Every finding on record at Lighthouse Rehabilitation and Healthcare Center

Based on observations, interviews and record review, the facility failed to ensure the Resident's environment was free from accident hazards, for one Resident #126, out of a sample of 30 Residents. Specifically, the facility failed to implement a fall care plan intervention which led to Resident #126 falling and sustaining a fracture.Findings include:A review of the facility policy titled 'Falls-Clinical Protocol' with a revision date of September 2012 indicated the following:-The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. Risk factors for falling include environmental hazards.-The staff will evaluate and document falls that occur while the individual is in the facility, for example when and where they happen, any observations of the events, etc.-For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. Causes refer to factors that are associated with or that directly result in a fall.-Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.Resident #126 was admitted to the facility in January 2025 with diagnoses including Dementia and a history of falling.Review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 0 out of a possible 15 indicating severe cognitive impairment.Review of the Activities of Daily Living (ADL) care plan indicated the following:-Dressing: I require 1 staff assist with dressing. Care plan initiated,1/31/25.-Transfers: I require 1 staff assist for transfers. Care plan initiated,1/31/25. Review of the Health Care Proxy dated 11/18/19 indicated it was invoked on 12/16/25.Review of a Fall report titled 'Full QA Report' dated 11/10/25 indicated the following:Fall Details-During round, about 3:30 A.M., resident found sitting up right, on the floor at his/her bedside. Calm, alert, and verbally responsive per baseline. Denied pain. Stated that he/she did not hit his/her head. When asked resident what happened? he/she said he/she was getting out of bed; lost balance and fell on his/her bum. Resident assisted from the floor to bed by 2 staff members. Footwear-non-skid socks. Injuries-No Injuries noted. Actions-Care plan updated and Resident education (This writer educated the Resident to use the call light for help and wait for help to arrive.)Investigate/conclusion-Removed slippers and family member will bring in new slippers with closed back for better grip. Problem statement-Resident lost his/her balance while getting out of bed. Why-maybe weakness, unsteady, forgetful/dementia. Root cause-Resident lost his/her balance while getting out of bed and fell. Review of a Fall report titled 'Full QA Report' dated 12/24/25 indicated the following:Fall Details: Resident ambulating in room, found lying on back on floor. Footwear: Slippers/nonskid socks. Injuries-No injuries noted. Actions-Care plan updated.Investigate/conclusion-Resident fell while ambulating, the resident had slippers with no back and slightly too big. Family to bring in slippers with back. Problem statement-Older backless slippers. Why-Slippers a little big but resident refuses to change. He/she was also wearing nonskid socks. Root cause: Family will bring better fitting slippers with backs so that his/her feet are secure. Review of a Fall report titled 'Full QA Report' dated 2/11/26 indicated the following:Fall Details/type-Resident found on floor, lying on right side with right hand on his/her face. Footwear-Slippers/nonskid socks. Injuries-Closed fracture of the nasal bone and facial hematoma. Actions-Care plan updated.Investigate/conclusion-Resident was found in the bathroom lying on his/her right side. He/she had blood coming out of the right side of his/her nose and facial hematoma. Resident was able to move all extremities and assisted back to bed. MD (Medical Doctor) and family notified. Resident sent to hospital for evaluation and sustained a nose fracture and facial hematoma. Slippers were removed from the room and family educated not to bring in slippers with no backs. Resident is wearing slipper socks now. Resident to be toileted during am and pm care, after meals, during rounds and as needed. Problem statement-Resident fell in the bathroom. Why-Resident lost his/her balance due to resident's shoes, slippers have no backs. Root cause-Staff will encourage resident to wear nonskid socks only when ambulating with his/her rolling walker. Slippers have been removed. Review of the Fall care plan interventions initiated 12/24/25 indicated the following:-Family will supply resident with his/her sneakers removed slippers and family will bring in new slippers with closed back for better grip. Review of the hospital Discharge summary dated [DATE] indicated the following:Diagnoses-Fall, initial encounter, closed fracture of nasal bone, initial encounter, facial hematoma, initial encounter. On 2/19/26 at 7:40 A.M., the surveyor observed backless slippers in the Resident's room. Resident #126 was seated on his/her bed wearing nonskid socks.On 2/19/26 at 11:14 A.M., the surveyor observed Resident #126 in the Activity room wearing nonskid socks and backless slippers.A review of the progress notes dated 12/24/25 indicated the following:-Family aware of fall and asked if he could bring slippers with a back. A review of the progress note dated 12/25/25 indicated the following:-Status post fall, denied pain when asked, neurological tests as ordered. Continues to be unsafe.A review of the progress notes dated 2/16/26 indicated the following:-This writer notified family about a possible room change, due to resident's fall risks. Family stated that he wants resident to remain in his/her room due to resident liking his/her room and liking his/her current roommate. This writer educated family about slippers not being safe for the resident in which he verbalized understanding. Will continue to monitor resident and maintain safety precautions. Further review of progress notes between 12/24/25 and 2/16/26's communication to the Resident's son failed to indicate the Resident being encouraged to wear nonskid socks while the facility waited for the son to bring in slippers with a back.During a telephone interview on 2/20/26 at 10:48 A.M., Certified Nurse's Assistant (CNA) #3 said she provided Activities of Daily Living (ADL) care for the Resident yesterday, 2/19/26. CNA #3 said she did see backless slippers in the Resident's room during ADL care. CNA #3 said she did not put the backless slippers on the Resident because the Resident could fall. CNA #3 said the Resident did try to put on the backless slippers on his/her own. CNA #3 redirected him/her to not wear the backless slippers. CNA #3 said the Resident is able to put the backless slippers on his/her own. CNA #3 was not able to tell the surveyor if she can view the Kardex (documentation that serves as a concise and quick reference for patient care) on the electronic health record she has access to, CNA #3 said she had no idea how to view the Resident's fall care plan from the electronic health record she has access to.During a telephone interview on 2/20/26 at 11:15 A.M., Resident #126's family member and Health Care Proxy said he was made aware by the facility of the concerns of the backless slippers for first time yesterday, 2/19/26. The Health Care Proxy said he visits the Resident daily; the backless slippers are the Resident's favorite footwear and are always in the room. The Health Care Proxy said the Resident can put on the backless slippers on his/her own. The Health Care Proxy said the facility did inform him about all of the Resident's falls, however they never emphasized the backless slippers concerns. The Health Care Proxy said if the facility had informed him about the backless slippers concerns, he would have asked the facility to dispose them. The Health Care Proxy said after he was told about the concerns with the backless slippers, on 2/19/26, he asked the facility to dispose the backless slippers immediately.During an interview on 2/20/26 at 11:23 A.M., Unit Manager #3 said the backless slippers were in the Resident's room yesterday, 12/19/26. Unit Manager #3 said the Resident is not supposed to have the backless slippers in his/her room. Unit Manager #3 said she talked to the Resident's family member who is also the Health Care Proxy, to get permission to dispose the backless slippers. Unit Manager #3 said the family member had been made aware about the backless slippers concerns prior to yesterday, but it is the facility's responsibility to maintain the Resident's safety by implementing the fall care plan interventions. Unit Manager #3 said she was not sure if CNAs can access the Kardex on the electronic health record they have access to.During an interview on 2/20/26 at 12:02 P.M., the Director of Nurses said the 12/24/25 and 2/11/26 falls were caused by the Resident's backless slippers. The DON said the Resident's family was notified about bringing in slippers with a closed back. The DON said it is the facility's responsibility to maintain regular communication with the Resident's family member if the family member is not following through with the communication to bring in closed back slippers for the Resident. The DON said it is the facility's responsibility to make sure the backless slippers are not in the Resident's room to maintain the Resident's safety. The DON said if the Resident refuses to remove the backless slippers, staff should contact the Health Care Proxy for a final decision. The DON said CNAs do have access to the Kardex on the electronic health record they have access to. The DON said this access allows them to read Residents' care plans. The DON said the original care plan has to have the initial 'K' so the CNAs can view the Kardex on their electronic health record. The DON said Resident #126's fall care plan did not have the initial 'K' so the CNAs could not view the Kardex on their electronic health record. The DON said fall care plan interventions should be implemented after fall investigations are completed.

Based on observation and interview, the facility failed to ensure that services provided met professional standards of practice for one Resident (#31) out of a total sample of 30 Residents. Specifically, for Resident #31 the facility failed to administer medications timely and in accordance with physician's orders.Findings include: Review of facility policy titled Administering Medications, dated as revised April 2019, indicated the following:-Medications are administered in a safe and timely manner, and as prescribed.-Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Resident #31 was admitted to the facility in October 2025 with diagnoses that included acute post hemorrhagic anemia and pulmonary embolism.Review of the most recent Minimum Data Set (MDS) assessment, dated 1/15/26, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Review of physician's orders indicated the following:-Ferrous Sulfate Tablet 325 mg (milligrams) by mouth one time daily, every other day to be administered at 9:00 A.M., dated 10/22/25.-Lisinopril 2.5 mg one time a day to be administered at 9:00 A.M., dated 10/22/25.-Eliquis oral tablet 5 mg two times daily for pulmonary embolism, to be administered at 9:00 A.M. and 9:00 P.M., dated 10/21/25-Multiple Vitamin give one tablet one time a day, to be administered at 9:00 A.M., dated 10/22/25.-Cetirizine 10 mg give 0.5 tablet one time a day, to be administered at 9:00 A.M., dated 10/22/25.-Cholecalciferol 125 mcg one tablet one time a day, to be administered at 9:00 A.M., dated 10/22/25.-Calcium-Vitamin D3 oral tablet 600-10 mg-mcg give one tablet by mouth two times a day, to be administered at 9:00 A.M. and 9:00 P.M., dated 10/22/25 During an observation on 2/19/26 at 12:10 P.M., the surveyor observed Nurse #1 preparing medications for administration. Review of the medication administration screen indicated that she was preparing to administer 9:00 A.M. medications to Resident #31. Review of the Medication Administration Audit Report, dated 2/19/26, indicated that Resident #31's 9:00 A.M. medications were administered between 12:11 P.M., and 12:15 P.M., over three hours after they were indicated to be administered per physician's orders. During an interview on 2/20/26 at 7:34 A.M., Unit Manager #1 said that medications should be given within one hour before or one hour after the administration time indicated in the physician's orders. He said that the Resident's medication should not have been given that late. During an interview on 2/20/26 at 8:49 A.M., the Director of Nurses said that it is unacceptable that medications were being administered that late. She said that the expectation is that medications are administered within the time frame of one hour before or one hour after the indicated administration time in the order.

Based on observation, record review and interview the facility failed to ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two Residents (#11 and #14) out of a total of 30 sampled residents. Specifically,1. For Resident #11 the facility failed to provide assistance to shave unwanted facial hair. 2. For Resident #14 the facility failed to provide assistance to cut fingernails. Findings include: Review of the facility policy titled Activities of Daily Living (ADL), Supporting, dated 2001 indicated the following: Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1. Resident #11 was admitted to the facility in October 2024 with diagnoses including anxiety disorder, depression and schizophrenia. Review of the Minimum Data Set assessment, dated 11/14/25, indicated that Resident #11 is cognitively intact, scoring a 15 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #11 requires supervision/touching assistance for personal hygiene. Review of the care plan indicated a focus of the following: I have an ADL (activity of daily living) Self Care Performance Deficit r/t Activity Intolerance, Fatigue. with an intervention of the following: PERSONAL HYGIENE: I require staff assistance with grooming/personal hygiene. Date Initiated: 10/01/25. Further review failed to indicate that Resident #11 refuses care. Review of the progress notes failed to indicate Resident #11 refuses care.On 2/18/26 at 8:20 A.M., the surveyor observed Resident #11 to have significant chin and upper lip hair. During an interview on 2/18/26 at 8:20 A.M., Resident #11 said he/she wants the hair removed. Resident #11 said that the hair is embarrassing but nobody will do anything about it.On 2/18/26 at 1:57 P.M., the surveyor observed Resident #11 in the main dining room, participating in activities, with the same amount of chin and upper lip hair.On 2/19/26 at 7:39 A.M. the surveyor observed Resident #11 to have significant chin and upper lip hair. On 2/19/26 at 1:39 P.M., the surveyor observed Resident #11 in the main dining room, participating in activities, with the same amount of chin and upper lip hair.During an interview on 2/19/26 at 1:45 P.M., Nurse #1 said that the Certified Nurse's Aides (CNA's) are responsible to help residents shave.During an interview on 2/19/26 at 1:45 P.M., CNA #1 said that the CNA's are responsible for shaving the residents, but she didn't realize Resident #11 wanted to be shaved.2. Review of the facility policy titled Activities of Daily Living (ADL), Supporting, dated 2001 indicated the following: Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Resident #14 was admitted to the facility in August 2025 with diagnoses including stroke, cancer and malnutrition. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #14 is cognitively intact, scoring a 15 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #14 is dependent on staff for all activities of daily living. Review of the current care plan indicated that Resident #14 is dependent for all activities of daily living. Further review failed to indicate that Resident #14 refuses care. Review of the progress notes failed to indicate that Resident #14 refuses care.On 2/18/26 at 7:49 A.M., the surveyor observed Resident #14 in bed with a contracted right arm and hand. The surveyor then observed Resident #14's right hand fingernails to be long and curling over the tip of his/her fingers. On 2/19/26 at 8:52 A.M., the surveyor and Nurse #1 observed Resident #14 in bed with a contracted right arm and hand. The surveyor and Nurse #1 then observed Resident #14's right hand fingernails to be long and curling over the tip of his/her fingers. During an interview on 2/19/26 at 8:52 A.M., Resident #14 said that the Certified Nurse's Aides (CNA's) are supposed to cut his/her fingernails, but no one has recently. During an interview on 2/19/26 at 8:53 A.M., Nurse #1 said that the CNA's are supposed to cut fingernails and if for some reason they can't they are to notify the nurse. Nurse #1 then said that Resident #14's fingernails are not supposed to be that long. During an interview on 2/19/26 at 8:58 A.M., CNA #1 said that she has Resident #14 for the 7:00 A.M.-3:00 P.M. shift but has not seen his/her nails as she works mainly on another floor. CNA #1 then said that CNAs are responsible for cutting fingernails and nails should never get so long as to curl over the tip of the finger. CNA #1 then said that if she couldn't cut the nails then she would get the nurse.

