Every finding on record at Civita Care Meadowbrook

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for activities of daily living (ADL) care, the facility failed to ensure a safe environment and protect a non-ambulatory, cognitively impaired resident who was totally dependent on staff for transfers from injury. This failure resulted in Resident #1 sustaining a femur fracture and displaced tibia and fibula fractures requiring surgical intervention. The findings include:Resident #1 was admitted to the facility with diagnoses that included dementia and osteoarthritis. Resident #1 had a power of attorney for health decisions. The Fall Risk assessment dated [DATE] identified Resident #1 was at risk for falls.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 0) and was always incontinent of bowel and bladder.The Resident Care Plan (RCP) dated 1/14/26 identified Resident #1 had an ADL deficit related to cognitive loss/dementia, impaired mobility and non-ambulatory total lift. Interventions included assist of two (2) dependent for bed mobility, assist of two (2) for transfers and customized wheelchair (WC) with head rest and bilateral leg rests.A progress note by APRN #1 dated 1/29/26 identified Resident #1 had baseline confusion due to dementia. APRN #1 identified Resident #1's musculoskeletal system identified no pain and was moving all extremities and had contractures to bilateral knees.The physician's orders dated February 2026 directed Hoyer lift with assist of two (2) for transfers and assist of one (1) ADL's and toileting at bed level.The physician's order dated February 2026 directed Acetaminophen 650 mg three (3) times a day for pain (at 8:00 AM, 2:00 pm and 8:00 PM).A skin check dated 2/7/26 identified Resident #1 had no new skin impairments.A nurse's note by RN #1 dated 2/10/26 at 4:00 PM, late entry, identified the Charge Nurse notified RN #1 that Resident #1 had increased body pain early that morning including lower bilateral pain. Per the Charge Nurse, Resident #1 was uncomfortable when personal care was provided and Tylenol was administered. Resident #1 was out of bed in the WC in the dining room. Resident #1's left leg was swollen, skin was intact but painful to touch. The pain regiment was discussed with the provider. APRN #1 was on site and notified of the change. Resident #1 was transferred to bed for further assessment by APRN #1 and new orders were placed for an ultrasound to rule out deep vein thrombosis (DVT) and an x-ray.The x-ray report dated 2/11/26 identified displaced angulated recent appearing proximal tibial and fibular fractures.A nurse's note by RN #1 dated 2/11/26 at 2:13 PM identified Resident #1 had a bedside x-ray and preliminary images appeared to show a fracture of the lower left leg. APRN #1 was notified and directed Resident #1 be transferred to the emergency department (ED).A physician note dated 2/11/26 identified he was updated on the results of the left leg x-ray that identified an acute left tibial fracture. He identified likely etiology as fracture due to severe osteoporosis which could have happened while transferring Resident #1 onto his/her lift. The physician ordered Resident #1 be sent to the ED for further evaluation.The hospital Discharge summary dated [DATE] to 2/16/26 identified the primary discharge diagnoses of tibia/fibula fracture and fracture of the right femur. Resident #1 underwent a left open reduction and internal fixation surgery and right lower extremity splint.The Reportable Event (RE) form dated 2/11/26 identified on 2/10/26 Resident #1 had a complaint of left lower extremity pain. The APRN ordered an x-ray and Doppler to rule out DVT or trauma. The x-ray that resulted on 2/11/26 appeared to show a fracture on the lower left leg. Resident #1 was transferred to the ED for further evaluation where Resident #1 was diagnosed with a left tibia/fibula fracture and a right femur fracture. The RE identified on 2/9/26 during the afternoon, Resident #1's family member identified Resident #1 complained of left leg pain but did not report it due to chronic pain. Following review of the hospital documentation, the Medical Director stated there was no clear etiology for the fractures. It was possible the injuries represented osteoporosis-related fragility fractures, potentially associated with mechanical lift transfers.Interview with NA #1 on 3/10/26 at 1:00 PM identified on 2/9/26 she was assigned to provide care for Resident #1 on the 6:00 AM to 3:00 PM shift. She identified she performed morning care for Resident #1 around 6:30 AM and Resident #1 had no pain and was not crying out. She identified Resident #1 had lower extremity baseline edema but there was no discoloration or bruising. She identified Resident #1 was transferred to his/her WC with the Hoyer lift and assistance from NA #2. She Identified there were no issues with the transfer. She was then transferred back to bed around 12:15 PM with the Hoyer lift and assistance from NA #2 with no issues with the transfer. She further identified on 2/10/26 she was assigned to provide care for Resident #1 on the 6:00 AM to 3:00 PM shift and when she went to apply socks on Resident #1 around 6:30 AM, Resident #1 started screaming. She identified she stopped care and notified LPN #2 (11:00 PM - 7:00 AM charge nurse). She identified she also notified LPN #1 (7:00 AM - 3:00 PM charge nurse). She identified Resident #1 calmed down and was transferred to his/her WC with the Hoyer lift and NA #2 without issue. She identified Resident #1 appeared comfortable during the day and around lunch Resident #1 was transferred back to bed with the Hoyer lift and assistance from NA #3.Interview with LPN #1 on 3/12/26 at 3:50 PM identified on 2/10/26 she was Resident #1's LPN for the 7:00 AM - 3:00 PM shift. She identified NA #1 notified her that Resident #1 was screaming in the morning. She identified she notified the Supervisor (RN #1) and APRN #1 around 8:00 AM. She identified Resident #1 received scheduled Tylenol at 8:00 AM with good effect. Resident #1 had no signs or symptoms of pain throughout the shift.Interview with RN #1on 3/10/26 at 2:40 PM identified on 2/10/26 she was Resident #1's RN for the 7:00 AM - 3:00 PM shift. She identified Resident #1 did not have pain after NA #1 performed morning care. She identified around 11:30 AM, with APRN #1, Resident #1 was observed sitting at the dining room table. Resident #1 was not crying out or complaining but appeared uncomfortable. APRN #1 had Resident #1 transferred back to bed for further assessment and ordered a Doppler and x-rays of the lower left extremity.Interview with APRN #1 on 3/10/26 at 3:02 PM identified on 2/10/26 when she was rounding, she was notified that Resident #1 complained of left leg pain and there was no known trauma. APRN #1 assessed Resident #1 around 12:00 PM and ordered a Doppler to rule out DVT and x-ray.Interview with APRN #2 on 3/10/26 at 3:11 PM identified if Resident #1 had fallen alone, he/she would not have been able to get up independently. Resident #1 had no recent falls reported and was an assist of two staff for transfers with a Hoyer lift. She identified if Resident #1 did fall out of bed, she would expect different injuries would have presented. She identified that she does not think the injuries occurred during care with rolling Resident #1 because that would not cause bilateral injuries and Resident #1 was not frail. She identified the probable cause of injury was from the Hoyer lift.Interview with the DNS on 3/10/26 at 10:00 AM identified the incident was discussed with the Medical Director to try to identify the cause of Resident #1's injuries. A probable cause could have been a Hoyer lift accident therefore, in-services, education and competencies were conducted for Hoyer lift transfers.Review of the Activities of Daily Living policy directed that residents will be provided with care, treatment and services to ensure that their activities of daily living do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminished ADL's are unavoidable.The facility presented a corrective action plan dated 2/13/26 which included:Facility-wide audit of residents requiring mechanical lift transfers and extensive ADL assistance.Maintenance evaluation of all mechanical lifts.Staff education dated 2/11/26 to include: Safe resident handling and mechanical lift use Proper ADL assistance and positioning Monitoring for changes in resident condition Timely physician and family notification Accurate documentation of resident careClinical competency evaluations for Transferring a Resident Using a Mechanical Lift were conducted.Weekly Audits of 3 residents requiring mechanical lift transfers.Compliance date 2:13/26The corrective action plan for past non compliance was accepted by the state agency during an on site visit on 3/10/26.

Based on review of the clinical record, facility documentation, and interviews for one (1) of two (2) residents (Resident #1) reviewed for medically-related social services, the facility failed to ensure medically-related social services were provided and documented.The findings include: Resident #1 was admitted to the facility with diagnoses that included dementia and schizoaffective disorder. Resident #1 had a power of attorney (POA) for health decisions. The Social Work (SW) Annual assessment dated [DATE] identified Resident #1 was alert to self primarily with observed cognition deficits related to place and times as well as confusion. The note identified the SW was available for emotional support as well as concerns or complaints.The Social Service Quarterly assessment dated [DATE] identified Resident #1 continued to present with severe cognitive impairment due to advanced dementia. Resident #1's mood remained stable and continued to appear calm and friendly with poor insight and judgement. The note identified the SW would remain available for ongoing support, care coordination and advocacy for Resident #1's needs and comfort.The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 0) and Resident #1 was rarely/never understood.The Resident Care Plan (RCP) dated 1/14/26 identified Resident #1 was in a facility for long term care due to care needs. Interventions included to encourage Resident #1 to make needs known, only ask about Money Follows the Person (MFP) during comprehensive assessments and orient Resident #1 to the environment and staff. The RCP further identified Resident #1 had diagnoses of schizoaffective disorder and bipolar disorder with interventions that included to encourage Resident #1 to express his/her thoughts and feelings, provide support and validation as needed and psychiatric services within the facility.Review of the clinical record failed to identify SW quarterly progress notes since 7/2/25 (total of 8 months).Review of the clinical record failed to identify SW annual assessments since 11/13/24 (total of one year and four months).Interview with the DNS on 1/14/26 identified there were no further SW notes in Resident #1's clinical record.Subsequent to surveyor inquiry, SW #1 documented a care plan progress note dated 1/14/26, late entry, regarding a care plan meeting with Resident #1's POA.Interview with SW #1 on 3/10/26 at 4:00 PM identified she is the only SW for the building. She identified Resident #1's annual and quarterly progress notes were missed due to an oversight. She identified the computerized medical record does not prompt her to document. She identified progress notes should be completed at a minimum of quarterly and annually.Although requested, a SW documentation and assessment policy was not provided.

Based on review of the clinical record, review of facility policy and interviews for one of twenty-three sampled residents (Resident #4) reviewed for advance directives, the facility failed to ensure the physician's order matched the wishes of the resident/responsible party. The findings include: Resident #4's diagnoses included atrial flutter, Type 1 diabetes mellitus with hyperglycemia, and mild intellectual disability. The quarterly MDS assessment dated [DATE] identified Resident #4 had intact cognition, required moderate assistance with personal hygiene, was independent with bed mobility and utilized a walker for mobility. Resident #4's clinical record (physical) identified a folded Advanced Directives Declaration Code Status form that identified Resident #4 had elected a code status of Do Not Resituate (DNR) which means if the resident stops breathing or if the resident's heart stops beating, cardiopulmonary resuscitation will not be provided. It also identified that the election of Do Not intubate (DNI) which indicates the resident does not want a breathing tube) had also been designated. The form was signed by the resident's Power of Attorney (POA) and dated [DATE]. The form was not signed by the physician.The Care Plan dated [DATE] identified Resident #4 had an advance directive that established the resident elected the code status of full code indicating the resident's wish to receive cardiopulmonary resuscitation if the resident stops breathing or the heart stops beating.Review of the physician's orders for the period of [DATE] to [DATE], directed a code status of Full Code/Cardiopulmonary Resuscitation (CPR). Interview with Resident #4's Power of Attorney (Person #2) on [DATE] at 1:00 PM identified that a code status of DNR had been elected because that was Resident #4's wishes. Person #2 identified that she had discussed DNR status with the facility. Interview and clinical record review with the charge nurse (LPN #5) on [DATE] at 1:34 PM identified that if Resident #4 had a life-threatening emergency where the decision to administer CPR or withhold CPR needed to be made, she would check the resident's code status. LPN #5 identified the code status is found in the computer on the banner section of the computer screen in the resident's electronic medical record, in the resident's clinical record (physical) under the advance directive tab and the physician's order. After reviewing the flagged folded Advanced Directives Declaration Code Status consent form, the physician's orders and the electronic medical record with LPN #5, she noted that the physician's order and the electronic medical record banner indicated full code while the Advanced Directive Declaration Code Status consent form indicated DNR which was signed on [DATE]. In addition, LPN #5 identified that the physician's order should match the newest signed Advanced Directive Declaration Code Status consent form. LPN #5 identified that the code status is obtained on admission and physician's orders are obtained by 2 nurses if the provider is not in the building, if consent is obtained over the phone, then the form is flagged in the chart for the physician to sign, which is usually within 24 hours. Interview with the Nursing Supervisor (RN #3) on [DATE] at 1:57 PM identified code status is obtained on admission, readmission, and change in condition and a telephone physician order with 2 nurses present to obtain consent and for orders. RN #3 identified she was unable to state why the consent was not reviewed by the provider and an order not in place reflecting the most recent advance directives consent form.Interview with the ADNS on [DATE] at 2:45 PM identified that when the advance directive consent is signed by the resident/resident representative, then a telephone order is obtained until the provider comes in the facility to sign the actual consent form. The Advanced Directive policy and procedure identified that at the time of admission the facility reviews the Advance Directive form with the competent resident or responsible party/conservator. After reviewing, the appropriate party will check the appropriate box on the forms and sign the form. Based on the CPR/DNR consent form the nurse is then responsible for obtaining an order from the physician. The resident or responsible party/conservator has the right to change the code status at any time, and the physician is to be notified, and a new code status order obtained. The policy further identified that for the Department of Developmental Services (DDS) client all contemplated DNR orders are communicated to the case manager and the regional health coordinator by social service. Social services then obtain a signed Release of Medical Information from the client guardian, responsible party or family member prior to this notification. The facility will provide all medical information necessary to facilitate DDS's review for appropriateness of the contemplated DNR order.

