Every finding on record at Meadowbrook Acres

Based on observation, record review and staff interview the facility failed to develop and implement the care plan for applying bed rails to the beds. This was true for three (3) of the eleven (11) residents that were reviewed for bed rails. Resident Identifiers: #49, #30 and #19. Facility Census: 58 Findings Include: a) Resident #49 On 11/04/25 at 10:10 AM record review of current orders for Resident #49 shows 1/2 bilateral upper siderails to assist with bed mobility and transfers. On 11/04/25 at 10:20 AM review of the care plan for Focus (Residents name) hasd an ADL self care performance deficit related to deconditioning, weakness, pain. Resident #49s interventions./tasks show Bilateral 1/2 side rail to aid in turning and repositioning. On 11/04/25 at 10:45 AM observation of Resident #49 shows she has no side rails in place at this time. The above findings were confirmed with the Director of Nursing on 11/05/25 at 9:15 AM at which time she agreed there were no side rails present on the bed. b) Resident #30 A record review on 11/04/25 at 10:30 AM, revealed a fall care plan for Resident #30, that has an intervention implemented on 08/018/25 that reads as follows: Half bilateral side rails to head of bed for increased independence with positioning and personal care. An observation on 11/04/25 at 10:40 AM, revealed Resident #30 lying in bed, no side rails in place per the care plan. During an interview on 11/04/25 at 10:45 AM, The Director of Nursing (DON), confirmed that the side rails were not on Resident #30's bed as care planned. c) Resident #19 A record review on 11/05/25 at 12:25 pm, revealed a Care Plan order for Resident #19, completed on10/13/2025 that reads as follows: Resident #19 (name) has been approved for use of bilateral quarter side rails for assisting with repositioning and bed mobility. An observation on 11/06/25 at 9:40 AM, revealed the resident lying in bed, no bilateral quarter side rails in place per order. During an interview on 11/06/25 at 1:45 PM, The Director of Nursing (DON) acknowledged that the side rails were not in place as ordered for Resident #19.

Based on record review, staff interview, and observation the facility failed to provide care in accordance with professional standards of practice, by not following doctors orders for side rail implementation and neuro checks. This failed practice was found true for (4) four of (4) four residents reviewed for fall interventions during the Complaint Survey Process. Resident identifiers #19, #30, #49, and #23. Facility Census 58.Findings Include: a) Resident #49 On 11/04/25 at 10:10 AM record review of current orders for Resident #49 shows 1/2 bilateral upper siderails to assist with bed mobility and transfers ordered on 08/14/24. The care plan for Focus (Residents name) hasd an ADL self care performance deficit related to deconditioning, weakness, pain. Resident #49s interventions./tasks show Bilateral 1/2 side rail to aid in turning and repositioning. A review of Task GG Roll Left and Right shows Resident #49 is either Partial.moderate assistance or Substantial.maximal asistance for turns. On 11/04/25 at 10:45 AM observation of Resident #49 shows she has no side rails in place at this time. The above findings were confirmed with the Director of Nursing on 11/05/25 at 9:15 AM at which time she agreed there were no side rails present on the bed. b) Resident #23 On 11/04/25 at 12:40 PM record review found that Resident #23 has had several unwitnessed falls since her admission. The Change in Condition report was obtained and reviewed which shows an unwitnessed fall on 10/31/25 at 9:30 AM which occurred in the lounge. The Incident description reads resident was observed on floor in front of couch. The Resident description reads resident states she slid off the couch. According to the Neurological Evaluation Policy as of 01/26/23 which was provided to the surveyor, Neurological evalutaion will be performed as indicated or ordered. When a Resident sustains an injury to the head or has an unwitnessed fall the following evlauations will be performed: Every 15 minutes X one hour Every 30 minutes X two hours Every 60 minutes X four hours Every 8 hours until 72 hours (3 days) During an interview on 11/04/25 at 2:10 PM the Director of Nursing stated neurological checks are performed on all residents that have an unwitnessed fall. She also stated that there are no neurological assessments for Resident #23 for the unwitnessed fall on 10/31/25 and they should have been performed. c) Resident #19 A record review on 11/05/25 at 12:25 pm, revealed a Care Plan order for Resident #19, completed on10/13/2025 that reads as follows: Resident #19 (name) has been approved for use of bilateral quarter side rails for assisting with repositioning and bed mobility. An observation on 11/06/25 at 9:40 AM, revealed the resident lying in bed, no bilateral quarter side rails in place per order. During an interview on 11/06/25 at 1:45 PM, The Director of Nursing (DON) acknowledged that the side rails were not in place as ordered for Resident #19. b) Resident #30 A record review on 11/04/25 at 10:30 AM, revealed an order for Resident #30, dated 08/18/25 that reads as follows: Half bilateral side rails to head of bed for increased independence with positioning and personal care. An observation on 11/04/25 at 10:30 AM, revealed the resident lying in bed, no half bilateral side rails in place per order. During an interview on 11/04/25 at 10:45 AM, The Director of Nursing (DON) confirmed that the side rails were not in place as ordered for Resident #30 and stated, We did an audit a few weeks back and that is her new bed. I did not do a new assessment. I guess I dropped the ball on that one.

Based on observation, and staff interview the facility failed to provide residents with a dignified activity experience by passing medications during Bible Study. This failed practice was a random opportunity for discovery during the Complaint Survey. Resident identifier #9. Facility Census 58.Findings Include:a) Resident #9An observation on 11/04/25 at 2:18 PM, revealed the recreation room door to be closed and a sign that read, Bible Study on the closed door.Further observation revealed Registered Nurse (RN) #48, opening the closed door that read, Bible Study and administering Resident #9 a medication.During an interview on 11/04/25 at 2:30, RN #48 stated, If we are running behind we give them during activities or in the dining room. SA asked the RN if he was behind today and RN #48 stated, Not really, I just wanted to get done. SA then asked what medication did you give the resident? RN #48 replied, Baclofen.During an interview on 11/04/25 at 3:14 PM, Activity Assistant (AA) #73 confirmed that the RN gave the medicine during Bible Study and stated, They give medicines in all of our activities.A policy review on 11/04/25 at 3:30 PM, revealed a policy titled {Medication Administration}, {Policy Explanation and Compliance Guidelines}, under bulletin seven (7) reads; Provide Privacy