Based on observation, record review and interview the facility failed to implement interventions to prevent pressure ulcers from developing for one Resident (#40) out of a total sample of 30 residents. Specifically, the facility failed to ensure Resident #40's heels were elevated off the mattress. Findings include: Review of the facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated 2001, failed to indicate that staff are to follow the care plan interventions to prevent and heal pressure areas. Resident #40 was admitted to the facility in December 2023 with diagnoses including muscle wasting and atrophy, major depressive disorder and osteoarthritis. Review of the Minimum Data Set assessment, dated 1/15/26, indicated that Resident #40 scored a 3 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Further review indicated that Resident #40 is totally dependent for all activities of daily living and at risk for the development of pressure ulcers. Review of the active care plan indicated a focus of risk for skin breakdown with an intervention of elevate heels while in bed as tolerated. Further review failed to indicate that Resident #40 refuses care. Review of the progress notes failed to indicate Resident #40 refuses to have his/her feet elevated off of the mattress. On 2/18/26 at 7:55 A.M., the surveyor observed Resident #40 lying in bed with both heels directly on the mattress. On 2/18/26 at 10:23 A.M., the surveyor observed Resident #40 lying in bed with both heels directly on the mattress. On 2/18/26 at 1:43 P.M., the surveyor observed Resident #40 lying in bed with both heels directly on the mattress. On 2/19/26 at 7:26 A.M., the surveyor observed Resident #40 lying in bed with both heels directly on the mattress. On 2/19/26 at 11:05 A.M., the surveyor observed Resident #40 lying in bed with both heels directly on the mattress. Review of the physician orders dated February 2026 indicated an order to Elevate heels while in bed as tolerated every shift. During an interview on 2/19/26 at 11:03 A.M., Certified Nurse's Aide (CNA) #2 said that it is the responsibility of the CNA to follow the care plan and elevate heels off of the mattress if that is what the care plan says to do. During an interview on 2/19/26 at 11:05 A.M., Nurse #1 said that it is the CNA's and nurse responsibility to ensure the care plan is followed. Nurse #1 said that Resident #40 should have his/her heels elevated off of the mattress. Nurse #1 then said that if a resident refuses or isn't tolerating an intervention then it should be documented in the medical record. During an interview on 2/19/26 at 11:06 A.M., Unit Manager #1 said that it is the CNA's and nurse responsibility to ensure the care plan is followed. Unit Manager #1 said that Resident #40 should have his/her heels elevated off of the mattress. Unit Manager#1 then said that if a resident refuses or isn't tolerating an intervention then it should be documented in the medical record.

Based on observation, record review and interview the facility failed to provide care consistent with professional standards of practice for one Resident (#132) with a peripherally inserted central catheter (PICC) line (a long, flexible catheter inserted into a vein in the upper arm and threaded into a large central vein near the heart to deliver medications, fluids, or nutrition and to draw blood) out of a total sample of 30 Residents. Specifically, the facility failed to change the PICC line dressing on admission as indicated in the physician's orders or when the PICC line dressing was lifting on the edges. Findings include: Review of facility policy titled Central Venous Catheter Care and Dressing Changes, dated as revised October 2024, indicated the following:-A physician's order is needed for this procedure.-Assess central venous access devices with each infusion and at least daily.-Remove any non- transparent dressing and visually inspect the insertion site if any signs or symptoms of complication are present.-Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled)-Change the dressing if it becomes damp, loosened or visibly soiled and: immediately if the dressing or site appears compromised-Assessment: Observe insertion site and surrounding area for complications. Resident #132 was admitted to the facility in February 2026 with diagnoses that included Sepsis due to methicillin resistant staphylococcus aureus and depression. There was no Minimum Data Set data available for the Resident. During an observation and interview on 2/19/26 at 7:25 A.M., the surveyor observed Resident #132 awake in bed. The Resident had a PICC line to the left upper arm. There was a dressing in place dated 2/14/26. The dressing was peeling and lifting along the sides. The insertion site was not visible due to a tan foam under the transparent dressing. The Resident said the dressing had been peeling off for a few days now and had not been changed since being admitted to the facility despite the Resident having asked staff to change it. On 2/19/26 at 11:12 A.M., the surveyor observed the Resident in bed. The Resident was receiving intravenous antibiotics at this time. The same PICC line dressing remained in place, dated 2/14/26 and peeling and lifting on the edges. The insertion site was not visible. On 2/19/26 at 1:13 P.M., the surveyor observed the Resident's PICC line dressing. There was a dressing in place dated 2/14/26. The dressing was peeling and lifting along the sides. The insertion site was not visible due to a tan foam under the transparent dressing. On 2/20/26 at 7:07 A.M., the surveyor observed the Resident's PICC line dressing. The dressing had been changed and was dated 2/20/26. The insertion site was visible, and the dressing edges were reinforced with tape that was peeling up. Review of Physician's orders indicated the following:-Vancomycin HCl Intravenous Solution 750 MG/150ML (Vancomycin HCl), use 250 ml intravenously every 12 hours for infection bacteremia until 02/26/2026 23:59 vancomycin 750mg/250ml sol IVPB, dated 2/17/26.-IV: (Midline, PICC, CVAD) Change Transparent Dressing on admission and then every 7 days; Caps to be changed during dressing change, dated 2/18/26. Review of Resident #132's medical record on 2/19/26 failed to indicate that the PICC line dressing had been changed since admission to the facility Review of Resident #132's Nursing progress note written 2/19/26 at 1:00 P.M., indicated the following:Resident is currently receiving IV [intravenous] antibiotics(vancomycin)for infection. Medication administers as ordered. IV site assessed clean, dry and intact, with no sign of infection noted vital sign checked and stable. Will continue to monitor resident condition closely and observe for any adverse reaction and patient's condition. [sic] During an interview on 2/20/26 at 7:10 A.M., Nurse #3 said that he had worked overnight. He said that he assisted the 3:00 P.M. - 11:00 P.M. nurse change the PICC line dressing overnight. He said that he was not sure if the edges were peeling on the dressing, but he said that on admission when Resident #132 was admitted the insertion site was not able to be assessed because there was a small foam dressing under the clear dressing. He said that generally when a Resident was admitted with a PICC line they do not change the dressing but change it every week or as needed. He said if a PICC line dressing was peeling or lifting, or the insertion site was not visible then the dressing should be changed. During an interview on 2/20/26 at 7:16 A.M., Unit Manager #2 said that PICC line dressing changes were done weekly, but not necessarily on admission unless there were orders to change it, or it was not intact. She said that if the PICC line dressing was assessed to be lifting, then it should be reinforced or changed if needed. She said it was not necessarily concerning to not see the insertion site. She said if there was an order to change the PICC line dressing on admission that it should have been changed, and if for some reason it was not changed then it should have been documented in the progress notes. During an interview on 2/20/26 at 9:19 A.M., the Director of Nurses said that nurses must assess a PICC line and the dressing on admission, and every shift or when administering intravenous medications. She said the insertion site needs to be visible in order to assess it. If it was not visible, the dressing needed to be changed. She also said that if the dressing was lifting it should be changed.

Based on observation, record review and interview the facility failed provide for one Resident (#79) the necessary respiratory care and services that is in accordance with professional standards of practice and the Resident's care plan out of a total sample of 30 residents. Specifically, the facility failed to ensure Resident #79's oxygen was administered according to physician orders.Findings include: Review of the facility policy titled Oxygen Administration, dated 2001, indicated that staff are to adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Resident #79 was admitted to the facility in December 2022 with diagnoses including chronic obstructive pulmonary disease, heart disease and high blood pressure. Review of the Minimum Data Set assessment dated [DATE] indicated that Resident #79 is cognitively intact, scoring a 15 out of 15 on the Brief Interview for Mental Status exam. Further review indicated that Resident #79 requires supervision/touching assistance with most activities of daily living. Review of the physician's orders indicated an order, dated 9/11/25, for Oxygen at 2L/min via Nasal Cannula PRN (as needed). Review of the care plan failed to indicate that Resident #79 adjusts the oxygen flow rate. Review of the progress notes failed to indicate that Resident #40 self-adjusts the flow rate of the oxygen. On 2/18/26 at 8:01 A.M., the surveyor observed Resident #79 in bed receiving oxygen (O2) via nasal cannula. The surveyor observed the O2 concentrator to be set at 3.5 liters/minute (L/min).On 2/18/26 at 11:08 A.M. the surveyor observed Resident #79 in bed receiving oxygen (O2) via nasal cannula. The surveyor observed the O2 concentrator to be set at 3.5 L/min. During an interview on 02/18/26 at 11:08 A.M., Resident #79 said that he/she does not set the flow rate of oxygen, the nurse does. On 2/18/26 at 1:51 P.M. the surveyor observed Resident #79 in bed receiving oxygen (O2) via nasal cannula. The surveyor observed the O2 concentrator to be set at 3.5 L/min. On 2/19/26 at 8:30 A.M., the surveyor and Nurse #2 observed Resident #79 in bed receiving oxygen (O2) via nasal cannula. The surveyor and Nurse #2 observed the O2 concentrator to be set at 3.5 L/min. During an interview on 2/19/26 at 8:30 A.M., Resident #79 said that he/she does not mess with the dial. During an interview on 2/19/26 at 8:30 A.M., Nurse #2 said that the oxygen is supposed to be set at 2L/min.

Based on record review and interview, the facility failed to electronically submit direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 4 2024 (July 1 - September 30), in accordance with the schedule specified by CMS. Findings include: During an interview on 2/11/25 at 2:58 P.M., with the facility Administrator he said that he started at the facility in November 2024 and was aware that the facility had not submitted the previous quarters staffing data to CMS. The Administrator said that at that time the facility was owned by another company. During an interview on 2/13/25 at 10:49 A.M., with the Regional Administrator she said that the facility was taken over by a new company in October 2024, but could not get the staffing data from the last company so they did not submit it.

Based on record review and interviews, the facility failed to report allegations of potential abuse (injuries of unknown, and an allegation of neglect) to the State Agency for three Residents (#87, #118, and #55) out of a sample of 30 Residents. 1. For Resident #87, the facility failed to report an X-ray (X-radiation-images created inside of a body by passing beams of radiation through the body) positive for a fracture from an unknown origin to the State Agency within two hours. 2. For Resident #118 the facility failed to notify the state agency of an injury of unknown within 2 hours once the Director of Nursing became of a new fracture (an acute right intertrochanteric [thigh bone] fracture) of unknown origin. 3. For Resident #55 the facility failed to notify the state agency of an allegation of neglect. Findings include: A review of the facility policy titled, 'Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating' with a revision date of September 2022 indicated the following: -All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. -If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. - Immediately is defined as, within two hours of an allegation involving abuse or result in serious bodily injury. 1. Resident # 87 was admitted to the facility in July 2022 with diagnoses including dementia. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident is rarely/never understood. A review of Resident #87's X-ray results dated 1/21/25 indicated the following: -X-ray chest view. -Findings: Comparison is made to 6/28/2024. Minimal linear markings are seen in the lower left lung. Multilevel right rib multilevel right rib fractures are noted. [sic] -Conclusion: Minimal left lower lung atelectasis scarring. No CHF (Congestive Heart Failure) or pneumonia. -Electronically signed by the Medical Director, 1/21/2025 3:57:27 PM Eastern. A review of the Nursing progress notes dated 1/21/25 at 22:31 (10:31 PM) indicated the following: -X-ray chest view. -Findings: Comparison is made to 6/28/2024. Minimal linear markings are seen in the lower left lung. Multilevel right rib multilevel right rib fractures are noted. [sic] -Conclusion: Minimal left lower lung atelectasis scarring. No CHF or pneumonia. No new orders at this time. All parties aware. During an interview and record review on 2/14/25 at 8:13 A.M., the Assistant Director of Nurses said she was made aware of the multilevel right rib fractures noted in the chest X-ray after staff received the results on 1/21/25. The ADON said she has access to the HCFRS (Health Care Facility Reporting System) but she had issues with her log in and did not report the injury of unknown origin after staff notified her. The ADON said she did not notify the Director of Nurses about the chest X-ray results immediately after staff informed her. She said since the right rib fractures were an injury of unknown origin at that point, she should have reported the X-ray results to the Director of Nurses immediately. The ADON said she reported this injury of unknown origin to the Director of Nurses on 1/23/25. The ADON said injuries of unknown origin should be reported to the state agency within two hours. During an interview on 2/14/25 at 7:21 A.M., the Director of Nurses said staff should notify her when injuries of unknown origin occur even though she is not in the facility. She said staff were aware of Resident #87's right rib fractures on 1/21/25 but did not notify her until 1/23/25. The DON said she reported the right rib fracture on 1/23/25 to the state agency. She said injuries of unknown origin should be reported to the state agency within two hours. Review of the HCFRS indicated that the facility reported Resident #87's injury of unknown origin on 1/23/25 after the ADON was first made aware of the injury of unknown origin on 1/21/25. 44095 2. Resident #118 was admitted to the facility in December 2024 with diagnoses including ataxia, vascular dementia, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 12/14/24, indicated that Resident #118 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. This MDS indicated Resident #118 required assistance with transfers. Review of Resident #118's health status note, dated 1/5/25, indicated: - Complained of severe pain to right leg, on call provider notified, new order for STAT X-ray to right hip/pelvis 2/3 views. Order to apply lidocaine patch topically to right leg and reassess pain, resident remains in pain when right leg is touched by staff. Review of Resident #118's radiology report, dated 1/5/25 at 8:29 P.M., indicated: - FINDINGS: There is an acute, mildly displaced right intertrochanteric fracture. Mild bilateral hip degenerative joint changes. The bony pelvis is intact, but the soft tissues are unremarkable. CONCLUSION: Acute right intertrochanteric fracture. During an interview on 2/14/25 at 7:15 A.M., Nurse #3 said that he became aware of the fracture results on 1/6/25 between 4:30 A.M. and 5:00 A.M., and he notified the Director of Nursing on 1/6/25 at around 8:30 A.M. Review of Resident #118's incident report, dated 1/5/25, indicated that Resident #118 had an injury of unknown, that was not witnessed. Notifications of the following. Administrator on 1/6/25 at 9:00 A.M., Director of Nursing 1/5/25 at 7:00 P.M., and the Department of Health on 1/10/25 at 9:00 P.M. The incident report was signed off on 1/22/25 at 12:09 P.M., by the Director of Nursing. During an interview on 2/13/25 at 1:27 P.M., the Assistant Director of Nursing (ADON), said she became aware of the fracture on 1/6/25 during clinical rounds around 9:00 A.M. The ADON said that the Director of Nursing is responsible for reporting injuries of unknown to the state agency within 2 hours. During an interview on 2/13/25 at 10:47 A.M., the Director of Nursing said she was made aware of Resident #118's fracture on 1/6/25 around 8:30 A.M., when Nurse #3 made her aware. The DON said that although the incident report indicated she was made aware of the new injury of unknown on 1/5/25 at 7:00 P.M., this was not true, and she should have been immediately notified. The DON said she did not report the fracture to the state agency within two hours when she found out about the fracture, but she should have. During an interview on 2/13/25 at 10:40 A.M., the Administrator said that injuries of unknown should be reported to the stage agency within 2 hours as required. Review of the Health Care Facility Reporting System (HCFRS) indicated that the facility reported Resident #118's injury of unknown on 1/10/25 at 9:46 P.M., 108 hours after the DON was first made aware of the injury of unknown. 45763 3) Resident #55 was admitted to the facility in November 2024 with diagnoses including cancer, other lack of coordination, difficulty in walking, cerebral infarction (lack of blood flow to the brain), and spinal stenosis (a condition where the spinal canal, the space within the spine that houses the spinal cord and nerve roots, becomes narrowed which can put pressure on the nerves, causing pain, numbness, weakness, and other symptoms.) Review of the most recent MDS assessment, dated 12/18/24, indicated that Resident #55 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15. Review of Resident #55's activities of daily living (ADL) care plan indicated the Resident had ADL self care performance deficit related to activity tolerance, deconditioned status post hospitalization , and fatigue with the following intervention: - Bed mobility: I require the assist of 1 staff and sheet for turning and repositioning, initiated 11/13/24. - Transfers: I require 1 staff assist for transfers, initiated 11/13/24. Review of Resident #55's documentation survey report, dated February 2025, indicated the Resident required staff assistance with bed mobility four out of the 21 recorded instances, and required assistance with lying to sitting on the side of the bed 13 out of 31 recorded instances, During an interview on 2/11/25 at 9:13 A.M., Resident #55 said that earlier that morning he/she was lying in bed and had asked a staff member for help getting up. Resident #55 said that the staff member refused, said you can get yourself up, and left the room without helping the Resident get up. Resident #55 said he/she could not get up because he/she was experiencing back pain, the Resident said he/she was able to eventually get him/herself up once the pain subsided which was later than he/she wanted to get up. Resident #55 said that he/she had not told anybody about this event. During an interview on 2/11/25 at 9:19 A.M., the surveyor told the administrator that Resident #55 was lying in bed earlier that morning, had asked a staff member for help getting up as he/she was not able to get up on his/her own due to pain, that the staff member refused, said you can get yourself up and left the resident without helping him/her. The administrator verbalized understanding. During an interview on 2/12/25 at 9:29 A.M., Social Worker #1 said that if a resident makes an allegation of abuse/neglect that nursing would call the social workers, the Director of Nursing (DON) and the administrator who would report the allegation to state agencies within two hours and then investigate whether abuse/neglect actually occurred. Social Worker #1 defined neglect as a situation if a resident needed help but staff refused to provide it. Social Worker #1 said she had been told that Resident #55 had a bad interaction with staff and that the Resident had trouble sitting up due to back pain. Social worker #1 said that Resident #55 had pain, and some days required help getting up as he/she could not do it on his/her own. Social Worker #1 said the facility had filed a grievance instead of reporting the allegation. Social Worker #1 said she would have expected the DON to report the allegation as what the Resident reported was not okay, it was neglectful and that the Resident felt bad yesterday about the situation. Social Worker #1 said Unit Manager #1 had taken over the investigation. During an interview on 2/12/25 at 9:55 A.M. Unit Manager #1 said Social worker #1 had brought Resident #55's allegation to his attention, Unit Manager #1 said Resident #55 had asked for assistance but the staff member could not provide the assistance. Unit Manager #1 said he did not have concern for neglect because he trusted the staff and that the situation was not one that he had heard before. Unit Manager #1 said he had interviewed staff who denied the allegation and he believed them; Unit Manager #1 said that despite him being new the staff were good so far. Unit Manager #1 defined neglect as when a resident needed assistance, but staff pass by and ignore the resident. Unit Manager #1 said when an allegation of neglect is made, he would expect the administrator to report the allegation. Unit Manager #1 said allegations of neglect should be reported right away, and that Resident #55's allegation was considered something that needs follow up. Unit Manager #1 said that administration never asked him if he considered the allegation concerning for neglect/abuse. During an interview on 2/12/25 at 10:12 A.M., the DON said when a resident makes an allegation of neglect/abuse she will initiate an investigation, which includes an interview with the resident, to determine if abuse had occurred. The DON said she had spoken with Resident #55 who had told her that although the Resident usually got up on his/her own that yesterday morning the Resident needed help, had asked staff for help, and that the staff would not help the Resident get up but instead encouraged him/her to get up on his/her own. The DON said that if a resident asks for help that staff should help the resident regardless of what the Resident's ADL status was. The DON said that she had filed a grievance regarding the Resident's allegation and that the Grievance had not yet been resolved. Review of Resident #55's grievance summary, dated 2/11/25, indicated that the Resident had asked nursing staff for help to sit up, and that nursing staff had encouraged her to sit up on his/her own as the Resident was independent with positioning. During a follow-up interview on 2/12/25 at 12:57 P.M. Resident #55 said he/she did not feel that staff were trying to encourage him/her to get up as the staff member had her head turned, was walking out the door, and sounded annoyed/irritated. Resident #55 said this made him/her feel alone, and that the staff member was not trying to help at all. During an interview on 2/12/25 at 1:05 P.M. the Administrator defined neglect as if we were doing something on purpose not to take care of somebody, and that the investigation into Resident #55's allegation hadn't yet been concluded at that time. The Administrator said that neglect/abuse would need to be reported to state agencies within two hours. Review of the Health Care Facility Reporting System (HCFRS) indicated that the facility reported Resident #55's allegation of neglect to state agencies on 2/12/25 at 2:34 P.M., 29 hours after the administrator was made aware of the Resident's allegation.

