, who stated that the third shift staff were expected to go through the medication room and carts at least weekly and then of course the nurses should be going through the medication carts on a daily basis as they were medicating residents to ensure that everything was dated and labelled correctly. The DON stated insulin vials were good usually for 28 days after being opened and coming out of the refrigerator and the nurses should be keeping track of the 28 days by dating the insulin vial or pen when it was opened.
The Administrator was interviewed on 05/02/24 at 3:29 who stated that all insulin vials should be dated when they were opened.
3.
Review of a facility policy titles Storage and Expiration Dating of Medications, Biologicals revised last on 08/07/23 read in part, facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened.
A.
An observation of the 500/600 hall medication room refrigerator was made on 04/30/24 at 3:34 PM along with Nurse #3. The observation revealed a vial of Tuberculin serum that was dated as being opened on 03/12/24.
B.
An observation of the 300/400 hall medication room refrigerator was made on 04/30/24 at 3:46 PM along with Nurse #4. The observation revealed an opened vial of Tuberculin serum that had no date of when it was opened.
Nurse #4 was interviewed on 04/30/24 at 4:00 PM, she stated she was fairly new to the facility, and she was not sure about the vial of serum and would have to ask the Director of Nursing (DON).
The DON was asked to observe the 500/600 hall medication room refrigerator and the 300/400 hall medication room refrigerator on 04/30/24 at 3:57. The DON stated she was not aware that the vials of Tuberculin serum were undated and were kept past the 30-day shelf life after opening. The DON again confirmed that the tuberculin serum was good for 30 days after opening and then should be discarded.
The Administrator was interviewed on 05/02/24 at 3:29 PM who stated he expected the staff to follow the facility policy and procedures for dating vials of medication and removing them by their use by or expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff and Resident interviews the facility failed to assess the resident for the ability to self-administer medications for 1 of 1 resident (Resident #25) reviewed for self-administration of medication.
The findings included:
Resident #25 was admitted to the facility on [DATE].
A review of Resident #25's physician orders revealed an order dated 04/01/23 for Fluticasone Propionate Nasal Suspension 50 micrograms per activation (mcg/act) 2 sprays, in both nostrils one time a day for allergies. The order did not include the Resident could self-administer the medication.
A further review of Resident #25's physician orders revealed there were no orders for over the counter pain patches or an albuterol sulfate inhaler.
There was no Self Administration assessment for an inhaler or pain patch.
A review of Resident #25's quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact.
A review of Resident #25's medical record revealed a Self-Administration assessment dated [DATE] that indicated the Resident was mentally and physically able to self-administer the Fluticasone Nasal Spray. The assessment was completed by Nurse #1.
On 04/29/24 at 4:06 PM an observation and interview were conducted with Resident #25 in her room. On the Resident's over bed table was a bottle of Fluticasone Nasal Spray that the Resident explained she used every day for her allergies. Resident #25 also had a pain patch on her right knee, and she explained that she kept them in her cabinet and only used it when she had pain in her knee. The Resident removed a box of over the counter pain patches to show there were two remaining in the box. Resident #25 explained that she also had an inhaler in her purse that she used when she needed to and produced an Albuterol Sulfate inhaler.
During an interview with Resident #25 on 04/30/24 at 8:56 AM the Resident explained again the use of the nasal spray which was sitting on her over bed table, the pain patch and the inhaler and stated they were still in her room.
An interview was conducted with Nurse #1 on 04/30/24 at 3:02 PM. The Nurse explained that she remembered assessing Resident #25's ability to administer her nasal spray but stated she took the nasal spray to the Resident in the morning when she gave her morning medications to her and allowed the Resident to administer the nasal spray. Nurse #1 stated she was not aware that the Resident kept pain patches and an inhaler in her room and stated she did not have an order for them. She indicated she would need to obtain an order for the inhaler and pain patches and assess her ability to administer them.
During an interview with the Director of Nursing (DON) on 04/30/24 at 3:12 PM she explained that the Resident should have been assessed for the ability to self-administer every medication that she kept in her room and there needed to be an order for that medication as well. The DON also stated the staff needed to be educated to monitor medications at the Residents' bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete Care Area Assessments (CAAs) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 5 sampled residents (Residents #67 and #32).
The findings included:
Resident #67 was admitted to the facility on [DATE] with diagnosis that included depression.
Review of a physician order dated 01/11/24 read; Fluoxetine HCL (antidepressant) 10 mg by mouth every day for depression.
Review of the comprehensive admission Minimum Data Set (MDS) dated [DATE] revealed Resident #67 was cognitively intact and had no behaviors, rejection of care, or wandering and no signs of delirium were noted during the assessment reference period. The MDS indicated that Resident #67's diagnosis included depression and that he had taken an antidepressant during the assessment reference period.
Review of the triggered Care Area Assessment (CAA) worksheet for Psychosocial wellbeing dated 01/23/24 had the following boxes checked: resident says or indicated they feel lonely and indicted that Resident #67 had diagnosis of depression. Health status factors that may inhibit social involvement had the following boxes checked: decline in functional abilities, mood or behavior problem, health problems such as fall, and change in communication. The nature of the problem contained no information describing Resident #67's psychosocial needs, behaviors, medications, or how the facility would address and meet Resident #67's psychosocial needs. The care plan decision was made to proceed. The CAA was completed by MDS Nurse #1.
MDS Nurse #1 was interviewed via phone on 05/02/24 at 9:47 AM. MDS Nurse #1 explained that when completing the CAA, she gathered the information from what she used to complete the MDS assessment, which included chart review, therapy notes, and doctor notes. Once the information was gathered, she would go into the CAA and check any applicable boxes and then make the care plan decision and develop the care plan. MDS Nurse #1 was asked if she had had ever been told that she needed to thoroughly assess each resident and their condition that was applicable to each CAA that triggered, she replied, I honestly felt like stating to proceed and then addressing it in the care plan was sufficient enough and that was why she did not further elaborate in the CAA.
The Director of Nursing (DON) was interviewed on 05/02/24 at 3:16 PM. She stated that she would expect the CAA to be comprehensive and thorough and give the appropriate information to paint a picture of the resident, their condition, and their identified needs.
2. Resident #32 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, amnesia, mood disturbance and psychotic disorder.
A review of Resident #32's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was coded as moderately impaired. A review of section V of the MDS (care areas triggered for assessment to indicate need for care plan) revealed the care area of psychotropic drug use was triggered but the facility did not include information in the analysis of findings that described the Resident's problems, possible causes and contributing factors, risk factors related to the care area and reasons to proceed to care planning.
A review of Resident #32's medical record revealed the last gradual dose reduction of antipsychotic medication was 08/23/23 for Risperdal 1 milligram (mg) by mouth once a day to 0.5 mg by mouth once a day for psychotic disorder.
A review of Resident #32's quarterly MDS dated [DATE] revealed her cognition was moderately impaired and she had no behaviors or rejection of care. The MDS also indicated Resident #32 received an antipsychotic medication.
A review of Resident #32's April Medication Administration Record for 04/2024 revealed the Resident received a daily antipsychotic medication.