Based on record review, and staff interview the facility neglected to provide supervision and monitoring to prevent repeated elopement's. This failed practice resulted in Resident #60 having over 20 attempted elopement's and/or exit seeking behaviors during a (9) nine month period. This failed practice was found true for (1) one of (3) three residents reviewed for elopement risk during the Complaint Survey Process. Resident identifier #60. Facility Census 58.Findings Include:a) Resident #60A review on 11/04/25 at 2:15 PM, revealed a reportable incident for Resident #60 for an elopement dated 04/22/24. The elopement is summarized as follows: On 04/22/24 the facility received a phone call from a (Local Emergency Room) saying that Resident #60 had been brought in by someone and that she had eloped from this nursing home. During the investigation it was determined by medical records and staff interviews that when (3) three evening shift staff members entered the facility they did not make sure the door properly latched making the elopement possible. It was also determined during the investigation by the facility that the resident had been gone for approximately 2 hours, according to the statements, meal tickets and medication administration times. A record review on 11/05/25 at 10:40 AM, revealed Nursing Notes, and Behavior Notes from 09/2023 to 04/22/24 showing that Resident #60 was exit seeking, or had went out the front door, A hall door, or B hall door at least 20 times. Further record review of Resident #60's incidents revealed that between 9/2023 to 04/22/24, five (5) of the elopement attempts were successful and Resident #60 did get out of the facility. Further record review also revealed that Resident #60 had (3) three scheduled wandering risk assessments completed, which all had her at risk for elopement, and that A wander guard bracelet had been placed since admission.Continued record review revealed an elopement care plan created on 04/14/23 that had only the following interventions until her elopement on 04/22/24:Attempt to involve (Resident #60 name) in activities of choice for as long as shewill maintain focus even though it's for short periodsDate Initiated: 04/23/2024Distract (Resident #60 name) from wandering by offering pleasant diversions,structured activities, food, conversation, television, take outside in the court yardwhen weather is nice and give her the baby doll.Date Initiated: 04/14/2023 WANDER ALERT: Wander guard bracelet to be worn at all timesand applied to right ankle.Date Initiated: 04/14/2023Check wander guard bracelet at bedtime for proper function andplacementDate Initiated: 04/14/2023Report any exit seeking behaviors to nursing and SupervisorDate Initiated: 04/14/2023Wander guard bracelet to be changed yearly per recommendationsand PRN for non-functioning device.Date Initiated: 04/14/202During an interview on 11/05/25 at 1:45 PM, with The Director of Nursing (DON), and Licensed Social Worker (LSW), The DON stated, I know 360 Psych had seen her, and she had a couple infections. The LSW stated, I know I talked to her family about moving her to a locked unit, but they wouldn't agree, but I don't have that documented anywhere. The DON further stated, I started as DON in September of 2023. I had never been in Long-Term Care. My mind then wasn't what it is now. Looking back on it I would of put her on one on one visits or at least 15 minute checks.b) PolicyA review on 11/05/25 at 2:30 PM of the policy last reviewed on 04/01/13 titled {Elopement/Missing Resident protocol, defines elopement as follows: When a resident leaves the premises or safe area without authorization. A resident who leaves the premises has the potential to experience heat/cold exposure, dehydration and/or medical complications, drowning or being struck by a vehicle.Purpose:To initiate emergency protocol should a resident exit the facility unescorted by staff member or legally responsible party. Resident straying beyond the normal view or control of employees may be at risk for injury or death. During an interview on 11/05/25 at 2:45 PM, the DON confirmed that the above policy was the one in place when the elopement took place on 04/22/24, and that a new policy has been put in place since. The DON further stated, I noticed our policy had not been reviewed since 2013 and got us a new one.

Based on record review, and staff interview the facility failed to ensure the environment in which it had control over was as free from accidents/ hazards as possible, by not providing supervision and monitoring to prevent repeated elopements. This failed practice was found true for (1) one of (3) three residents reviewed for elopement risk during the Complaint Survey Process. Resident identifier #60. Facility Census 58. Findings Include:a) Resident #60A review on 11/04/25 at 2:15 PM, revealed a reportable incident for Resident #60 for an elopement dated 04/22/24. The elopement is summarized as follows: On 04/22/24 the facility received a phone call from a (Local Emergency Room) saying that Resident #60 had been brought in by someone and that she had eloped from this nursing home. During the investigation it was determined by medical records and staff interviews that when (3) three evening shift staff members entered the facility they did not make sure the door properly latched making the elopement possible. It was also determined during the investigation by the facility that the resident had been gone for approximately 2 hours, according to the statements, meal tickets and medication administration times. A record review on 11/05/25 at 10:40 AM, revealed Nursing Notes, and Behavior Notes from 09/2023 to 04/22/24 showing that Resident #60 was exit seeking, or had went out the front door, A hall door, or B hall door at least 20 times. Further record review of Resident #60's incidents revealed that between 9/2023 to 04/22/24, five (5) of the elopement attempts were successful and Resident #60 did get out of the facility. Further record review also revealed that Resident #60 had (3) three scheduled wandering risk assessments completed, which all had her at risk for elopement, and that A wander guard bracelet had been placed since admission.Continued record review revealed an elopement care plan created on 04/14/23 that had only the following interventions until her elopement on 04/22/24:Attempt to involve (Resident #60 name) in activities of choice for as long as shewill maintain focus even though it's for short periodsDate Initiated: 04/23/2024Distract (Resident #60 name) from wandering by offering pleasant diversions,structured activities, food, conversation, television, take outside in the court yardwhen weather is nice and give her the baby doll.Date Initiated: 04/14/2023 WANDER ALERT: Wander guard bracelet to be worn at all timesand applied to right ankle.Date Initiated: 04/14/2023Check wander guard bracelet at bedtime for proper function andplacementDate Initiated: 04/14/2023Report any exit seeking behaviors to nursing and SupervisorDate Initiated: 04/14/2023Wander guard bracelet to be changed yearly per recommendationsand PRN for non-functioning device.Date Initiated: 04/14/202During an interview on 11/05/25 at 1:45 PM, with The Director of Nursing (DON), and Licensed Social Worker (LSW), The DON stated, I know 360 Psych had seen her, and she had a couple infections. The LSW stated, I know I talked to her family about moving her to a locked unit, but they wouldn't agree, but I don't have that documented anywhere. The DON further stated, I started as DON in September of 2023. I had never been in Long-Term Care. My mind then wasn't what it is now. Looking back on it I would of put her on one on one visits or at least 15 minute checks.b) PolicyA review on 11/05/25 at 2:30 PM of the policy last reviewed on 04/01/13 titled {Elopement/Missing Resident protocol, defines elopement as follows: When a resident leaves the premises or safe area without authorization. A resident who leaves the premises has the potential to experience heat/cold exposure, dehydration and/or medical complications, drowning or being struck by a vehicle.Purpose:To initiate emergency protocol should a resident exit the facility unescorted by staff member or legally responsible party. Resident straying beyond the normal view or control of employees may be at risk for injury or death. During an interview on 11/05/25 at 2:45 PM, the DON confirmed that the above policy was the one in place when the elopement took place on 04/22/24, and that a new policy has been put in place since. The DON further stated, I noticed our policy had not been reviewed since 2013 and got us a new one.