Based on observations, interviews, and record reviews for three Residents (#22, #376 and #70) out of four residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. Three out of four nurses observed made 3 errors out of 33 opportunities resulting in a medication error rate of 9.09%. Specifically, 1.) For Resident #22, Nurse #1 administered the incorrect dose of a medication spray (Fluticasone, medication used for allergies) 2.) For Resident #376, Nurse #4 did not follow manufacture's recommendations and crushed a medication (metoprolol extended-release tablet, cardiac medication that once crushed becomes immediate release) which indicated do not crush. 3.) For Resident #70, Nurse #5 administered the incorrect medication (calcium with vitamin D) that was also expired. Findings include: Review of the facility policy titled, Administering Medications, dated as revised April 2019, indicated that medications are administered in a safe and timely manner, and as prescribed. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. 1.) Resident #22 was admitted to the facility in August 2022 with diagnoses including end stage renal disease, heart failure, and peripheral vascular disease. Review of the most recent Minimum Data Set assessment, dated 1/29/25, indicated that Resident #22 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 2/12/25 at 8:01 A.M., the surveyor observed Nurse #1 administered medications to Resident #22 including: - Fluticasone, spray one in each nare. Review of Resident #22's physician's order, dated 11/5/22, indicated: - Fluticasone 50 micrograms, 2 sprays in each nostril one time a day for allergy/nasal congestion. During an interview on 2/12/25 at 8:15 A.M., Resident #22 said that he/she takes one spray each nose. 2. Resident #376 was admitted to the facility in February 2025 with diagnoses including atrial fibrillation, hypertension, and metabolic encephalopathy. On 2/12/25 at 8:43 A.M., the surveyor observed Nurse #4 administered medications for Resident #376. Nurse #4 crushed and administered Resident #376's metoprolol extended-release tablet. Review of Resident #376's physician's order, dated 2/4/25, indicated: - May crush, open, and combine medications as per manufacturer guideline and pharmacy recommendations. Review of Resident #376's physician's order, dated 2/5/25, indicated: - Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 milligrams, give 0.5 tablet by mouth one time a day for hypertension. Review of Resident #376's metoprolol medication card included the following manufacturer's instructions: do not crush, swallow whole. During an interview on 2/12/25 at 2:00 P.M., Nurse #4 said she should not have crushed Resident #376's extended-release medication. 3.) Resident #70 was admitted to the facility in April 2023 with diagnosis including dementia and diabetes. On 2/12/25 at 9:28 A.M., the surveyor observed Nurse #5 administer medications to Resident #70. Nurse #5 administered one tablet of calcium with vitamin D. Review of the manufacture's guidelines indicated the serving size is two tablets which is equal to calcium 400 milligrams and vitamin d 12.5 micrograms. Further review of the medication bottle indicated the medication expired in November 2024. Review of Resident #70's physician's order, dated 4/13/23, indicated: - Calcium Carbonate Tablet 600 milligrams (mg), give one tablet by mouth two times a day for supplementation. During an interview on 2/12/25 at 2:22 P.M., Nurse #5 said she should have administered the correct form and dose of calcium, and she said she should have verified the expiration date prior to administering medications. During an interview on 2/12/25 at 3:13 P.M., the Director of Nursing said nursing should verify the correct dose prior to administering medications, nursing should follow manufacture's guidelines and not crush medications that are do not crush, and she said that nursing should verify the correct medication and expiration date prior to administering medications.

Based on observations and interviews the facility failed to ensure drugs and biologicals were stored in accordance with acceptable professional standards of practice. Specifically: 1. Nursing failed to secure the medication carts on 2 of 3 units. 2. Nursing failed to ensure medication was stored in the packaging containers or other dispensing system in which it was received. 3. Nursing failed to ensure medications were dated once opened, and stored according to manufacturer's guidelines, in two of three medication carts observed. Findings include: The facility policy titled Medication Labeling and Storage, undated, indicated the following: -The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light control. Only authorized personnel have access to keys -Medication and biologicals are stored in the packaging containers or other dispensing system in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 1. On 2/11/25 at 6:55 A.M., the surveyor observed an unlocked and unattended medication cart on the 1st floor unit. The surveyor was able to open and access the cart and the nurse was unaware. During an interview on 2/11/25 at 7:09 A.M., with Nurse #1 she said that when she came in to her shift that morning the medication cart was already unlocked and that it should always be locked when unattended. On 2/11/25 at 8:34 A.M., the surveyor observed an unlocked and unattended med cart able on the 3rd floor unit. The surveyor was able to open and access the cart and the nurse was unaware. During an interview on 2/11/25 at 8:36 A.M., Nurse #2 said that the medication cart should always be locked when unattended. During an interview on 2/12/25 at 10:57 A.M., with the Director of Nursing she said that the medication carts should be locked when unattended. 2. On 2/11/25 at 6:55 A.M., the surveyor observed an unlocked and unattended medication cart on the 1st floor unit. The surveyor was able to open and access the cart and observe that in the top drawer of the cart there were three unlabeled cups filled with pills. During an interview on 2/11/25 at 7:09 A.M., with Nurse #1 she said that she had arrived on shift a short while earlier and found the medication cart unlocked so she decided to start preparing morning medication. Nurse #1 struggled to remember who 2 of the 3 cups were for and identified them by room number. Nurse #1 said that the night nurse still had the key to the medication cart and that they had not yet counted out the medication cart. She said that medication should not be pre-poured. During an interview on 2/12/25 at 10:57 A.M., with the Director of Nursing (DON) the surveyor shared the observations and information reported by Nurse #1 the previous morning, The DON said that's not okay. 44095 3. Review of the facility policy titled, Medication Labeling and Storage, undated, indicated the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Medication Storage: 6. Medications requiring refrigeration are stored in the refrigerator. Medication Labeling: 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. 6. Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date. a. On 2/11/25 at 7:17 A.M., the Surveyor and the Nursing Supervisor observed on the second-floor 'long hall' medication cart: - one bottle of brinzolamide ophthalmic suspension drops, opened and undated - one bottle of latanoprost eye drops, opened and undated - one bottle of brimonidine 0.2% ophthalmic drops, opened and undated - one fluticasone furoate/ vilanterol inhaler, opened and undated - one fluticasone propionate/ salmeterol inhaler, opened and undated - one insulin glargine pan, opened and undated During an interview on 2/11/25 at 7:20 A.M., the Nursing Supervisor said that nursing is responsible for dating eye drops, inhalers, and insulin pens based on manufacture's recommendations. b. On 2/11/25 at 7:31 A.M., the Surveyor and Nurse #1 observed on the first-floor 'long hall' medication cart: - one bottle of liquid protein, opened and undated. Manufacture's guidelines indicated good for 3 months once opened. - one fluticasone furoate/ vilanterol inhaler, opened and undated - one umeclidinium and vilanterol inhaler, opened and undated. - one insulin aspart, unopened. Manufacture's guidelines indicated refrigerate until opened. During an interview on 2/11/25 at 7:36 A.M., Nurse #1 said that nursing is responsible for dating liquid protein, dating inhalers once opened, and nursing should ensure insulins are stored in the refrigerator until it is opened. During an interview on 2/13/24 at 3:17 P.M., the Director of Nursing said that nursing should store medications according to manufactures guidelines.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that staff dated resident food and drinks in three of three unit kitchenette refrigerators. Findings include: Review of the facility's undated policy titled Food Brought by Family/Visitors indicated, but was not limited to, the following: - Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. - Family members and visitors are asked to inform nursing staff when foods are brought for a resident. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. o Perishable foods are stored in re-sealable containers with tight-fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date. - The nursing staff will discard perishable foods on or before the use-by date. - The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul order, past due package expiration dates). On 2/11/25 at 7:24 A.M., the surveyor made the following observations in the first floor kitchenette refrigerator: - One bottle of a nutritionally fortified supplemental shake, opened but undated - One white plastic bag containing an open package of hot dogs and a plastic container of baked beans, undated. - One pitcher of apple juice dated 2/4, use by 2/10. - One container of spreadable cheese, open but undated. On 2/11/25 at 7:31 A.M., the surveyor made the following observations in the second floor kitchenette refrigerator: - One pitcher filled with apple juice, undated. - One single-serve bottle of orange juice, open with a straw inside. The juice was separated and sediment had settled at the bottom of the bottle, there was an expiration date of 1/24/25. - One slice of pizza wrapped in tin foil labeled with a resident room number but undated - One container of resident food dated 2/7 and 2/9. - One package of sharp white cheddar cheese, opened, labeled with resident room number but undated. On 2/11/25 at 7:38 A.M. the surveyor made the following observations in the third floor kitchenette refrigerator: - One pitcher filled with orange juice dated 2/4 with a use-by date of 2/10. - One resealable bag containing hard boiled eggs, undated. - One pitcher filled with apple juice, undated. During an interview on 2/13/25 at 10:16 A.M., the Food Service Director (FSD) said kitchenette refrigerators should be checked at least daily for label dates/expiration dates. The FSD said food should be labeled, dated and discarded after three days and that juice should be dated and discarded after five days; the FSD said that unlabeled food or juice should be discarded.