Based on clinical record reviews, review of facility documentation, and review of facility policy for one of three sampled residents (Resident #40) reviewed for medication reconciliation, the facility failed to ensure the medications from the hospital discharge instructions were accurately transcribed to the facility electronic physician's orders to prevent medication error and for one sampled resident (Resident #88) reviewed for bowel function, the facility failed to ensure the bowel regimen was followed as per physician order and facility policy. The findings include:1. Resident #40's was admitted to the facility on [DATE] with diagnoses that included multiple fractures of the ribs, wedge compression fracture of 4th lumbar vertebrae, delirium, glaucoma, Gastro-Esophageal Reflux Disease (GERD), depression and dementia. Review of Resident #40's hospital Discharge summary dated [DATE] identified the following medication instructions: continue taking cyanocobalamin 100 microgram (mcg) (vitamin) by mouth once a day, donepezil 10 milligram (mg) (dementia) by mouth once a day, memantine 10 mg (dementia) by mouth twice a day, pantoprazole 40 mg (GERD) by mouth once a day, sertraline 50 mg (anti-depressant) give 2 tablets by mouth once a day, Xalatan ophthalmic solution 0.005% (glaucoma) give 1 drop to both eyes at evening, oxycodone 5 mg (opioid analgesic) give one half tablet every 6 hours for mild to moderate pain, and oxycodone 5 mg give 1 tablet every 6 hours for severe pain. Review of the medications transcribed in the facility's electronic physician's orders dated 11/4/25 directed to administered cyanocobalamin 100 mcg by mouth once a day, donepezil 10 mg by mouth once a day, memantine 10 mg by mouth twice a day, pantoprazole 40 mg by mouth once a day, sertraline 50 mg give 2 tablets by mouth once a day, Xalatan ophthalmic solution 0.005% (glaucoma) give 1 drop to both eyes at bedtime, oxycodone 5 mg give one half tablet every 6 hours for mild to moderate pain, and oxycodone 5 mg give 1 tablet every 6 hours for severe pain. Further review of the physician's orders identified the following medications were also transcribed: administer gabapentin 300 mg (anti-convulsant) by mouth four times per day for neuropathy and senna-s (laxative) give 2 tablets by mouth at bedtime. The gabapentin 300 mg and senna-s medications were not part of Resident #40's medication instructions from the hospital. The Resident Care Plan (RCP) dated 11/4/25 identified Resident #40 had a fracture rib and wedge compression fracture. Care plan interventions directed to administer medication per physician's order to promote comfort, assist resident with position changes as needed for optimal comfort, physical and occupational therapy evaluation and treatment as physician orders. Review of the Medication Administration Record (MAR) from 11/4/25 to 11/6/25 identified Resident #40 had received the gabapentin 300 mg by mouth on 11/5/25 at 5:00 PM and 9:00PM and senna-s 2 tablets by mouth (laxative) on 11/5/25 at 8:00 PM. The facility accident and incident report dated 11/6/25 at 12:40 AM identified Resident #40 had incorrect medications entered in the physician's orders. There were 2 doses of gabapentin 300 mg were given on 12/5/25 at 5:00 PM and 9:00 PM and 1 dose of senna-s 2 tablets was given on 11/5/25 at 8:00 PM. The nurse's note dated 11/6/25 at 2:15 PM identified that the ADNS was notified regarding a medication error that had occurred. Resident #40 received 2 doses of gabapentin 300 mg and one dose senna-s which were not prescribed to the resident. The physician was notified of the medication error who ordered the following laboratory tests; a Basic Metabolic Panel (BMP) and a Complete Blood Count (CBC). The orders also instructed to monitor Resident #40's neurological signs every 4 hours for 48 hours. Resident #40 denied pain or discomfort. The family was also notified with the medication error. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #40 had severe cognitive impairment and required extensive assistance with personal hygiene, dressing, toileting, and transfer. Interview with the ADNS on 11/26/25 at 10:25 AM identified she was notified that there was a medication error that had occurred with Resident #40's medication reconciliation. She identified that the gabapentin 300 mg and senna-s medication were incorrectly added to Resident #40's physician orders and he/she had received 2 doses of gabapentin 300 mg and 1 dose of senna-s medications. She identified that the process of medication reconciliation was the admitting nurse would enter all the medications in the physician order queue, and another nurse verifies that all physician orders are accurately transcribed from the hospital discharge record and activates the physician orders when it is verified that all medication in the physician order were accurately transcribed. She identified that the admitting nurse incorrectly transcribed the medication in the physician orders and second nurse activated the physician orders. She further identified that there were multiple admissions on 11/4/25 and the nurse accidentally added a medication in the physician's orders that did not belong to Resident #40 medication listing. Interview with LPN #2 on 11/26/25 at 2:10 PM identified that the facility asked her if she could help with the admission on [DATE] because there were five admissions expected. In addition, she identified that the charge nurse was not feeling well so the nursing supervisor worked on the nursing unit. She identified that she transcribed the medications in the physician's order queue, but she accidentally transcribed the gabapentin 300 mg and senna-s that did not belong for Resident #40. She also identified that the second nurse is supposed to verify the medications transcribed in the physician's order queue before activating the physician's orders to ensure that they were correct. She identified that although she had accidentally transcribed the wrong medication the second nurse who activated the physician's orders should have verified all medications matched what was in the discharge summary medication list. An attempt to interview LPN #6 was made (who activated the physician's order) but she was not available for interview during the survey period. A review of the Medication Reconciliation policy identified that the process of verifying the resident's current medication list matches the physician's orders for the purpose of providing the correct medications to the residents. The policy also identified to compare the physician's orders to the hospital record and obtain clarification as needed; the facility nurse would transcribe the physician's order in accordance with the procedures for admission orders and the second nurse would review the transcribed physician's orders for accuracy and co-sign the physician's order to indicate the review. 2. Resident #88 was admitted to the facility on [DATE] with diagnoses that included fusion of the cervical spine, cognitive communication deficit, and weakness. A nursing admission assessment dated [DATE] identified Resident #88's abdomen was soft, non-tender, and had normal bowel sounds. The assessment also indicated that Resident #88's last bowel movement was on 8/28/2025. A nursing note dated 8/29/2025 at 12:21 PM identified Resident #88 arrived at the facility alert and forgetful from the hospital. The physician's orders dated 8/29/25 directed to administer oxycodone extended release (a narcotic pain medication) 10 milligrams (mg) by mouth every morning and at bedtime for pain control and directed to implement bowel routine as per policy. A review of the medication administration record (MAR) identified Resident #88 received the scheduled oxycodone medication once on 8/29/2025, twice on 8/30/2025, and twice on 8/31/2025. A nursing note dated 8/31/2025 at 2:24 PM indicated Resident #88 had a syncopal episode while in the bathroom attempting to have a bowel movement and noted Resident#88's abdomen was firm, distended, and had decreased bowel sounds. The note further indicated that the on-call medical provider was notified, and a bowel regimen was started. A review of physician's orders identified that on 8/31/2025 at 2:28 PM the following orders were placed: 1) Give 30 milliliters (ml) of Milk of Magnesia Suspension 400 mg/ 5 ml for constipation, use first; 2) Insert one suppository of Bisacodyl Suppository 10 mg as needed for constipation if Milk of Magnesia was ineffective; 3) Administer Fleet Enema 7-19 grams (gm)/118 ml as needed for constipation if Bisacodyl ineffective. A review of the MAR for 8/31/2025 did not identify that bowel regimen medications were administered. On 9/1/2025 at 7:29 PM, Resident #88 was given 30 ml of Milk of Magnesia suspension 400mg/5ml; (17 hours after the bowel regimen was ordered). Additionally, the MAR identified that the medication was ineffective. On 9/2/2025 at 1:11 PM, an abdominal x-ray was taken. At 1:43 PM, Resident #88 was administered a bisacodyl suppository, 18 hours after the administration of Milk of Magnesia. On 9/2/2025 at 8:00 PM, Resident #88 was given two tablets of scheduled sennosides (a medication for constipation) 8.6 mg. At 11:00 PM, and 15 ml of lactulose solution (a medication for constipation) 10mg/15ml. A nursing note dated 9/3/2025 identified Resident #88 had a bowel movement; three days after Resident #88 was noted to have a firm and distended abdomen, and six days after the last documented bowel movement. On 12/1/2025 at 1:45 PM, an interview with LPN#4 identified that she did not recall whether she had administered bowel regimen medication to Resident #88 on 8/31/2025, but indicated that if she had administered anything, it would have been documented. Additionally, LPN#4 indicated that any shift can start the bowel regimen protocol and if the medication given is ineffective, then it would be reported to the next shift, so the resident can be administered the next step in the bowel regimen protocol. LPN#4 further indicated that the time between the different steps in the bowel regimen protocol is one shift or 8 hours. On 12/1/2025 at 3:11 PM, an interview with APRN#1 identified that on 9/2/2025, she evaluated Resident #88 and noted that the resident did not have a bowel movement after the bowel regimen was ordered. APRN#1 identified that she then ordered an abdominal x-ray, and when the x-ray results returned in the evening, she ordered a dose of lactulose. APRN#1 indicated that although she was not the provider on-call on 8/31/2025, she indicated that Resident#88's syncopal episode was most likely a vasovagal reaction while trying to have a bowel movement. APRN#1 indicated that if the bowel regimen was ordered on 8/31/2025 after the resident was noted to be constipated, then the bowel regimen medications should have been started that day. On 12/2/2025 at 9:59 AM, an interview with RN#5 identified that she did not recall whether she had administered a bowel regimen medication for Resident #88 on 8/31/2025. The Bowel Evacuation Protocol identified that the bowel protocol should start with Milk of Magnesia in the 3 PM to 11 PM shift. If the Milk of Magnesia were not effective, then the 11 PM to 7 AM shift would administer a bisacodyl suppository. If the bisacodyl suppository were ineffective, then the 7 AM to 3 PM shift would administer a Fleets enema. The protocol also indicated that if the bowel protocol was ineffective, notify the medical provider.