Based on observation and interviews, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery of a resident smoking in non-designated areas, a medication cart and janitor closet unlocked and unattended. Resident identifier: #5. Facility census: 54. Findings included: a) An observation on 04/08/25 at 12:20 PM of an unlocked janitors closet on the B hall. A second observation on 04/08/25 at 1:00 PM of the unlocked janitors closet on the B hall found: -Clorox Clean-up -Sani-Clean 2 spray -Odor Neutral -Clorox bleach germicidal wipes -Glass Cleaner -DNA bath cleaner -Clorox urine cleaner -Sun burst neutral cleaner An interview on 04/08/25 at 1:08 PM with the Maintenance Assistant revealed the closet should always be locked and the lock was broken. He stated he was unsure how long the lock had been broken. An observation on 04/09/25 at 9:55 AM found the Medication Cart on the B Hall was unlocked and unattended. An interview with Licensed Practical Nurse (LPN #33) on 04/09/25 at 10:00 AM revealed that the medication cart should not be unlocked when unattended. 45173 c) Resident #5 On 04/08/25 at 6:47 PM, a review of the list of resident smokers was completed. The review found one (1) resident listed as a smoker. Resident #5 smoked a vape (electronic cigarette). The resident was allowed to smoke at designated times and places with a staff member. The designated times were 9:00 AM, 11:00 AM, and 1:30 PM. The designated area was in the outer gazebo at the side of the building. A smoking assessment was completed on 03/24/25. The smoking assessment stated, Smoking safety note: Electronic cigarette to be used with staff supervision during scheduled smoke breaks. Electronic cigarette to be stored in med (medication) cart and charged by nurse as needed. On 04/09/25 at 9:05 AM, the resident was being pushed in a wheelchair by a staff member; and, before the resident exited the door of the lobby, the resident began smoking the vape. Nurse Aide (NA) # 91 was the staff member pushing the resident's wheelchair. An interview was held with NA #91 at 9:30 AM. NA #91 was asked, Does the resident usually use the vape prior to exiting the building? NA #91 stated, Not normally, but I did tell her not to smoke it before we got out of the building NA #91 was then asked, Does the resident usually hold the vape prior to exiting the building? NA #91 stated, She normally doesn't smoke until we are outside the building. On 04/09/25 at 9:40 AM, the Administrator confirmed the resident should not be vaping before she got outside to the designated smoking area. The Administrator stated, Maybe the staff member should hold on to the vape until they get to the designated spot. On 04/09/25 at 10:00 AM, a review of the facility policy was completed. Under the heading of Policy Explanation and Compliance Guidelines: Number 7 stated, Any resident who is exempt from the Smoke Free Facility policy, in accordance with his/her right to self-determination and participation, will be allowed to smoke in designated smoking areas (weather-permitting), at designated times, and in accordance with his/her care plan.

Based on observation and staff interview the facility failed to store plate lids in accordance with professional standards for food service safety related to storage. This could have affected all residents that received their nutrition from the kitchen. Facility Census: 54 Findings included: a) Kitchen During the initial kitchen tour on 04/08/25 at 9:48 AM, an observation revealed a rack of plate lids stored up against the dirty open utility-room door. There was a mop sink, dirty mops, rags, and chemicals stored in the utility room. During an interview with the Dietary Manager (DM) on 04/08/25 at 9:49 AM, DM stated that they probably should not be stored there with the door open.