Based on staff interview and record review, the facility failed to ensure the Nursing staff completed the required 12 hours (no less than ) of annual training, which at minimum includes dementia training for 4 out of 5 employee records reviewed. Findings include: The facility policy titled Staff Education and Competency, undated, indicated the following: -Education is a key component to ensuring that our residents receive quality care. Education is provided to staff in various formats. We use Relias(C) as an online training resource. In addition, we provide both individual and group training sessions. -Education begins at orientation which includes job specific training. All new staff receive a general orientation to core facility processes, policies, and procedures. Orientation training topics include, but are not limited to, hand hygiene, infection control, bloodborne pathogens, resident rights, abuse and neglect, HIPAA, dementia and behavior management, fire safety, disaster preparedness, emergency response, workplace safety, and additional topics as required by the State of Massachusetts. Competency evaluations are conducted as they may apply to the new employee. Department specific training and competencies are completed with staff throughout employment to ensure that they can safely and competently provide the levels and types of care required by our resident population. Education is provided to contracted staff and volunteers consistent with their expected roles. Annual education requirements are in place for all staff to ensure robust ongoing education and competency. In addition to the required annual education courses for all staff, supplemental annual training is also provided to direct care staff and certified nursing assistants. Annual competency evaluations are conducted for all staff with additional annual competencies for nurses and certified nursing assistants. -As part of ongoing education and training, mock drills are scheduled on a rotating shift and day schedule. This enables the facility to receive a wide variety and sampling of staff participation. The Staff Development Coordinator and the Director of Maintenance collaborate in the development of the Drill schedule for the facility. -In addition to the required annual education and competencies, the facility identifies educational opportunities based upon the specific resident population and care needs. Education specific to the individual employee is conducted as opportunities for individual staff growth are identified and as determined through performance reviews. The facility also implements additional staff education as a result of QAPI actions and those incorporated in plans of correction. Review of 5 employee records (2 nurses and 3 Certified Nursing Assistants) indicated that 5 of 5 had not completed the required annual training, including dementia training, for the past year. During an interview on 2/14/25 at 11:19 A.M., with the Director of Nursing (DON), she said that when the facility got taken over by a new company in the Fall they lost all access to the education system including proof of staff training and competency. The DON was able to verify that 4 of the 5 employee records reviewed did not have the required dementia training hours.

Based on observation, record review and interview the facility failed to provide a dignified existence for one Resident (#110) out of a total sample of 30 residents. Specifically: For Resident #110, who is dependent on staff for feeding, the staff stood beside the bed, looking down at Resident #110, rather than seated at eye level while feeding him/her meals. Findings include: The facility policy titled Dignity, dated February 2021, indicates the following: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life and feelings of self-worth ad self-esteem. -5. When assisting with care, residents are supported in exercising their rights. For example, residents are: e. provided with a dignified dining experience. Resident #110 was admitted to the facility in February 2024 and has diagnoses that include Alzheimer's disease, history of falling and hemiplegia affecting right dominant side. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/18/24, indicated that on the Brief Interview for Mental Status exam Resident #110 scored a 3 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #110 had no behavior of rejecting care and was dependent on staff for all Activities of Daily Living (ADLs). Review of the current care plan for Resident #110 indicated the following: -Focus: Resident is at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing eating, bed mobility, transfer, locomotion, toileting related to: recent illness, fall hospitalization , etc, resulting in fatigue, activity intolerance, confusion, etc. -Interventions include: Provide assist to the resident with meals-prefers to eat in his/her bedroom, initiated 2/19/24 Review of the Functional Abilities and Goals Assessment, dated 12/18/24, indicated Resident #110 was dependent on staff for all ADLs, including eating. Review of the Task documentation for eating, in the past 14 days, indicated Resident #110 was dependent on staff for eating. On 2/11/25 at 9:00 A.M., the surveyor observed Resident #110 in bed, while a staff person stood beside the bed, looking down at Resident #110 feeding him/her. On 2/12/25 between 9:02 A.M., and 9:08 A.M., the surveyor observed Resident #110 in bed, while a staff person stood beside the bed, looking down at Resident #110 feeding him/her. On 2/13/25 at 9:28 A.M., the surveyor observed Resident #110 in bed, while a staff person stood beside the bed, looking down at Resident #110 feeding him/her. There was a second staff person in the room, standing while feeding Resident #110's roommate. During an interview and observation on 2/13/25 at 9:33 A.M., with the Assistant Director of Nursing (ADON) she said staff should be seated at eye level while assisting with meals. The two CNAs were observed standing while feeding and the ADON instructed them to get chairs and sit while feeding the residents.

Based on observations and interviews, the facility failed to ensure resident protected health information (PHI) was secure and not visible to others on two of three nursing units. Findings include: Review of the facility policy titled Confidentiality of Information and Personal Privacy, dated as revised February 2021, indicated the following: 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 2. The facility will strive to protect the resident's privacy regarding his or her: b. medical treatment 4. Access to resident personal and medical records will be limited to authorized staff and business associates. On 2/11/25 at 8:28 A.M., the surveyor observed an unattended medication cart on the third-floor unit. The computer on top of the cart was open, displaying a resident's name and a list of his/her medications. During an interview on 2/11/25 at 8:31 A.M., with Nurse #5 said that the screen on her computer, displaying a resident's medical information, should be privatized and not left open when unattended. On 2/11/25 at 3:30 P.M., the surveyor observed an unattended nursing laptop in the first-floor unit's common area. The screen was open, displaying a resident's name, date of birth, and medication, visible to anyone who passed by. During an interview on 2/14/25 at 9:43 A.M., with the Director of Nursing said the computers with resident's information should be shut down or put to sleep when unattended.

Based on observations, record review and interviews, the facility failed to complete an assessment for an air mattress with bolsters for one Resident #87 out of a sample of 30 Residents. Specifically, the facility failed to complete a restraints assessment before applying an air mattress with bolsters in the Resident's bed. Findings include: A review of the facility policy titled 'Use of Restraints' with a revision date of April 2017 indicated the following: - Physical Restraints are defined as any manual method or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. -The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. -Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. -Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. Resident #87 was admitted to the facility in July 2022 with diagnoses including dementia. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident is rarely/never understood. Further review of the MDS indicated the following: -Roll left to right-Dependent (Helper does all the effort. Resident does none of the effort to complete the activity). -Sit to lying-Dependent (Helper does all the effort. Resident does none of the effort to complete the activity). -Lying to sitting on side of the bed-Dependent (Helper does all the effort. Resident does none of the effort to complete the activity). -Chair/bed-Chair transfer. The ability to transfer to and from a chair or (wheelchair)-Dependent (Helper does all the effort. Resident does none of the effort to complete the activity). On 2/11/25 at 8:02 A.M., the surveyor observed the Resident in bed, sleeping, wiggling from side to side with both legs over the bolster of the air mattress. On 2/12/25 at 8:36 A.M., the surveyor observed the Resident in bed, sleeping, wiggling from side to side with both legs over the bolster of the air mattress. A review of Resident #87's February active and discontinued physician's orders indicated the following: -Low air loss mattress every shift per weight or resident's comfort, check setting and functioning. Start Date: 1/29/25, Discontinued. -Low air loss mattress with bolster every shift per weight and/or resident's comfort, check setting and functioning. Start Date, 2/12/25, Active. During an interview and observation on 2/12/25 at 9:34 A.M., Certified Nurse's Assistant (CNA) #4 and the surveyor observed Resident #87 in bed, Resident #87 was awake in bed, his/her legs were placed over the bolsters. CNA #4 said the air mattress with bolsters was put in place to prevent the Resident from coming out of the bed on his/her own. CNA#4 said the Resident does put his/her legs over the bolsters when he/she tries to get out of bed on his/her own. During an interview on 2/12/25 at 9:35 A.M., Unit Manager #3 said Resident #87 was recently hospitalized and he/she fell in the facility on 2/1/25 after returning from the hospital. She said the air mattress with bolsters was a fall intervention put in place on 2/1/25 to prevent the Resident from falling while he/she was in bed. She said the Resident does put his/her legs over the bolsters and wiggles while in bed. Unit manger #3 said she did not complete a written restraints assessment prior to adding the air mattress with bolsters in the Resident's bed. During an interview and observation on 2/12/25 at 8:33 A.M., the Assistant Director of Nurses observed Resident #87 with the surveyor. The Resident was in bed awake. The ADON said the Resident is able to put his/her legs over the bolsters. She said the air mattress with bolsters was added as a fall intervention to prevent the Resident from falling out of bed. She said a written restraints assessment was not completed prior to adding the air mattress with bolsters in the Resident's bed. During an interview on 2/13/25 at 10:02 A.M., the Director of Nurses said a written restraints assessment should have been completed prior to adding the air mattress with bolsters in Resident #87's bed.

Based on record review and interviews, the facility failed to report injuries of unknown origin to facility administration for two Residents (#87 and #118) out of a sample of 30 Residents. Specifically: 1. For Resident #87, the facility failed to report an X-ray (X-radiation-images created inside of a body by passing beams of radiation through the body) positive for a fracture from an unknown origin. 2. For Resident #118 the facility failed to implement their abuse policy and notify facility administration of a new fracture (an acute right intertrochanteric [thigh bone] fracture) of unknown origin. Findings include: A review of the facility policy titled, 'Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating' with a revision date of September 2022 indicated the following: -All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. -If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. - Immediately is defined as, within two hours of an allegation involving abuse or result in serious bodily injury. 1. Resident # 87 was admitted to the facility in July 2022 with diagnoses including dementia. A review of the most recent Minimum Data Set (MDS) dated [DATE] indicated that the Resident is rarely/never understood. A review of Resident #87's X-ray results dated 1/21/25 indicated the following: -X-ray chest view. -Findings: Comparison is made to 6/28/2024. Minimal linear markings are seen in the lower left lung. Multilevel right rib multilevel right rib fractures are noted. [sic] -Conclusion: Minimal left lower lung atelectasis scarring. No CHF (Congestive Heart Failure) or pneumonia. -Electronically signed by the Medical Director 1/21/2025 3:57:27 PM Eastern. A review of the Nursing progress notes dated 1/21/25 at 22:31 (10:31 PM) indicated the following: -X-ray chest view. -Findings: Comparison is made to 6/28/2024. Minimal linear markings are seen in the lower left lung. Multilevel right rib multilevel right rib fractures are noted. [sic] -Conclusion: Minimal left lower lung atelectasis scarring. No CHF or pneumonia. No new orders at this time. All parties aware. During an interview and record review on 2/14/25 at 8:13 A.M., the Assistant Director of Nurses said she was made aware of the multilevel right rib fractures noted in the Resident's chest X-ray after staff received the results on 1/21/25. She said she did not notify the Director of Nurses about the chest X-ray results immediately after staff informed her. She said since the right rib fractures were an injury of unknown origin at that point, she should have reported the X-ray results to the Director of Nurses. The ADON said she reported this injury of unknown origin to the Director of Nurses on 1/23/25. During an interview on 2/14/25 at 7:21 A.M., the Director of Nurses said staff should notify her when injuries of unknown origin occur even though she is not in the facility. She said staff were aware of Resident #87's rib fractures on 1/21/25 but did not notify her until 1/23/25. 44095 2. Resident #118 was admitted to the facility in December 2024 with diagnoses including ataxia, vascular dementia, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 12/14/24, indicated that Resident #118 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. This MDS indicated Resident #118 required assistance with transfers. Review of Resident #118's eMar - Electronic Medication Administration note, dated 1/4/25 at 9:00 A.M., indicated: - Acetaminophen (APAP) Tablet 325 milligrams, give 2 tablets by mouth every 6 hours as needed (PRN) for mild pain. Documented as administered by nursing. Review of Resident #118's nursing progress note, dated 1/4/25 at 10:38 P.M., indicated: - Resident complained of pain 8/10 to left leg, medicated with PRN APAP with ineffective results. Resident's pain level documented in Nurse Practitioner's (NP's) log. (The nurse who wrote this note clarified that the leg pain was the right leg) During an interview on 2/13/25 at 10:01 A.M., Nurse #4 said that Resident #118 was experiencing right leg pain on 1/4/25 which was new, and she was not aware of any incident that may have occurred to cause the pain. Nurse #4 said that Resident #118 has poor safety awareness and Resident #118 could not get him/herself up off the floor if he/she had fallen. Nurse #4 thought that Resident #118 may have injured his/her leg during a self-transfer, but she was not certain. Review of Resident #118's consultant telehealth progress note, dated 1/5/25 at 12:58 P.M., indicated: - History Present Illness: Patient with new right hip and thigh pain. patient is unable to left/[lift] the right leg. [sic] when trying to move extremity the patient yells out in pain. when asking the patient where the pain is specifically points to his/her thigh and holds his/her right hip. there is no external S/S (signs and symptoms) of injury. no bruising or edema or redness noted. patient has no complaints with left leg. able to move extremity at baseline. will obtain STAT (immediately) x-rays. patient has not had any recent falls/injuries per RN. Review of Resident #118's health status note, dated 1/5/25, indicated: - Complained of severe pain to right leg, on call provider notified, new order for STAT X-ray to right hip/pelvis 2/3 views. Order to apply lidocaine patch topically to right leg and reassess pain, resident remains in pain when right leg is touched by staff. Review of Resident #118's radiology report, dated 1/5/25 at 8:29 P.M., indicated: - FINDINGS: There is an acute, mildly displaced right intertrochanteric (thigh bone) fracture. Mild bilateral hip degenerative joint changes. The bony pelvis is intact, but the soft tissues are unremarkable. CONCLUSION: Acute right intertrochanteric fracture. Review of Resident #118's PDPM Nursing Daily Skilled Pathway note, dated 1/5/25 at 11:05 P.M., indicated: - Resident is alert and pleasantly confused, stay in bed the whole day today complaints of pain right hip, with Tylenol with minimal effect, provider aware and stat right hip x-ray done around 7:00 P.M., will continue to monitor. During an interview on 2/14/25 at 8:43 A.M., Nurse #11 said that on 1/5/24 around 11:30 P.M., she saw the x-ray results for the new fracture in the electronic health record. Nurse #11 said that there are no faxes sent directly to the facility and all x-ray results are uploaded in the electronic health record by the vendor. Nurse #11 said that she did not notify facility administration of the new fracture. Nurse #11 said that she was not sure what caused Resident #118's fracture, and that Resident #118 was confused. During an interview on 2/14/25 at 7:15 A.M., Nurse #3 said that he became aware of the fracture results on 1/6/25 between 4:30 A.M. and 5:00 A.M., when he saw the x-ray results printed on the fax machine. Nurse #3 said that he notified the provider, but he did not make facility administration aware of the injury of unknown because they would be coming in for the day around 8:00 A.M. Nurse #3 said that Resident #118 was confused and had poor safety awareness, and he was not aware of any event that would have caused the fracture. Review of Resident #118's consultant telehealth progress note, dated 1/6/25 at 8:01 A.M., indicated: - History Present Illness: Resident is presenting for radiology review of hip x-ray. Nurse denies any known trauma, but resident complained of right hip pain. Xray hip: Acute mildly displaced Right intertrochanteric fracture. Transfer to Emergency Department for acute right hip fracture and ortho evaluation Orders: Transfer to Emergency Department for acute right hip fracture and ortho evaluation Disposition: Transfer to Emergency Department Review of Resident #118's incident report, dated 1/5/25, indicated that Resident #118 had an injury of unknown, that was not witnessed. Conclusion: Resident sustained a right hip fracture. During the investigation and through staff interviews it was determined that the resident did not fall. The resident was observed transferring from his/her wheelchair to a standard chair at the nurses' station and plopped down hard into the chair before staff could assist him/her. According to the hospital paperwork resident has age related osteoporosis with pathological fracture. Investigative statements were obtained from Nurse #3, Nurse #4 and Unit Manager #2. Notifications of the following. Administrator on 1/6/25 at 9:00 A.M., Director of Nursing 1/5/25 at 7:00 P.M., and the Department of Health on 1/10/25 at 9:00 P.M. The incident report was signed off on 1/22/25 at 12:09 P.M., by the Director of Nursing. During an interview on 2/13/25 at 10:10 A.M., Unit Manager #2 said that Resident #118 had right leg pain, and he/she could not move his/her right leg which was new. Unit Manager #2 said that Resident #118 has poor safety awareness and did not have a fall. Unit Manager #2 said that faxes from the x-ray company are no longer provided and that the x-ray results are uploaded in the electronic record. During an interview on 2/13/25 at 1:27 P.M., the Assistant Director of Nursing (ADON), said she became aware of the fracture on 1/6/25 during clinical rounds around 9:00 A.M. The ADON said she was not aware of any event that caused the fracture. The ADON said that the Director of Nursing is responsible for reporting injuries of unknown to the state agency within 2 hours. During an interview on 2/13/25 at 10:47 A.M., the Director of Nursing said that Resident #118's fracture results came in around 12:00 A.M., on 1/6/25. The DON said she was not made aware of the injury of unknown until 1/6/25 around 8:30 A.M., when Nurse #3 made her aware. The DON said that although the incident report indicated she was made aware of the new injury of unknown on 1/5/25 at 7:00 P.M., this was not true, and she should have been immediately notified. The DON said she was not sure of an event the caused the fracture. During an interview on 2/13/25 at 10:40 A.M., the Administrator said that nursing staff should notify facility administration within 2 hours of an injury of unknown.