Based on review of the clinical record, review of facility policy and interviews for one sampled resident reviewed for hydration (Resident #88), the facility failed to ensure a resident's hydration needs were assessed and did not ensure that intake and output were consistently documented as per facility policy. The findings include: A hospital discharge summary report dated 8/28/2025 identified Resident #88 may have been dry with a creatinine that had increased from 1.2 to 1.5 on 8/24/2025 and that there were no concerns that would necessitate hospitalization. Resident #88 was then admitted to the facility on [DATE] with diagnoses that included fusion of the cervical spine, cognitive communication deficit, and weakness. A nursing admission assessment dated [DATE] at 9:30 AM identified Resident #88 was alert and oriented to person, place, and time. The resident's abdomen was soft, non-tender, and had normal bowel sounds, and the last bowel movement was on 8/28/2025. The admission assessment also indicated Resident #88 was independent with eating and oral hygiene, and dependent for bed mobility. A medical provider's note dated 8/29/2025 identified Resident #88 had moist mucus membranes. The note identified that Resident #88's most recent laboratory data was from 8/20/2025. The note did not identify any fluid intake goals. A physician's order dated 8/29/2025 directed to monitor I & O (intake and output) every shift for 72 hours upon admission/readmission and to document on the I&O paper flowsheet. A review of the I&O flowsheet identified that no I&O documentation for 8/29/2025, although Resident #88 had been readmitted to the facility on [DATE] at 9:30 AM. The I&O flowsheet for 8/30/2025 failed to identify if Resident #88 drank or had fluids offered from 12:00 AM to 3:00 PM. Additionally, two instances of intake of 240mL each were recorded for a total of 480mL of total fluid for the 3:00 PM to 11:00 PM shift. No 24-hour estimated fluid needs were recorded in the designated area of the I&O flowsheet. A nursing note dated 8/31/2025 at 2:24 PM indicated Resident #88 had a syncopal episode while in the bathroom attempting to have a bowel movement. The note identified that Resident#88's abdomen was firm and distended, with bowel sounds present but decreased. The note also indicated that the on-call medical provider was notified, and the facility's bowel regimen was started. The I&O flowsheet for 8/31/2025 identified a total intake of 1,320 ml the flowsheet for 9/1/2025 identified a total intake of 1,620 ml, and the flowsheet for 9/2/2025 identified a total intake of 1,500 ml. No 24-hour estimated fluid needs were recorded in the designated area of the I&O flowsheet. The I&O flowsheet for 9/3/2025 identified a total intake of 1,440 ml. A 24-hour estimated fluid needs of 3,431 mL was recorded in the designated area of the I&O flowsheet. A further review of the medical record failed to identify a nursing hydration assessment or a nutritional assessment after the resident was admitted on [DATE] or after the resident was found to be constipated on 8/31/2025. On 12/01/2025 at 3:11 PM, an interview with APRN #1 identified that all residents are placed on I&O monitoring for three days and that if residents are not meeting their fluid intake needs, then staff would notify the medical provider. APRN#1 indicated that the Dietitian calculates the fluid needs and puts it in their assessment, and that nursing staff could also calculate the fluid needs from a chart. APRN#1 also indicated that she would try to look at lab values from the hospital when a resident gets admitted to the facility but could not recall if she looked at Resident#88's lab values recorded in the hospital discharge summary; APRN #1 indicated that the lab values in her note were from 8/20/2025 and that those must have been the lab values she looked at when admitting Resident #88 to the facility. A record review with APRN#1 identified that the Resident's BUN and creatinine (lab tests used to evaluate kidney function) had increased from 8/20/2025 to 8/24/2025. The BUN had gone from 29 milligrams (mg)/deciliter (dL) to 39 mg/dL (normal range is 9 to 20 mg/dL), and the creatinine had gone from 1.0 mg/dL to 1.5 mg/dL (normal range is 0.7 mg/dL to 1.3 mg/dL). APRN#1 indicated that it could indicate a hydration need, but that other information would need to be gathered, such as medications the resident may have been on; APRN#1 further indicated that a hydration evaluation would have been helpful in managing care. On 12/2/2025 at 12:01 PM, an interview with ADNS indicated that a hydration assessment should be done on each admission and readmission if a resident had been on medical leave for over 24 hours. On 12/02/2025 at 12:33 PM, an interview with the Dietitian identified that she sees all admissions and readmissions to the facility and calculates hydration needs. The Dietitian indicated that she looks at general intake, laboratory values, and a clinical assessment when determining if someone is dehydrated or to evaluate their hydration needs. The Dietitian indicated that she may not have seen Resident #88 because she works two days a week at the facility, and the resident may have been at the hospital. The Dietitian indicated that had she seen the resident, she would have looked at lab values taken at the hospital, including the resident's BUN and creatinine. The Dietitian indicated that nursing staff can also estimate a resident's fluid needs, but that an estimated fluid need of 3,431 ml, as was written in the I&O sheet for 9/3/2025, would not be accurate. Attempts to contact RN#2 were not successful. A review of the facilities' Hydration policy identified that at-risk residents would be reviewed and provided with interventions to promote hydration. The policy also indicated that a Registered Dietitian, MD, or licensed nurse would determine the minimum fluid needs range. If the resident consumed less than their estimated needs for three consecutive days, a dehydration evaluation would be completed. The facilities policy for I&O identified that I&O monitoring would be done for 72 hours after a resident is admitted or readmitted and that I&O should be documented for each shift.

Based on observation, review of facility policy/procedures and interviews for 1 of 2 medication carts reviewed for medication storage (unit 3), the facility failed to ensure control drugs were secured under double lock. The findings include:Observation on 12/1/25 at 11:10AM with LPN#3 identified the unit 3 medication cart identified LPN #3 used a key to unlock the medication cart and once opened she was able to lift the door to the compartment that contained the controlled medications (the controlled medications were not double locked).Interview on 12/1/25 at 11:15 AM with LPN#3 identified that sometimes due to the cards in the drawer the drawer does not click shut. However, the drawer closed and locked when LPN#3 attempted to secure the lock and identified the lock does work and is not broken. Interview on 12/2/25 at 1:30 PM with the DNS identified that control drugs should be secured under double lock in the medication cart. The nurse should have had the lock box inside the cart secured. She had not heard of any issue with the medication cart having any difficulty locking. Review of the Control Substance Handling policy directed all controlled drugs shall be stored in a 2 door double locked cabinet with 2 separate keys designed for that purpose, separate from all other drugs.

Based on observations, review of facility policy and interviews, the facility failed to ensure expired food items stored in the first-floor nourishment room, were removed. The findings include:Observation on 11/25/25 at 1:08 PM identified the first-floor nourishment room refrigerator contained; 14-(4) ounce individual containers of orange juice with an expiration date of 11/7/25, 3-(4) ounce individual containers of orange juice with an expiration date of 11/19/25, and a container of yogurt with an expiration date of 11/15/25.Interview on 11/25/25 at 1:30 PM with the Food Service Director (FSD), identified the prep cook is responsible for checking the refrigerators daily and removing any expired items and restocking the refrigerators. The orange juice and yogurt should have been removed. All expired orange juice and yogurt were removed by the FSD and discarded. An attempt to interview the Prep [NAME] on 11/26/25 at 11:42 AM was unsuccessful. The Personal Food Policy directed that the dietary aides were responsible for checking nourishment refrigerator's daily. Food Brought in From Visitors policy identified the dietary staff are to adhere to food safety standards to prevent foodborne illness and meet local, state and federal regulations.

Based on clinical record reviews, review of facility documentation, review of facility policy, and interviews for two sampled residents (Resident #86 and #88) reviewed for hospitalization and discharge to the community, the facility failed to ensure the Ombudsman's office was provided with the required notification of the transfer and the discharge. The findings include: 1. Resident #86's diagnoses included malignant neoplasm of brain and unspecified part of bronchus or lung, hypertensive heart disease with heart failure, and aphasia. The admission MDS assessment dated [DATE] identified Resident #86 had moderate cognitive impairment. RN #2's progress note dated 9/3/25 at 9:00 PM identified that on 9/2/25 Resident #86 was observed in respiratory distress had oxygen saturation rates in the 70's, was placed on a non-rebreather oxygen mask at 6 liters and was sent to the acute care hospital. The Director of Social Service's (SW #1) progress note dated 9/3/25 at 9:58 AM identified Resident #86 was transferred out to the hospital on 9/2/25 with no anticipated return date. On 12/1/25 at 9:30 AM, the Director of Social Service (SW #1) was asked to provide the last four months of the monthly report of transfers and discharges sent to the ombudsman's office. The report was not provided. A review of the facility's Action Summary Report for the last five months identified the following: In June 2025, thirty-two residents were discharged and/or transferred from the facility. In July 2025, twenty-six residents were discharged and/or transferred from the facility. In August 2025 forty-three residents were discharged and/or transferred from the facility. In September 2025 thirty residents were discharged and/or transferred from the facility. In October 2025 thirty-six residents were discharged and/or transferred from the facility. Interview with SW #1 at 12:20 PM identified she was responsible for sending the routine transfer and discharges to the Ombudsman offices monthly. SW #1 identified she had not submitted the routine transfer and discharge reports to the Ombudsman office for the months requested. She further indicated that she fell behind and the last report was sent in June for the May 2025 discharges. Interview with the Administrator on 12/1/25 at 3:30 PM identified that the Social Worker is responsible for sending the reports of the transfers and discharges to the Ombudsman's office monthly via the portal. The Administrator identified that she was unaware that the Ombudsman's notifications were not being sent, however she was aware that the Director of Social Services was behind. On 12/1/25 (after surveyor inquiry) the facility updated the Ombudsman's office of all discharges and transfers that occurred during the period of June/2025 through November/2025. The discharge planning policy and procedure for notice to the ombudsman identified that the Ombudsman will be provided with copies of notices and/or a monthly listing of individuals transferred to the hospital on an emergency basis. 2. Resident #88 was admitted on [DATE] with diagnoses that included fusion of the cervical spine, cognitive communication deficit, and weakness. A 5-day MDS assessment identified Resident #88 had moderately impaired cognition and required substantial/maximal assistance with bed mobility and bed/chair transfers. A nursing note dated 9/6/2025 indicated Resident #88 was discharged from the facility against medical advice. Interview with the Social Worker on 12/2/2025 at 12:20 PM identified that all discharges and transfers are supposed to be sent to the state ombudsman every month. She noted that notifications had not been made since May 2025 because she had fallen behind with her workload and had not been submitting the discharges and transfers to the state ombudsman's office monthly. A review of the facility policy for Discharge Planning identified that the state ombudsman is provided with copies of notices or a monthly listing of individuals transferred to the hospital but did not include residents that were discharged . However, the policy indicated that social services would ensure systems are implemented to provide written notification to the resident/responsible party in accordance with federal guidelines.

Based on review of facility documentation, review of facility policy/procedures and interviews for 2 of 3 Nurse Aides (NA #1 and NA #2) reviewed for annual performance evaluations, the facility failed to ensure they were completed and available for review. The findings include:Based on review of facility documentation, review of facility policy/procedures and interviews for 2 of 3 Nurse Aides reviewed for annual performance evaluations, the facility failed to ensure they were completed and available for review. The findings included: Review of personnel records for Nurse Aide performance reviewed identified NA#1 had an evaluation 11/20/24 and was due to have one completed 11/2025. No evaluation was available to review in the personnel record or could be located for NA#1. NA#2 had an evaluation completed 10/9/25 and no 2024 evaluation was available in the personnel record or could be located to review.Interview on 11/26/25 at 9:30AM with Human Resources identified he started in May of 2025 and was unable to locate the missing reviews. It was his understanding that the DNS completed the annual performance reviews for nursing and had recently done some before going out on leave, however NA#1 from 2025 and NA#2 from 2024 could not be found. Interview on 12/2/25 at 9:27AM with the DNS identified that she does complete all of the nursing reviews and usually she gets a list at the beginning of the year as it comes around and completes them a couple of months in advance. Corporate will also send out a list of evaluations to get completed. The DNS identified that she used to leave the evaluation with the supervisor and then they would not get done. When she is done giving the evaluation which is sometimes done over the phone she asked the employee to come into HR to sign the evaluation and gives the evaluations to HR. Once she had given the reviews to HR she is unsure why they would not be placed into the employee file. Review of the Performance evaluation appraisals policy directed department heads and supervisors will complete performance appraisals prior to the anniversary date of employment. Once complete the employee and supervisor will sign and date the review and the evaluation will be placed in the employee's file.

