Every finding on record at Catholic Memorial Home

Based on observations, interviews, and record review, the facility failed to provide necessary treatment, services, or interventions to promote healing and prevent new ulcers from developing for two Residents (#5 and #203), out of a total sample of 35 residents. Specifically, the facility failed to:1. Evaluate and implement new interventions, if indicated, for Resident #5's right mid-back pressure injury for 21 days after observation of a change in the wound's condition; and2. For Resident #203, ensure the Wound Consultant's recommendation for offloading felt to his/her left plantar heel pressure injury was implemented. Findings include: 1. Review of the facility's policy titled Wound & Skin Care Protocol Policy, dated 1/2026, indicated, but was not limited to, the following: -Notify the healthcare provider and responsible party for any changes in wound condition or development of new eschar (a dead layer of tissue that forms over a wound, often appearing dark brown or black). -Treatment change will be considered and implemented as appropriate for a wound that does not show evidence of progression towards wound healing in 2-4 weeks, where the goal is healing. Review of the National Pressure Injury Advisory Panel document titled Evolution of Deep Tissue Pressure Injury, undated, indicated, but was not limited to the following: -Deep tissue pressure injury remains one of the most serious forms of pressure injury. The pressure is exerted at the muscle-bone interface, but due to the resiliency of the skin, the color change is not immediate, in contrast to a bruise. The process leading to deep tissue pressure injury precedes the visible signs of purple or maroon skin by about 48 hours. Then about 24 hours later, the epidermis lifts and reveals a dark wound bed. This phase of deep tissue injury evolution is often confused with skin tears. Within another week, the wound bed is often necrotic. Resident #5 was admitted to the facility in August 2021 with diagnoses including dementia and diabetes. Review of Resident #5's Minimum Data Set (MDS) assessment, dated 5/15/26, indicated the Resident was severely cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Further review of the MDS assessment indicated the Resident was at risk of developing pressure ulcers/injuries and did not have any unhealed pressure ulcers/injuries. Review of Resident #5's Norton Plus Pressure Ulcer Scale (a clinical tool used to assess a resident's risk of developing pressure ulcers by evaluating factors such as physical condition, mental state, activity, mobility, and incontinence), dated 5/14/26, indicated the Resident was at moderate risk for pressure ulcer development. Review of Resident #5's Progress Notes, including Nursing and Occupational Therapy, indicated, but were not limited to, the following: -5/21/26 at 3:08 P.M.: Pt (patient) reportedly had a blister-like area to his/her right mid-back. It now appears like a skin tear or sheer [sic] injury whereas it is open with serosanguinous (thin, watery, pink-tinged fluid that typically appears during the early stages of healing) drainage present. Measuring approximately 2.5cm (centimeters) by 1.5cm. -6/3/26 at 3:13 P.M.: DSG (dressing) change at R (right) thoracic back wound, DSG had moderate purulent drainage (pus, drainage that comes from an infected wound). Cleansed, new DPD (dry protective dressing). Have evaluated by wound nurse. -6/24/26 at 11:35 A.M.: Rehab request sent in regard to need for cushion while in w/c (wheelchair) due to area on back. PRN [NAME] (as needed Tylenol) for gen disc (general discomfort), monitoring effect. -6/25/26 at 10:25 A.M.: Provided ROHO cushion (an air-filled cushion designed to reduce pressure points and enhance comfort when sitting) for pressure relief. Review of Resident #5's medical record failed to indicate the Resident was evaluated by the facility's Wound Nurse until 7/1/26. Review of the Wound Nurse's Progress Note, dated 7/1/26 at 1:50 P.M., indicated the following: Initial assessment: The area located on the right mid-back appears to be a deep tissue injury that measures 1.5x1.5x0 (sic). It presents as a deep maroon center without exudate (drainage), blanchable erythema of peri wound, warm and tender with gentle palpation. Noncritical in np (nurse practitioner) binder with treatment recommendation. The charge nurse was made aware of new treatment. The area will be monitored weekly by wound nurse. Review of Resident #5's medical record failed to include measurements and description of the Resident's mid-back