Based on record review and interviews, the facility failed to thoroughly investigate an injury of unknown origin (a fracture), for one Resident (#118) out of a total sample of 30 residents. Specifically for Resident #118 who on 1/4/25 experienced pain which was new and on 1/5/25 Resident #118 was found to have an acute right intertrochanteric (thigh bone) fracture, the facility failed to conduct interviews from staff members (on all shifts) who had contact with the resident during the period of the alleged incident. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated as revised September 2022, indicated that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. - Investigating Allegations 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and I. documents the investigation completely and thoroughly. 8. The following guidelines are used when conducting interviews: d. Witness statements are obtained in writing, signed and dated. The witness may write his/her statement, or the investigator may obtain a statement. 11. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator. - Follow - Up Report 1. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. 2. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. 3. The follow-up investigation report will provide as much information as possible at the time of submission of the report. Resident #118 was admitted to the facility in December 2024 with diagnoses including ataxia, vascular dementia, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 12/14/24, indicated that Resident #118 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. This MDS indicated Resident #118 required assistance with transfers. Review of Resident #118's eMar - Medication Administration note, dated 1/4/25 at 9:00 A.M., indicated: - Acetaminophen (APAP) Tablet 325 milligrams, give 2 tablets by mouth every 6 hours as needed (PRN) for mild pain. Documented as administered by nursing. Review of Resident #118's nursing progress note, dated 1/4/25 at 10:38 P.M., indicated: - Resident complained of pain 8/10 to left leg, medicated with PRN APAP with ineffective results. Resident's pain level documented in Nurse Practitioner's (NP's) log. (The nurse who wrote this note clarified that the leg pain was the right leg) During an interview on 2/13/25 at 10:01 A.M., Nurse #4 said that Resident #118 was experiencing right leg pain on 1/4/25 which was new, and she was not aware of any incident that may have occurred to cause the pain. Nurse #4 said that Resident #118 has poor safety awareness and Resident #118 could not get him/herself up off the floor if he/she had fallen. Nurse #4 thought that Resident #118 may have injured his/her leg during a self-transfer, but she was not certain. Review of Resident #118's consultant telehealth progress note, dated 1/5/25 at 12:58 P.M., indicated: - History Present Illness: Patient with new right hip and thigh pain. patient is unable to left/[lift] the right leg. [sic] when trying to move extremity the patient yells out in pain. when asking the patient where the pain is specifically points to his/her thigh and holds his/her right hip. there is no external S/S (signs and symptoms) of injury. no bruising or edema or redness noted. patient has no complaints with left leg. able to move extremity at baseline. will obtain STAT (immediately) x-rays. patient has not had any recent falls/injuries per RN. Review of Resident #118's health status note, dated 1/5/25, indicated: - Complained of severe pain to right leg, on call provider notified, new order for STAT X-ray to right hip/pelvis 2/3 views. Order to apply lidocaine patch topically to right leg and reassess pain, resident remains in pain when right leg is touched by staff. Review of Resident #118's radiology report, dated 1/5/25 at 8:29 P.M., indicated: - FINDINGS: There is an acute, mildly displaced right intertrochanteric (thigh bone) fracture. Mild bilateral hip degenerative joint changes. The bony pelvis is intact, but the soft tissues are unremarkable. CONCLUSION: Acute right intertrochanteric fracture. Review of Resident #118's PDPM Nursing Daily Skilled Pathway note, dated 1/5/25 at 11:05 P.M., indicated: - Resident is alert and pleasantly confused, stayed in bed the whole day today complaints of pain right hip, with Tylenol with minimal effect, provider aware and stat right hip x-ray done around 7:00 P.M., will continue to monitor. During an interview on 2/14/25 at 8:43 A.M., Nurse #11 said that she was not sure what caused Resident #118's fracture, and that Resident #118 was confused. During an interview on 2/14/25 at 7:15 A.M., Nurse #3 said that Resident #118 was confused, and he/she had poor safety awareness, and he was not aware of any event that would have caused the fracture. Review of Resident #118's consultant telehealth progress note, dated 1/6/25 at 8:01 A.M., indicated: - History Present Illness: Resident is presenting for radiology review of hip x-ray. Nurse denies any known trauma, but resident complained of right hip pain. Xray hip: Acute mildly displaced Right intertrochanteric fracture. Transfer to Emergency Department for acute right hip fracture and ortho evaluation Orders: Transfer to Emergency Department for acute right hip fracture and ortho evaluation Disposition: Transfer to Emergency Department Review of Resident #118's incident report, dated 1/5/25, indicated that Resident #118 had an injury of unknown, that was not witnessed. Conclusion: Resident sustained a right hip fracture. During the investigation and through staff interviews it was determined that the resident did not fall. The resident was observed transferring from his/her wheelchair to a standard chair at the nurses' station and plopped down hard into the chair before staff could assist him/her. According to the hospital paperwork resident has age related osteoporosis with pathological fracture. Investigative statements were obtained from Nurse #3, Nurse #4 and Unit Manager #2. The incident report was signed off on 1/22/25 at 12:09 P.M., by the Director of Nursing. During an interview on 2/13/25 at 10:10 A.M., Unit Manager #2 said that Resident #118 had right leg pain, and he/she could not move his/her right leg which was new. Unit Manager #2 said that Resident #118 has poor safety awareness and did not have a fall. Unit Manager #2 said that she wrote a statement regarding Resident #118's fracture, but she was not part of the investigation. During an interview on 2/13/25 at 1:27 P.M., the Assistant Director of Nursing (ADON) said she was not aware of any event that caused the fracture. The ADON said that she interviewed Nurse #3, Nurse #4 and Unit Manager #2 and she received statements from them. The ADON said she did not interview any other staff members. During an interview on 2/13/25 at 10:47 A.M., the Director of Nursing said she started the investigation into the injury of unknown and she spoke with the nurses and did not obtain any witness statements from the Certified Nurse Assistants (staff who provided direct care to the resident) or any other staff member. The DON thought that the fracture may have occurred when Resident #118 self-transferred and bumped him/herself on a standard chair. The DON reviewed the investigation file and said there were only statements from 2 nurses and the Unit Manager and that is all she had. During an interview on 2/13/25 at 10:40 A.M., the Administrator said that investigations should include statements from all staff who are working, including CNAs.

Based on record review and interviews, the facility failed to meet professional standards of practice for one Resident (#113) out of a total of sample of 30 residents. Specifically, for Resident #113, the facility failed to ensure nursing clarified a physician's orders for two different suprapubic (SPT) catheter flushes. Findings include: Resident #113 was admitted to the facility in April 2024 with diagnoses including neuromuscular dysfunction of the bladder, diabetes, and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/8/25, indicated that Resident #113 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. The MDS further indicated Resident #113 required an indwelling catheter. Review of Resident #113's active physician's order, dated 12/7/24, indicated: -Flush SPT three times daily (3x/day) by using 50 cc catheter tip syringe and normal saline and injecting through yellow port of the SPT into the bladder and aspirating to ensure drainage, three times a day. Scheduled three times daily at 6:00 A.M., 2:00 P.M., and 10:00 P.M., Review of Resident #113's active physician's order, dated 1/24/25, indicated: -Flush suprapubic tube (SPT) with 50 milliliters (ml) normal saline, two times a day. Scheduled twice daily at 6:00 A.M. and 6:00 P.M. During an interview on 2/12/25 at 11:43 A.M., Nurse #4 said she routinely works the day shift. Nurse #4 said she flushes Resident #113's SPT based on the physician's order and said she has already flushed the SPT today. (prior to the 2:00 P.M. scheduled time) During an interview on 2/13/25 at 7:32 A.M., Nurse #3 said that he routinely works the overnight shift. Nurse #3 said he routinely flushes the catheter around midnight and again at 6:00 A.M. (twice during his shift but there are two orders both with a 6:00 A.M. administration time) During an interview on 2/14/25 at 8:52 A.M., Nurse #11 said she routinely works the evening shift, and she said that she follows the orders, and she flushes Resident #113's SPT once a shift. (once during her shift, however, there are orders at 6:00 P.M. and 10:00 P.M.) During an interview on 2/13/25 at 11:26 A.M., Unit Manager #2 said nursing should flush Resident #113's suprapubic catheter according to the physician's orders. Unit Manager #2 said on 1/24/25 Resident #113 said he/she did not want his/her catheter to be flushed three times daily and she made the provider aware, and the provider said that it was ok to flush the catheter twice a day. Unit Manager #2 said that she did not discontinue the previous order but should have. During an interview on 2/13/24 at 3:13 P.M., the Director of Nursing said that nursing should have clarified the two orders for SPT flushes.

Based on record review and staff interview, the facility failed to document the recapitulation of the Resident's stay that included his/her course of illness/treatment for one Resident (#123), of two closed records Findings include: Review of the facility policy titled Discharge Summary and Plan, dated as revised October 2022, indicated the following: -When a resident's discharge is anticipated, a discharge summary and post discharge plan is developed to assist the resident with discharge. 1. The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's stats at the time of discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: 1. current diagnosis; b. medical history; c. current illness, treatment and/or therapy since entering the facility; d. current laboratory, radiology, consultation and diagnostic test results; e. physical and mental functional status; f. ability to perform activities of daily living; g. sensory and physical impairments; h. nutritional status and requirements including: 1. weight and height; 2. nutritional intake; and 3. eating habits, preferences and dietary restrictions; i. special treatments and procedures; j. mental and psychosocial status; k. discharge potential; l. dental condition; m. activities potential; n. rehabilitation potential; o. cognitive status; and p. medication therapy. 11. A member of the IDT (interdisciplinary team) reviews the final post-discharge plan with the resident and family at least twenty-four (240 hours before the discharge is to take place. 12. A copy of the following is provided to the resident and receiving facility and a copy will be filed in the resident's medical record: a. An evaluation of the resident's discharge needs; b. The post-discharge plan; and c. The discharge summary. Resident #123 was admitted to the facility in October 2024 and had diagnoses that included fracture of the right wrist, and a stage 3 pressure ulcer of the sacral region with a wound vacuum in place. Review of the medical record indicates that Resident #123 was discharged on 12/13/24. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 10/26/24, indicated that on the Brief Interview for Mental status exam Resident #123 scored a 10 out of a possible 15, indicating moderately impaired cognition. Review of Resident #123's electronic and paper medical record: -Failed to indicate a discharge note was written; and -Failed to indicate a Discharge Summary was completed. The section titled Recapitulation of stay was blank and the section titled Social Service (which indicates any home services) was blank. The record indicated that on 12/13/24 Resident #123 received a notice from the facility titled Less than 30 Day Notice of Intent to Discharge/Transfer Resident. The notice was served by the facility on 12/13/24 for a discharge for 12/13/24 and the following line was checked: -Your health has improved sufficiently so that you no longer need the services provided by the facility. During an interview on 2/14/25 at 10:19 A.M., the Director of Nursing (DON) said that when a resident is discharged a discharge note should be written and a discharge summary, including a recapitulation of stay should be completed. During a follow-up interview on 2/14/25 at 10:40 A.M., the DON said that Resident #123 is in a Community based program and they make all decisions about the resident's stay and discharge. The DON said that Nursing should have written a discharge note and probably should have completed the discharge summary's recapitulation of stay.

Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for three dependent Residents (#61, #15 and #48) out of a total sample of 30 residents. Specifically, the facility failed to: 1) Provide assistance with grooming for Resident #61. 2) Provide supervision with meals for Resident #15. 3) Provide assistance with grooming for Resident #48. Findings Include: Review of the undated facility policy, titled Activities of Daily Living (ADL), Supporting, revised in March 2018, indicated, but was not limited to, the following: - Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). - Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1) Resident #61 was admitted to the facility in October 2024 with a diagnosis of debility, cardiorespiratory conditions. Review of the MDS, dated [DATE], indicated that Resident #61 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. Further review of the MDS indicated the Resident was dependent on staff for assistance with personal hygiene. Review of Resident #61's ADL care plan indicated that the Resident required assistance with ADL care in grooming related to limited mobility with the following intervention: - Provide resident with assist of 1 for personal hygiene (grooming), initiated on 9/17/24. On 2/11/25 at 8:45 A.M., the surveyor observed that a few of Resident #61's fingernails were elongated and protruding approximately half an inch beyond the Resident's nail bed; there was a dark substance beneath the Resident's nails. The surveyor observed Resident #61's chin hair which was approximately an inch in length. On 2/11/25 at 11:22 A.M., the surveyor observed that a few of Resident #61's fingernails were elongated and protruding approximately half an inch beyond the Resident's nail bed; there was a dark substance beneath the Resident's nails. The surveyor observed Resident #61's chin hair which was approximately an inch in length. During an interview and observation on 2/12/25 at 8:58 A.M., the surveyor observed that a few of Resident #61's fingernails were elongated and protruding approximately half an inch beyond the Resident's nail bed; there was a dark substance beneath the Resident's nails. The surveyor observed Resident #61's chin hair which was approximately an inch in length. Resident #61 said his/her nails and facial hair were too long and that he/she would like to have them cut. Certified Nursing Aide (CNA) #1 said that CNA's were responsible for checking Resident nails and facial hair every day during care. CNA #1 said Resident #61's nails were disgusting and that the Resident's nails and facial hair should be cut. CNA #1 said that if a resident refused care that the CNA should re-attempt offering assistance, and if the resident continues to refuse that the CNA will communicate with the nurse who will document the refusal. During an observation and interview on 2/12/25 at 9:05 A.M., Nurse #9 said CNA's will defer to care plans to determine what level assistance a resident needs with ADLs. Nurse #9 said CNA's should check for grooming needs daily, when caring for the resident and throughout the day; Nurse #9 said that CNAs should be offering grooming assistance to residents who need it. Nurse #9 said if a resident refuses care the CNA will reattempt and then communicate the refusal to the nurse who would document it. Nurse #9 said that Resident #61 doesn't refuse assistance with grooming and that the Resident is unable to groom his/her own nails or facial hair. Nurse #9 said that she would have expected CNAs to offer assistance with grooming based on how Resident #61's nails and facial hair looked. During an interview on 2/12/25 at 4:59 P.M., the Director of Nursing (DON) said CNAs should be offering to take care of Resident's nails and hair during daily care. The DON said that refusals would be documented. Review of Resident #61's medical record failed to indicate that the Resident refused assistance with grooming. 48671 2. Resident #15 was admitted to the facility in July 2022 with diagnoses including dysphagia (difficulty swallowing), muscle weakness, chronic kidney disease and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/15/24, indicated that Resident #15 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 10 out of 15. Further review of the MDS indicated that Resident #15 had a swallowing disorder including holding food in mouth/cheeks or residual food in mouth after meals and required a mechanically altered diet. Review of Resident #15's hospital discharge summary, dated 12/13/2024, indicated Resident #15 was admitted to the hospital on 12/10/24 for recurrent aspiration (inhaling something into the airway) with pneumonia. The Resident had ongoing aspiration events and recommendations include pureed solids, thin liquids, resident to be sitting upright with meals and continuously observed while eating to prevent aspiration. Review of Resident #15's physician's order dated 12/13/24, indicated: Aspiration precaution at all times, every shift for Aspiration PNA (pneumonia) 1:1 (one to one) feed at mealtimes. Review of Resident #15's nursing progress note, dated 12/14/24, indicated the following: Resident was readmitted back to the facility s/p (status post) aspiration PNA, and respiratory failure. The Resident is on aspiration precautions and requires supervision with meals at all times. On 2/11/25 at 9:01 A.M., the surveyor observed Resident #15 eating breakfast alone in his/her room. There were no staff in the Resident's room or within eyesight of the Resident, his/her hand was trembling while attempting to self-feed. On 2/12/25 at 8:30 A.M. the surveyor observed Resident #15 eating breakfast alone in his/her room. There were no staff in the Resident's room or within eyesight of the Resident, his/her hand was trembling while attempting to self-feed. On 2/13/25 at 8:45 A.M. the surveyor observed Resident #15 eating breakfast alone in his/her room. There were no staff in the Resident's room or within eyesight of the Resident, and the Resident was coughing. During an interview on 2/13/24 at 12:41 P.M., Certified Nurse Assistant (CNA) #1 said Resident #15 can't eat alone and needs supervision with meals because he/she sometimes coughs when eating and was hospitalized due to pneumonia. During an interview on 2/13/24 at 1:15 P.M., Nurse #10 said Resident #15 should not be eating alone and required supervision while eating because he/she chokes food and was hospitalized last year due to pneumonia. Nurse #10 said Resident #15 remains on aspiration precautions and must be supervised. During an interview on 2/14/24 at 9:51 A.M., the Director of Nurses said Resident #15 requires supervision with all meals and said aspiration precautions must be followed according to the physician orders. 3. Resident #48 was admitted to the facility in December 2022 with diagnoses including tinea unguium (nail fungus), low back pain, and difficulty walking. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/11/24, indicated that Resident #48 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 7 out of 15. Further review of the MDS indicated that Resident #48 required partial/moderate assistance with personal hygiene. Review of Resident #48's Activities of Daily Living (ADL) care plan indicated that the Resident requires assistance and may be dep. (dependent) in ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to Recent illness, fall, hospitalization , resulting in fatigue, activity intolerance, Impaired balance, limited mobility, with the following interventions initiated on 12/11/22: -Provide resident assist of 1 for personal hygiene, grooming, may be Dep. at times. -Provide resident with assist of 1 for bathing, may be Dep. at times. During an observation and interview on 2/11/25 at 9:06 A.M. the Surveyor observed Resident #48 in his/her room, the Residents fingernails were elongated with visible dirt beneath. The Resident's fingernails were approximately 1/2 an inch in length extending beyond the nail bed. Resident #48 said his/her nails are too long and wants to have the nails cut but staff do not cut them when he/she asks them to cut them. On 2/12/25 at 12:19 P.M. the Surveyor observed Resident #48 in his/her room, the Residents fingernails were elongated with visible dirt beneath. The Resident's fingernails were approximately 1/2 an inch in length extending beyond the nail bed. During an observation and interview on 2/12/25 at 3:54 P.M., Nurse #9 said Resident #48 did not refuse assistance with care. Nurse #9 observed the Resident's fingernails; said they were long and that they should be cut. Resident #48 agreed to have his/her nails cut and said I've been trying to get them cut but I can't find anyone to do it. During an interview on 2/12/25 at 4:59 P.M., the Director of Nursing (DON) said CNAs should be offering to take care of Resident's nails and hair during daily care. The DON said that refusals would be documented. On 2/13/25 at 8:48 A.M. the Surveyor observed Resident #48 in his/her room, the Residents fingernails were elongated with visible dirt beneath. The Resident's fingernails were approximately 1/2 an inch in length extending beyond the nail bed. During an interview on 2/13/25 at 12:45 P.M., Certified Nursing Assistant #1 said the Resident can have his/her nails cut if he/she wants them to be cut. During an interview on 2/13/25 at 1:03 P.M., Nurse #1 said that Resident #48 can't trim his/her own nails and needs help from staff to do so.