Based on observation, record review and staff interview it was determined the facility failed to ensure proper reconciliation of the narcotic medication logbook was performed. Facility census: #54 Findings include: a) A Hall On 04/09/25 at 8:24 AM during the medication administration observation process, it was noted that the narcotic medication logbook reconciliation was not completed properly for each daily shift change. The current narcotic medication logbook on hand begins on 02/18/25 through 04/09/25. The following dates were not reconciled as required as explained by the Administrator. 02/21/25 no entry for 7 PM - 7 AM shift 02/22/25 no entry for 7 AM - 7 PM shift 02/23/25 no entry for 7 PM - 7 AM shift 02/28/25 no entry for 7 PM - 7 AM shift 03/01/25 no entry for 7 AM - 7 PM shift 03/01/25 no entry for 7 PM - 7 AM shift 03/06/25 no Nurse signature for going off duty for 3 PM shift 03/08/25 no Nurse signature for going off duty for 7 PM - 7 AM shift 03/09/25 no entry for 7 PM - 7 AM shift 03/12/25 no Nurse signature for going off duty for 7 PM - 7 AM shift 03/17/25 no Nurse signature for going off duty for 1:30 PM shift change 03/18/25 no Nurse signature for going off duty for 7 PM - 7 AM shift 03/19/25 no Nurse signature for going off duty for 3 PM shift change 03/20/25 no Nurse signature for going off duty for 7 PM - 7 AM shift 03/27/25 no Nurse signature for going off duty for 1 PM shift change 03/28/25 no entry for 7 PM - 7 AM shift 03/31/25 no Nurse signature for going off duty for 7 AM - 7 PM shift 04/02/25 no Nurse signature for going off duty for 7 PM - 7 AM shift 04/04/25 no entry for 7 PM - 7 AM shift 04/07/25 no Nurse signature for going off duty for 7 AM - 7 PM shift The above missing entries were confirmed on 04/09/25 at 10 AM with the Administrator who agreed the reconciliation process had failed on these dates. b) B Hall On 04/09/25 at 8:24 AM during the medication administration observation process, it was noted that the narcotic medication logbook reconciliation was not completed properly for each daily shift change. The current narcotic medication logbook on hand begins on 02/18/25 through 04/09/25. The following dates were not reconciled as required as explained by the Administrator. 02/21/25 no entry for 7 AM - 7 PM shift 02/21/25 no entry for 7 PM - 7 AM shift 02/27/25 no Nurse signature for coming on duty for 7 AM - 7 PM shift 02/28/25 no entry for 7 PM - 7 AM shift 03/09/25 no entry for 7 AM - 7 PM shift 03/14/25 no Nurse signature for coming on duty for 7 AM - 7 PM shift 03/16/25 no entry for 7 AM - 7 PM shift 03/16/25 no Nurse signature for going off duty for 7 PM - 7 AM shift 03/17/25 no Nurse signature for going off duty for 7 PM - 7 AM shift 03/20/25 no Nurse signature for coming on duty for 7 AM - 7 PM shift 03/20/25 no entry for 7 PM - 7 AM shift 03/21/25 no entry for 7 AM - 7 PM shift 03/21/25 no Nurse signature for going off duty for 7 PM - 7 AM shift 03/25/25 no Nurse signature for going off duty for 7 PM - 7 AM shift 03/26/25 no Nurse signature for coming on duty for 7 AM - 7 PM shift 04/01/25 no Nurse signature for coming on duty for 7 AM - 7 PM shift 04/01/25 no Nurse signature for going off duty for 3 PM shift change 04/09/25 no entry for 7 AM - 7 PM shift The above missing entries were confirmed on 04/09/25 at 10 AM with the Administrator who agreed the reconciliation process had failed on these dates.

Based on record review, and staff interview, facility failed to ensure residents was free from unnecessary medications in regard to psychotropic medication. This was true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier #23. Facility census: 54. Finding included: a) Resident #23 A review for Unnecessary Medication for Resident #23 on 04/14/25 found, Physician order for: Zoloft oral tablet 50MG (Sertraline HCI) Give one (1) tablet by mouth one time a day related to anxiety disorder. Continued review found no consent form for Zoloft in the medical record. During an interview on 04/14/25 at 4:15 PM the Director of Nursing (DON) stated that there was no signed consent form for Zoloft for Resident #23

Based on record review, and staff interview, facility failed to ensure residents and/or their medical representatives were given the right to be informed of participate in the decision to initiate a psychotropic medication. This was true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier #23. Facility census: 54. Finding included: a) Resident #23 A review for Unnecessary Medication for Resident #23 on 04/14/25 found, Physician order for: Zoloft oral tablet 50 MG (Sertraline HCI) Give one (1) tablet by mouth one time a day related to anxiety disorder. Continued review found no consent form for Zoloft in the medical record. During an interview on 04/14/25 at 4:15 PM the Director of Nursing (DON) stated that there was no signed consent form for Zoloft for Resident #23

Based on record review and staff interview, the facility failed to ensure an accurate and complete record for Resident #35. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident identifier: #35. Facility Census: 57. Findings Included: a) Resident #35 On 04/09/25 at 10:00 AM, a record review was completed for Resident #35. The review found two (2) medications without diagnoses. The medication is as follows: --Eye Scrubs External Pad apply to eyes topically every day, which started on 11/07/24. --Metoprolol Tartrate 25mg (milligram) by mouth twice daily, which started on 03/08/25. On 04/09/25 at 4:00 PM, the Administrator and the Director of Nursing (DON) confirmed the medication did not have diagnoses.

Based on record review and staff interview, the facility failed to ensure two (2) monthly pharmacy reviews were reviewed by the facility physician for Resident #35. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident identifier: #35. Facility Census: 57. Findings Include: a) Resident #35 On 04/09/25 at 1:03 PM, a record review was completed for Resident #35. The review found two (2) monthly pharmacy reviews, 03/2024 and 01/2025, were not signed by the facility physician. The pharmacy reviews had no indication if the facility physician agreed or disagreed with the pharmacy recommendations. On 04/14/25 at 10:32 AM, the Administrator confirmed neither of the two (2) pharmacy reviews were signed by the facility physician.

Based on record review, and staff interview. The facility failed to assist dependent residents with activities of daily living (ADL's) in accordance with the residents assessed needs for care. This was true for one (1) of one (1) residents reviewed for ADL care. Resident identifier:164. Facility census: 54. Findings included: a) Resident #164 A record review revealed Resident #164 was covered in feces on 11/17/24 and reported to the facility by her son. Statement from Nurse Aide #113 revealed Resident #164 was covered in dried feces from head to toe. Statements from Registered Nurse #87 confirmed that dried feces was all over the resident and the bed. Continued record review found the incident was reported to appropriate state and local authorities for neglect. The allegations were found substantiated by the facility and the NA assigned to Resident #164 was suspended and resigned at that time. An interview with the Director of Nursing on 04/14/25 at approximately 2:10 PM confirmed that Resident #164 did not get ADL care timely.