Based on a clinical record review, review of facility documentation and staff interviews for one of three sampled residents reviewed for hospitalization (Resident #1), for the newly admitted resident, the facility failed to ensure a baseline care plan was developed and implemented to address the residents fractured (broken) ribs. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included diabetes, hypertension, metabolic encephalopathy and dementia with behavioral disturbances. Review of Resident #1's Chest CT (computed tomography) performed at Hospital #1 on 4/15/23 (prior to admission to the long term care facility) identified the resident with an acute/subacute nondisplaced left posterior, 10th rib fracture. Further review of hospital documentation identified the resident with pleural effusion and a malignancy was suspected. Review of Hospital #1's discharge summary dated 4/22/23 (printed on 7/3/24) identified the resident with recurrent falls and an acute/subacute nondisplaced left posterior 10th rib fracture. Review of Hospital #1's Inter-Agency Referral Report (W-10) dated 4/22/23 failed to identify that the resident had a rib fracture. Review of Resident #1's clinical record identified a handwritten, undated note with the resident's name written on top of the page. Further review of this documentation identified the resident had a fall, was incontinent, and had bruising with intact skin and had a R (right) rib fracture. Review of a pain evaluation dated 4/22/23 identified the resident was unable to vocalize pain. Non-verbal pain evaluation identified the resident with non-verbal symptoms present, facial expressions, protective body movements or posture and the resident was able to point and/or indicate level of pain hurts even more. Review of the History and Physical Examination Form dated 4/23/23 by MD #1 identified the resident had a fall with R (right) sided rib #. Further review directed to monitor rib pain and administer Tylenol (analgesic) as needed. The nurse's note dated 4/23/23 identified that Resident #1 was alert and confused lying in bed moaning, restless and rubbing rib area. Tylenol was given with good relief; and the resident fell asleep. Review of Resident #1's care plan initiated on 4/24/23 and last revised on 4/28/23, identified there was no documented evidence that facility's staff developed a care plan with goals and interventions to address the resident's fractured ribs. The APRN #1 progress note dated 4/25/23 identified Resident #1 was admitted to the facility following hospitalization after a fall without injuries. The resident denied pain. Review of Resident #1's 72 Hour Meet and Greet Admission Meeting form dated 4/25/23 failed to identify that the resident had rib fracture. A Resident Care Card (communication mechanism to caregivers) last updated on 4/26/23 indicated Resident #1 was incontinent of bowel and bladder and required assistance of two staff with care. However, no interventions addressing the resident's rib fracture injury were identified. The 5-day MDS assessment dated [DATE] identified Resident #1 had severe impaired cognition and required extensive assistance of two for bed mobility, transfer, dressing, toilet use and personal hygiene. Review of Resident #1's clinical record identified the resident had two falls while at the facility on 4/25/23 and on 4/28/23, the resident was assessed after each fall and no injuries were noted. The nurses note dated 4/28/23 identified Resident #1 had abnormal blood work results, APRN was notified and ordered to send the resident to the hospital. Further review failed to provide evidence that the hospital was notified of the resident's rib fracture. Review of Resident #1's whole-body CT performed at Hospital #2 on 4/29/23 identified the resident with multiple acute nondisplaced right 4th through 10th rib fracture, pleural effusion and age-indeterminate T6 fracture. Further review identified the assessment and plan included optimizing pain control for rib fractures as well as respiratory optimization with breathing treatments as much as the resident can tolerate. Interview and physical therapy note review with the Director of Physical Therapy on 7/3/24 at 10:50 AM identified the rehabilitation department should have been notified of the resident's diagnosed rib fracture on admission to the facility. Had they been notified PT and OT would have assessed the resident and not necessarily have changed the treatment but would have exercised caution of his/her rib pain, especially when the resident had no complaints of pain during therapy. Additionally, on 4/27/23 physical therapy documented Resident #1's participation was limited by complaints of pain, but the resident had difficulty expressing exactly where the pain was. It was further stated during this interview, if aware,the rehabilitation department would have worked with nursing on developing and implementing a plan of care to improve the resident's comfort and increase participation in care. Interview and clinical record review with ADNS on 7/3/24 at 12:51 PM identified she would have expected Resident #1 to have had a care plan addressing his/her diagnosed rib fracture. The ADNS further identified the handwritten note filed in the resident's clinical record with the resident's name and medical information including right rib fracture information, it was a report from the hospital taken on the telephone by the facility nurse prior to the resident's admission to the facility on [DATE]. The ADNS identified the Inter-Agency Referral Report (W-10) dated 4/22/23 was available for nursing staff to review when the resident was admitted to the facility, but the report had no information about the resident's rib fracture. The ADNS further identified that although the hospital discharge summary dated 4/22/23 identified the resident with a nondisplaced left 10th rib fracture, the handwritten report from the hospital written by the facility nurse identified right rib fracture, and MD #1 examination form dated 4/23/23 identified concern with right sided rib, the information probably was not available and/or not reviewed by the facility. Additionally, the ADNS failed to identify a care plan that was developed to reflect the resident had fractured ribs and therefore no interventions were in place to address on how to care for the resident with multiple rib fractures. The facility failed to communicate that the resident had a fractured rib and failed to notify the hospital when the resident was transferred on 4/29/23. Although attempted, an interview with MD #1 was not obtained. Interview with RN #2 on 7/3/24 at 2:40 PM identified that had he been aware that Resident #1 had a rib fracture, he would have requested the rehabilitation department to assess the resident to direct the resident's care needs. Interview with the Administrator on 7/3/24 at 2:48 PM identified the facility will investigate the incident to determine where this information that the resident had fractured ribs came into a halt and will train staff to ensure that this will never happen again. After surveyor enquiry, on 7/3/24, MD #2 at Hospital #1 reviewed Chest CT images dated 4/15/23 and identified that in addition to left rib fracture, the resident also had nondisplaced fractures of a few right-sided ribs. Evaluation was limited due to decreased bone mineral density and respiratory artifact affecting multiple ribs. Further review identified there was a subtle irregularity of the right 7th, 8th, 9th and 10th rib. All these fractures were nondisplaced and might be acute, subacute, or chronic in nature. Interview with MD #2 on 7/3/24 at 3:05 PM identified the resident's rib fractures were consistent with falls. The resident had recurrent falls and diagnosed rib fractures prior to admission to the facility. MD #2 further identified if the facility had questions about the rib fractures identified at the hospital, they should have called Hospital #1 for clarification. Review of the facility Care Planning policy identified an interim plan of care is developed within 24-hours of admission to the facility based on information obtained during the admission process as a guide for care until the interdisciplinary care plan is developed. The process included to obtain physician orders upon admission, complete the nursing admission assessment, begin interdisciplinary assessment process, review inquiry and transfer information, interview resident and family if appropriate, develop interim plan of care and initiate care plan.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to notify the physician of critical lab values timely. The findings include: Resident #1's diagnoses included methicillin resistant staphylococcus aureus infection, urinary tract infection, dysphagia, and depression. The RCP dated 1/21/2024 identified Resident #1 was receiving intravenous (IV) therapy (Vancomycin) for recurrent UTI's (urinary tract infection). Interventions directed to monitor intake and output every shift, and to administer IV Vancomycin as ordered. A physician order dated 1/21/2024 directed to obtain lab work for CBC (complete blood count) with differential, CMP (comprehensive metabolic panel), ESR (erythrocyte sedimentation rate), CRP (c-reactive protein), and a Vancomycin trough weekly on Mondays. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had severely impaired cognition and received IV antibiotics. Nursing note dated 2/5/2024 (a Monday) identified Resident #1 had a vancomycin trough drawn at 9:50 AM. Review of Resident #1's lab results dated 2/5/2024 (a Monday) at 4:15 PM identified the lab results were called into the facility and reported to [NAME] by Lab Technician (LT) #1. Results were read back to the caller and results have been faxed to the requester. Resident #1 had the following critical labs results: 1. BUN was 77 (normal range is 10-24). 2. Creatinine was 4.1 (normal range is 0.7-1.5). 3. Vancomycin Trough was greater than 50 (normal 10 to 20). Review of the Fax Results/Received History for the facility identified Resident #1's lab results were faxed to the facility on [DATE]. Although requested, the facility was unable to provide the cover page included for Resident #1's lab results sent on 2/5/2024. Review of the SBAR Communication Form and Progress Note dated 2/6/2024 at 1:00 PM by the ADON identified Resident #1 had elevated Vancomycin trough and declining kidney function labs. Reported to MD #1 with new recommendation to transfer Resident #1 to the hospital. Family and NP #1 were in the facility and aware. Clinical record review failed to identify the facility called for lab results, or acted on lab results prior to 2/6/2024 at 1 PM (28 hours after the labs were drawn). Review of Person #1's provided documentation identified on 2/6/2024 at 1:04 PM, Person #1 notified the Infectious Disease (ID) office nurse/RN #2 regarding Resident #1's critical lab values from 2/5/2024, and the ID office was not aware of the critical lab values. The documentation indicated the ID office nurse/RN #2 then called the facility regarding the lab results. Review of the clinical record failed to identify the ID physician was notified of the critical lab values prior to notification by Person #1 at 1:04 PM (28 hours after the lab work was drawn). Interview with the ADON on 6/5/2024 at 12:45 PM identified the RN supervisor during the shift is responsible for handling any incoming lab results that are sent to the facility. The ADON stated lab results will also be faxed to the facility, and the results will be printed in the secretary's office. The ADON stated she was unaware if any staff reported the critical lab results to MD #1's office, and was unable to provide documentation that MD #1 was notified of the lab results prior to 1 PM (28 hours after the lab work was drawn). Further, the ADON identified the facility does not have an employee named [NAME] and was unable to verify who the results were reported to. Interview with RN #2 (Outpatient Infectious Disease RN) on 6/5/2024 at 1:05 PM identified on 2/6/2024, the office received a phone call from Person #1 indicating Resident #1 had critical lab values and wanted to ensure if MD #1 was aware. RN #2 identified at that time; the office had not received any results from the facility and had not received any messages requesting a call back or messages during off hours with results. RN #2 called the facility and spoke to the ADON, who verified the critical lab results for Resident #1. RN #2 questioned the ADON as to why the office was not notified sooner, and the ADON responded they were working on the issue. RN #2 reported the results to MD #1, and MD #1 called the facility and directed to transfer Resident #1 to the hospital for evaluation. Interview and review of physician documentation with MD #1 on 6/5/2024 at 1:15 PM identified reviewing his own notes, he was notified of Resident #1's critical lab values by his office team on 2/6/2024 and stated the facility did not update him or his office of the critical lab values. MD #1 stated when he was notified on 2/6/2024 he called the facility to direct Resident #1 to be transferred to the hospital. although interview identified MD #1 would have wanted to be notified of the critical lab results on 2/5/2024, and he was aware it was alleged Resident #1 received an extra dose of Vancomycin, the extra dose would not have harmed or impacted Resident #1's overall scenario. MD #1 stated the hospital nephrologist indicated Resident #1 was admitted with acute kidney failure related to acute tubular necrosis secondary to Vancomycin toxicity and worsening of hypotension, and the treatment plan was IV fluids. Interview and record review with the DON on 6/5/2024 at 3:40 PM identified MD #1 should have been contacted regarding Resident #1's critical lab values and was unable to provide an explanation why the physician was not notified timely by the facility staff. Review of the Physician Notification Policy dated 11/2016 identified the facility will provide or obtain laboratory and other diagnostic services ordered by a physician, physician assistant or nurse practitioner and report results to the physician, physician assistant or nurse practitioner. Although requested, a facility policy for reporting critical lab results was not provided for surveyor review.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure IV antibiotics were administered timely in accordance with physician orders. The findings include: Resident #1's diagnoses included methicillin resistant staphylococcus aureus infection, urinary tract infection, dysphagia, and depression. The RCP dated 1/21/2024 identified Resident #1 was receiving intravenous (IV) therapy (Vancomycin) for recurrent UTI's (urinary tract infection). Interventions directed to monitor intake and output every shift, and to administer IV Vancomycin as ordered. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had severely impaired cognition and received IV antibiotics. a. A physician order dated 1/21/2024 directed to administer Vancomycin HCI Intravenous Solution 1500 mg/300 ml, every 18 hours, IV. Review of the January 2024 eMAR (electronic medication administration record) identified the following: 1. Resident #1 received IV Vancomycin on 1/28/2024 at 1:30 PM. The next dose was administered on 1/29/2024 at 9:30 AM. A total of twenty (20) hours between doses; the dose was administered 1 hour late. 2. Resident #1 received IV Vancomycin on 1/29/2024 at 9:30 AM. The next dose was administered on 1/30/2024 at 12:43 AM. A total of fifteen (15) hours and thirteen (13) minutes between doses; the dose was administered one(1) hour and 47 minutes early. Interview with DON on 6/5/2024 at 3:40 PM identified the nursing staff are expected to administer medications according to physician orders within one hour before and after the scheduled time. The DON was unable to explain why the IV medication was not administered in accordance with physician orders. b. Physician order dated 1/30/2024 directed to discontinue Vancomycin IV every 18 hours. A nursing progress note dated 2/5/2024 at 10:31 AM by the ADON identified MD #1 (Infectious Disease physician) called the facility with new orders to discontinue Vancomycin and start Daptomycin IV daily, through 2/11/2024. Review of the February 2023 eMAR failed to reflect that Vancomycin was administered on 2/5/2024. Review of Person #1's photograph identified an empty Vancomycin IV bag on an IV pole labeled with Resident #1's name, the facility name, and Vancomycin 1.24 grams (gm) in 250 ml of normal saline. The directions on the label directed to infuse every 18 hours. The label also had handwritten 2/5 and 1:30 PM on the label indicating the Vancomycin was administered on 2/5/2024 (6 days after the order was discontinued). Interview with the ADON on 6/5/2024 at 12:45 PM identified Person #1 had alleged Resident #1 received an extra dose of Vancomycin but indicated on the day that Person #1 verbalized the concern, there was an old Vancomycin IV bag that was labeled 2/4/2024 at 8:05 PM (5 days after the Vancomycin was ordered to be discontinued). Interview with DON on 6/5/2024 at 3:40 PM identified although she did not think Resident #1 received an extra dose of IV Vancomycin, the DON was unable to explain the IV bags labeled 2/4 and 2/5/2024. The DON identified nursing staff should administer medications per physician's orders. Although requested, the facility did not provide a policy regarding IV administration.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for hydration, the facility failed to ensure intake and output was monitored in accordance with physician orders, and failed to perform a dehydration evaluation timely for a resident not meeting their estimated daily fluid needs. The findings include: Resident #1's diagnoses included methicillin resistant staphylococcus aureus infection, urinary tract infection, dysphagia, and depression. A physician order dated 1/20/2024 directed to monitor intake and output (I & O), every shift for 72 hours, upon admission/readmission, and to document on I & O paper flowsheet. Review of Resident #1's Nutrition Evaluation dated 1/20/2024 identified Resident #1's estimated daily fluid needs totaled 1875 milliliters (mls). The care plan dated 1/25/2024 identified Resident #1 as at risk for malnutrition related to severe cognitive changes, variable oral intake, slight weight loss, aspiration risk, and on antibiotics. Interventions directed to monitor oral intake, and lab work as ordered. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had severely impaired cognition and required set up assistance for eating/drinking. Review of the I & O Paper Flowsheet identified the following: The facility failed to provide I & O records for 1/20, 1/21, and 1/22/2024. On 1/20/2024, Resident #1's total intake was 760 ml (1115 ml under the daily recommendation). On 1/23/2024 Resident #1's total intake was 660 ml (1215 ml under the daily recommendation). The facility failed to provide I & O records for 1/25, 1/26, and 1/27/2024. On 1/28/2024, Resident #1's total intake was 180 ml (1695 ml under the daily recommendation). The facility failed to provide I & O records for 1/29, 1/30, 1/31, 2/1, 2/2, 2/3, and 2/4/2024. On 2/5/2024, Resident #1's total intake was 450 ml (11425 ml under the daily recommendation). Interview with DON and ADON on 6/5/2024 at 3:40 PM identified I & O's are entered by any nursing staff, but are tallied/finalized by the night shift nurses. The DON indicated if a resident is not meeting their fluid goal, the nursing staff should notify the physician. The DON stated she was unaware Resident #1 was missing I & O Flowsheets and was unable to explain why the low intake levels were not addressed when Resident #1 did not meet the recommended daily fluid intake. Subsequent to surveyor inquiry, the facility was not able to provide the missing I & O Flowsheets for Resident #1. Review of the Intake and Output Monitoring Policy dated 4/2015 identified intake and output will be monitored initially for 72 hours after a resident is admitted or readmitted . Continued monitoring may be required based on the resident's risk factors for dehydration, as outlined in the Hydration Policy, or based on the results of a Dehydration Evaluation, if conducted. a. Interview with DON and ADON on 6/5/2024 at 3:40 PM identified it is not the facility policy to perform a dehydration risk evaluation upon admission. The DON identified the nursing staff utilize other assessment measures (such as assessing skin turgor or mucous membranes) to determine if a resident is a dehydration risk. The DON was unable to explain when Resident #1 did not meet his/her estimated daily fluid needs on 1/20, 1/23, 1/28 and 2/5/2024 why a dehydration assessment was not completed. Review of the facility Hydration Policy dated 4/2015 identified residents identified for potential to be at risk for dehydration will be placed on intake and output monitoring until adequate hydration status is achieved or until I & O monitoring is no longer clinically indicated. If the resident has consumed less than their estimated needs for three (3) consecutive days, complete a Dehydration Evaluation.