On 05/01/24 at 4:57 PM during an interview with the Psychiatric Nurse Practitioner (NP) the NP explained that she routinely visited with Resident #32 for auditory hallucinations and paranoia in that someone was trying to get to her. She continued to explain that the Resident required an antipsychotic medication that in the past the gradual dose reductions had failed and recently (08/23/23) the medication was reduced again. She indicated she would continue to consult with the Resident.
MDS Nurse #1 was interviewed via phone on 05/02/24 at 9:47 AM. MDS Nurse #1 explained that when completing the CAA, she gathered the information from what she used to complete the MDS assessment, which included chart review, therapy notes, and doctor notes. Once the information was gathered, she would go into the CAA and check any applicable boxes and then make the care plan decision and develop the care plan. MDS Nurse #1 was asked if she had had ever been told that she needed to thoroughly assess each resident and their condition that was applicable to each CAA that triggered, she replied, I honestly felt like stating to proceed and then addressing it in the care plan was sufficient enough and that was why she did not further elaborate in the CAA.
An interview was conducted with the Director of Nursing (DON) on 05/02/24 at 3:16 PM. The DON explained that she expected the care area assessments to be comprehensive and thorough and give the appropriate information to paint a picture of the residents, their condition and their identified needs.
During an interview with the Social Worker (SW) on 05/02/24 at 3:22 PM the SW explained that Resident #32 was seen by psychiatric services because she was refusing to take her medications and started to be fixated on her roommate and would not let the staff in her room. She indicated the Resident was stable at present and psychiatric services would continue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to develop a care plan that included an area of focus for a urinary catheter for 1 of 3 residents (Resident #17) reviewed for urinary catheters.
The finding included:
Resident #17 was admitted to the facility on [DATE] with a cumulative diagnosis including urinary retention.
A review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was moderately impaired and she was always incontinent of urine. The MDS was coded as not having an indwelling urinary catheter.
A review of Resident #17's care plan last reviewed on 04/24/24 revealed there was no care plan for a urinary catheter.
A review of a Urology consult dated 04/12/24 revealed a #16 urinary catheter with 10 cubic centimeters (cc) was inserted into the bladder for significant history of Parkinson Disease, urinary infections, incontinence of bladder and bowel and immobility. Change urinary catheter monthly at nursing facility.
A review of Resident #17's physician orders dated 04/17/24 revealed orders for a) urinary catheter, b) change catheter as needed (prn), c) stabilizing device, d) privacy bag, e) catheter care and f) keep catheter below bladder.
An interview was conducted with Minimum Data Set (MDS) Nurse #2 on 05/02/24 at 9:00 AM. The Nurse explained that her coworker (MDS Nurse #1) normally attended the clinical meetings in the morning and would have been the MDS Nurse who should have initiated a care plan for Resident #17's urinary catheter but MDS Nurse #1 was out on leave, so the care planning was up to her. MDS Nurse #2 stated that she did not know that Resident #17 had a urinary catheter placed.
Attempts were made to interview MDS Nurse #1, but the attempts were unsuccessful.
On 05/02/24 at 2:37 PM during an interview with the Director of Nursing (DON) she stated Resident #17 went for a urology consult and came back with a urinary catheter. The DON explained that the catheter should have been care planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to prevent urinary catheter bags from touching the floor for 2 of 3 residents (Resident #11 and Resident #17) reviewed for urinary catheters.
The findings included:
1. Resident #17 with a cumulative diagnosis that included urinary retention.
A review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was moderately impaired and she was always incontinent of urine. The MDS was also coded as not having an indwelling urinary catheter.
A review of Resident #17's care plan revealed there was no care plan for a urinary catheter.
A review of a Urology consult dated 04/12/24 revealed a #16 urinary catheter with 10 cubic centimeters (cc) was inserted into the bladder for significant history of Parkinson Disease, urinary infections, incontinence of bladder and bowel and immobility. Change the urinary catheter monthly at nursing facility.
A review of Resident #17's physician orders dated 04/17/24 revealed orders for a) urinary catheter, b) change catheter as needed (prn), c) stabilizing device, d) privacy bag, e) catheter care and f) keep catheter below bladder.
Multiple observations were made during the survey of Resident #17's urinary catheter bag positioned on the floor. The observations were as noted:
-04/30/24 at 12:00 PM Resident #17 was sitting in the dining room in her wheelchair with the catheter bag mounted under the wheelchair and the catheter bag was positioned on the floor. Multiple staff were observed walking around in the dining room.
-04/30/24 at 12:27 PM Resident #17 was sitting in the dining room in her wheelchair with the catheter bag positioned on the floor. Multiple staff were observed walking around in the dining room.
-04/30/24 at 12:57 PM Resident #17 remained in the dining room sitting in her wheelchair. Multiple staff walked by the Resident while the catheter bag was positioned on the floor.
-04/30/24 at 3:32 PM Resident #17 was observed sitting in her wheelchair in the activity room with staff present. The catheter bag was mounted under the wheelchair and the catheter bag was positioned on the floor.
05/01/24 10:55 AM Resident #17 was observed in her room sitting in her wheelchair with the catheter bag mounted under the wheelchair and positioned on the floor.
05/01/24 at 11:09 AM accompanied staff into the Resident #17's room for interview and observation of the transfer of Resident #17 being put into bed by Nurse Aide (NA) #1 and NA #2. Both NAs noted the Resident's catheter bag positioned on the floor under the wheelchair. NA #1 explained that she mounted the catheter bag under the wheelchair because she did not have anywhere else to attach it. The NA continued to explain that it was not touching the floor when she hung it there and stated it should not be on the floor because it could cause infection.
05/01/24 at 11:13 AM An interview was conducted with Nurse #5 who was assigned to care for Resident #17 on 05/01/24. The Nurse explained that she did not know the specific reason for Resident #17's catheter but she did know that Resident #17 went for a urology consult last week (04/12/24) and came back with the catheter. She stated the Resident had numerous complaints of burning on urination and was tested monthly for urinary tract infections. Nurse #5 also explained that the catheter bag should not be on the floor due to the potential for infection. She stated that she did not notice the catheter bag was on the floor when she worked with her, but she stated she did not specifically look for it either.
On 05/02/24 at 2:37 PM during an interview with the Director of Nursing (DON) she stated Resident #17 went for a urology consult and came back with a urinary catheter. She stated the catheter bag should not be positioned on the floor for infection control reasons.
2. Resident #11 was admitted to the facility on [DATE] with diagnoses that included presence of urogenital implants, history of urinary tract infections, history of falling and urinary retention.
Review of Resident #11's quarterly Minimum Data Set assessment dated [DATE] revealed her to be cognitively intact without delirium, behaviors, or rejection of care. Resident #11 was coded as not having a catheter at the time and was occasionally incontinent of bladder and always continent of bowel.
An observation of Resident #11 on 04/29/24 at 12:19 PM revealed her to be in her room, in bed resting. Resident #11's catheter bag was observed to be ¾ full and resting on the floor causing the bag to fold in on itself.
Another observation of Resident #11 was completed on 04/30/24 at 11:51 AM. Resident #11 was observed to be in her room, in bed asleep. Resident #11's catheter bag was observed to be laying flat on the floor due to her bed being placed in the lowest possible position.