Based on observation, staff interviews, electronic medical record and policy review the facility failed to ensure they implemented their policy regarding the training of nurse aide staff following a substantiation of allegations of neglect. This is true of one (1) of six (6) residents reviewed for abuse and neglect. Resident identifier: #161. Facility census: 54. Findings included: a) Resident #161 A record review found an allegation from 05/07/24 where Nurse Aide NA #94 and NA #114 did not follow the plan of care and did not use the lift during a transfer causing a skin tear to Resident # 161's arm. A medical record review revealed the following care plan: Focus: (Name) has a ADL self-care performance deficit related to Dementia, blindness and limited functional mobility as well as generalized muscle weakness. Goal: Resident will maintain the current level of function in ADLs through the review date Interventions: Transfers: require two (2) staff assistance using a full body Hoyer lift and placing him in a Rock and Go Chair. A reportable was completed with action notes: NA's involved will be re-educated/disciplined. All other NA's will be re-educated. Continued review found NA's #94 and #114 were re-educated. No other documentation could be provided for education with all other NA's. During an interview the Administrator verified that all NA's were not re-educated. Subsequent record review found that an allegation from 05/21/24 where Nurse Aide NA #8 and NA #91 did not follow the plan of care and did not use the lift during a transfer causing pain into Resident #161s leg. A reportable was completed with action notes: NA's involved will be re-educated / disciplined. All other NA's will be re-educated. Continued review found NA's #8 and #91 were re-educated. No other documentation could be provided for education with all other NA's. Record review of the facility's policy titled, Abuse, neglect, and exploration, showed: Report allegations to appropriate state and local authorities involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property not later than two (2) hours after the allegation is made if it does result in serious bodily injury. Report allegations to appropriate state and local authorities involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of patient property not later than (24) hours after the allegation is made if it does not result in serious bodily injury. Taking all necessary actions as a result if the investigation, which may include, but not limited to, the following: Analyzing the occurrence to determine abuse, neglect, misappropriation of resident property or exportation occurred, and what changes are needed to prevent further occurrences. Define how care provision will be changed and /or improved to protect residents receiving services. Training of staff on changes made and demonstration of competency after training is implemented. The expected date for implementation; and Identification of staff responsible for monitoring and implementation of the plan. During an interview the Administrator verified that all NA's were not re-educated.

Based on observation, and staff interview the facility failed to treat each resident with respect and dignity regarding meal service. This was a random opportunity for discovery. Resident identifier: # 211. Facility census: 54. Findings included: a) Resident #211 During an observation of meal services on 04/08/25 at 12:08 PM revealed Resident #211's sitting in the dining room at a table with 2 other residents and a visitor that was eating their lunch. Resident #211 watched as everyone around consumed their lunch. Continued observation revealed seven more tables were served, prior to surveyor intervention. During an interview on 04/08/25 at 12:20 PM the Director of Nursing (DON) verified that Resident #211 should have been served when the other residents at the table received their meal.

Based on record review and staff interview, the facility failed to provide evidence that the required Notification of Medicare Non-Coverage (NOMNC) notice was issued in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifier: #4 . Facility census: 54. Findings included: a) Resident #4 On 04/10/25 at 11:30 AM, a review was completed regarding the beneficiary protection notification liability notice given for the following resident who was discharged home following the last covered day of Medicare Part A services: -Resident #4's last covered day of Part A Services was on 01/08/25. -Resident #4 was discharged to home on 01/08/25; however, the NOMNC was only issued 24 hours prior on 01/07/25 . The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two (2) calendar days before Medicare covered services end . The instructions also state: A NOMNC must be delivered even if the beneficiary agrees with the termination of services. The Business Office Manager (BOM) Employee #39 confirmed the Beneficiary Protection Notification Review was outside of the notification date range of only 24 hours as opposed to required minimal 48 hours notice.

Based on record review and staff interview the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives for each resident related to resident's behaviors. This is true for two (2) of two (2) residents reviewed for behavioral care plans. Resident Identifiers: Resident #43 and Resident #6. Facility Census: 59 Findings Include: a)Resident #43 During a review of the reportable dated 04/08/24, Resident #43's incident was as follows: Reported to this nurse per restorative aide that resident was sitting in quiet lounge beside another resident (2935) touching her, when he put his hand in her face and she bit him on the pointer finger. Residents separated, small red bite mark to pointer finger on 2935 has since dissipated. (Physician name) made aware and verbalized understanding. POA( Power of Attorney) (name) contacted and verbalized understanding. Further review of the care plan with an initiated date 12/20/22 and revision date 01/11/13 no behavioral focus, goal or interventions were implemented after the 04/08/24 incident. During an interview on 05/06/24 at 11:40 AM,the Administrator acknowledged the care plans did not reflect appropriate behavioral interventions. b) Resident #6 A review of the reportable dated 04/30/24, reported the following: CNA reported to this nurse that while resident was in A hallway by clean linen door, she punched resident #52 in the right stomach/hip area. Per report from CNAs resident #6 stated after she punched the other resident that They are thieves. Residents were immediately separated. Residents went separate directions down the hall. Resident sitting in wheelchair in quiet lounge conversing with another resident at this time, will continue with current plan of care. Residents' hands assessed at this time and noted to be per baseline for resident. No increased pain or swelling noted at this time, will continue with current plan of care. Further review of the care plan initiated on 08/24/22 and revised on 02/22/24, found there were no behavioral focus, goal or interventions were implemented after the 04/30/24 incident. During an interview on 05/06/24 at 11:40 AM, the administrator acknowledged the care plans did not reflect appropriate behavioral interventions. 50551

Based on record review and staff interview the facility failed to establish and implement a grievance policy to ensure prompt resolution of grievances. The facility's policy indicated they would keep evidence of the resolution of all grievances for a period of three (3) years from the date the grievance was filed. The facility was unable to provide evidence of the prompt resolutions of grievances for the previous six (6) months. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 56. a) Policy Review A review of the facility's policy titled; Grievances found the following: .Documentation: The facility will keep evidence of the resolution of all grievances for a period of three (3) years from the date the grievance decision is issued. This policy was not dated. a) Grievances In the afternoon of 08/28/23 the grievances and concerns for the previous six months were requested from the Nursing Home Administrator (NHA). Upon leaving the building on 08/28/23 at approximately 4:00 PM the NHA was reminded we were still waiting for the grievances and concerns to review. The NHA stated, I cannot find them, but I will tear this place apart tonight looking for them. On 08/29/23 at 1:26 PM, the NHA was asked if she had found the grievances and concerns for the previous six (6) months. She stated, No I cannot find them. I know we had them, but I can't find them. She agreed her policy indicated they would keep evidence of the resolution of all grievances for a period of three (3) years from the date the grievance decision was issued.