wound between 5/21/26 and 7/1/26. Review of Resident #5's Physician Progress Notes, dated 6/5/26 and 6/17/26, failed to indicate the presence of the Resident's right mid-back pressure injury. Review of Resident #5's medical record failed to indicate the physician was notified of the change in wound condition on 6/3/26 so a new treatment could be ordered, if indicated. Resident #5's Physician's Orders indicated, but was not limited to, the following: -Right mid-back: cleanse area with NS (normal saline), pat dry, and cover w/ (with) DPD QD (daily) and PRN (as needed). (order date 5/21/26, end date 7/1/26) -Right mid-back: cleanse ulcer on right mid-back with normal saline pat dry, apply collagen powder to wound bed, apply skin prep topically to intact peri wound then cover with dry protective dressing daily and prn if soiled/missing until resolved (order date 7/1/26) Review of Resident #5's Care Plan indicated, but was not limited to, the following: -Problem: Integumentary – I am at risk for skin breakdown r/t (related to) decreased mobility and muscle weakness limits me from doing things I used to do on my own. I am at risk for skin injuries secondary to fragile skin and aspirin/anticoagulant therapy. -Approach: Right mid-back: cleanse ulcer on right mid-back with normal saline pat dry, apply collagen powder to wound bed, apply skin prep topically to intact peri wound then cover with dry protective dressing daily and prn if soiled/missing until resolved. ** may use a foam bordered dressing monitor for skin irritation report to wound nurse/nurse manager ** (start date 7/2/26) -Approach: Report any signs of skin breakdown (sore, tender, red, or broken areas) to MD (physician)/NP, wound nurse, and dietitian to come up with the best treatment plan for me and follow any of their recommendations. (start date 12/9/21) -Approach: Assess for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. (start date 12/9/21) Review of Resident #5's Wound Management documentation indicated, but was not limited to, the following: -Wound type: Deep tissue injury (a form of pressure injury resulting from sustained pressure, shear forces, or a combination of both, which disrupts blood flow and leads to tissue damage that can rapidly progress to severe tissue breakdown and necrosis). -Date identified: 7/1/26 at 1:43 P.M. -Location: Right thoracic back (mid-back) -Observation history: 7/1/26 at 1:43 P.M.: Initial assessment: The area located on the right mid-back appears to be a deep tissue injury that measures 1.5x1.5x0 cm. It presents as a deep maroon center without exudate, blanchable erythema of peri wound, warm and tender with gentle palpation. Noncritical in np binder with treatment recommendation. The charge nurse was made aware of new treatment. The area will be monitored weekly by wound nurse. 7/6/26 at 2:24 P.M.: The pressure area located on the right mid-back currently measures 1x1.5x? cm unable to determine depth as wound bed is covered by 75% moist, tan slough that is well adhered to wound base and 25% granulation tissue (new tissue that grows from the base of a wound) of perimeter. There is a light amount of serosanguineous exudate without foul odor after normal saline cleanse and blanchable erythema of intact peri wound. The resident showed no signs or symptoms of pain facial expression remained neutral no moaning, grimacing or crying out during TX (treatment). During an interview on 7/8/26 at 2:19 P.M., the Wound Nurse said she was just recently made aware of Resident #5's wound on his/her back and completed her initial assessment of the wound on 7/1/26. The Wound Nurse said she determined the wound was caused by pressure on the Resident's back from his/her bra strap, kyphosis (forward curvature of the spine), and his/her back resting against his/her wheelchair. The Wound Nurse said she determined the wound was an unstageable pressure injury because she could not see the true wound bed due to the presence of slough (necrotic tissue accumulated on the surface of the wound). The wound nurse said she did not see the wound when it first developed but did see there was a report indicating there was some kind of lump in the area prior. The Wound Nurse said she was not involved in the evaluation or management of the Resident's wound prior to 7/1/26 and did not know how the wound first presented. The Wound Nurse said interventions in place to treat the wound included an air mattress on the Resident's bed, a cushion on the Resident's wheelchair, and new treatment orders implemented on 7/1/26. On 7/8/26 at 3:30 P.M., the surveyor