An interview with NA #4 on 04/30/24 at 12:31 PM revealed she had been assigned to Resident #11 on 04/29/24 and 04/30/24. She reported Resident #11 required to be kept with her bed in the lowest position due to her being a fall risk. She reported she was aware Resident #11 had a catheter and indicated resident's catheter bag being on the floor was due to her having to be in the lowest position. NA #4 reported she was aware that the catheter bag would be resting on the floor when Resident #11's bed was placed in the lowest position.
An interview with Nurse #3 on 04/30/24 at 12:40 PM revealed Resident #11 was a fall risk and was required to keep her bed in the lowest position. Nurse #3 also reported that she was aware Resident #11 had a catheter and that Resident #11's bed should be kept in the lowest possible position that prevented the catheter bag from resting on the floor.
An observation of Resident #11 with Nurse #3 completed on 04/30/24 at 12:43 PM revealed Resident #11's catheter bag resting on the floor. Nurse #3 reported the catheter bag would occasionally come into contact with the floor due to Resident #11 having to be in a low bed but there had been no issues with Resident #11's catheter and the output was still good. Nurse #3 ultimately raised Resident #11's bed to ensure the catheter bag was not in contact with the floor.
During an interview with the Director of Nursing on 05/02/24 at 1:36 PM she reported she was familiar with Resident #11 and was aware she had a catheter. The Director of Nursing reported that catheter bags should never come into contact with the floor and if a resident was required to be kept in a low bed, then the bed should be kept in the lowest possible position that prevented the catheter bag from touching the floor.
An interview with the Administrator on 05/02/24 at 2:21 PM revealed he expected catheter bags to not touch the floor. He reported if a resident was required to be in a low bed, then the bed should be low enough to ensure that catheter bags were kept off the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on test tray observations, resident, and staff interviews the facility failed to serve food that was palatable in taste for 7 of 7 residents reviewed for food (Resident #25, Resident #26, Resident #30, Resident #47, Resident #77, Resident #124, and Resident #126). This practice had the potential to affect other residents.
The findings included:
1a. Resident #25 was admitted to the facility 10/14/21.
A review of Resident #25's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and required set up assistance with eating activity.
An interview was conducted with Resident #25 on 05/01/24 at 2:50 PM. The Resident was sitting in her wheelchair at her bedside and when asked about her lunch she remarked that they served her beef stir fry, rice and a roll with mango mousse for dessert. The Resident explained that she could not eat the beef stir fry because it was too salty, so she ate the rice, roll and the mousse. The Resident stated she would have to wait until supper to eat again.
b. Resident #26 was admitted to the facility on [DATE].
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #26 was cognitively intact and required set up assistance with eating.
An interview was conducted with Resident #26 on 05/01/24 at 1:10 PM. Resident #26 was sitting in his wheelchair on the front porch of the facility. When asked how his lunch was, Resident #26 shook his head and stated, I could not eat it, it was too salty. When asked if he had eaten anything Resident #26 stated he had not and stated he would be ok until dinner time.
c. Resident #30 was admitted [DATE].
A review of Resident #30's quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact, and she required set up assistance with eating activity.
During an interview with Resident #30 on 05/01/24 at 4:10 PM the Resident explained that she was served beef stir fry and rice for lunch, but she could not eat the beef because it was too salty. The Resident stated luckily, they brought her baked chicken, or she would not have eaten any meat until supper.
d. Resident #47 was admitted to the facility on [DATE].
A review of Resident #47's quarterly Minimum Data Set assessment dated [DATE] revealed her cognition was moderately impaired and she was independent with her eating activity.
During an interview with Resident #47 on 05/01/24 at 4:15 PM the Resident explained that she was given beef stir fry and rice for lunch, but she could not eat the beef stir fry because it was too salty and spicy for her taste. She stated she would have to wait for supper before she would eat again.
e. Resident #77 was admitted to the facility on [DATE].
A quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #77 was cognitively intact and required set up assistance with eating. The MDS also indicated that Resident #77 received a therapeutic diet during the assessment reference period.
An interview was conducted with Resident #47 on 05/01/24 at 3:01 PM. Resident #47 was up in her wheelchair in her room. She stated, lunch was terrible, I took a couple of bites, and it was too salty, and I could not take it. Resident #47 stated she had not asked the staff for anything else, she just snacked on some things that that she had in her room to tide her over until dinner.
f. Resident #124 was admitted to the facility on [DATE].
The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #124 was cognitively intact and required set up assistance with eating. The MDS further revealed that Resident #124 received a therapeutic diet during the assessment reference period.
An observation and interview were conducted with Resident #124 on 05/01/24 at 3:00 PM. Resident #124 was resting in bed in a gown. She was observed to have a package of pecan wheels on her bedside table and 2 had been eaten. Resident #124 stated she could not eat the beef stir fry because it was full of salt and then there was clump of rice with no gravy or anything on it. It was terrible. Resident #124 stated she had eaten 2 pecan wheels because she had to have something to eat all I had for breakfast was a small box of cereal.
g. Resident #126 was admitted to the facility on [DATE].
The admission Minimum Data Set (MDS) dated [DATE] indicated that Resident #126 was cognitively intact and required no assistance with eating.
An observation and interview were conducted with Resident #126 on 05/01/24 at 5:30 PM. Resident #126 was sitting in her wheelchair in room visiting with her family member. There was a cup that had a milkshake in it on her bedside table. Resident #126 stated she could not eat the beef stir fry that was served for lunch because it was too salty. She stated someone from the facility had brought her some chicken nuggets and her family member had brought her a milkshake so she was full but again stated that lunch was just too salty, and she could not eat it.
Cook #1 was interviewed on 05/02/24 at 12:24 PM. [NAME] #1 confirmed that she had prepared lunch on 05/01/24 and confirmed that it was beef vegetable stir fry. She stated that she had prepared the meat on the flat top grill and chopped the meat and vegetables (broccoli, green beans, peas, cauliflower, and red peppers) together. Once the meat was cooked and vegetables chopped, she added the soy sauce. [NAME] #1 stated that the recipe called for 2 cups of soy sauce for 50 people, and she was preparing for 100 people so added 4.5 to 5 cups of soy sauce. She stated that before she added the soy sauce, she tasted the stir fry and it tasted perfect, but she had not tasted it after she added the soy sauce. [NAME] #1 confirmed that the soy sauce was not low sodium and that she thought it was a lot of soy sauce but stated I thought it would balance out since I was cooking a big portion.
2. An observation of the test tray was conducted on 05/01/24 at 12:46 PM along with the Administrator and Dietary Manager (DM). The tray was served on a plate that was enclosed on an insulated plate bottom and covered with an insulated lid. When the lid was lifted off the plate there was visible steam noted. The plate contained a portion of rice and beef stir fry. There was no egg roll or dessert (mango mousse) served with the test tray. The test tray was sampled and noted to be hot, the rice was a bit mushy, and the stir fry was very salty. The DM indicated that the beef stir fry was too salty for her as well but stated that they had followed the recipe that called for 2 cups of soy sauce for 50 people, and they doubled it since they were preparing for 100 people.