Based on observation, record review, and staff interview, the facility failed to ensure a care plan was implemented for one (1) of three (3) residents reviewed for the care area of accidents. Resident identifier: #52. Facility census: 56. Findings included: a) Resident #52 Review of the medical record found the following: Review of the medical record found the current care plan: The care plan addressed the following: Resident is at risk of falls related to poor safety awareness related to dementia. The goal associated with the care plan: Resident will have no further falls through review date, revised on 8/8/23 Interventions included: Fall mat to left side of bed, dated 05/30/23 Observation at 12:25 PM on 08/29/23, with Registered Nurse #27, and Nurse Aides (NA) #67 and #49 found the fall mat was on the resident's right side of the bed. RN #27 said, well if you were standing at the foot of the bed the fall mat is on the left side of the bed. Both NA's stated they believed when an order says to place something on the right or left side, it is the Resident's right and left side, not the onlookers right and left side. At 2:30 PM, the Administrator stated the order has been corrected.

Based on record review and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for accidents received adequate assistive devices to prevent accidents. Resident identifier: #54. Facility census: 56. Findings included: a) Resident #54 Record review found the Resident was care planned for: Additional falls related to a history of frequent falls, impaired cognition/poor safety awareness, impaired strength/balance/coordination, incontinence, adverse reaction of medications. Further review found the resident had the following falls since 05/01/23: 05/04/23 05/11/23 06/15/23 07/30/23 Review of the medical record found a nursing note dated 05/01/23: I walked into the resident's room to find (name of resident) sitting on the floor with her back against the wardrobe undressing. I had just been in and woke her for her 0600-medication administration. There did not seem to be incontinence at that time due to no smell being noted. The fall mat was down but she was between the mat and the bed. Legs were in front of her as she was taking off her depends, already having removed her hipsters. She was incontinent of a large amount of liquid stool. Her alarm was not placed on her when she was put into bed last evening and therefore was not sounding. Assessment of (name of resident) indicated no injuries and I called a CNA (certified nursing assistant)in to assist with placing her in the WC (wheelchair) after we put on nonskid socks. She initially was barefoot from sleeping. She was immediately taken into the shower after the initial Neuro checks were obtained and noted to be within normal limits for residents. Upon return from the shower, she was placed back into bed, per her request, and is resting quietly with tab alarm in place. MPOA (Medical Power of Attorney) was notified via telephone and informed of the fall. (Name of medical director) was notified via telephone and message left on voice mail. On 8/29/23 at 2:45 PM, the Administrator was asked if there was any investigation completed regarding the alarm not being placed on the resident's bed? The Administrator stated, the Nurse Aide was terminated around that date for an unrelated issue.