observed Resident #5 sitting in his/her wheelchair in the unit's activity room. The Resident was sitting on a Roho cushion on his/her chair with his/her back resting on the back of the wheelchair. During an interview on 7/8/26 at 3:35 P.M., the Wound Nurse said if the nurses feel a resident should be evaluated by the Wound Nurse, they notify her via email, send a message via the facility's electronic health record system, or call and leave a voicemail. The Wound Nurse said she was notified of the need for evaluation of Resident #5's back wound on 7/1/26 from the nurse working the floor that day. During a wound care observation and interview on 7/9/26 at 10:38 A.M., Nurse #5 said the facility's Wound Nurse rounds on the unit every Monday and had recently recommended adding collagen powder to Resident #5's wound treatment to aid in wound healing. During wound care, the surveyor observed a round, approximately quarter-sized open wound on Resident #5's right mid-back with yellow/tan tissue covering most of the wound bed with red tissue around the perimeter. During an interview on 7/9/26 at 10:58 A.M., Unit Manager #4 said she has been covering as Unit 7's Unit Manager since March 2026. Unit Manager #4 said she was made aware of Resident #5's wound when it first developed and knew that the top layer of skin had opened but the wound was not deep when it first developed. Unit Manager #4 said the Wound Nurse was not involved at that point because the wound appeared superficial and was not deep. Unit Manager #4 said she probably was made aware in June that the wound was worsening, but she was not sure why the Resident was not evaluated by the Wound Nurse. Unit Manager #4 said the nurse assigned to the Resident should have emailed the Wound Nurse to request an evaluation in addition to writing a progress note. During an interview on 7/9/26 at 11:18 A.M., the Director of Nursing (DON) said when a nurse identifies a wound that should be seen by the Wound Nurse, the nurse should call and leave the Wound Nurse a voicemail or speak to her in person when she is in the facility on Mondays, Wednesdays, and Fridays. The DON said the nurse identifying a concern with Resident #5's wound should have contacted the Wound Nurse for evaluation on 6/3/26. During an interview on 7/9/26 at 12:17 P.M., Physician #1 said he could not recall if he was notified in June of the wound. Additionally, he said due to the location of the wound on the mid-back, his/her kyphosis, and bra strap location, we determined the wound probably started from pressure on their back. 2. Review of the facility's policy titled Wound and Skin Care Protocol Policy, last reviewed, January 2026, indicated but was not limited to: -Purpose: -identify outcomes-based approaches for the care of residents identified at-risk and those with existing wounds, and -define appropriate interventions which foster timely and cost-effective healing. -The facility will designate and support a multidisciplinary skin care team whose purpose is to review the plan of care for all residents with wounds on a weekly basis and make recommendations to the plan of care. -The interdisciplinary plan of care will address problems, goals, and interventions relative to the prevention and treatment of pressure ulcers. -Treatment change will be considered and implemented as appropriate for a wound that does not show evidence of progression towards wound healing in 2-4 weeks, where the goal is healing. Resident #203 was admitted to the facility in April 2026 with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy (a common, progressive nerve complication of type 2 diabetes mellitus caused by prolonged high blood sugar damaging peripheral nerves that frequently causes numbness, tingling, burning pain, and weakness, primarily starting in the feet and legs, which significantly increases the risk of foot ulcers and infections) and left great toe amputation. Review of the MDS assessment, dated 4/8/26, indicated Resident #203 was cognitively intact as evidenced by a BIMS score of 15 out of 15. During an interview with observation on 7/8/26 at 12:01 P.M., the surveyor observed Resident #203 sitting in his/her chair with slipper socks on his/her feet which were resting flat on the floor. Resident #203 said he/she had a wound on his/her left heel and was being followed by the facility's Wound Care Nurse and by the Wound Clinic. Resident #203 said his/her left heel dressing was changed by the Facility's Wound Care Nure that morning (7/8/26) and was not due to be changed again until Friday (7/10/26). Review of Resident #203's Physician's Orders indicated but was not limited to: - Left plantar (bottom or sole surface of the foot) ulcer: cleanse wound bed with normal saline, skin prep (skin barrier for adhesive) topically to intact peri (around) wound, collagen (used to absorb wound drainage) sheet cut to size apply to wound bed, cover with abdominal gauze, wrap with rolled gauze, tape to secure, cover with elasticated tubular compression bandage (used to treat sprains, strains, soft tissue injuries, and swelling) daily on Monday, Wednesday, and Friday and as needed if soiled/dislodged special instructions: change as needed Start: 5/18/26, discontinue 7/5/26 -Left Heel: Apply skin prep and cover with foam dressing. Change every three days, Start 7/5/26. Review of the Wound Physician's recommendations, dated 5/29/26, indicated but was not limited to: -Wound pressure injury left plantar heel (active) -New neuropathic ulcer plantar left heel (open sore caused by nerve damage, loss of sensation, and continuous pressure) -Instructions: Offloading felt (a dense, medical-grade adhesive felt used in podiatry and orthopedics to relieve pressure on specific areas of the foot) to left heel- Change if wet, soiled, shifted, or compressed. -Agree with above wound recommendations from wound clinic, signed by Physician #1, dated 5/29/26. Review of the Facility's Non-Critical Report, dated 5/29/26, indicated but was not limited to: -Weight bearing as tolerated, may use surgical boot for transfer only. Do you agree? -Response: Agree with wound clinic recommendations. Signed by the Physician, dated 5/29/26 Review of the Physician progress note, visit date 5/29/26, indicated but was not limited to: -Chief Complaint: Left great toe amputation site, left plantar heel wound -History of Present Illness: Resident was seen today at the request of nursing staff for evaluation and management of left great toe amputation site and left plantar heel wound. Wound care recommendations were reviewed. -Plan: Agree with wound clinic recommendations. Left heel- Weight bearing as tolerated. May use surgical boots for transfers only. Further review of Resident #203's physician's orders failed to indicate an order for offloading felt was implemented as recommended by the wound clinic. During an interview on 7/9/26 at 2:33 P.M., Unit Manager #2, with the surveyor, reviewed Resident #203's wound consultant recommendation, dated 5/29/26, and medical record and physician's orders. She said the Physician signed the 5/29/26 wound clinic recommendations and the Physician wrote on the wound consult agree with above wound recommendations from wound clinic and signed it on 5/29/26. She said Resident #203's wound clinic recommendation for offloading felt were not implemented, but should have been. During a telephonic interview on 7/9/26 at 2:48 P.M., the Wound Clinic Nurse said offloading felt was used to relieve pressure from pressure areas by cutting out a hole the size of the wound and applying it to the surrounding area around the wound and supporting the patient's weight while keeping the weight off the wound. She said the Wound Clinic Physician recommended Resident #203 use offloading felt at all times to relieve the pressure of his/her pressure wound. She said the order should have been implemented as recommended because not implementing the offloading felt could prevent the wound from healing or make the wound deteriorate. She said the facility's Wound Nurse was present at the appointment and was aware of the recommendation. During an interview on 7/9/26 at 4:17 P.M., the DON said when a resident goes outside to a consultant, the recommendations from the consultant go on the facility's non-critical form along with the note from the consultant for the Physician or NP to review. She said if the Wound Consultant ordered Resident #203 to have offloading felt and the Physician agreed with the recommendations, then the order should have been implemented. During a telephonic interview on 7/9/26 at 4:50 P.M., the Physician said he follows the Wound Consultant's recommendations and if he does not then he would write a rationale for why he decided not to follow the Wound Consultant's recommendation. The Physician and surveyor reviewed the recommendation from the Wound Clinic, dated 5/29/26, and said he agreed with the Wound Clinic's recommendations for offloading felt and it was his intention for the order for the offloading felt to be implemented. During a telephonic interview on 7/10/26 at 11:36 A.M., the Wound Nurse said when a resident goes out to the Wound Clinic she reviews the