The Administrator was interviewed on 05/02/24 at 3:36 PM. He stated that the DM had been at the facility since it opened but recently just moved into the manager role. He stated that he had worked with her closely for about a month then that allowed her to take over and run the show. He stated that they were getting some feedback from the residents that required them to take a step back and look at the whole operation of the kitchen. He stated for palatability the kitchen staff were required to send him a picture of the meals and he had accumulated over 200 pictures of the meals that were served to the residents. The Administrator did state that he did not conduct test trays and had not eaten the food at the facility.

Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 06/04/21. This failure was for two deficiencies that were originally cited in the areas of Resident Assessment (F636) and Pharmacy Services (F761) that were subsequently recited on the current recertification and complaint investigation survey of 05/02/24. The repeat deficiencies during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QA program.
The findings included:
This tag is cross referred to:
F636: Based on record review and staff interviews, the facility failed to complete Care Area Assessments (CAAs) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 5 sampled residents (Residents #67 and #52).
During the recertification and complaint survey of 06/04/21 the facility failed to complete the Minimum Data Set (MDS) within 14 days of a resident's admission for 1 of 5 sampled residents.
F761: Based on observations, record review, and staff interviews, the facility failed to ensure a controlled substance medication ordered for a resident was safely stored and secured using a double lock feature for 1 of 4 medication storage refrigerators observed (Resident #65). A controlled substance has an accepted medical use, a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. The facility also failed to date an open vial of insulin on 1 of 2 medication carts reviewed (300/400 hall medication cart) and failed to date a vial of Tuberculin Serum (used to conduct tuberculosis screening) and failed discard the Tuberculin serum after 30 days in 2 of 4 medication rooms reviewed 300/400 hall medication cart and 500/600 hall medication cart).
During the recertification and complaint survey of 06/04/21 the facility failed to ensure a controlled substance medication ordered for a resident was safely stored and secured using a double locked feature for 1 of 2 medication storage refrigerators observed. A controlled substance has an accepted medical use, a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. The facility also failed to remove medications placed at bedside for 1 of 1 resident were reviewed for medications left at bedside.
The Administrator was interviewed on 05/02/24 at 4:50 PM. He stated that the Quality Assurance (QA) committee met on a monthly basis and included the administrator, Director of Nursing, Social Worker, Business office Manager, Unit Managers, MDS Coordinator's, Maintenance Director, and Medical Director. Each member of the QA committee had a role, and they were required to bring last month's data to review which included infections, falls, weights, wound, quality measures, risk tools, abuse investigations, medication errors, elopements, and any other issues that needed to be reviewed and discussed. The Administrator stated that the committee also reviewed all policy updates and conducted mock surveys to help achieve and maintain ongoing compliance. The Administrator stated that at least quarterly the QA committee reviewed previous survey data to ensure nothing had changed and through that review they identify areas of opportunity to put a plan of correction in place, do a grievance or any other action that the facility may need to improve upon.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff the facility failed to clarify a physician's order for pain medication to include the frequency of administration between doses for 1 of 5 residents reviewed for pain (Resident #96).
The findings included:
Resident #96 was admitted to the facility on [DATE] with diagnoses including a displaced fracture of left femur.
Review of the care plan focus for pain initiated on 12/21/22 revealed Resident #96's pain was related to a left hip fracture. Interventions included administer medications as ordered.
Review of the admission Minimum Data Set (MDS) dated [DATE] assessed Resident #96 as being cognitively intact. The MDS revealed scheduled and as needed pain medication was received or offered during the assessment period.
Review of the physician's order written on 12/31/22 instructed to give tramadol (an analgesic opioid pain medication) 50 mg as needed for pain. The order did not include frequency of administration between each dose. The physician's order was transcribed by Nurse #6.
Review of the Medication Administration Record (MAR) revealed a 50 mg dose of tramadol was administered on 01/01/23 at 8:24 AM and a second 50 mg dose at 2:45 PM and a third 50 mg dose at 7:58 PM for pain and documented as effective. The first and second doses of tramadol given on 01/01/23 at 8:24 AM and 2:45 PM were administered by Nurse #3. On 01/02/23 the MAR revealed a 50 mg dose of tramadol was administered at 3:59 PM and a second 50 mg dose was administered at 7:53 PM by Medication Aid #1 for pain and documented as effective.
An interview was conducted on 01/06/23 at 8:17 AM with Nurse #6. Nurse #6 confirmed she transcribed the physician's order for tramadol on 12/31/22 for Resident #96. After review of the order Nurse #6 stated she transcribed it incorrectly and indicated it was an oversight on her part. Nurse #6 revealed she didn't include the frequency between doses that was a requirement for a complete physician's order of a medication being used as needed.
An interview was conducted on 01/06/23 at 5:41 PM with Nurse #3. Nurse #3 revealed the medication label included the frequency between doses to give every 6 hours and she recalled telling the oncoming nurse to give it every 6 hours because it wasn't on the physician's order or MAR. Nurse #3 stated she should've called the Medical Doctor to clarify the order to include the frequency between doses.
During an interview on 01/06/23 at 5:18 PM Medication Aid #1 confirmed she administered Resident #96's tramadol on 01/02/23. Medication Aid #1 revealed she did not ask for clarification of the frequency between doses and when Resident #96 asked for the medication she administered it.
An interview was conducted with the Director of Nursing (DON) on 01/06/23 at 2:46 PM. The DON stated she would expect the administering nurse to get clarification from the Medical Doctor (MD) to include time parameters between doses to administer tramadol as needed. The DON revealed the clinical team reviewed new medication orders and two checks were done to ensure physician orders were complete.
During an interview on 01/06/23 at 4:46 PM the Administrator stated he would expect the nurse to get clarification for an incomplete order to include when to administer an as needed pain medication with no time parameter between doses.

Based on record review, observations, and interviews with staff the facility 1) failed to implement their policy and procedures for Hand Hygiene when Nurse Aide #2 did not perform hand hygiene before donning gloves and after possible contact with body fluids before touching other surfaces in the room for 1 of 1 resident reviewed for incontinence care (Resident #49), 2) failed to store soiled linens off the floor for 1 of 1 laundry room, 3) failed to follow the Droplet Precautions signage posted by the door of a resident's room when 1 of 1 staff (Activity Assistant #1) did not don a gown while feeding a resident for 1 of 4 residents on droplet/contact precautions (Resident #98).
The findings included:
Review of the facilities Hand Hygiene/Hand Washing policy revised on 07/14/21 read in part, hand washing was the most important component for preventing the spread of infection and the use of gloves does not replace the need for hand cleaning. The policy provided guidance when to perform hand hygiene including before and after having direct contact with residents and after contact with body fluids or excretions.
1. During an observation and interview on 01/05/23 at 1:07 PM Nurse Aide (NA) #2 donned a pair of gloves without performing hand hygiene and began to provide care for an episode of urinary incontinence for Resident #49. NA #2 used premoistened wipes to clean the front peri-area then asked Resident #49 to roll to the side then wiped the buttocks. Without removing her gloves and performing hand hygiene NA #2 applied a clean brief then removed a tube of barrier cream from the nightstand drawer. NA #2 applied the cream to Resident #49's buttocks and replaced the tube back in the drawer and closed it. Without removing her gloves and performing hand hygiene NA #2 used the opposite hand to grab the bed remote and reposition the head of the bed. NA #2 then removed her gloves. NA #2 revealed she knew infection control procedures and should've washed her hand hands before donning gloves and removed her gloves and performed hand hygiene after possible contact with body fluids before she touched other items in the room.