Based on observation of the kitchen and nourishment room and interview for 1 of 2 nourishment rooms, the failed to failed provide a safe and sanitary ice maker and ensure safe nourishment room cabinet without in disrepair. The findings include: Observation on 1/16/24 at 11:16 AM of second floor, Unit II nourishment room, identified the door was open and accessible to residents. The ice maker dispensing machine was streaked with a large amount of whitish colored scale-like build-up and rusted black/gray grates on the ice maker machine's catch tray. The catch tray also contained brown-reddish colored areas, the countertop edge and door were flaking with lifting or missing laminate, brownish streaks were observed dried and dripping down inner side of cabinet door, and the cabinet area under and in the sink's cabinet wood was lumpy and swollen. On 1/16/24 at 11:21 AM interview and observation of second floor, Unit II nourishment room with LPN #1 identified the ice machine was not cleaned. She indicated that the ice maker had been cleaned on 1/15/24, as per paper hanging on the machine titled the ice machine need to be cleaned monthly. Additionally, she indicated that residents do use the ice maker and residents do come to get their own ice from the ice making machine. On 1/16/24 at 11:27 AM interview and observation of the nourishment room ice maker with Housekeeper #1, indicated the ice maker was cleaned on 1/15/24, there was rust on the grill of the ice maker's catch basin, that on the area behind where the ice comes out she had tried all kinds of things including stainless steel polish to clean the machine but the white substance would not come off and the ice machine had been present since her employment 5 years ago. The manufacturer's maintenance specifications for the Manitowoc ice maker directed the machine to be cleaned/sanitized a minimum of once every six months.

Based on clinical record review, review of facility policy and interviews for 1 of 2 residents reviewed for abuse (Resident #333), the facility failed to ensure administration was notified immediately of the resident's threatening statement about NA # 9 per facility practice. The findings include: Resident #333's diagnoses included diabetes mellitus, Type 2, Benign Prostatic Hyperplasia (BPH), and adjustment disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #333 was moderately cognitively impaired and required extensive assistance with toilet use, dressing and personal hygiene. A nursing note dated 10/3/22 at 4:18 PM by the Director of Nursing Services (DNS) identified Resident #333 expressed concerns related to care received during the 11:00 PM to 7:00 AM shift. Resident #333 indicated his/her sweatpants were removed and placed on the bedside chair while care was given. The DNS explained the standard of care to the resident, the rounding process, and how hygienic care was given. Resident #333 had agreed to continue receiving care at night, however, indicated s/he did not want a Nurse Assistant (#9) to provide his/her care during the night shift. Review of the completed grievance sheet dated 10/3/22 by the DNS indicated Resident #333 reported the nursing assistant removed his/her sweatpants and placed them on the bedside chair which made him/her cold. The resulting plan of action from the 10/3/22 grievance involved removing Resident #333 from NA # 9 's assignment as requested. The Resident Care Plan revised on 10/4/2022 identified Resident #333 with an Activities of Daily Living (ADL) deficit and was at risk for incontinence due to decreased mobility. Interventions directed to provide bed level ADL care with the assistance of one and to promote privacy. A nursing note dated 10/10/22 at 8:50 AM by Registered Nurse (RN# 4) identified he/she was on rounds on Unit 1 at 1:00 AM when s/he heard Resident #333 complaining about not wanting (NA #9) in his/her room. RN #4 further indicated Resident #333 had threatened to call the state police, shoot NA #9 with a gun if he had it on him/her, and stated s/he (Resident #333) would come back to shoot NA #9 dead after leaving the facility. RN #4 also indicated the Director of Nursing Services (DNS) was updated. Review of the late entry nursing note dated 10/10/22 at 11:30 AM identified the DNS and Social Worker (SW#1) met with Resident #333 regarding the comment made to shoot NA #9 and explained a comment like that could be considered a threat and involve the police. Resident #333 indicated /he was not aware, would not say it again and the resident was placed on one-to-one supervision until seen by the psychiatric team. The psychiatric note dated 10/10/22 at 11:23 AM by the Physician Assistant (PA #1) identified Resident #333 did not want the NA from the 11:00 PM to 7:00 AM shift caring for him/her because s/he removed Resident # 333's pants, which made him/her cold, had laughed at Resident #333 because s/he was cold. NA # 9 was not allowed to care for Resident #333 or go into his/her room but had entered his/her room at 1:30 AM for no known reason. Resident #333 reported to PA #1 that he/she was afraid of NA# 9 and in fear as he/she was unable to run from him/her and reported making remarks, saying if he/she had a handgun, he/she would not be afraid to use it. Resident #333 also identified to PA #1 that he/she did not have or own a gun, that he/she had a moment of anger, anxiety, and fear, and was apologetic stating he/she did not want to hurt him/herself or others. PA #1 cleared Resident #333 of one-to-one supervision, indicated the resident was not a threat to him/herself or others and indicated the resident did make remarks out of extreme anxiety and fear but indicated s/he did not want to hurt her/himself or others. A late entry noted dated 10/10/22 at 11:35 AM by the DNS indicated he/she followed up on Resident #333's concern regarding NA #9 had entered his/her room and was laughing at her/him. The DNS further indicated, according to the night staff that evening, Resident #333 was cared for by the nurse and another female nursing assistant all night on the 11:00 PM to 7:00 AM shift. A nursing note dated 10/10/22 at 4:55 PM by the DNS indicated Resident #333 was afraid because he/she saw NA #9 enter her/his room to provide care causing Resident # 333 to become afraid for his/her life, and that he/she threatened NA #9's life with a gun. The DNS further noted Resident #333 became upset as he/she felt NA #9 had entered his/her room and was laughing at him/her. Resident #333 was offered a room change to another unit, to which s/he agreed, and was assessed by the psychiatric PA, deemed not a real danger to others at this time as s/he did not have access to a gun, and was sent to the hospital for a psychiatric follow-up. Review of the grievance sheet completed on 10/10/22 by the DNS indicated Resident #333 had reported a NA was in his/her room laughing at him/her. The plan of action from the 10/10/22 grievance identified an investigation was completed, NA # 9 was never in Resident #333's room throughout the 11:00 PM to 7:00 AM shift and when care was provided to the resident two staff members were present (nurse and NA together). A hospital psychiatric consultation note dated 10/10/22 identified Resident #333 had reported receiving poor treatment, especially by NA #9, who had deliberately removed Resident #333's pants for prolong periods of time in the cold temperature while verbally mocking and waking Resident #333 up at inappropriate times. Resident #333 indicated the staff at the facility had used Resident #333's diarrhea-soiled clothes to cover and clean his/her open groin wound, and that after being provoked and mistreated by NA #9, who stayed in the vicinity of Resident #333 during the night shift despite being asked to leave, had become frustrated and stated if I had a gun, I would shoot you (NA #9). A review of the clinical record on 10/10/22 failed to reflect the facility the DNS and the administrator had been notified of Resident # 333's concerns regarding allegations of abuse by NA # 9 and Resident # 333's threatening statement to staff about NA # 9. The On-the-Job Training dated 10/19/22 for Notification As Soon As Possible (ASAP) of Emergency Incident in the facility lecture given by the DNS for RN # 4. Objective /Purpose of Training Session was to ensure the DNS is called immediately for all emergency situations involving residents or staff at the facility. Additionally directed to notify the DNS and administrator immediately of any resident-to-resident injury, staff to resident injury, any verbal abuse or any lift threatening event from resident to staff and any abuse. Review of the Abuse Prohibition Policy, revised on 1/3/24, directed the facility is responsible for ensuring that each resident has the right to be free from abuse, mistreatment, neglect, exploitation through identification of events, occurrences, patterns, and trends of potential abuse for residents. The policy also directs staff to perform internal facility investigations of alleged violations and identification of staff members responsible for investigating incidents and the reporting of same to proper authorities. Interview with DNS on 1/22/24 at 9:55 AM identified he/she was not aware of the allegations Resident #333 had made during his/her psychiatric consultation at the hospital on [DATE] until 10/17/22 as the nurse supervisor scheduled at the time the resident was readmitted to the facility did not review the hospital discharge paperwork.