recommendations, then fills out a non-critical form, follows-up with the Physician or NP, then writes the order, or if another nurse transcribes the order, then she would review the order to ensure it was implemented per the consultant's recommendations. She said she accompanied Resident #203 to his/her Wound Clinic appointment on 5/29/26 and the Wound Clinic applied offloading felt around Resident #203's wound and said he/she needed to wear it at all times. She said Resident #203 did not have an order for offloading felt. She said because she went to Resident #203's appointment on 5/29/26, when they returned she passed the recommendations on to a nurse to follow up with them. She said because she went with Resident #203 to his/her Wound Clinic appointment and knew what the Wound Physician recommended for a treatment she did not go back and proofread the order to ensure it was implemented per the Wound Physician's recommendation as it should have been. Refer to F580

Based on observation, interviews, and record review, the facility failed to make information on how to file a grievance or complaint available to the residents and failed to formulate a written grievance and follow up with one Resident (#40) following a voiced grievance. Specifically, Resident #40 voiced concerns regarding agency nurses not knowing the residents and an agency nurse attempting to give him/her another resident's medication and had not received any follow-up to their concern. Resident #40 and members of the facility Resident Council were unaware of how or where to file a grievance.Findings include:Review of the facility's policy titled Resident/Staff/Family Member Grievances, dated April 2026, indicated the following: -a resident grievance will be responded to within 72 hours and resolved-any resident who has a complaint or suggestion, shall report to the charge nurse or social worker on the unit involved, or complete a grievance form-the charge nurse or social worker will respond appropriately, after assessing the nature of the complaint, and will complete the grievance form if one has not already been completed by the resident-the grievance report itself will be submitted to the Administrator/Department Head as soon as possible-grievances are resolved utilizing a team approach with the aggrieved person's well-being in mind. The resident will be appropriately kept apprised of ongoing progress towards resolution.-grievances, actions taken, and results are to be documented on the grievance report and kept on file in the Administrator's office During an interview on 7/8/26 at 1:35 P.M., Resident #40 said the facility used nurses from an agency who were unfamiliar with the residents. He/she said they had concerns about how the facility was ensuring the nurses from agencies knew which residents were which. He/she said about six weeks ago an agency nurse attempted to give him/her medication that was not his/hers and only after the nurse attempted to give the medication did the nurse ask Resident #40 his/her name. Resident #40 said he/she had told a staff member and then never heard what the facility did about it. He/she said they had no idea how to complete a grievance and had never seen a grievance form. On 7/8/26 at 1:45 P.M., the surveyor held a group meeting with 22 residents in attendance. During the meeting, residents said they did not know how to file a grievance, had not seen grievance forms, and did not know about the grievance process. Review of the Grievance binder (separate from the lost/damaged items binder) indicated the last grievance from a resident or family member was filed in March of 2025, 15 months prior. On 7/8/26 at 3:25 P.M., the surveyor observed the 2nd floor (units 3 and 4) with posters for Resident Rights and one of the rights listed was the right to voice concerns and problems, along with recommended changes, to the facility staff or others, without fear of reprisal or recrimination. The entire floor (encompassing 3 units) failed to include any additional information regarding the grievance process or grievance forms. On 7/9/26 at 9:15 A.M., the surveyor observed the following:-the main entrance lobby with a large sign regarding visitation with respiratory symptoms; behind the sign was a hanging wall file labeled grievances with blank grievances forms. The forms were not visible from the front entrance as it was obstructed by the large sign.