An interview was conducted on 01/06/23 at 8:45 AM with Unit Manager #1. Unit Manager #1 revealed she provided infection control and hand hygiene education to NA staff during their orientation upon hire and ongoing throughout their employment. Unit Manager #1 explained she reviewed procedures for when to wash your hands that included before donning gloves and if there was possible contact with body fluids. Unit Manager #1 stated she expected the NA staff to wash their hands prior to donning gloves and remove gloves and wash their hands after wiping a resident clean for incontinence before touching other surfaces in the room.
2. An observation and interview were conducted on 01/06/23 at 9:58 AM of the laundry room with Housekeeper/Laundry Aide #1. A small pile of bed linens and blankets were observed on the floor by the washing machine. Housekeeper/Laundry Aide #1 revealed the laundry on the floor was dirty and putting it there made it easier to sort. Housekeeper/Laundry Aide #1 revealed she was used to seeing dirty/soiled laundry on the floor in the laundry room. There were 2 large sized empty storage bins available and located close to the dirty laundry. Housekeeper/Laundry Aide #1 donned gloves and removed the soiled linens and blankets off the floor and placed in a storage bin.
An interview was conducted on 01/06/23 at 10:09 AM with the Maintenance/Laundry Supervisor. The Maintenance/Laundry Supervisor stated soiled laundry should not be placed directly on the floor instead placed in the designated laundry bins and pointed to the 2 large empty bins located by where the soiled laundry was on the floor. The Maintenance/Laundry Supervisor revealed the 2 bins were dedicated for soiled laundry and he would label them to make it easier for the staff to identify where to place dirty/soiled laundry.
An interview was conducted on 01/06/23 at 2:58 PM with the DON. The DON stated soiled laundry should not be placed directly on the floor in the laundry room. The DON stated she would expect Housekeeping/Laundry staff to use the designated soiled linen bin in the laundry room.
3. Droplet Precautions include:
a. A mask is worn for close contact with infectious resident.
b. Gloves, gown, eye protection are worn adhering to Standard Precaution guidelines.
An observation of a sign titled Droplet Precautions outside Resident #98's room on 01/04/23 at 09:23 AM revealed the sign stated anyone entering the room must perform hand hygiene and wear a surgical mask, gloves, and a gown. A cart containing isolation gowns was positioned outside Resident #98's room.
An observation of Activity Assistant #1 on 01/04/22 at 09:24 AM revealed she was feeding Resident #98 breakfast. Activity Assistant #1 was observed to be wearing a mask and gloves. Activity Assistant #1 was not wearing a gown while feeding Resident #98.
During an interview with Activity Assistant #1 on 01/04/23 at 09:32 AM she confirmed she was not wearing a gown while feeding Resident #98. When Activity Assistant #1 was asked if she saw the sign outside Resident #98's room directing anyone who entered the room to wear a gown, gloves, and mask she stated she did not. Activity Assistant #1 stated if she had seen the Droplet Precautions sign outside Resident #98's room she would have put on a gown before entering the room.
An interview with Unit Manager #1 on 01/05/22 at 02:16 PM revealed Resident #98 was placed on droplet precautions on 01/02/23 due to her roommate testing positive for COVID-19 on 01/02/23.
An interview with the Director of Nursing (DON) on 01/06/23 at 03:14 AM revealed if a resident was on droplet precautions she expected staff to wear a gown while feeding the resident.

Based on observations, record review, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey of 06/04/21 and the focused infection control and complaint survey of 7/23/2020. This was for two deficiencies that were originally cited in June and July 2020 in the area of respiratory care and infection control and prevention and was subsequently recited on the current recertification survey of 01/07/23. The continued failure of the facility during two federal surveys of record shows a pattern of the facility ' s inability to sustain an effective Quality Assurance Program.
The Findings Included:
This tag is cross referred to:
F695 - Based on record review and interviews with staff the facility failed to obtain a physician's order for use of a continuous positive airway pressure (CPAP) machine for a resident admitted with a diagnosis of moderate obstructive sleep apnea (sleep-related breathing disorder) for 1 of 2 residents reviewed for oxygen (Resident #251).
During the recertification and complaint investigation survey completed on 06/04/21 the facility failed to ensure an oxygen tank had oxygen in it and was delivering oxygen to the resident.
F880 - Based on record review, observations, and interviews with staff the facility 1) failed to implement their policy and procedures for Hand Hygiene when Nurse Aide #2 did not perform hand hygiene before donning gloves and after possible contact with body fluids before touching other surfaces in the room for 1 of 1 resident reviewed for incontinence care (Resident #49), 2) failed to store soiled linens off the floor for 1 of 1 laundry room, 3) failed to follow the Droplet Precautions signage posted by the door of a resident's room when 1 of 1 staff (Activity Assistant #1) did not don a gown while feeding a resident for 1 of 4 residents on droplet/contact precautions (Resident #98).
During the recertification and complaint investigation survey completed on 06/04/21 the facility failed to implement enhanced droplet precautions for a resident who readmitted to the facility and was unvaccinated against COVID-19 and failed to implement enhanced droplet precautions for a newly admitted resident who was unvaccinated against COVID-19.
During the focused infection control and complaint survey on 7/23/20 the facility failed to ensure staff performed hand hygiene after contact with a resident or objects in the residents room for 3 of 3 residents failed to ensure proper Personal Protective Equipment (PPE) were donned and doffed when entering and exiting a resident room with signage indicating Advance Droplet Contact Precautions for 3 of 3 residents (Resident #1, #2,and #3), failed to perform proper decontamination and removal of items removed from a room with signage indicating Advanced Droplet Contact Precautions (Resident #3), the facility failed to develop and implement policies on wearing face coverings (Staff 1 of 1), the facility failed to develop and implement policies for wearing PPE and performing hand hygiene when entering and exiting resident care rooms for residents on Advanced Droplet Contact Precautions (Staff 5 of 5), and ensure proper usage of face coverings by reception staff when screening employees and visitors. (Staff 1 of 1). These failures in proper infection control practices occurred during a COVID-19 pandemic and had the potential to affect all residents and staff in the facility through the transmission of COVID-19.
During an interview with the Administrator on 01/06/23 he reported the facility's Quality Assurance (QA) Team met once a month and reviewed current plans within the QA process. He indicated that respiratory care was not currently in the QA plans but reported it would included moving forward. The Administrator stated however, infection control and prevention was in the QA process and that he felt the breakdown with infection control during the recertification survey revolved around his staff being in a rush and a lack of thorough thinking. He reported the staff member at the center of the infection control breakdown had received training upon hire and then multiple other times during their employment at the facility. The Administrator stated all repeat citations would be placed back into the QA process along with additional new citations and all non-cited complaint allegation areas.

Based on observations and staff interviews the facility failed to ensure the area around the dumpster was free of trash and debris for 1 of 2 dumpster reviewed.