Based on clinical record reviews, facility documentation, facility policy and interviews for 2 of 2 residents reviewed for abuse (Resident #75 and Resident #333), the facility failed to ensure timely reporting of allegations of abuse and/or threats to the state facility. The findings included: 1. Resident #75's diagnosis' included diabetes mellitus, chronic kidney disease, acute kidney failure and anxiety. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #75 was cognitively intact. The Resident Care Plan (RCP) dated 12/18/2023 indicated Resident #75 had a history of anxiety Interventions included in part to provide a calm quiet environment and to offer support and reassurance. An Admissions Progress Note dated 1/21/2024 at 10:44 AM indicated in part, while speaking with a family member it was identified that the person did not want to hold Resident #75's bed while hospitalized secondary to Resident #75 was yelled at by a nurse. The resident was unable to identify the staff member. On 1/21/2024 at 6:00PM a Reportable Event was filed at the state agency which identified during a telephone conversation with the facility's Admissions Director a family member of Resident #75 stated Resident # 75 was yelled at by a nurse when being transferred to the hospital for respiratory distress. The report further indicated the facility was unable to identify who the nurse was at the time of the incident. The report indicated the date and time of the event was first known on 1/21/2024 at 6:00 PM. However, the incident was not reported to the state agency until 7:51 PM. On 1/22/2024 at 9:00 AM an interview with the DNS indicated an allegation of abuse was submitted to the state agency on 1/21/2024 at 6:00PM and an investigation was started. The DNS indicated while reviewing progress notes on 1/22/2024 at 6:00PM he/she read the Admission Director's note from earlier in the day indicating during a phone call with Resident #75's family member it was alleged Resident #75 was yelled at by a nurse. The DNS further indicated at this time the facility was unable to pinpoint a day, time, or exact nurse to be able to suspend the staff member while investigating. The DNS further indicated the Admissions Director reported the incident to the Administrator who instructed staff to complete a grievance. However, when the DNS read the Admissions Director's note s/he realized the incident was an allegation of abuse that needed to be reported to the state agency. An interview and record review on 1/22/2024 at 1:43 PM with the Admission Director identified s/he made a call on 1/21/2024 to Resident #75's family member regarding holding the resident's bed while in the hospital. The family member indicated s/he would call back the next day to discuss the matter. The Admissions Director indicated receiving a call from the family member in the morning on Sunday 1/22/24, in which s/he called the Administrator into the admissions office to listen and indicated the Administrator was present briefly but had to leave. The conversation included concerns with care of Resident #75 who was yelled at by a nurse. The Admissions Director indicated reporting the allegation to the Administrator by updating the Administrator on concerns that upset the family member which included Resident #75 being yelled at by a nurse and family not wanting to hold bed during hospitalization . The Admission Director further indicated that he/she was new to the position and had received training on abuse during onboarding with the facility. An interview with the Administrator on 1/22/24 at 2:30 PM indicated the Admissions Director had called him/her into his/her office while the family member was on the phone and s/he overheard some of the conversation but had to step out briefly but heard the family member indicate feeling the facility missed something when transferring the resident to the hospital, so the Admissions Director was directed to complete a grievance form. The Administrator further indicated not perceiving the family member as saying Resident #75 was yelled at by a nurse, it was only later when speaking with the Director of Nursing Services (DNS) who read the Admission Directors note in the medical record when it was determined an allegation of abuse was made and needed to be reported. The Administrator further indicated if there had been clearer communication between the Admission Director and the Administrator at the time of the family members phone call, the allegation would have been reported to the state agency at that time and an investigation started. The Administrator also indicated the investigation was still in progress and abuse re-education with all staff including the Admissions Director would be completed. On 1/23/24 at 10:30 AM an interview with the DNS indicated s/he reported the incident to the state agency as soon as s/he became aware of the allegation on 1/21/24 at 6:00 PM when reading the Admissions Director's note in the medical record (6 hours 16 minutes after the allegation was made). The facility abuse policy labeled Abuse, Neglect and Exploitation dated 2/2023, indicated in part, abuse includes verbal abuse, and an alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative or others but has not yet been investigated and if verified could be indicative of non-compliance with federal requirements. The policy further indicated reporting of all allegations to the required facility personnel and state and other agencies would be done immediately but no later than 2 hours after the allegation was made. 2. Resident #333's diagnoses included diabetes mellitus, Type 2, Benign Prostatic Hyperplasia (BPH), and adjustment disorder. The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #333 was moderately cognitively impaired and required extensive assistance with toilet use, dressing and personal hygiene. A nursing note dated 10/3/22 at 4:18 PM by the Director of Nursing Services (DNS) identified Resident #333 expressed concerns related to care received during the 11:00 PM to 7:00 AM shift. Resident #333 indicated his/her sweatpants were removed and placed on the bedside chair while care was given. The DNS explained the standard of care to the resident, the rounding process, and how hygienic care was given. Resident #333 had agreed to continue receiving care at night, however, indicated s/he did not want a Nurse Assistant (#9) to provide his/her care during the night shift. Review of the completed grievance sheet dated 10/3/22 by the DNS indicated Resident #333 reported the nursing assistant removed his/her sweatpants and placed them on the bedside chair which made him/her cold. The resulting plan of action from the 10/3/22 grievance involved removing Resident #333 from NA # 9 's assignment as requested. The Resident Care Plan revised on 10/4/2022 identified Resident #333 with an Activities of Daily Living (ADL) deficit and was at risk for incontinence due to decreased mobility. Interventions directed to provide bed level ADL care with the assistance of one and to promote privacy. A nursing note dated 10/10/22 at 8:50 AM by Registered Nurse (RN# 4) identified he/she was on rounds on Unit 1 at 1:00 AM when s/he heard Resident #333 complaining about not wanting (NA #9) in his/her room. RN #4 further indicated Resident #333 had threatened to call the state police, shoot NA #9 with a gun if he had it on him/her, and stated s/he (Resident #333) would come back to shoot NA #9 dead after leaving the facility. RN #4 also indicated the Director of Nursing Services (DNS) was updated. Review of the late entry nursing note dated 10/10/22 at 11:30 AM identified the DNS and Social Worker (SW#1) met with Resident #333 regarding the comment made to shoot NA #9 and explained a comment like that could be considered a threat and involve the police. Resident #333 indicated /he was not aware, would not say it again and the resident was placed on one-to-one supervision until seen by the psychiatric team. The psychiatric note dated 10/10/22 at 11:23 AM by the Physician Assistant (PA #1) identified Resident #333 did not want the NA from the 11:00 PM to 7:00 AM shift caring for him/her because s/he removed Resident # 333's pants, which made him/her cold, had laughed at Resident #333 because s/he was cold. NA # 9 was not allowed to care for Resident #333 or go into his/her room but had entered his/her room at 1:30 AM for no known reason. Resident #333 reported to PA #1 that he/she was afraid of NA# 9 and in fear as he/she was unable to run from him/her and reported making remarks, saying if he/she had a handgun, he/she would not be afraid to use it. Resident #333 also identified to PA #1 that he/she did not have or own a gun, that he/she had a moment of anger, anxiety, and fear, and was apologetic stating he/she did not want to hurt him/herself or others. PA #1 cleared Resident #333 of one-to-one supervision, indicated the resident was not a threat to him/herself or others and indicated the resident did make remarks out of extreme anxiety and fear but indicated s/he did not want to hurt her/himself or others. A late entry noted dated 10/10/22 at 11:35 AM by the DNS indicated he/she followed up on Resident #333's concern regarding NA #9 had entered his/her room and was laughing at her/him. The DNS further indicated, according to the night staff that evening, Resident #333 was cared for by the nurse and another female nursing assistant all night on the 11:00 PM to 7:00 AM shift. A nursing note dated 10/10/22 at 4:55 PM by the DNS indicated Resident #333 was afraid because he/she saw NA #9 enter her/his room to provide care causing Resident # 333 to become afraid for his/her life, and that he/she threatened NA #9's life with a gun. The DNS further noted Resident #333 became upset as he/she felt NA #9 had entered his/her room and was laughing at him/her. Resident #333 was offered a room change to another unit, to which s/he agreed, and was assessed by the psychiatric PA, deemed not a real danger to others at this time as s/he did not have access to a gun, and was sent to the hospital for a psychiatric follow-up. Review of the grievance sheet completed on 10/10/22 by the DNS indicated Resident #333 had reported a NA was in his/her room laughing at him/her. The plan of action from the 10/10/22 grievance identified an investigation was completed, NA # 9 was never in Resident #333's room throughout the 11:00 PM to 7:00 AM shift and when care was provided to the resident two staff members were present (nurse and NA together). A hospital psychiatric consultation note dated 10/10/22 identified Resident #333 had reported receiving poor treatment, especially by NA #9, who had deliberately removed Resident #333's pants for prolong periods of time in the cold temperature while verbally mocking and waking Resident #333 up at inappropriate times. Resident #333 indicated the staff at the facility had used Resident #333's diarrhea-soiled clothes to cover and clean his/her open groin wound, and that after being provoked and mistreated by NA #9, who stayed in the vicinity of Resident #333 during the night shift despite being asked to leave, had become frustrated and stated if I had a gun, I would shoot you (NA #9). The hospital crisis clinician contacted the facility and was told by RN #5 he/she was not working over the weekend the threat was made; however, Resident # 333's overall mood was okay, there was no psychiatric history, and Resident #333 would need a no harm letter to return to the facility. A review of the clinical record on 10/10/22 failed to reflect the facility the DNS and the administrator had been notified of Resident # 333's concerns regarding allegations of abuse by NA # 9 and Resident # 333's threatening statement to staff about NA # 9. The On-the-Job Training dated 10/19/22 for Notification As Soon As Possible (ASAP) of Emergency Incident in the facility lecture given by the DNS for RN # 4. Objective /Purpose of Training Session was to ensure the DNS is called immediately for all emergency situations involving residents or staff at the facility. Additionally directed to notify the DNS and administrator immediately of any resident-to-resident injury, staff to resident injury, any verbal abuse or any lift threatening event from resident to staff and any abuse. The nursing note dated 10/11/22 at 7:25 AM identified Resident #333 was readmitted to the facility at 6:50 AM and transferred to his/her new room. Review of the Facility Licensing and Investigation Section Reportable Event Report identified the allegation involving Resident #333 was reported on 10/17/22 at 3:00 PM. Review of the Abuse Prohibition Policy Reporting/Documentation Requirements (revised on 1/3/24) directs all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made. Interview with DNS on 1/22/24 at 9:55 AM identified he/she was not aware of the allegations Resident #333 had made during his/her psychiatric consultation at the hospital on 10/10/22 until 10/17/22 as the nurse supervisor scheduled at the time the resident was readmitted to the facility did not review the hospital discharge paperwork. The DNS further indicated he/she submitted the Reportable Event to the Facility Licensing and Investigation Section website as soon as he/she learned of the allegation on 10/17/22 (6 days) later. 47491

Based on clinical record review, observation, and interviews for 1 of 1 resident (Resident #54) reviewed for Communication-Sensory, the facility failed to ensure a resident's ability to hear was comprehensively assessed prior to coding the Minimum Data Set (MDS) assessment. The findings include. Resident #54's diagnosis' included fall with hip fracture, depression, and generalized anxiety disorder. The admission nursing assessment dated [DATE] indicated minimal difficulty hearing with no hearing aid. The Recreation assessment dated [DATE] indicated Resident #54's hearing was poor. The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #54's ability to hear was adequate, could understand others and indicated the resident was cognitively intact. The Care plan dated 12/19/2023 indicated in part, Resident #54 had a history of anxiety. Interventions included encouraging participation in activities of interest and encourage verbalizing thoughts and feelings. An observation on 1/17/2023 at 9:23 AM indicated Resident #54 was hard of hearing having to speak up louder and leaning ear toward his/her hearing speaker. On 1/22/24 at 10:30 AM an interview and record review with the Recreation Director indicated the recreation evaluation completed on 12/3/2023 indicated poor hearing. The Recreation Director indicated if hearing concerns were noted which required staff assistance, the resident would be offered a device for the television or a hearing device if residents had no hearing aids. The Recreation Director indicated part of the assessment of a resident is visual and the other is what the resident indicates they want. The Recreation Director further indicated having ongoing observations and talking with Resident #54 as to how recreation activities were in general, and no concerns were noted or given by the resident. The Recreation Director further indicated the hearing item on the evaluation has only two choices good or poor, so if a resident has some difficulty with hearing, poor is chosen. Review of the Recreation Care plan for Resident #54 made no mention of the poor hearing as indicated on the evaluation. Interventions included monitoring or assisting the resident. The Recreation Director further indicated recreation staff continue to monitor the resident and if a problem was noted or the resident indicated a concern, an intervention would be offered and added as needed. An interview on 1/22/24 at 11:00 AM with Nurse Aide (NA #7) indicated he/she had to raise his/her voice slightly at times for Resident #54 to hear what was being said, but not all the time. An interview and record review on 1/22/24 at 11:15 AM with the MDS Coordinator RN # 3 indicated the decision to code Resident #54's hearing as adequate on the MDS was solely based on his/her own interaction with Resident #54 during the 72-hour meeting where the resident was able to understand what was said. RN # 3 further indicated s/he did not read other team members' assessment and recreational evaluation or speak with staff regarding the resident hearing. RN #1 indicated the RAI manual provides guidance on how to evaluate residents for hearing to code the hearing section of the MDS accurately. During review, the RAI manual section for hearing notes in part to talk with the resident and to gain input from other departments like recreation as well as talking with staff. RN # 3 further indicated a modification of the Admission MDS assessment would be made. RN # 3 indicated the MDS staff would be re-educated on how to complete and code the hearing assessment as outlined in the RAI manual.

Based on clinical record review, observation, and interviews for 1 of 1 resident (Resident #54) reviewed for Communication-Sensory, the facility failed to ensure the resident had comprehensive person-centered care plan to address the resident's hearing needs. The finding include: Resident #54's diagnosis' included fall with hip fracture, depression, and generalized anxiety disorder. The admission nursing assessment dated [DATE] indicated minimal difficulty hearing with no hearing aid. The Recreation assessment dated [DATE] indicated Resident #54's hearing was poor. The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #54's ability to hear was adequate, could understand others and indicated the resident was cognitively intact. The Care plan dated 12/19/2023 indicated in part, Resident #54 had a history of anxiety. Interventions included encouraging participation in activities of interest and encourage verbalizing thoughts and feelings. An observation on 1/17/2023 at 9:23 AM indicated Resident #54 was hard of hearing having to speak up louder and lean in toward ear to his/her hear speaker. On 1/22/24 at 10:30 AM an interview and record review with the Recreation Director indicated the recreation evaluation completed on 12/3/2023 indicated poor hearing. The Recreation Director indicated if hearing concerns were noted which required staff assistance, the resident would be offered a device for the television or a hearing device if residents had no hearing aids. The Recreation Director indicated part of the assessment of a resident is visual and the other is what the resident indicates they want. The Recreation Director further indicated having ongoing observations and talking with Resident #54 as to how recreation activities were in general, and no concerns were noted or given by the resident. The Recreation Director further indicated the hearing item on the evaluation has only two choices good or poor, so if a resident has some difficulty with hearing, poor is chosen. Review of the Recreation Care plan for Resident #54 made no mention of the poor hearing as indicated on the evaluation. Interventions included monitoring or assisting the resident. The Recreation Director further indicated recreation staff continue to monitor the resident and if a problem was noted or the resident indicated a concern, an intervention would be offered and added as needed. An interview on 1/22/24 at 11:00 AM with Nurse Aide (NA #7) indicated he/she had to raise his/her voice slightly at times for Resident #54 to hear what was being said, but not all the time. An interview and record review on 1/22/24 at 11:15 AM with the MDS Coordinator RN # 3 indicated a care plan was being entered now for risk of difficulty understanding.