Based on record review, resident interview, and staff interview, the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, psychosocial and mental well-being. This was true for three (3) of fifteen (15) Stage 2 sampled residents. The facility failed to adequately assess and treat Resident #79's complaints of pain. There were errors in the Resident's pain medication regimen which caused her to miss and/or receive late doses of her scheduled pain medication, the staff administered as needed pain medication without proper assessment of her pre and post pain levels, and failed to provide nonpharmacologic interventions for complaints of pain prior to administering the as needed pain medication. Additionally, Resident #79 reported to the surveyor she was in extreme pain during an interview. The resident's nurse was made aware of the Resident's complaints of pain and failed to act upon those complaints. The failure to provide optimal pain management to Resident #79 resulted in actual harm to this resident. Also, for Resident #79, the facility failed to obtain the resident's pulse and/or blood pressure prior to administering two (2) medications which had specific physician's orders [REDACTED]. The facility also failed to follow the physician's orders [REDACTED].#91. For Resident #17, the facility failed to ensure she received all her ordered medications upon admission to the facility. Resident Identifiers: #79, #91, and #17. Facility Census: 57. Findings Include: a) Resident #79 1. Pain Management During a Stage 1 interview during the facility's Quality Indicator Survey, at 10:21 a.m. on 01/13/16, Resident #79 was asked, Do you have any discomfort now or have you been having discomfort such as pain, heaviness, burning, or hurting with no relief? The resident replied, Yes, I hurt all the time mostly in my hips, and right arm. When asked if she received any relief from this pain she stated, No, the medicine they give me is just not strong enough. Resident #79 was then asked if she could rate her pain using a numerical scale with zero (0) being no pain at all and ten (10) being the worst possible pain. The resident stated her pain was a 10. At 10:30 a.m. on 01/13/16, Resident #79's assigned nurse, Licensed Practical Nurse (LPN) #68, was informed of Resident #79's complaints of pain. LPN #68 was told the resident complained of current pain with no relief and that she rated her pain as a 10 on a zero (0) to ten (10) pain scale with 10 being the worst possible pain. LPN #68 voiced understanding and reported she would check on the resident. She stated, I gave her a pain pill about an hour and a half ago, but I will go and check on her. A review of Resident #79's medical record at 8:52 a.m. on 01/14/16, found Resident #79 was admitted to the facility on [DATE] from another local skilled nursing facility. Her diagnoses, added to the resident ' s medical record on 11/05/15, included other [MEDICAL CONDITION] disease, flaccid [MEDICAL CONDITION] affecting the right dominate side, dysphagia, [MEDICAL CONDITION], intervertebral disc degeneration, and pain unspecified. At the time of this review, the record contained nothing to indicate LPN #68 ever assessed Resident #79 for pain after it was brought to her attention the previous day by the surveyor. There was nothing to indicate she attempted any nonpharmacologic interventions to help alleviate Resident #79's pain, no indication she notified the attending physician of Resident #79's complaints of pain, and she wrote no nursing notes to indicate the resident was still in pain after administration of her scheduled pain medication earlier that morning. On 01/18/16, the Nursing Home Administrator provided a copy of LPN #68's handwritten statement she had given in regards to this issue. The statement was (typed as written), Surveyor reported to me that resident, (Resident #79's initials) was in pain. This resident was given a [MEDICATION NAME] ([MEDICATION NAME] and [MEDICATION NAME] are interchangeable) approx (approximately) 30 minutes prior to the surveyor approaching me. I immediately went and checked on resident and told her I had given her a pain pill and med had not gotten into her system yet. Informed resident if pain did not decrease to let me know I would give her an extra pain med as pt (patient) also had order for prn (as needed) [MEDICATION NAME]. I told her I was allergic to pain and I did not want her to hurt. Resident agreeable and no further complaint of pain reported or seen. A review of the facility's Controlled Medication Utilization Tecord (narcotic sign out sheet) on 01/19/16, at approximately 2:00 p.m., found on 01/13/16, LPN #68 administered Resident #79 a 7.5/325 mg [MEDICATION NAME] at 8:00 a.m. which was two and a half hours prior to this surveyor reporting to her that Resident #79 was still in pain. This was ample time for this medication to be in Resident #79's system which indicated the medication was ineffective in treating Resident #79's pain on this occasion. There was no indication that LPN #68 attempted any other forms of pain management with Resident #79. Her statement was inconsistent with the documented time she administered the pain medication, her statement made no mention of any nonpharmacologic interventions, and there were no notations in the record that the resident ' s pain was not effectively controlled on this occasion. An interview with Resident #79 on 01/14/16 at 1:04 p.m., confirmed she did not recall the nurse coming in and asking her about her pain yesterday after the interview with the surveyor. When asked if she always reported her pain to nursing, she stated, Sometimes I don't because all they do is throw another pill at you. Review of Resident #79's admission orders [REDACTED]. The Medication Administration Record [REDACTED]. Further review of the medical record found a physician's orders [REDACTED]. Review of the MAR for November 2015 found Resident #79 received no scheduled doses of [MEDICATION NAME] from 2:00 p.m. on 11/07/15 until 11/10/15 at 2:00 p.m., indicating this 11/07/15 order was never added to the MAR, but the 11/05/15 order was discontinued from the MAR indicated [REDACTED]. Those doses were at 9:00 p.m. on 11/08/15, 6:00 p.m. on 11/09/15, and 9:00 a.m. on 11/10/15. Review of Resident #79's nursing progress notes found a note dated 11/10/15, Residents POA (power of attorney) in the facility stating resident's pain medication is not strong enough to keep the resident comfortable during therapy. POA advised the pain medication was scheduled per request starting today; it has not had sufficient time to judge whether or not it will be effective during therapy. POA wanted physician to be aware of her concern. Pass on to next shift in report and added to the physician's book. On 11/10/15 at 11:45 a.m., a verbal order from Resident #79's attending physician was entered into her medical record for, Change [MEDICATION NAME] 5/325 mg to one (1) tablet po (by mouth) TID (three times a day) for pain/ [MEDICATION NAME] 5/325 mg q (every) 4 hr (hours) prn (as needed) There was never a physician's orders [REDACTED].#79's scheduled pain medication from scheduled to as needed. The new order for the scheduled [MEDICATION NAME] on 11/07/15 was never placed on the MAR, therefore the Resident did not receive any scheduled pain medication from 11/07/15 at 2:00 p.m. until 11/10/15 at 2:00 p.m. During which time she had an increase in her pain, which the POA noticed and who requested it be addressed. A continued review of the medical record found a physician's orders [REDACTED]. A review of the MAR for November 2015 found the 7.5/325 dose of [MEDICATION NAME] was scheduled to be administered at 8:00 a.m., 2:00 p.m., and 8:00 p.m This was six (6) hours apart, leave 12 hours during which no pain medication was scheduled, as opposed to the previous 5/325 mg dose, which was also ordered as TID and was scheduled eight (8) hours apart. Review of the physician's progress notes found the following occasions when the attending physician mentioned Resident #79's pain management, -- 11/06/15: . chronic pain- [MEDICATION NAME] -- 11/18/15: indicated the resident was reporting right arm pain and requesting more pain medication Pt reports leg and lower back pain with ambulation. -- 12/05/15: . Past medical history chronic pain . Chronic Pain stable with [MEDICATION NAME] and Neurotin. -- 01/14/16: . complaints of right shoulder pain when her arm is moved . will