The findings included:
An observation of the dumpster area and interview with the Dietary Manager (DM) was conducted on 01/03/23 at 11:05 AM. The observation revealed 2 dumpsters one for cardboard that was noted to be empty. The other dumpster was for trash, the door on the left side was open and a clear trash bag that was busted laid next to the open door. The bag was busted with food and trash littered all over the ground and up against the dumpster. There were multiple clear bags that were busted and debris of food, food pans, cups, utensils, broken and unbroken plates, glass plates, used gloves, glove boxes, and paper was littered approximately ten feet around the dumpster area. The DM stated she was not sure who was responsible for cleaning the dumpster area.
An interview was conducted with Dietary Aide (DA) #1 on 01/03/23 at 11:08 AM. DA #1 stated that the DM had summoned him to the dumpster area with a broom and dustpan. He stated that the dumpsters were emptied every 2-3 days but usually they only emptied them about every 4 days. DA #1 stated that it was housekeeping and maintenance responsibility to keep the dumpster area clean.
An interview was conducted with the Floor Tech on 01/03/23 at 11:11 AM who stated he also worked in the maintenance department at the facility. He stated that the dumpsters were emptied every day, and they just did a cleanup in the dumpster area not too long ago. The Floor Tech added that it was everyone's responsibility to keep the area clean. He described the area as nasty and indicated that all the food and debris should be in the dumpster because it had the potential to attract rats and other rodents.
The Administrator was interviewed on 01/06/23 at 6:45 PM who confirmed the dumpsters were emptied two times a week and the maintenance staff would go out there once a week to ensure the area was clean and that there was no trash or debris on the ground. The Administrator stated that he had sent out a text to all the departments last week letting everyone know that they were responsible for ensuring their own trash was disposed of properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff the facility failed to obtain a physician's order for use of a continuous positive airway pressure (CPAP) machine for a resident admitted with a diagnosis of moderate obstructive sleep apnea (sleep-related breathing disorder) for 1 of 2 residents reviewed for oxygen (Resident #251).
The findings included:
Review of the hospital discharge summary revealed Resident #251 was admitted on [DATE] with an active list of problems and diagnoses that included moderate obstructive sleep apnea. The hospital discharge also included a summarization of Resident #251's medical history that listed obstructive sleep apnea with the use of a CPAP. Resident #251 was discharge from the hospital on [DATE] with no physician orders in place for the use of a CPAP.
Resident #251 was admitted to the facility on [DATE] with diagnoses including heart failure and chronic obstructive pulmonary disease (a chronic inflammatory lung disease obstructing airflow). Resident #251 was discharged to the community on 06/02/22.
Review of the admission Minimum Data Set (MDS) dated [DATE] assessed Resident #251 as being cognitively intact and indicated the use of oxygen and a CPAP occurred while a resident at the facility.
Review of the physician orders written on 05/20/22 directed staff to put on the CPAP for Resident #251 at bedtime every night using the home settings for sleep and remove every morning.
Review of the comprehensive care plan revealed on 05/23/22 the use of a CPAP was initiated and included the intervention for nursing staff to put the CPAP on Resident #251 at bedtime and remove in the morning per Medical Doctor (MD) orders.
During an interview on 01/05/23 at 2:27 PM Nurse #1 confirmed she completed the admission assessment but didn't recall Resident #251. Nurse #1 stated if Resident #251 was admitted with a CPAP it was the nurses responsibility to assist putting it on and would be left on the home settings. Nurse #1 stated an MD order was needed for the use of a CPAP machine.
During an interview on 01/06/23 at 11:09 AM the MDS Coordinator revealed she would review the hospital records when a resident was admitted and if Resident #251's discharge summary discussed the use of a CPAP for the diagnosis of obstructive sleep apnea a physician's order was needed. The MDS Coordinator stated we should've clarified the use of the CPAP with the MD and obtained an order for the use prior to 5/20/22.
An interview was conducted on 01/06/23 at 2:54 PM with Director of Nursing (DON). The DON stated if there was no MD order, she would expect the nurses to clarify the use of the CPAP with the physician and obtain an order.
An interview was conducted on 01/06/23 at 4:37 PM with the Administrator. The Administrator stated he would expect an MD order was in place for the use of a CPAP at the time of admission. The Administrator revealed if the hospital discharge summary identified Resident #251 had sleep apnea and used a CPAP with no physician order, he would expect the nurse to obtain clarification from the MD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of document titled Preadmission Screening Resident Review (Pasrr) dated 06/07/22 indicated that Resident #9 was determined to be Level 2 Pasrr.
Resident #9 was admitted to the facility on [DATE] with diagnoses that included paranoid personality disorder and traumatic brain injury.
Review of the admission comprehensive Minimum Data Set (MDS) dated [DATE] indicated that Resident #9 did not have a Level 2 Pasrr and was completed by the MDS Coordinator.
The MDS Coordinator was interviewed on 01/06/23 at 12:31 PM. The MDS Coordinator confirmed she had completed the admission comprehensive MDS dated [DATE] for Resident #9 and confirmed he had a Level 2 Pasrr in place. She stated it was probably an accident, I meant to click yes and accidentally clicked no. The MDS Coordinator stated she would correct the mistake immediately.
The Director of Nursing (DON) was interviewed on 01/06/23 at 4:34 PM. The DON stated that she expected the MDS assessments to be completed accurately including the Pasrr information.
The Administrator was interviewed on 01/06/23 at 5:19 PM. The Administrator stated that the MDS should be coded accurately including the Pasrr information.
Based on record review and facility staff interviews, the facility failed to accurately code a Minimum Data Set Assessment for the use of antipsychotics for 1 of 5 residents reviewed for unnecessary medications (Resident #12), failed to accurately code a level II Preadmission Screening and Resident Review (PASRR) for 1 of 2 residents reviewed for PASRR (Resident #9), and failed to accurately code a discharge location for 1 of 3 residents reviewed for discharges. (Residents #90).
The findings included:
1. Resident #12 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, and mood disorder.
A review of Resident #12's quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed she received antipsychotic medications 7 of 7 days during the assessment period. Resident #12 was coded as not receiving antipsychotics on a scheduled or routine basis.
A review of Resident #12's physician orders revealed an order dated 03/02/22 for Aripiprazole tablet 2 milligrams - give 1 tablet by mouth one time a day for mood disorder.
During an interview with MDS Nurse #1 on 01/05/23 at 11:48 AM, she reported the facility's corporate MDS Nurse completed the assessment and must have mis-clicked the box indicating whether or not Resident #12 had received antipsychotic medications on a routine basis. She verified the Minimum Data Set Assessment was inaccurate and that antipsychotic use should be coded correctly.
During an interview with the Corporate Nurse on 01/05/23 at 5:06 PM, she reported Minimum Data Set assessments should accurately reflect the use of antipsychotic medications and the error should have been caught before submission and corrected.
During an interview with the Administrator on 01/06/23 at 7:32 PM he reported the facility had a system in place that audited MDS assessments for accuracy. He stated however, the audit system was not a 100% audit so there were opportunities for inaccuracies to slip through. He reported MDS assessments should be accurate and reflect the use of antipsychotic medications for Resident #12
3. Resident #90 was admitted to the facility on [DATE] and discharged to home on [DATE].
Review of the facility Discharge summary dated [DATE] revealed Resident #90 was to be discharged home with her family.