Based on observation, record review, and interview, the facility failed to identify and address significant weight losses for 3 Residents (#55, #73, and #70) out of a total of 24 sampled residents. Findings include: Review of the facility policy titled Weights and Heights, dated 1/31/20, indicated the following: -Policy: Patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary team. -Purpose: To obtain baseline weight and identify significant weight change, to determine possible causes of significant weight change. -Significant Weight Change Management: Significant changes will be reviewed by the licensed nurse for assessment. Significant weight changes are defined as: 5% in one month, 10% in six months. -The licensed nurse will: notify the physician and Dietitian of significant weight changes, document notification of the physician and dietitian in the [clinical record]. -The interdisciplinary care plan will be updated to reflect individualized goals and approaches for managing the weight change. 1. Resident #55 was admitted to the facility in December 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #55's Minimum Data Set (MDS) assessment dated [DATE] indicated he/she is moderately cognitively impaired and requires set up assistance with meals. During an interview with Resident #55 on 5/10/21 at 10:28 A.M., the surveyor observed that he/she was thin and frail. Review of Resident #55's weights indicated the following: -1/1/21: 140.8 lbs (pounds) -1/2/21: 139.4 lbs -2/5/21: 136 lbs -2/8/21: 133.6 lbs (a loss of 5.11% of his/her total body weight since 1/1/21) -2/18/21: 130.9 lbs (a loss of 7.03 % of his/her total body weight since 1/1/21) -2/23/21: 128.8 lbs (a loss of 8.52% of his/her total body weight since 1/1/21) Review of the Resident #55's dietary notes indicated the Dietitian assessed Resident #55's weight loss on 2/25/21; 17 days after his/her initial significant weight loss. The Dietitian's note indicated he/she recommended and implemented increasing Resident #55's house supplements (drinks) from once to twice per day. Review of the Resident #55's physicians orders indicated that the supplements were initiated on 2/25/21. Additional review of Resident #55's weights for March 2021 indicated he/she continued losing weight: -3/3/21: 127.2 lbs (a loss of 9.66 % of his/her total body weight since 1/1/21) -3/12/21: 126.2 lbs (a loss of 10.37% of his/her total body weight since 1/1/21) -3/18/21: 126.4 lbs -3/20/21: 127.4 lbs Review of Resident #55's Dietitian notes indicated he/she assessed Resident #55's continued weight loss on 3/18/21; 15 days after Resident #55 sustained a continued weight loss of 9.66% of his/her total body weight. The Dietitian recommended an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review Resident #55's physician's orders indicated the order for the house supplement cup, effective 3/19/21. Review of Resident #55's weights for April 2021 and May 2021 indicated the following: -4/5/21: 125 lbs (a loss of 11.22% of his/her total body weight since 1/20/21) -4/15/21: 122.8 lbs (a loss of 12.78% of his/her total body weight since 1/20/21) -4/27/21: 123 lbs -5/5/21: 123.2 lbs -5/11/21: 125 lbs Review of Resident #55 clinical record indicated that the dietitian had not assessed Resident #55 since 3/31/21 despite having continued documented significant weight loss. Review of Resident #55's Nutrition Care Plan, initiated 1/4/21, indicated the following: -Focus: Resident need therapeutic and mechanically altered diet to aid chewing and swallowing, history of weight loss. -Goal: Resident will maintain a stabilized weight without significant changes through review date Target date: 6/29/21 -Interventions: Monitor for changes in nutritional status and report to food and nutrition/physician as indicated. -Monitor intake at all meals and offer alternate choices as needed, alert dietitian and physician to any decline in intake -Provide diet as ordered -House supplement as ordered During an interview with Unit Manager #3 on 5/12/21 at 8:38 A.M., she said that whenever Resident #55 has had a weight change, she has alerted the physician. Unit Manager #3 said that Resident #55's physician has told them to monitor his/her weight loss. Review of Resident #55's meal intake percentages from 4/12/21 to 5/11/21 indicated he/she ate 25% of his/her meals for 10 out of 82 documented meals; all other meals were documented as being between 50%-100% consumed. The surveyor made observations of Resident #55 during his/her lunch meals on 5/10/21 and 5/11/21. On both dates Resident #55 ate approximately 70% of his/her meal and said he/she liked the food. During an interview with the Dietitian on 5/12/21 at 10:02 A.M., she said she could not say why there had been delays in responding to Resident #55's weight losses in February 2021 and March 2021. The Dietitian said that she was aware of Resident #55's continued weight loss in April 2021 and acknowledged she had not assessed Resident #55 since 3/31/21. The Dietitian said she was aware of Resident #55's documented weight of 122.8 lbs on 4/22/21. The Dietitian said that no interventions were implemented in response to Resident#55's continued weight loss and did not provide a reason as to why. 2. Resident #73 was admitted to the facility in April 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Resident #73 on 5/10/21 at 1:44 P.M , Resident #73 said he/she did not like the food. Review of Resident #73's weights indicated the following: 4/14/21: 188 lbs (pounds) 4/15/21: 187 lbs 4/16/21: 187.8 4/25/21: 186.8 lbs 5/2/21: 181.6 lbs 5/9/21: 175 lbs (a loss of 6.9% of his/her total body weight since 4/14/21) Review of Resident #73's clinical record failed to indicate a re-weigh was completed to determine the validity of the weight loss per facility policy, and failed to indicate that the Dietitian was notified of Resident #73's potential weight loss. During an interview with Unit Manager #1 on 5/12/21 at 8:05 A.M., she said that when residents sustain a weight loss, she is usually notified by the nurse documenting the weight or the Dietitian becomes aware after running a facility report. When asked about Resident #73's documented weight loss, Unit Manager #1 said she was not aware of the weight loss and had not spoken with Resident #73's physician or the Dietitian about it. Unit Manager #1 said she would obtain a new weight for Resident #73 to determine the validity of the documented weight loss. During an interview with the Dietitian on 5/12/21 at 10:02 A.M., she said that she was not aware of Resident #73 having had a documented weight loss. As of 5/13/21; Resident #73 had refused multiple attempts to re-weigh him/her. 3. Resident #70 was admitted to the facility in April 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data (MDS) assessment, dated 4/14/21, indicated that on the Brief Interview for Mental Status (BIMS) exam Resident #70 scored 3 out of 15, indicating severely impaired cognition. The MDS also indicated Resident #70 was able to feed him/herself after set-up. Review of the nutrition care plan for Resident #70 indicated that the resident is at nutritional risk for weight loss and had an intervention to notify the dietitian and physician of any significant weight loss or gain. Review of the Weight Report for Resident #70 indicated the following weights: * 4/11/21: 122.8 pounds (lbs) * 4/17/2: 120.6 lbs. (there were no further weights recorded for 22 days, until 5/9/2, despite physician orders for weekly weights) * 5/9/21: 114 lbs. (7.17 % weight loss in less than 4 weeks). There was no indication in the record that the dietitian or physician were notified. During a record review for Resident #70 on 5/11/21 at 8:55 A.M., the following was indicated: * A physician's order, dated 4/8/21 for weekly weights x 4, then monthly. * A nutrition assessment dated [DATE] completed by the dietitian, indicating Resident #70 reported a fair appetite and to monitor oral (PO) intake and weight for changes. * The resident was not re-weighed on 5/9/21 when the weight loss was identified, nor was the dietitian or physician notified. It was not until 5/12/21 when the surveyor brought the weight loss to the attention of the nurse unit manager and dietitian that a re-weigh was requested. On 5/12/21 at 8:44 A.M., the surveyor observed Resident #70 seated at a side of his/her bed with a full, untouched breakfast tray that she first received at 8:11A.M. The meal tray was untouched, and Resident #70 was just looking at it, as if she unsure what to do. The surveyor attempted to interview Resident #70, who responded that the meal was good and then Resident #70 resumed staring at the tray. During an interview on 5/12/21 at 8:51 A.M., CNA #3 said Resident #70 barely ate food and that she always made the nurses aware of this. She said Resident #70 never refused care, nor refused to be weighed. CNA #3 said that when she asks Resident #70 if he/she needed assistance with the meals Resident #70 would respond that he/she can feed him/herself and that the food was good. CNA #3 said that Resident #70 received no supplements that she was aware of. During an interview with the Nurse Unit Manager (UM) #1 on 5/12/21 at 8:57 A.M., Resident #70's weight report was reviewed and she said she was not aware that Resident #70 had not been weighed between 4/17/21 and 5/9/21, nor was she aware that the resident's weight on 5/9/21 indicated a significant weight loss. She said Resident #70 should have been weighed weekly, as ordered by the physician, and a re-weigh should have immediately been done on 5/9/21. She said once the weight was verified the dietitian and physician should have been notified of a significant weight loss was recorded on 5/9/21. As well, UM #1 said that the family would be notified by her of a significant weight loss, but that in this case the famliy had not been notified of a weight loss as she was not aware that one had occured. During an interview on 5/12/2021 at 10:02 A.M., the dietitian said although she was aware that Resident #70 was at risk for weight loss, she was not aware that the Resident had not been weighed as ordered. Further, she said she had not been notified of Resident #70's weight on 5/9/21, although she had been in the building and working on 5/10/21. She said that if she had been aware she would have immediately requested a re-weigh and determined appropriate interventions to address the unplanned weight loss.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to prevent an incident of resident neglect, when Certified Nurse Aide (CNA) #1 failed to get a second staff member to assist with a mechanical lift transfer, which resulted in Resident #1 falling from the sling of the lift, sustaining two lacerations to the back of his/her head and bruising to his/her left arm and left inner thigh, was transferred to the Hospital Emergency Department, and required staples to the lacerations on his/her head. Findings include: The Facility Policy titled Abuse Prohibition, dated 7/1/2018, indicated neglect was defined as the failure of the Facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The Facility Policy titled, Safe Resident Handling and Transfer Equipment, dated 5/15/17, indicated a minimum of two staff members were required to transfer residents when using a mechanical lift. Resident #1 was admitted to the Facility in (MONTH) 2013, [DIAGNOSES REDACTED]. The Care Plan, dated 10/8/17, indicated Resident #1 was totally dependent of two staff for transfers and required the use of a mechanical lift for all transfers. The Lift Transfer Reposition Assessment, dated 11/11/18, indicated Resident #1 required two assistance for transfers using the mechanical lift. The Facility's Investigation, undated, indicated that on 12/1/18, at approximately 6:30 P.M., during a mechanical lift transfer, Resident #1 fell from the sling onto the floor, was bleeding from the back of his/her head, and was transferred to the Hospital Emergency Department. The Statement indicated Resident #1 was diagnosed with [REDACTED]. The Investigation indicated CNA #1 and CNA #2 initially reported to the Director of Nurses and Unit Manager #1 that both of them were performing the Mechanical Lift transfer when Resident #1 fell from the sling. The Investigation indicated that on 12/3/18, two days after the incident, CNA #2 recanted her initial statement, and said she was not involved in the mechanical lift transfer of Resident #1. The Statement indicated the Facility determined CNA #1 had performed the mechanical lift transfer by himself. The Surveyor interviewed CNA #1 at 12:26 P.M. on 1/15/19. CNA #1 said the Facility's Policy was that two staff members were required for mechanical lift transfers. CNA #1 said that on 12/1/18, at approximately 6:30 P.M., he and CNA #2 were transferring Resident #1 using the mechanical lift. CNA #1 said that while Resident #1 was up in the lift and he was moving him/her from the chair to the bed, the lift shook, and Resident #1 fell out of the sling and onto the floor. The Surveyor interviewed CNA #2 at 1:05 P.M. on 1/14/19. CNA #2 said she had not assisted with the mechanical lift transfer of Resident #1, and said she lied to the Director of Nurses and Unit Manager #1 when interviewed on 12/1/18. CNA #2 said she told the Director of Nurses and Unit Manager #1 that she had assisted with the mechanical lift transfer, and said that on 12/3/18, she told them the truth that she had not been in the room during the transfer. The Surveyor interviewed CNA #5 at 2:18 P.M. on 1/15/18. CNA #5 said that on 12/1/18, at approximately 6:30 P.M., she was in another resident's room across the hall when CNA #1 came to her, said he had an accident, and asked her to say she was in the room during the transfer, or words to that effect. CNA #5 said she went to Resident #1's room, saw him/her on the floor, and ran to the nurses station to get help. CNA #5 said CNA #1 was the only person in Resident #1's room when he told her about the accident, and said she did not see CNA #2 or any other person in the room. The Surveyor interviewed Unit Manager #1 at 1:36 P.M. on 1/14/19. Unit Manager #1 said that on 12/1/18, she and the Director of Nurses interviewed CNA #1 and CNA #2 separately regarding Resident #1's fall from the mechanical lift. Unit Manager #1 said CNA #1 and CNA #2's descriptions of the fall were different, said she was suspicious that CNA #1 had performed the mechanical lift transfer without assistance, and that CNA #2 was lying. Unit Manager #1 said CNA #2 recanted her statement on 12/3/18, and said she had not assist CNA #1 with Resident #1's transfer on 12/1/18. Unit Manager #1 said CNA #1's actions of not having a second staff member assist with the mechanical lift transfer was neglectful. The Surveyor interviewed the Director of Nurses at 9:37 A.M. and throughout the day on 1/14/19. The Director of Nurses said that at approximately 6:30 P.M. on 12/1/18, she received a call that Resident #1 had fallen from the mechanical lift. The Director of Nurses said she and Unit Manager #1 initiated an investigation immediately, and said CNA #1 and CNA #2 said they were both involved in the mechanical lift transfer of Resident #1 when Resident #1 slid from the sling and landed on the floor. The Director of Nurses said that when interviewed separately, CNA #1 and CNA #2's accounts of the incident had conflicting information, and said she suspected that CNA #1 had performed the mechanical lift transfer himself, and said she suspected CNA #2 had lied by saying she was present for the transfer. The Director of Nurses said that on 12/3/18, CNA #2 recanted her statement, and said she was not involved in the transfer. The Director of Nurses said once CNA #2 recanted her initial statement, the Facility reported the event to the Department of Public Health as an incident of neglect. On 1/14/19 the Facility provided the Surveyor with a plan of correction which addressed the concerns as evidenced by: The Director of Nurses, Administrator, and Medical Director attended a Quality Assurance/Performance Improvement Meeting on 12/5/18, discussed the investigation findings related to Resident #1's fall, initiated staff re-education and re-assessment of all resident care plans requiring mechanical lift transfers. The Facility completed In-service education on 12/4/18 for all staff regarding the Facility's Policy titled, Abuse Prohibition. The Facility completed In-service education between 12/1/18 to 12/17/18. Staff were re-educated to the Facility's Policy titled, Safe Resident Handling and Transfer Equipment. The Facility completed Individual Competencies with 36 Nurses and 58 CNAs, which indicated nursing staff were evaluated for competency with mechanical lift transfer. Staff interviewed said the Facility had provided recent re-education and competency evaluations regarding safe mechanical lift transfers, and recent education regarding abuse prohibition and reporting requirements. The Facility completed audits of resident transfer statuses, dated 12/2/18 to 12/4/18, on all units, which indicated resident care plans were reviewed for appropriate transfer status and safety.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to ensure the staff followed the comprehensive plan of care related to safe transfers, when Certified Nurse Aide (CNA) #1 transferred Resident #1 without a second staff member using a mechanical transfer lift. Resident #1 fell from the sling of the mechanical lift, sustained lacerations to the back of his/her head, was transferred to the Hospital emergency room , where he/she was diagnosed with [REDACTED]. Findings include: The Facility policy titled, Safe Resident Handling and Transfer Equipment, dated 5/15/17, indicated a minimum of two staff members were required to transfer residents when using a mechanical lift. Resident #1 was admitted to the Facility in (MONTH) 2013, [DIAGNOSES REDACTED]. The Care Plan, dated 10/8/17, indicated Resident #1 was totally dependant of two staff for transfers and required the use of a mechanical lift for all transfers. The Facility's Investigation, undated, indicated that on 12/1/18, at approximately 6:30 P.M., during a mechanical lift transfer, Resident #1 fell from the sling onto the floor, was bleeding from the back of his/her head, and was transferred to the Hospital Emergency Department. The Statement indicated Resident #1 was diagnosed with [REDACTED]. The Investigation indicated CNA #1 and CNA #2 initially reported to the Director of Nurses and Unit Manager #1 that both of them were performing the Mechanical Lift transfer when Resident #1 fell from the sling. The Statement indicated that on 12/3/18, two days after the incident, CNA #2 recanted her initial statement, and said she was not involved in the mechanical lift transfer of Resident #1. The Statement indicated the Facility determined CNA #1 had performed the mechanical lift transfer by himself. The Surveyor interviewed CNA #1 at 12:26 P.M. on 1/15/19. CNA #1 said that on 12/1/18, at approximately 6:30 P.M., he and CNA #2 were transferring Resident #1 using the mechanical lift. CNA #1 said he knew it was Facility Policy that any mechanical lift transfer required two staff members. CNA #1 said that while Resident #1 was up in the lift and he was moving him/her from the chair to the bed, the lift shook, and Resident #1 fell out of the sling and onto the floor. The Surveyor interviewed CNA #2 at 1:05 P.M. on 1/14/19. CNA #2 said she had not assist with the mechanical lift transfer of Resident #1, and said she lied to the Director of Nurses and Unit Manager #1 when interviewed by them on 12/1/18. CNA #2 said that on 12/3/18, she told them the truth that she had not been in the room during the transfer. The Surveyor interviewed Unit Manager #1 at 1:36 P.M. on 1/14/19. Unit Manager #1 said that on 12/1/18, she and the Director of Nurses interviewed CNA #1 and CNA #2 separately regarding Resident #1's fall from the mechanical lift. Unit Manager #1 said CNA #1 and CNA #2's versions of the fall were different, and said she was suspicious that CNA #1 had performed the mechanical lift transfer without assistance. Unit Manager #1 said CNA #2 recanted her statement on 12/3/18, and said she had not assisted CNA #1 with Resident #1's transfer on 12/1/18. The Surveyor interviewed the Director of Nurses at 9:37 A.M. and throughout the day on 1/14/19. The Director of Nurses said that at approximately 6:30 P.M. on 12/1/18, she received a call that Resident #1 had fallen from the mechanical lift. The Director of Nurses said she and Unit Manager #1 initiated an investigation immediately, and said CNA #1 and CNA #2 said they were both involved in the mechanical lift transfer of Resident #1 when Resident #1 slid from the sling and landed on the floor. The Director of Nurses said that when interviewed separately, CNA #1 and CNA #2's accounts of the incident had conflicting information, and said she suspected that CNA #1 had performed the mechanical lift transfer himself, and said she suspected CNA #2 had lied by saying she was present for the transfer. The Director of Nurses said that on 12/3/18, CNA #2 recanted her statement, and said she was not involved in the transfer. On 1/14/19 the Facility provided the Surveyor with a plan of correction which addressed the concerns as evidenced by: The Director of Nurses, Administrator, and Medical Director attended a Quality Assurance/Performance Improvement Meeting on 12/5/18, discussed the investigation findings related to Resident #1's fall, initiated staff re-education and re-assessment of all resident care plans requiring mechanical lift transfers. The Facility completed In-service education between 12/1/18 to 12/17/18. Staff were re-educated to the Facility's Policy titled, Safe Resident Handling and Transfer Equipment. The Facility completed Individual Competencies with 36 Nurses and 58 CNAs, which indicated nursing staff were evaluated for competency with mechanical lift transfer. Staff interviewed said the Facility had provided recent re-education and competency evaluations regarding safe mechanical lift transfers. The Facility completed audits of resident transfer statuses, dated 12/2/18 to 12/4/18, on all units, which indicated resident care plans were reviewed for appropriate transfer status and safety.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), the Facility failed to ensure staff maintained appropriate safety measures to prevent injury, when Certified Nurse Aide (CNA) #1 transferred Resident #1 via mechanical lift without a second staff member present, resulting in Resident #1 falling from the lift. Resident #1 sustained two lacerations to the back of his/her head, was transferred to the Hospital Emergency Department, was diagnosed with [REDACTED]. Findings include: The Facility Policy titled, Safe Resident Handling and Transfer Equipment, dated 5/15/17, indicated a minimum of two staff members were required to transfer residents when using a mechanical lift. Resident #1 was admitted to the Facility in (MONTH) 2013, [DIAGNOSES REDACTED]. The Care Plan, dated 10/8/17, indicated Resident #1 required the use of a mechanical lift for all transfers. The Lift Transfer Reposition Assessment, dated 11/11/18, indicated Resident #1 required two assistance for transfers using the mechanical lift. The Lift Transfer Reposition Assessment, dated 11/11/18, indicated Resident #1 required two assistance for transfers using the mechanical lift. The Facility's Statement of the Incident, undated, indicated that on 12/1/18, at approximately 6:30 P.M., during a mechanical lift transfer, Resident #1 fell from the sling onto the floor, was bleeding from the back of his/her head, and was transferred to the Hospital Emergency Department. The Statement indicated Resident #1 was diagnosed with [REDACTED]. The Communication Form, dated 12/1/18, indicated Resident #1 was transferred via the mechanical lift, slipped bottom first from the lift, and hit his/her head on the floor, and was bleeding. The Form indicated Resident #1 was transferred to the Hospital Emergency Department. The Change in Condition Note, dated 12/2/18, indicated Resident #1 returned from the emergency room , had two lacerations to the back of his/her head, one with three staples in place and one with seven staples in place, and had bruising to his/her left arm and left inner thigh area. The Facility's Investigation, undated, indicated CNA #1 and CNA #2 initially reported to the Director of Nurses and Unit Manager #1 that both of them performed the Mechanical Lift transfer when Resident #1 fell from the sling. The Statement indicated that on 12/3/18, two days after the incident, CNA #2 recanted her initial statement, and said she was not involved in the mechanical lift transfer of Resident #1. The Statement indicated the Facility determined CNA #1 had performed the mechanical lift transfer by himself. The Surveyor interviewed CNA #1 at 12:26 P.M. on 1/15/19. CNA #1 said the Facility's Policy was that two staff members were required for mechanical lift transfers. CNA #1 said that on 12/1/18, at approximately 6:30 P.M., he and CNA #2 were transferring Resident #1 using the mechanical lift. CNA #1 said that while Resident #1 was up in the lift and he was moving him/her from the chair to the bed, the lift shook, and Resident #1 fell out of the sling and onto the floor. The Surveyor interviewed CNA #2 at 1:05 P.M. on 1/14/19. CNA #2 said she had not assisted with the mechanical lift transfer of Resident #1, and said she lied to the Director of Nurses and Unit Manager #1 when interviewed by them on 12/1/18. CNA #2 said she told the Director of Nurses and Unit Manager #1 that she had assisted CNA #1 with the mechanical lift transfer, and said that on 12/3/18, she told them the truth that she had not been in the room during the transfer. The Surveyor interviewed CNA #5 at 2:18 P.M. on 1/15/18. CNA #5 said that on 12/1/18, at approximately 6:30 P.M., she was in another resident's room across the hall when CNA #1 came to her, said he had an accident, and asked her to say she was in the room during the transfer, or words to that effect. CNA #5 said she went to Resident #1's room, saw him/her on the floor, and ran to the nurses station to get help. CNA #5 said CNA #1 was the only person in Resident #1's room when he told her about the accident. The Surveyor interviewed Unit Manager #1 at 1:36 P.M. on 1/14/19. Unit Manager #1 said that on 12/1/18, she and the Director of Nurses interviewed CNA #1 and CNA #2 separately regarding Resident #1's fall from the mechanical lift. Unit Manager #1 said CNA #1 and CNA #2's telling of the fall were different, and said she was suspicious that CNA #1 had performed the mechanical lift transfer without assistance, and that CNA #2 was lying. Unit Manager #1 said CNA #2 recanted her statement on 12/3/18, and said she did not assist CNA #1 with Resident #1's transfer on 12/1/18. The Surveyor interviewed the Director of Nurses at 9:37 A.M. and throughout the day on 1/14/19. The Director of Nurses said that at approximately 6:30 P.M. on 12/1/18, she received a call that Resident #1 had fallen from the mechanical lift. The Director of Nurses said she and Unit Manager #1 initiated an investigation immediately, and said CNA #1 and CNA #2 said they were both involved in the mechanical lift transfer of Resident #1 when Resident #1 slid from the sling and landed on the floor. The Director of Nurses said that when interviewed separately, CNA #1 and CNA #2's accounts of the incident had conflicting information, and said she suspected that CNA #1 had performed the mechanical lift transfer himself, and said she suspected CNA #2 had lied by saying she was present for the transfer. The Director of Nurses said that on 12/3/18, CNA #2 recanted her statement, and said she was not involved in the transfer. On 1/14/19 the Facility provided the Surveyor with a plan of correction which addressed the concerns as evidenced by: The Director of Nurses, Administrator, and Medical Director attended a Quality Assurance/Performance Improvement Meeting on 12/5/18, discussed the investigation findings related to Resident #1's fall, initiated staff re-education and re-assessment of all resident care plans requiring mechanical lift transfers. The Facility completed In-service education between 12/1/18 to 12/17/18. Staff were re-educated to the Facility's Policy titled, Safe Resident Handling and Transfer Equipment. The Facility completed Individual Competencies with 36 Nurses and 58 CNAs, which indicated nursing staff were evaluated for competency with mechanical lift transfer. Staff interviewed said the Facility had provided recent re-education and competency evaluations regarding safe mechanical lift transfers. The Facility completed audits of resident transfer statuses, dated 12/2/18 to 12/4/18, on all units, which indicated resident care plans were reviewed for appropriate transfer status and safety.