Based on clinical record review, policy review and interview for 1 of 5 residents (Resident #184) reviewed for unnecessary medications, the facility failed to review and revise the residents care plan related to Activities of Daily Living (ADL) and feeding. The findings include: Resident #184 diagnoses include Alzheimer's disease, dementia, and generalized weakness. The physician's orders dated 1/1/24 directed regular diet. The admission MDS assessment dated [DATE] indicated Resident #184 was moderately cognitively impaired and required partial/moderate assistance in eating, toileting, and hygiene. The occupational orders dated 1/9/24 indicated Resident #184 was a total assistance self-feed. The rehabilitation screening dated 1/9/24 failed to screen Resident #184 for feeding abilities. The Resident Care Plan (RCP) dated 1/9/24 indicated Resident #184 has an ADL deficit related to generalized weakness and recent hospitalization for seizures with goals for the resident to participate in ADLs as able times 90 days. Interventions included Occupational Therapy Evaluation and treat as ordered, 2 assist with ADL/toileting bed level, assist with gathering and setting up clothing, toiletries, and equipment, encourage resident out of bed (OOB) with all meals, provide privacy while bathing/dressing. The care plan failed to indicate or identify Residents #184's feeding abilities. The occupational therapy notes dated 1/13/24 indicated that Resident #184 completed the breakfast meal with set/up assistance, cues to attend to task. The readmission MDS assessment dated [DATE] indicated that Resident #184 was moderately cognitively intact and required moderate assistance with eating and was dependent for toileting and dressing. The Dietary/nutritional evaluation dated 1/18/24 indicated Resident #184's eating abilities was feed/self. The occupational therapy notes dated 1/19/24 indicated Resident #184 consumed the breakfast meal with intermittent supervision. The resident care kardex provided by the Director of Nursing on 1/18/24 indicated Resident #184 was a regular diet and failed to identify any need for assistance related to nutrition/feeding/eating. After surveyor's inquiry, the RCP dated 1/22/24 was revised to indicate Resident #184 has an ADL deficit related to generalized weakness and recent hospitalization for seizures with goals for the resident to participate in ADLs as able times 90 days. Interventions included Occupational therapy evaluation, treatment as ordered, 2 assist with ADL/toileting bed level, assist with gathering and setting up clothing, toiletries, and equipment, encourage resident out of bed (OOB) with all meals, provide privacy while bathing/dressing, set up for feeding. The Resident Care Kardex dated 1/22/24 indicated Resident #184 was a set up with assistance on a regular diet for nutrition. Interview on 1/22/24 at 10:30 AM with the Assistant Director of Nursing indicated she was not aware of what the order total assistance self feeding meant. She further indicated that she would have to get clarification in regards to the order and to ask a NA. Policy review dated 1/3/24 for comprehensive care plans notes care plans are a combination of data concerning the resident that is obtained from the physician, clinical records, evaluations completed by professional and other disciplines, the resident and/or family goals for treatment and acute/chronic events, behaviors, and/or illness.

Based on clinical record reviews, policy review and interviews for 1 of 1 resident (Resident #78) reviewed for death, the facility failed to obtain a physician's order for the release of the resident's body resident and for 1 of 1 resident (Resident #184) reviewed for nutrition, the facility failed to obtain a physician's order to clarify the resident's feeding abilities. The findings included. 1. Resident #78's diagnoses included atherosclerotic heart disease and heart failure. A physician's order dated [DATE] directed Resident #78's code status as Do Not Resuscitate (DNR), Do Not Intubate (DNI), and directed an RN may pronounce at the time of death. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #78 was cognitively intact. The care plan dated [DATE] identified Resident #78 for advanced directives included DNR and DNI. The progress note labeled RN Pronouncement of Death dated [DATE] at 2:27 PM for a completion on [DATE] at 2:20 PM by the Assistant Director of Nursing Services (ADNS) after Resident #78 had expired. The note further indicated the medical provider and receiving facility for the body were notified. Interview and record review with the DNS and ADNS on [DATE] at 12:20 PM indicated the documentation to whom the body was released would be found under the RN pronouncement note written on [DATE] at 2:47 PM was blank. They were also unable to locate a physician's order to release the body from the facility within the electronic chart. Interview and record review on [DATE] at 12:25 PM with the ADNS indicated s/he was unable to locate a physician's order to release the body from the facility after the death of Resident # 78. Although a policy and procedure were requested for Death of a resident but was not provided. 2. Resident #184 diagnoses include Alzheimer's disease, dementia, and generalized weakness. The physician's orders dated [DATE] directed regular diet. The admission MDS assessment dated [DATE] indicated Resident #184 was moderately cognitively impaired and required partial/moderate assistance in eating, toileting, and hygiene. The occupational orders dated [DATE] indicated Resident #184 was a total assistance self-feed. The rehabilitation screening dated [DATE] failed to screen Resident #184 for feeding abilities. The Resident Care Plan (RCP) dated [DATE] indicated Resident #184 has an ADL deficit related to generalized weakness and recent hospitalization for seizures with goals for the resident to participate in ADLs as able times 90 days. Interventions included Occupational Therapy Evaluation and treat as ordered, 2 assist with ADL/toileting bed level, assist with gathering and setting up clothing, toiletries, and equipment, encourage resident out of bed (OOB) with all meals, provide privacy while bathing/dressing. The care plan failed to indicate or identify Residents #184's feeding abilities. The occupational therapy notes dated [DATE] indicated that Resident #184 completed the breakfast meal with set/up assistance, cues to attend to task. The readmission MDS assessment dated [DATE] indicated that Resident #184 was moderately cognitively intact and required moderate assistance with eating and was dependent for toileting and dressing. The Dietary/nutritional evaluation dated [DATE] indicated Resident #184's eating abilities was feed/self. The occupational therapy notes dated [DATE] indicated Resident #184 consumed the breakfast meal with intermittent supervision. The resident care kardex provided by the Director of Nursing on [DATE] indicated Resident #184 was a regular diet and failed to identify any need for assistance related to nutrition/feeding/eating. After surveyor's inquiry, the RCP dated [DATE] was revised to indicate Resident #184 has an ADL deficit related to generalized weakness and recent hospitalization for seizures with goals for the resident to participate in ADLs as able times 90 days. Interventions included Occupational therapy evaluation, treatment as ordered, 2 assist with ADL/toileting bed level, assist with gathering and setting up clothing, toiletries, and equipment, encourage resident out of bed (OOB) with all meals, provide privacy while bathing/dressing, set up for feeding. Interview on [DATE] at 10:30 AM with the Assistant Director of Nursing indicated she was not aware of what the order total assistance self feeding meant. She further indicated that she would have to get clarification in regards to the order and to ask a NA. Interview on [DATE] at 10:33 AM with NA #6 indicated she was not aware of what the order total assistance self feeding meant. She further indicated that Resident #184 feeds is a self-feed and she has never seen any staff assist the resident with eating. Interview and observation on [DATE] at 12:18 PM with the DNS indicated she also was not aware of what the order total assistance self feeding was and that the order was unclear and she would have to speak to therapy in order to understand what it meant.

Based on clinical record review and interviews for one of three sampled residents reviewed for hospitalization (R#92) the facility failed to implement the bowel evacuation protocol in a timely manner and/or administered the bowel regimen in sequence as directed by physician orders and/or failed to consult the physician prior to manual disimpaction of the bowel and/or for one of three sampled resident reviewed for pressure ulcers (Resident #7), the facility failed to effectively recognize and/or manage the resident's pain related to wound care and/or for one of one sampled resident reviewed for non-pressure related skin conditions (Resident #37) the facility failed to obtain a dressing order prior to applying a dressing and/or failed to date and initial the dressing as per facility policy and/or for one of five sampled residents reviewed for unnecessary medications (Resident #153) the facility failed to ensure the medication included the dosage. The findings include: 1. Resident #92 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Resident Admission assessment dated [DATE] identified the resident as alert and oriented and requiring total assistance with all ADL's. Review of an admission note dated 3/07/17 identified last BM on 3/06/2017. An MDS dated [DATE] modified independence and requiring extensive assistance for bed mobility and toilet use. The RCP dated 3/20/2017 identified resident as incontinent of bowel and bladder. Interventions included to provide incontinent care every two hours and as needed. Physician order dated 3/07/2017 directed MOM 400 mg/5 ml give 30 ml by mouth every 8 hours as needed (prn) for constipation; Use 1st - give 30 ml by mouth as needed for constipation. [MEDICATION NAME] suppository 10 mg insert 1 suppository rectally every 8 hours as needed for constipation. Step 2 - insert 1 suppository rectally once daily if MOM ineffective. Fleet enema 7-19 gm/118 ml insert 1 application every 8 hours as needed for constipation, administer if [MEDICATION NAME] ineffective. Call MD for further orders if Fleet is ineffective. Nurse's note dated 3/08/17 at 15:31 identified R#92 was up for breakfast with poor appetite, prn, [MEDICATION NAME] administered for nausea. Nurse's note dated 3/09/2017 12:11 identified resident continues with poor appetite. Nurse's note dated from 3/10/2017 through 3/19/2017 identified resident continued with poor appetite. Nurse's note dated 3/20/2017 at 16:01 identified resident complains of constipation, requested suppository given with no results, hard stool felt in rectal vault, enema given with just liquid return, positive bowel sounds all four quadrants, appetite poor. Nurse's note dated 3/20/2017 at 21:48 identified resident complained of constipation, abdomen hard and distended, BS all four quadrants, fleet administered with no effect. Nurse's note dated 3/21/2017 at 5:30 AM written by RN#2, Late entry: Resident family called at 3:30 AM and resident is in so much pain, inquired about the pain and was then informed about constipation by charge nurse. Requested to give a dose of MOM and suppository. Ten minutes later this writer went to assess the resident and given suppository and MOM po, waited for results, found none. Found stool impaction and tried to pull out the stool, with more than medium removed, Abdomen distended, SOB noted, after removal resident felt much better, started sleeping. Reassessed around 5:30 AM had good relief, Supervisor aware. Nurse's note dated 3/21 8:28 MOM offered for constipation, resident declined. Nurse's note written by RN#1 dated 3/21/17 at 14:23 (2:23 PM) identified resident vomiting upon arrival to shift, coffee ground like emesis, Third shift nurse reports suppository and enema were ineffective. Resident hasn't had a BM in > 3 days. Abdomen distended, tender with hypoactive BS. [MEDICATION NAME] administered at 0800 with poor effects. continues to vomit. APRN assessed, STAT labs and KUB order with results: colonic ileus, moderate amount of rectal stool present. Resident transferred to ED for treatment. Family aware. a. Review of nurse aide BM report documentation dated from 3/07/17 through 3/21/2017 identified that from 3/07 at 20:43 through 3/13 at 5:21 (6 days/17 shifts) R#92 had no bowel movements. Additionally documentation from 3/16 through 3/20 ( 4 days/12 shifts) R#92 had no bowel movements. Review of the MAR from 3/07 through 3/21/2017 failed to reflect that the resident received MOM, [MEDICATION NAME] suppository or Fleet enema as per physician order. Review of the facility policy and procedure on Bowel Evacuation Protocol indicates; If the resident has had no bowel movement for 9 consecutive shifts, begin the bowel protocol on the 3-11 PM shift. The bowel protocol is to give MOM on the 3-11 PM shift, If MOM ineffective, then the resident is to receive a [MEDICATION NAME] suppository on the 11:00 PM to 7:00 AM shift. If [MEDICATION NAME] ineffective, the resident is to receive a Fleets enema on the 7-3 shift. Record the results on the reverse side of the MAR and/or in nurse's notes. Notify the physician if the Bowel Protocol is ineffective. b. Review of Late entry nurses' note dated 3/21/2017 at 5:30 AM identified the resident's stool was removed manually by RN #2. However, review of physician orders failed to reflect an order for [REDACTED]. Interview with Corporate liaison and Administrator on 4/13/2017 at 10:00 AM identified that the facility has no policy on manual disimpaction and were unaware of facility practice on manual disimpaction. Interview with APRN #1 on 4/13/17 at 12:15 PM identified she/he first became aware of R#92's bowel problems on the 21st of March. 2. Resident #7's [DIAGNOSES REDACTED]. An admission nursing note dated 1/27/17 identified the resident's skin integrity upon admission was poor, with multiple open areas to the buttocks, open area under right breast and boggy heels. The wound evaluation dated 1/27/17, identified an open area to the left buttock measuring 4.5 cm x 2.5 cm with a depth of 0.2 cm and an open area to the right buttock measuring 8.0 cm x 6.0 cm x 0.2 cm. Resident Care Plan (RCP) dated 1/27/17 identified a potential for pain with interventions that included to administer pain medications as ordered, assess characteristics of pain, discuss with resident factors that precipitate pain and discuss with resident the need to request pain medications before it becomes too severe. Physician's order dated 1/27/17 directed Tylenol 975 mg by mouth every 8 hours as needed for discomfort. The physician's order dated 1/27/17 directed to cleanse the area to the right and left buttocks with normal saline, apply Santyl to the wound bed, followed by calcium alginate, cover with bordered gauze daily. Pain evaluation dated 1/27/17 identified the resident indicated he/she was experiencing intermittent pain to the buttocks and left hip with an intensity of a 4-6 on the pain scale (using the pain scale of 1-10 with 10 being the worst pain) and the resident's acceptable pain level was identified as 0. The pain evaluation dated 1/27/17 further identified that the resident reported his/her bottom hurt near the wounds when someone was touching them and leaving the areas alone without pressure relieved the pain. Nursing progress note dated 1/29/17 at 3:11 PM identified wound care was provided to both sides of the buttocks and the area was very sensitive with much discomfort noted during the treatment. Nursing progress note dated 1/29/17 at 10:28 PM identified the resident denied pain, however yelled when the buttocks was touched. A Wound APRN consult dated 2/01/17 identified the resident with unstageable pressure ulcers to the right and left buttock and indicated the resident was experiencing pain, most severe during the dressing change. An Admission MDS dated [DATE] identified the resident with moderately impaired cognition, required extensive assistance with activities of daily living and received prn pain medications, however denied pain for the assessment reference date (ARD) (despite documentation in the nursing progress notes indicating verbal and non - verbal signs of pain.) Pain evaluation dated 2/03/17 identified the resident denied having had pain or hurting at any time in the last five days. The same evaluation identified the resident was free from indicators of pain including non-verbal sounds, vocal complaints, facial expressions and protective body movements despite the nursing notes and/or wound APRN consult referenced above that indicated the resident was experiencing pain during the treatment to the buttocks. A review of the MAR for 1/27/17 through 2/01/17 failed to reflect that the resident was pre- medicated with Tylenol and/or any other pain medication prior to the dressing change procedure to the bilateral buttocks, despite documentation that the treatment change caused the resident discomfort. Interview with the Director of Nursing Services on 4/13/17 at 1:00 PM identified that it was the responsibility of the charge nurse who identified the resident was experiencing pain to report to the physician/APRN and/or to obtain a physician's order and/or pre-medicate the resident prior to the treatment to manage his/her discomfort. The facility's Pain Management policy and procedure identified the facility will recognize the presence of pain and develop and implement interventions/approaches to pain management, both pharmacological and nonpharmacological. 3. Resident #37's [DIAGNOSES REDACTED]. An Admission MDS dated [DATE] identified the resident with intact cognition and required extensive assistance with activities of daily living. Resident Care Plan (RCP) dated 3/25/17 identified the resident at risk for skin breakdown related to fragile skin. Interventions included to inspect skin for redness, irritation or breakdown during care and apply derma sleeves to bilateral arms and legs. The RCP also identified the resident was non-compliant with wearing the derma sleeves. Observation on 4/11/17 at 11:15 AM with RN #1 identified two Allevyn dressings to the left shin. Dressings had no date to indicate when they were applied and/or the initials of the licensed staff member that applied the dressing. Interview with the resident on 4/11/17 at 11:20 AM identified the dressings were applied the prior evening. RN #1 removed the dressings and there were two areas (size of a quarter and size of a dime) of dark drainage noted. RN#1 indicated that the resident had an old scar in that area that tends to drain when his/her lower extremity [MEDICAL CONDITION] increased. Review of the clinical record failed to reflect a physician's order directing a dressing to the left shin. Nursing notes and treatment administration record (TAR) failed to reflect documentation as to when the dressing was changed and/or by whom. Interview with LPN #2 on 4/12/17 at 2:55 PM identified he/she did not apply the dressing on the 3-11 shift on the evening of 4/10/17. Subsequent interview with Resident #37 on 4/13/17 at 10:30 AM identified he/she was unable to recall any specific details regarding the staff member that applied the dressing. Attempts to reach LPN #3 who was assigned the 11-7 shift on 4/10/17 were unsuccessful. Interview with the Director of Nursing Services on 4/13/17 at 1:00 PM identified it was the responsibility of the licensed staff to obtain a physician's order prior to applying the dressing and a dressing should be labeled with both the date it was applied as well as the initials of the staff member that applied it. Review of the facility's Clean Dressing Technique policy and procedure identified the licensed staff member should check for a physician's order for current, correct treatment and document the treatment. 4. Resident #153 [DIAGNOSES REDACTED]. Physician's orders dated 4/08/17 identified an order for [REDACTED]. The order failed to indicate a dosage of the medication to be administered. Interview and review of the facility's Medication Administration policy and procedure with the Director of Nursing Services on 4/13/17 at 1:00 PM identified the physician's order for the [MEDICATION NAME] should have included a specific dosage.