-the ambulance entrance in the basement had a visitor sign-in log, to the right of the visitor sign-in was a hanging wall file labeled grievances with blank grievance forms-at the administrator's office, on the first floor, was an unlabeled hanging wall file with blank grievance forms During an interview on 7/8/26 at 3:50 P.M., the Administrator said she was unaware of an agency nurse attempting to give Resident #40 the incorrect medication but would follow up. During an interview on 7/8/26 at 4:45 P.M., the Administrator said Resident #40 had voiced concerns regarding agency staff not knowing the residents. She said Resident #40 had informed staff of the concern with the agency nurse attempting to give the incorrect medication but because the issue was addressed immediately and the agency nurse was not allowed to return to the facility no written grievance was formulated. She said the facility had not followed up with Resident #40 on the outcome. During an interview on 7/9/26 at 9:47 A.M., Certified Nursing Assistant (CNA) #3 said if a resident had a concern or complaint, she would tell the nurse and if the concern was not addressed, she would tell the supervisor. She said she did not know anything about any forms that would get filled out. During an interview on 7/9/26 at 9:50 A.M., Nurse #2 said if a resident had a complaint, they would tell the Unit Manager or the Social Worker. She said there wouldn't be anything for her to fill out, just the Unit Manager or the Social Worker would fill something out.During an interview on 7/9/26 at 9:52 A.M., Unit Manager #3 said if a resident had a concern or complaint and it was a quick resolution they would handle it right away. She said if there was something more complex, she would let the Director of Nurses (DON) or Assistant Director of Nurses (ADON) know. She said the DON or ADON would handle any forms that needed to be filled out.During an interview on 7/9/26 at 10:05 A.M., Nurse #3 said if a resident had a concern or complaint, she would handle it herself, but if it could not be addressed, she would bring it to the Unit Manager. She said there were no forms to fill out, and the forms were only for if something was lost or something was broken.During an interview on 7/9/26 at 10:15 A.M., Unit Manager #2 said Resident #40 had not personally come to her with the concerns regarding a nurse attempting to give him/her another resident's medications. She said the process was for the staff to ask the resident if they would like to file a grievance. She said she was unsure if Resident #40 had been asked if they would like to file a grievance as she was unsure who the Resident had told.During an interview on 7/9/26 at 11:04 A.M., the DON said residents, including at Resident Council, had voiced concerns regarding agency nurses not knowing the residents. She said the facility had initiated a project to improve resident photos for identification and had encouraged consistent agency nurses. She said she was not sure who Resident #40 had told about his/her concern with the agency nurse attempting to give him/her another resident's medications but the DON had heard about it, and the agency nurse had been asked not to return. She said she had not written Resident #40s concern on a grievance form because they felt it had been dealt with right away. She said many times when residents have complaints the staff will ask them if they want to file a grievance and many times the residents will say no. She said she could not be sure if Resident #40 was ever asked about filing a grievance. She said the nursing staff should know about the grievance form and be able to offer it to residents.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three Residents (#5, #152, and #161), out of a total sample of 35 residents. Specifically, the facility failed:1. For Resident #5, to ensure Enhanced Barrier Precautions (EBP) were maintained during wound care;2. For Resident #152, to ensure Contact Precautions were maintained; and3. For Resident #161, to ensure Precaution orders and Signage were accurate and Contact Plus Precautions were maintained. Findings include: Review of the facility's policy titled EBP, dated as last reviewed 3/2026, indicated but was not limited to the following: -Purpose: to prevent the spread of multi-drug resistant organisms (MDROs). -EBP are to be initiated for residents who have an infection or colonization with a Centers for Disease Control and Prevention (CDC) targeted MDRO when contact precautions do not otherwise apply and for Residents with wounds or indwelling medical devices, even if not known to be infected or colonized. -Procedure: The use of gown and gloves for high contact resident care activities. -High Contact Care includes