Review of the care plan conference documentation dated 11/10/2022 revealed Resident #90 was scheduled for discharge to home on [DATE].
Review of the discharge Minimum Data Set (MDS) dated [DATE] noted Resident #90 had been discharged to an acute hospital with return not anticipated.
An interview was conducted with the MDS Coordinator on 1/5/2022 at 11:48 AM. The MDS Coordinator stated Resident #90's discharge MDS dated [DATE] should have noted she discharged to the community instead of to an acute hospital. The MDS Coordinator explained this must have been noted by accident.
An interview was conducted with the Corporate Nurse and the Administrator on 1/5/2022 at 5:06 PM: The Corporate Nurse stated that the discharge MDS dated [DATE] for Resident #90 should reflect that she was discharged to home not to the hospital. The Administrator stated that he expected all MDS data to be coded accurate and to reflect the resident's assessment and disposition.

Based on record review, staff interviews, and policy review the facility failed to thoroughly investigate alleged abuse and protect residents from further abuse and failed to implement their abuse policy and procedure in the area of reporting to the State Survey Agency when they received an allegation of staff to resident abuse for 1 of 3 residents (Resident #57) reviewed for abuse.
Findings included:
Review of the facility's policy titled Abuse, Neglect, and Exploitation last revised 10/03/22 read in part as follows, It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown source. Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy. Further review of the policy read in part as follows:
Section 4
If a staff member is accused or suspected of abuse, neglect, mistreatment, exploitation, involuntary seclusion, and/or misappropriation of property the facility immediately removes the staff member from the resident care are and requests a written statement from the accused staff member. The accused staff member will remain under direct supervision until statement is complete and/or law enforcement arrives if applicable. The accused staff member will then be removed from the facility and the schedule pending the outcome of the investigation.
Section 7
Once the Administrator and Director of Nursing (DON) are notified an investigation of the allegation or suspicion will be conducted. The investigation must be completed within five working days from the alleged occurrence.
Section 9
Final report will be submitted to applicable State Agency after the investigation is completed but no later than five working days from the alleged occurrence.
An interview with Resident #37 on 01/04/23 at 02:51 PM revealed she reported seeing through the room divider curtain in August 2022 (she could not recall the exact date) Nurse Aide (NA) #3 hit Resident #57 on the upper body while providing care. Resident #37 said she reported the incident to Nurse #5 the same day it occurred.
During an interview with the Administrator on 01/04/23 at 05:14 PM he confirmed he was the Abuse Coordinator. He stated he was notified by Nurse #5 on 08/21/22 that Resident #37 needed to speak to him regarding an allegation of abuse. The Administrator stated he spoke with Resident #37 on 08/21/22 and she reported that she saw through the room divider curtain NA #3 hit Resident #57 while providing care. He explained he felt it was not possible to see through a room divider curtain and he already had 3 abuse investigations in progress that involved random weekly skin checks and random abuse questionnaires. The Administrator stated a skin check was done on Resident #57 on 08/21/22 and no skin abnormalities were noted and he interviewed NA #3 and NA #4 who were assigned to care for Resident #57 and they denied Resident #57 was struck by NA #3 when care was provided. He confirmed he did not suspend NA #3 or obtain a written statement from her after the allegation of abuse was reported. The Administrator stated he did not complete a 24 hour/5-day investigation and looking back he probably should have.
An interview with NA #3 on 01/04/23 at 09:57 PM revealed she was aware of an allegation in August 2022 by Resident #37 that she struck Resident #57 while providing care to her. She stated she did not become aware of the allegation until several days after the incident when the former Director of Nursing (DON) told her Resident #37 stated she hit Resident #57. NA #3 stated the DON did not interview her regarding the incident. She stated the Administrator interviewed her the same day the DON made her aware of the allegation, but she never heard anything else about the incident. NA #3 stated on the day in question she and NA #4 provided incontinence care for Resident #57 and Resident #57 was combative during care, but they were able to complete the care with no problems. She stated she did not hit Resident #57 in August 2022 or any other time.
An interview with NA #4 on 01/05/22 at 11:32 PM revealed she was aware of an allegation in August 2022 by Resident #37 that NA #3 struck Resident #57 while providing care to her. She stated she did not become aware of the allegation until several days after the incident was said to have occurred. NA #4 stated the former DON asked her to write a statement regarding the reported incident and she did not hear anything else about the incident. She stated she never discussed the incident with the Administrator. NA #4 stated when she and NA #3 provided care to Resident #57 on the day in question the resident was swatting at the air, but she talked with Resident #57 and she calmed down and they completed care with no difficulty. NA #4 stated she was in the room with NA #3 the entire time care was provided to Resident #57 and NA #3 did not strike Resident #57.
An interview with Nurse #5 on 01/05/23 at 01:09 PM revealed Resident #37 reported to her one day in August 2022 (she could not recall the exact date) that the resident witnessed through a pulled room divider curtain NA #3 strike Resident #57 while NA #3 was providing care. Nurse #5 stated when Resident #37 reported the allegation of NA #3 striking Resident #57 she understood the incident had occurred a few days prior to Resident #57 reporting the incident to her but she notified the Administrator immediately of the report of abuse. Nurse #5 stated she asked Resident #37 to write a statement of what she witnessed between NA #3 and Resident #57, and she wrote a statement of what Resident #37 reported to her and placed both statements in the Administrator's mailbox at the end of her shift. She stated the Administrator or Director of Nursing (DON) employed at the facility in August 2022 did not interview her regarding what Resident #37 reported to her regarding alleged abuse.
In a follow-up interview with Resident #37 on 01/06/22 at 04:51 PM she stated the Administrator did not speak with her regarding her report of seeing NA #3 hit Resident #57 through the room divider curtain for over a week after she reported the incident to Nurse #5. Resident #37 stated the day she reported the incident to Nurse #5, Nurse #5 asked her to write a statement regarding what she observed and wrote a statement and gave it to Nurse #5.
An interview with the former DON revealed she did not recall any allegation by Resident #37 that NA #3 struck Resident #57 when care was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to honor a resident choice to get out of bed everyday for 1 of 3 residents reviewed for choices (Resident #44).
The findings included:
Resident #44 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction.
Review of a care plan updated on 07/12/22 read in part, Resident #44 had deficits in activities of daily living. The goal read, Resident #44 will maintain current level of function through the next review period. The interventions included transfer with total body lift with two-person assistance.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #44 was cognitively intact and required extensive assistance of two staff members with transfers. The MDS further revealed no rejection of care was noted during the assessment reference period.
Resident #44 was interviewed on 01/03/23 at 2:09 PM and revealed that last Saturday and Sunday (12/31/22 and 01/01/23) she was not able to get out of bed because there was no sling to use. Resident #44 explained that the Nurse Aides (NA) has been reporting to her that if the lift sling pad was soiled the staff were throwing it away instead of washing it. She further explained that when she asked why she was not able to get out of bed the NAs reported that there was not enough staff, there were not enough sling pads, or the lifts were not working correctly so she was not sure what the real reason why she could not get up those days. Resident #44 stated that she tried to accommodate the staff by not getting up by watching television, but added she liked to practice the piano and I can not do that from my bed. Resident #44 stated that she believed NA #1 was caring for her on Saturday and Sunday when she could not get out of bed.