Based on record review and staff interviews, the facility failed to provide appropriate supervision, monitor for effectiveness and modify interventions when necessary to prevent falls and injury for 1 of 11 applicable residents (#8) with falls, in a total sample of 23. Findings include: For Resident #8, the facility failed to utilize effective interventions that would protect the resident from 9 repeated falls between 7/21/14 and 11/9/14 including 3 falls with injury which required transfer to the hospital. Injuries included: cerebral contusion, bruised sacrum, 10th rib fracture, 3 centimeter laceration to back of head requiring 4 staples and hip pain with bulge. The clinical record was reviewed on 11/13/14. Resident #8 was admitted to the facility in 6/2014. [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], identified the resident as having a Brief Interview for Mental Status (BIMS) coded as (03) equal to severe cognitive impairment. The resident demonstrated verbal abusiveness toward others and required extensive assist of 2 for bed mobility and transfer and extensive assist of 1 for ambulation. The resident was incontinent of bowel and bladder and received antipsychotic medication, antibiotics and diuretics. The resident weighed 194 lbs. and did not utilize a restraint device. The most recent quarterly (MDS), dated ,[DATE], identified the resident as having a Brief Interview for Mental Status (BIMS) coded as (03) equal to severe cognitive impairment. The resident demonstrated verbal abusiveness toward others and required extensive assist of 2 for bed mobility and extensive assist of 1 for transfer and ambulation. The resident was incontinent of bowel and bladder and received antipsychotic medication, antibiotics and diuretics. The resident weighed 207 lbs., and did not utilize a restraint device. Between the above two assessments, the resident sustained [REDACTED]. The Falls Care Plan in place from admission to record review was dated 6/4/14. It was not the practice of the facility to date each new intervention when added. Sporatic dates were documented and included below: Problem: "... at risk for falls or injury secondary to decreased safety awareness, use of psychotropics, unsteady gait, bilateral lower extremity edema and refusal to use a walker." Goal: "Resident's risk of falls or injury will be minimized through 12/2014." Interventions included: * Bed and chair alarm * Clear instructions prior to transfer or ambulation * Ambulate with rolling walker to 30 feet (9/12/14) * Appropriate footwear at all times * Rehabilitation screen annually and after any fall * Seat in common area when out of bed for increased observation (However, there was no specific instructions for staff at nurses' station or common areas on how to provide effective supervision) * Sleeps in recliner at home - will use Broda PRN * May remove chair sensor when in supervised setting (6/13/14) * Dycem use (7/21/14) (8/7/14) (9/25/14) (10/3/14) until resident refused to sit on a chair with a dycem (10/30/14) * Soaker pad not on chair * Sit to Stand lift PRN for transfers (9/5/14) * May move bed to common area to allow resident to sleep in bed as resident allows (9/10/14) * Padded rails on bed (10/27/14) Documented falls in the clinical record and Occurrence Report and Investigation form included the following: Fall #1 - 7/21/14 witnessed fall - Attempted to sit unassisted on chair in the hallway with a soaker pad on the chair which was folded with the slippery side up. Without assistance, the resident slid off the chair onto the floor. Intervention: Do not place soaker pads on residents' chairs. Dycem to chair. There was no Rehabilitation Screen to review, as care planned. Fall #2 - 7/22/14 witnessed fall - Attempted to sit unassisted on hallway chair with soaker pad and slid off chair onto the floor. Intervention: Remove soaker pad from chair and place a Dycem. This was the intervention for the previous fall which was ineffective. No new interventions were developed. There was no Rehabilitation Screen to review. Fall #3 - 8/7/14 witnessed fall - Attempted to sit on edge of chair unassisted in the supervised area and slipped out of the chair onto the floor on the right side of body. Intervention: Dycem on chair. This was the intervention for the previous two falls and was not effective. Chair alarm had been removed as the resident was in the supervised area. No new interventions were developed. There was no Rehabilitation Screen to review, as care planned. Fall #4 - 8/31/14 at 2:00 P.M. - witnessed fall - While standing unassisted at the nurse's station the resident lost balance and fell backward landing on his/her buttocks. Walker was beside the resident. Intervention: Physical Therapy (P.T.) evaluation. Keep in supervised area when out of bed. Although this resident had been in a supervised area for all of the above falls, the resident continued to fall. Fall #5 - 8/31/14 at 3:15 P.M. - unwitnessed fall 45 minutes after the last fall at the nurse's station on the same day - Two nurses were behind the nurse's station when a bang was heard in front of the desk. When the nurses went around the station to observe, the resident was lying on his/her back on the floor with blood coming from the back of the resident's head. Pressure was applied to the area until the Emergency Medical Technician (EMTs) arrived to bring the resident to the emergency room (ER) for evaluation and treatment. This resulted in "a small area of hemorrhage, probably representing a cerebral contusion in the midline superiorly adjacent to the (cerebral) falx". The resident was then transferred from the initial hospital to another hospital for confirmation. A bruise on the resident's sacrum was noted upon return to the facility. Intervention: PT evaluation to be completed. Reported to the Department of Public Health. Although documentation indicated that the care plan had been revised, there was no evidence of care plan revision for that date, despite injury. Fall #6 - 9/25/14 witnessed fall - Attempted to reach forward toward a visitor when sitting in a standard chair other than his/her own. fell out of chair in front of the nurse's station onto right side of his/her body. Intervention: Cover all chairs in the hallway with a Dycem. During interview with the Director of Nursing on 11/13/14 at 2:00 P.M., it had been stated that the resident disliked sitting on a Dycem. This intervention was previously used unsuccessfully multiple times and continued to be used. The resident continued to fall. There was no Rehabilitation Screen to review. Fall #7 - 10/7/14 witnessed fall - Stood up from chair with walker unassisted in front of the nurse's station and the alarm sounded. The resident lost his/her balance and fell to a sitting position on the floor. The following day the resident complained of pain during a transfer to the toilet. An X-ray showed a 10th rib fracture on the left side. Intervention: Continue to keep in supervised area. This intervention had already been in place since shortly after admission. Despite 7 falls with 2 injuries in a supervised area/nurse's station, the facility continued to utilize this ineffective intervention. There was no Rehabilitation Screen to review. Reported to the Department of Public Health. Fall #8 - 10/8/14 witnessed fall - The nurse asked the resident to have a seat. The resident turned to sit unassisted and fell to the right side. Intervention: Trial Merry Walker when available. There was no evidence that this intervention was tried. There was no Occurrence Report or Investigation to review. Although this resident required extensive assistance of staff with transfer and ambulation, the resident was told to sit without assistance and he/she fell . There was no Rehabilitation Screen to review, as care planned. Fall #9 - 11/9/14 Unwitnessed fall - The resident was seated across from the nurse's station with a walker. The resident got up unassisted and began to ambulate, lost balance and fell backward. The nurse at the desk heard the alarm sound and stood up to observe the resident on the floor with blood noted to be coming from the back of his/her head. A collar was applied and the resident was transported to the Hospital where he/she was admitted for observation and diagnosed with [REDACTED]. The resident also complained of hip pain with a bulge noted. Intervention: Documentation indicated, "Multiple interventions are in place to reduce the risk of injury...."These were the former interventions that had been proven to be ineffective. And, the resident continued to fall. Although it had been determined that the resident refused to use a chair with a Dycem, it was still on the resident's chair according to the investigation. There were no new interventions developed. There was no Rehabilitation Screen to review. During interview with the Administrator and Director of Nurses on 11/17/14 at 2:00 P.M. and 11/18/14 at 11:00 A.M., they said that they had tried interventions and nothing seemed to work. They indicated that they had researched a bean bag chair and had recently ordered it. Until it is delivered and assessed by P.T., the resident will be on close supervision. The facility failed to develop an effective Falls Care Plan to prevent falls and follow it. They failed to show evidence that the Falls Care Plan had been reviewed and revised to prevent future falls. From review, it appeared that the same interventions were restated. For example, even though the resident had demonstrated that he/she disliked and refused the Dycem, it appeared to be an on-going intervention and continued to be utilized through the most recent fall with injury on 11/9/14. Even though the resident was assessed as requiring extensive assistance for transfer and ambulation, the resident was unassisted prior to most of the falls. Most of the above falls occurred in a supervised area/nurse's station and "keeping the resident in a supervised area" was a repeated intervention. There was no indication that the "supervised area" was assessed for effectiveness. Two of the three falls with injuries occurred as unwitnessed falls in a supervised area. Seven of the nine falls, including the third injury, were witnessed falls which occurred in a supervised area. This intervention was not effectively implemented to prevent falls or injury.

Based on record review and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1's medication regime was free of medication errors and that Resident #1 received only medications as prescribed. The physician orders [REDACTED]. Resident #1 was diagnosed with [REDACTED]. Findings include: The Surveyor interviewed the Director of Nurses (DON) at 9:09 A.M. on [DATE]. The Surveyor interviewed the Unit Manager at 10:10 A.M. on [DATE]. The DON and Unit Manager said the Facility used a computerized physician order [REDACTED]. The Hospital discharge orders, dated [DATE], indicated Resident #1 was prescribed [MEDICATION NAME] 10 milligrams orally, to be administered twice a day, and [MEDICATION NAME] 40 milligrams orally, to be administered once a day. The discharge summary, dated [DATE], indicated Resident #1's hospital [DIAGNOSES REDACTED].#1's diuretics were changed from [MEDICATION NAME] to [MEDICATION NAME]. The hospital summary indicated Resident #1 had [MEDICAL CONDITION] (low platelet counts) when hospitalized , and it was thought the [MEDICATION NAME] was the cause of the [MEDICAL CONDITION] 1. Resident #1's readmission telephone physician orders [REDACTED]. Review of the medication administration record entry, dated [DATE], indicated that at 9:00 A.M., Nurse #3 documented she administered [MEDICATION NAME] 100 milligrams to Resident #1. The Surveyor interviewed Nurse #3 at 11:00 A.M. on [DATE]. Nurse #3 said that on [DATE], at approximately 9:00 A.M., she gave Resident #1 [MEDICATION NAME] 100 milligrams as documented on the medication administration record. The Surveyor interviewed Nurse #1 at 12:30 P.M. on [DATE]. Nurse #1 said she worked the evening Resident #1 was readmitted to the Facility ([DATE]). Nurse #1 said as part of the readmission process, a nurse called a nurse practitioner or physician to review all the hospital discharge orders. Nurse #1 said when she entered the [MEDICATION NAME] orders, she had to do so using a computer drop down menu, which allowed her to pick the dose. Nurse #1 said she thought she chose the [MEDICATION NAME] 10 milligrams, but she apparently chose [MEDICATION NAME] 100 milligrams, which was directly below the 10 milligrams dose choice, in error. The DON and Unit Manager said the order for the [MEDICATION NAME] 100 milligrams was communicated electronically to the pharmacy, whose staff then delivered [MEDICATION NAME] 100 milligrams to the Facility. 2. The handwritten telephone orders, dated [DATE], indicated at 8:00 P.M., Nurse #1 obtained readmission orders may reinstate all prior med (medication) orders...." The previous orders included [MEDICATION NAME] and therefore, Nurse #1 reordered Resident #1's previous order for [MEDICATION NAME] 40 milligrams. This was not consistent with the information contained within the discharge summary, dated [DATE]. Nurse #1 said she did have a discharge summary and all the orders when Resident #1 returned from the Hospital on [DATE]. Nurse #2 said the orders were not clear regarding Resident #1's continued use of [MEDICATION NAME]. Nurse #1 said the covering nurse practitioner told her to simply read the orders from the hospital and she complied, but never attempted to tell the covering nurse practitioner that the [MEDICATION NAME] order conflicted with the information contained within the discharge summary regarding Resident #1's hospital course of treatment and continued plan of care. The nurse's note, dated [DATE], indicated that at 12:00 P.M., Resident #1 was transferred to the emergency department for evaluation following a medication error. Review of the medication administration record entry, dated [DATE], indicated that at 6:00 A.M., Nurse #2 administered [MEDICATION NAME] 40 milligrams to Resident #1. The Surveyor interviewed Nurse #2 at 12:25 P.M. on [DATE]. Nurse #2 said that on [DATE], he gave Resident #1 [MEDICATION NAME] at 6:00 A.M. as documented on the medication administration record. The Hospital admission history and physical, dated [DATE], indicated Resident #1 admission [DIAGNOSES REDACTED]. The Surveyor interviewed the Physician at 11:55 A.M. on [DATE]. The Physician said based on review of the hospital discharge documentation, it was the intent Resident #1 receive [MEDICATION NAME] 10 milligrams and no [MEDICATION NAME] when readmitted to the facility on [DATE]. The Physician said Resident #1 died weeks after the error, but due to Resident #1's preexisting [MEDICAL CONDITION], the medication errors did not cause Resident #1's death, but may have contributed to it. The Physician said Resident #1 was hospitalized in response to the errors, and his/her renal function tests worsened; and because Resident #1 had low blood pressure required gentle hydration and monitoring of his/her renal, cardiac, and respiratory status at the Hospital. 3. The DON and Unit Manager said normally, all physician orders [REDACTED]. The DON and Unit Manager said the night nurses were to review all the orders for current residents, new admissions, and readmissions to ensure they were transcribed or data entered accurately. The DON and Unit Manager said the re-admission orders [REDACTED]'s order not being implemented correctly. The DON and the Unit Manager said the second check of Resident #1's readmission orders [REDACTED]'s policy. The DON said that in response to the incident, the facility completed an investigation in an effort to determine the factors which contributed to the error and took corrective action in response. The DON said the nurses, including Nurse #2, were re-educated on [DATE] to re-enforce the expectation regarding completion of a second review of new orders. The DON said the pharmacy was contacted to change the sequence of the doses within the computerized system and provided reeducation to Nurse #1 and Nurse #2. The DON and Unit Manager said the Unit Manager now performs an independent review of all new admissions and readmission orders [REDACTED].