adjust pain med and give one hour prior to therapy. A review of the December 2015 MAR found the following instances in December when Resident #79 was administered an as needed dose of [MEDICATION NAME] 5/325 mg. On each instance, the facility failed to rate Resident #79's pain prior to administration, failed to provide nonpharmacologic interventions, and failed to assess Resident #79 for the effectiveness of the pain medication after the administration. -- 12/13/15 at 5:45 p.m. -- 12/16/15 at (the time administered was illegible) -- 12/18/15 at 6:00 a.m. For the month of January 2016, the facility administered no as needed doses of [MEDICATION NAME] 5/325 mg as of the time of this review. Review of Resident #79's most recent minimum data set (MDS) assessment, an admission MDS with an assessment reference date of 11/13/15, found Item J0300 - Pain Presence, identified the resident had pain within the last five (5) days, that the pain occurred frequently, and was severe in nature as described by Resident #79. An interview with Registered Nurse (RN) #75 at 1:49 p.m. on 01/14/2016, found she had just given Resident #79 her second scheduled dose of [MEDICATION NAME] 7.5/325 mg prior to her going to therapy. When asked what she would do if a resident reported to her that she was experiencing pain, she stated she would check to see when the last time pain medication was administered and then would try to reposition the resident, offer ice or heat or any other nonpharmacological interventions to alleviate the pain. She continued, if that did not help the pain she would administer an as needed pain medication if it was time for one. She said if the order was for every four (4) hours, it would have to be four (4) hours after any scheduled pain medication and four (4) hours prior to the next dose of scheduled pain medication in order for it to be administered. She indicated if the current pain medication was not relieving the resident ' s pain for the four (4) hour time frame, she would call and report this to the doctor because he might want to increase her pain medication. When asked if she would document her assessment of the resident ' s pain in the medical record she replied, Yes I would. During an interview at 2:10 p.m. on 01/14/16, Nurse Aide (NA) #51 reported she usually worked with Resident #79. When asked if Resident #79 ever suffered from pain, she stated, Yes her right arm hurts all the time. She stated that since admission to the facility, the resident continually grabbed her right arm and grimaced in pain anytime you worked with her. She stated the resident would not complain about the pain a lot, but you could tell it hurt by the way she grabbed it and the facial grimaces she made. NA #51 reported she had reported it nursing and therapy on multiple occasions, but did not know what they had done to help her with the pain. NA #51 reported that today Resident #79 reported her pain to the medical student. An interview with Resident #79's attending physician at 2:16 p.m. on 01/14/16, confirmed he could not remember anything specific about Resident #79's pain. He reviewed the resident ' s record and stated that they adjusted her pain medication on 11/18/15 and that today she was complaining of right shoulder pain. He stated he was not sure if that pain was related to her chronic pain or not. An interview with the Director of Nursing (DON) at 4:00 p.m. on 01/14/16, confirmed the facility did not have a pain management policy. She indicated that the process for assessing pain was to assess the severity of the pain prior to administration of any as needed pain medication and then to reassess the resident ' s pain severity about 30 to 45 minutes after administration of the medication. She stated nonpharmacological interventions should be attempted prior to administering any pain medication. She was asked to provide any additional information pertaining to Resident #79's pain management. At the time of exit on 01/19/16 at 6:00 p.m., she had provided no additional information to indicate Resident #79's pain had been managed adequately since her admission to the facility on [DATE]. On 01/14/16 at 10:41 p.m., after surveyor intervention, a new physician's orders [REDACTED].#79's medical record. This was an increase from the previously ordered prn dose of 5/325 mg. 2. Medication Parameters A review of Resident #79's medical record at 8:52 a.m. on 01/14/16, found physician's order [REDACTED].>-- Losartan tablet 50 milligrams (mg) take two (2) tablets by mouth once a day at 9:00 a.m. Hold if SBP (Systolic Blood Pressure) less than 100 or heart rate less than 60 beat per minute. -- [MEDICATION NAME] Tablet 50 mg give one (1) tablet by mouth two times a day ar 9:00 a.m. and 9:00 p.m. hold if SBP less than 100 or pulse less than 60 beats per minute. (Note: the mechanism of action of some medications for high blood pressure also results in slowing of the heart rate.) A review of Resident #79's Medication Administration Record [REDACTED] -- 12/14/15 9:00 a.m. - pulse was not obtained -- 01/07/16 9:00 a.m. - pulse was not obtained -- 01/08/15 9:00 a.m. - pulse was not obtained -- 01/13/16 9:00 p.m. - pulse and blood pressure were not obtained -- 01/14/16 9:00 a.m. - pulse was not obtained -- 01/15/16 9:00 a.m. - pulse was not obtained. In an interview on 01/19/16 at 10:43 a.m., the Director of Nursing was asked to provide the missing pulses and or blood pressures. She indicated she would have to look and see if they were anywhere else in the record. At 1:46 p.m. on 01/19/16, the DON said she could not find any indications that the missing pulses and/or blood pressures were obtained prior to administering the medication as directed by the physician's order [REDACTED].>b) Resident #91 A review of Resident #91's medical record at 11:31 a.m. on 01/18/16, found a physician's order [REDACTED]. (pound) increase in 2 (two) days or 5 lb. increase in 1 (one) week. A review of Resident #91's electronic medical record in conjunction with her January 2016 Medication Administration Record [REDACTED] -- 01/03/16 - 228.4 lb. -- 01/04/16 - 229.2 lb. -- 01/06/16 - 222.2 lb. -- 01/07/16 - 223.8 lb. -- 01/08/16 - 222 lb. -- 01/0916 - 224.8 lb. -- 01/10/16 - 228.2 lb. -- 01/11/16 - 228.2 lb. -- 01/12/16 - 229.2 lb. -- 01/13/16 - 226.1 lb. -- 01/14/16 - 228 lb. -- 01/15/16 - 227.6 lb. -- 01/16/16 - 229.8 lb. -- 01/18/16 - 234.0 lb. There were no recorded weights for 01/01/16, 01/02/16, 01/05/16, and 01/17/16 indicating the facility did not follow the physician's orders [REDACTED]. Additionally, Resident #91 gained 3.4 pounds between 01/09/16 and 01/11/16, which required physician notification as directed by the physician's order [REDACTED].>During a review of these findings with the Director of Nursing (DON) at 10:43 a.m. on 01/19/16, she stated she would have to see if the weights were recorded anywhere else. She said she would look to see if the attending physician was notified of the weight gain on 01/11/16. An additional interview with the DON at 1:36 p.m. on 01/19/15, confirmed she did not find any evidence the resident was weighed every day. She also indicated she could not find any documentation to support the physician was notified of the resident ' s weight gain on 01/11/16. c) Resident #17 Review of Resident #17's medical record on 01/19/16 at 9:00 a.m., revealed the resident was readmitted to the facility on [DATE]. Review of discharge instructions from the sending facility found multiple medication were not ordered as directed. No clinical documentation was found as to why the medications were not provided as instructed. The resident ' s [DIAGNOSES REDACTED]. The medications not ordered were: -- Klonopin 0.25 milligram (mg) in morning and 0.5 mg in evening. -- [MEDICATION NAME] 28 mg at night -- [MEDICATION NAME] 10 mg at night -- [MEDICATION NAME] 40 mg in evening -- Trazadone 300 mg at night -- Voltaran gel 1 percent (%) every day and evening to feet, legs and arms -- Biofreeze 4% gel to the shoulders twice daily -- [MEDICATION NAME] 150 mg twice daily. In an interview on 01/19/16 at 11:00 a.m., the DON revealed she did not know why the medications were not ordered as directed by the discharge summary. She confirmed the resident had been a resident of the facility and was discharged home on[DATE]. She further verified the resident had received these medications during her previous admission and could not understand why they were not continued.