An observation of Resident #44 was made on 01/06/23 at 2:33 PM. Resident #44 was noted to be in the mechanical lift and was being transferred from her recliner chair to her bed by NA #1.
An interview with NA #1 was conducted on 01/06/23 at 2:43 PM who confirmed that she cared for Resident #44 on 12/31/22 and 01/01/23 and that she was not able to get her out of bed because she could not find the appropriate lift sling pad for her. She explained that Resident #44 got up every day for a short period of time and usually her lift pad remained in her room. She stated that on 12/31/22 the lift pad was not in her room, so she had gone to the laundry to look for a sling and was unable to locate one. NA #1 stated that she had gone several times to laundry and could not locate a sling to use on Resident #44. On Monday 01/02/23 when the housekeeper came to collect Resident #44's laundry, NA #1 stated she discovered her sling pad in the bottom of her laundry basket, but she did not know that it was there until after the weekend. NA #1 stated she reported to Nurse #2 that they could not find a lift pad to get Resident #44 out of bed who found a sling pad in a resident's room that was empty because the resident had gone to the hospital earlier that day but because that resident was COVID positive Nurse #2 would not allow me to use the sling pad on Resident #44.
An observation of the laundry room was made with NA #1 on 01/06/23 at 2:50 PM. The laundry room was observed to have a very large bin on wheels that was covered. NA #1 pulled back the cover and the bin was observed to be full to the top with different sling pads. NA #1 stated that the bin was full on 12/31/22 and 01/01/23 but the lift pad that Resident #44 required was not in the bin and she could not use one that was not the right size or shape for Resident #44.
A follow up interview and observation with Resident #44 was made on 01/06/23 at 2:57 PM. Resident #44 was resting in bed. There was a large box behind her bed and laying on top of the open box was a sling pad. She stated that her lift pad was kept in that box because we try to hide it so we always have one available.
Nurse #2 was interviewed on 01/06/23 at 3:01 PM. Nurse #2 confirmed that she worked on 12/31/22 and 01/01/23 and that the staff had reported that they could not find a lift pad to get Resident #44 out of bed. Nurse #2 stated that NA #1 had gone several times to laundry and could not locate the correct sling to use on Resident #44. Nurse #2 explained that she had another resident who was very sick, and she had tested positive for COVID, and they had sent that resident to the hospital earlier and in her room, they found a sling pad that could be used on Resident #44 but because the resident had been COVID positive she would not allow NA #1 to use the sling on Resident #44 until it could be washed appropriately. She confirmed that Resident #44 got out of bed every day for a short period of time and would practice her piano a few times a week during the times that she was out of bed.
The Director of Nursing (DON) was interviewed on 01/06/23 at 4:41 PM. The DON explained she had only been working at the facility since 12/30/22 and was unaware that they could not find a sling pad to get Resident #44 out of bed. The DON stated that she expected the staff to honor Resident #44's request to get of bed when she wanted to.
The Administrator was interviewed on 01/06/23 at 5:35 PM. The Administrator stated that there should be sling pads available to get the residents out of bed. He stated that they have extra slings in the storage rooms. The problem is that often time the slings were not returned to the supply room. The Administrator stated that if the sling was soiled it should have been sent to the laundry and an extra sling pad obtain and used until the other sling was clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and family interviews the facility failed to fully complete and ensure the accuracy of a recapitulation of stay for 1 of 3 residents reviewed for discharge (Resident #143).
The findings included:
Resident #143 was admitted to the facility on [DATE] with diagnoses that included sequelae of cerebral infarction (stroke) and dysphagia (trouble swallowing). Resident #143 discharged to the community on 08/15/22.
Review of the comprehensive admission Minimum Data Set (MDS) dated [DATE] indicated that Resident #143 was severely cognitively impaired for daily decision making and required extensive assistance with activities of daily living to include bed mobility, toileting, dressing, and personal hygiene.
Review of a physician order dated 08/03/22 read cardiac puree diet with nectar thick liquids.
Review of a physician order dated 08/15/22 read; stable for discharge home on [DATE] with home health.
Review of a facility document titled Discharge Instructions dated 08/15/22 revealed a section titled Nursing and included dietary instructions that indicated Resident #143 was discharged on a regular diet with thin liquids and no special diet instructions were noted. The section was signed by Nurse #1. The document further revealed a section titled Rehab that was blank and contained no information about the resident's functional mobility or how much assistance was needed for activity of daily living care. The section was not signed by any staff member. The entire document was signed and dated by Resident #143's family member.
The Social Worker (SW) was interviewed on 01/05/22 at 9:47 AM. The SW stated that each morning in the clinical meeting she would announce the residents that were going to discharge that week. She stated that she would then open the recapitulation of stay or discharge instructions in the electronic medical record and each department manager would go in and fill out their appropriate sections. Upon discharge the nurse would print off the document, go over it with the resident and/or family, and then have the family sign the document and provide them a copy while the original copy would be placed in the resident's medical record. The SW stated that the department managers were aware that they were responsible for completing the document prior to the resident's discharge.
Nurse #1 was interviewed on 01/05/23 at 2:45 PM. Nurse #1 confirmed that she had discharged Resident #143 from the facility on 08/15/22. She further confirmed that she was responsible for completing the section titled Nursing on the recapitulation of stay and would have looked up the information to put on the form. Nurse #1 stated that the Rehab program manager would be responsible for completing the Rehab section. Each morning in their morning meeting the SW would go over the upcoming discharges and open the recapitulation of stay document in the electronic record then each department manager would go in and complete their section. Nurse #1 added upon discharge she would complete the nursing section print off and go over the document with the family and give them a copy and have them sign a copy of the document. Nurse #1 could not explain why the discharge instructions indicated that Resident #143 was a regular diet with thin liquids when she had a physician order to be on puree diet with nectar thick liquids. When asked if she educated the family on preparing thick liquids for Resident #143, she stated no.
The Rehab Program Manager was interviewed via phone on 01/05/23 at 4:29 PM. The Rehab Program Manager confirmed that it was her responsibility to complete the Rehab section of the recapitulation of stay. She explained that the SW would open the document in the electronic medical record and then in the morning meeting let everyone know that the resident was being discarded and when. Then the department managers would go in a fill out their appropriate section of the recapitulation of stay. The Rehab Program Manger stated that it was very possible that she may have missed completing the document for Resident #143 but added the social worker was really good about letting me know if I had not done my part.
An interview with Resident #143's family member was conducted via phone on 01/06/23 at 1:31 PM. The family stated that she picked up Resident #143 from the facility on 08/15/22 and cared for her at home with no issues until she found another facility that her mother could go to.
The Director of Nursing (DON) was interviewed on 01/06/23 at 4:30 PM. The DON stated that each resident that was discharged from the facility was to have a complete an accurate recapitulation of stay with a copy being provided to the resident and/or family.
The Administrator was interviewed on 01/06/23 at 5:10 PM. The Administrator stated the recapitulation of stay should be completed fully and be accurate and provided to the resident and/or family on discharge from the facility.