Based on review of the clinical record, review of facility documentation, and interviews for one of three residents reviewed for accidents (Resident #109), the facility failed to prevent an accident when the resident fell from the bed and fractured his/her hip. The findings include: 1. Resident #109 (R #109) had [DIAGNOSES REDACTED]. The care plan dated 1/13/16 identified that R #109 was risk for falls related to the resident's unawareness of safety needs, deconditioning, and incontinence. Interventions included to anticipate and meet the resident's needs, to keep call light within reach, encourage the resident to use it, and to promptly respond to all requests for assistance. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified that R #109 had severe cognitive impairment and required extensive assistance of two persons with bed mobility, transfers and personal hygiene. Review of facility documentation that included a Reportable Event Form dated 1/23/16 at 10:10 PM, identified that Nursing Assistant #4 (NA #4) was coming out from the bathroom and witnessed Resident #109 roll off the bed onto the floor. R #109 was subsequently assessed by Registered Nurse RN #1(RN #1). Review of the nursing progress note dated 1/23/16 identified that R #109 had positive Range of Motion (ROM), did not indicate any pain or distress by facial expression, (as the resident was nonverbal), and that there was no visible skin integrity interruptions or apparent skin discolorations. Review of the clinical record identified that the physician and family were notified of the incident. R #109 was subsequently transferred to the acute care hospital for an evaluation on 1/23/16. Review of the acute care hospital discharge paperwork dated 1/24/16 identified that R #109 was seen in the Emergency Department (ED) secondary to a fall from bed. Although the documentation indicated that the resident was discharged back to the facility with no acute intracranial hemorrhage, the record lacked documentation to reflect that x-rays of the resident's hips were obtained during the 1/23/16 ED visit. Review of facility documentation that included the facility's investigation identified that R #109's bed was not in low position at the time of the fall from the bed. Recommendations to prevent further falls included that the resident's bed was to remain in low position at all times when not providing care. Interview with NA #4, in the presence of another surveyor, on 5/10/16 at 3:30 PM identified that on the evening of 1/23/16, she/he repositioned R #109 in the bed using a draw sheet, and that the resident was then closer to the right side of the bed facing the window. NA #4 stated that he/she then elevated the bed to her/his waist level to provide care. NA #1 demonstrated to the surveyors, the height to which to bed was raised by pointing to his/her waist. NA #4 indicated that after raising the resident's bed, he/she went into the bathroom to wet a washcloth and that he/she saw the resident roll out of bed as he/she was coming back from the bathroom. Interview with the DNS on 5/11/16 at 11:30 AM indicated that it was the responsibility of NA #4 to keep R #109 safe during care. The DNS indicated that NA #4 received reeducation on 1/25/16 which included that residents who require assistance with bed mobility should be positioned in the center of the bed unless care planned otherwise and that the bed height of a resident's bed should be approximately knee level when a caregiver is not present. Review of facility documentation and review of the clinical record lacked documentation to reflect that R #109 experienced any further falls and/or unusual occurences between 1/23/16 and 1/25/16. The clinical record identified that staff continued to monitor R #109 and conducted post fall assessments. Nursing notes dated 1/25/16 at 10:11 AM identified that R #109 was observed to be grimacing in pain. R #109 was again transferred to the hospital for an evaluation of his/her pain, was found to have sustained a left hip femoral neck fracture, and subsequently underwent surgical repair of the hip. Review of the facility's job description for the nursing assistant directed to meet the nursing and rehabilitation needs of each resident.

Based on clinical record reviews and interviews for three of six residents reviewed for transfers and positioning, (R#1, R#2 and R#4), the facility failed to protect the residents from injuries. The findings include: 1. R#2's [DIAGNOSES REDACTED]. The MDS of 3/1/11 identified a Brief Interview for Mental Status Score of 14 (13-15 cognitively intact). Review of the RCP dated 3/17/11 directed that R#2 was at risk for falling and required transfers utilizing a Hoyer Lift. The physician orders [REDACTED]. Review of the post fall nurse's notes dated 4/22/11 identified R#2 fell from the Hoyer Lift in a high position and hit the back of the head. Review of an investigative report dated 4/22/11 identified that R#2 sustained a laceration to the back of the head and was sent to an acute care facility for treatment. The interagency communication form identified that R#2 received four staples to the head and that the Commuted Axial Tamography Scan (CAT Scan) was negative. Interview with Nurse Aide (NA)#4 on 8/26/11 at 12:00 PM identified that there were two nurse aides, utilizing the Hoyer Lift and that one corner of the sling slipped out, resulting in R#2 falling down to the floor hitting his/her head. Interview with the Director of Nursing (DNS) on 8/25/11 at 10:30 AM and 8/26/11 at 1:00 PM identified that the Hoyer Lift was a rental lift and was taken out of service. The DNS further stated that a fall from the Hoyer Lift should not have occurred and that had the straps been secured properly, it would not have slipped out. Interview with NA#3 on 8/29/11 at 3:00 PM identified that the fall happened very quickly when one side came off the hooks and the resident fell down and hit his/her head. He/she further stated that this was a different Hoyer Lift and had different hooks, but did not understand how it happened. Review of facility policy directed that the resident be checked that he/she cannot slip out of the sling prior to wheeling the lift off the bed and or chair. Review of the facility inservicing identified the staff members were inserviced on the proper use of a Hoyer Lift. 2. R#1's [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified an inability to perform a Brief Interview for Mental Status, short and long term memory deficit and an extensive assist with bed mobility. The Resident Care Plan (RCP) dated 5/13/11 identified R#2 as having a stroke with left sided weakness and neglect with interventions to assist out of bed with a Hoyer Lift and three person assistance and to assist with proper alignment and body positioning. The physician orders [REDACTED]. The nurse's notes dated 6/28/11 identified that R#1 was found on the floor on the side of the bed. An initial x-ray dated 6/28/11 of the left foot failed to identify a fracture. Follow-up x-ray on 7/2/11 identified an acute fracture of the left greater trochanter. An investigative report dated 6/28/11 identified the resident slipped off the bed when the bed was being changed and perineal care was being provided. The investigative report further identified that the NA # 1 turned away from the resident to grab a draw sheet and the resident grabbed onto the grab bar pulling herself closer to the edge of the bed and both aides were unable to hold the resident back and prevent the fall. Interview with the Director of Nursing on 8/25/11 at 10:00 AM identified that the fall from the bed should not have occurred and there should have been a hand on the resident at all times. Interview with NA#1 on 8/25/11 at 12:00 PM identified that he/she had turned to get a draw sheet and R#1 pulled his/herself right over so that the feet were dangling and she/he was not strong enough to prevent the fall. 3. R#4's [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified an inability to obtain a Brief Interview for Mental Status score, short and long term memory deficits, without speech and total dependence with transfers. The physician orders [REDACTED]. The nurse's notes dated 8/9/11 identified that R#4 was transferred out of the wheelchair into bed with the Hoyer Lift with two nurse aides and the resident slid down to the floor hitting his/her head. The resident was transferred to an acute care facility. Review of inter-agency patient referral from the acute care facility identified that R#4 was evaluated for a possible head and neck trauma and had no acute fracture and no acute process of chest and abdomen. An investigative report dated 8/9/11 identified two nurse aides were transferring R#4 utilizing the Hoyer Lift when the strap slid off the hook and the resident fell to the floor. Interview with NA#5 on 8/26/11 at 11:00 PM identified that one of the straps came off and the Hoyer Lift tipped back and the resident fell hitting his/ her head. He/she further stated that the Hoyer pad for this resident was a little different and fit loosely. Interview and observation of the Hoyer Lift and assessment of the Hoyer Pad with the Director of Nursing and the Corporate Nurse on 8/26/11 at 1:15 PM failed to identify a problem with either and stated that a fall from the lift could only have occurred if the straps were not secured and checked. Interview with the Director of Maintenance on 8/26/11 at 1:30 PM identified that the Hoyer Lifts are checked monthly and there had not been a problem with the Hoyer lifts. Review of facility policy directed that the resident be checked that he/she cannot slip out of the sling prior to wheeling the lift off the bed and or chair.