bathing, dressing, transferring, changing linens/briefs, toileting, device care, and wound care. Review of the facility's policy titled Contact Precautions, dated as last reviewed 4/2026, indicated but was not limited to the following: -Purpose: to prevent the transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. -Contact Precautions are used in conjunction with Standard Precautions when a resident has a suspected or confirmed case of Clostridium difficile (C-Diff), Rotavirus, gastroenteritis, MRDOs including Extended-Spectrum Beta-Lactamases (ESBL-bacteria resistant to a wide range of antibiotics, making infections caused by these bacteria difficult to treat). Personal Protective Equipment (PPE) includes: -Gloves shall be donned (put on) upon entering the resident's room. and worn whenever touching the resident's intact skin, environmental surfaces, and articles in close proximity to the resident. Wash hands with antimicrobial agent after glove removal. -Gown shall be donned upon entering the resident's room. Remove gown and observe hand hygiene before leaving the resident care area. 1. Resident #5 was admitted to the facility in August 2021 with diagnoses including dementia and diabetes. Review of Resident #5's Minimum Data Set (MDS) assessment, dated 5/15/26, indicated the Resident was severely cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Review of Resident #5's Care Plan indicated, but was not limited to the following: PROBLEM: I have been placed on EBP. APPROACH: Post clear signage on the door or wall outside the resident's room indicating the type of precautions and required PPE. For EBP the signage should indicate for high contact resident care requires the use of gown and gloves. Review of Resident #5's Physician's Orders/Treatment Administration Record (TAR) indicated, but were not limited to the following: -Right mid-back: cleanse ulcer on right mid-back with normal saline pat dry, apply collagen powder to wound bed, apply skin prep topically to intact peri wound then cover with dry protective dressing daily and prn if soiled/missing until resolved. (7/1/26) -EBP related to ESBL in urine. Clean hands when entering and exiting. Gown for high contact care (see room sign). Eye protection for resident encounters if applicable for splash (goggles/ or face shield) & gloves. (8/31/23) On 7/9/26 at 10:38 A.M., the surveyor made the following observations: -Resident #5 had an EBP sign posted outside his/her room. -Nurse #5 prepared wound care supplies. - Nurse #5 entered the room and failed to don (put on) a gown or gloves. -CNA #6 entered the room to assist and failed to don a gown or gloves. -Resident #5 was lying in bed on his/her left side, Nurse #5 removed the old dressing, revealing a quarter sized round open wound with a red border, and a yellow/tan slough (soft, stringy, or gooey tissue made up of dead skin cells, fibrin, and bacteria) center. The wound was cleaned and new dressing applied. CNA #6 assisted Nurse #5 rolling Resident #5 and then CNA #6 finished dressing Resident #5. Review of the EBP Sign posted at the door indicated the following: -EVERYONE MUST: clean hands before entering and when leaving the room. -PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High Contact Resident Care Activities: dressing, bathing, showering, transferring changing linens, providing hygiene, changing briefs or assisting with toileting, device care, and wound care. During an interview on 7/9/26 At 10:54 A.M., Nurse #5 said he and the CNA both should have had a gown on when they provided care. 2. Resident #152 was admitted to the facility in May 2026 with diagnoses including cellulitis and urinary tract infection. Review of the MDS Assessment, dated 7/6/26, indicated he/she had moderate cognitive impairment as evidenced by a BIMS score of 12 out of 15. Review of the Physician's Orders indicated but were not limited to the following: -Maintain contact precautions for Extended-Spectrum Beta-Lactamase (ESBL) infection in the urine every shift, gloves and gowns. Review of the Comprehensive Care Plan indicated but was not limited to the following: -Isolation -I have been placed on droplet precautions. (6/26) On 7/7/26 at 7:58 A.M, the surveyor observed a CONTACT PLUS PRECAUTIONS sign outside Resident #152's room. Review of the CONTACT PLUS PRECAUTIONS Sign posted at the door indicated the following: -Clean hands before entering a resident's room. -Put on gown. -Put on gloves. -Wash hands with soap and water before exiting a resident's room. -Hand Sanitizer alone, is not sufficient when EXITING a resident's room, -Hand Use dedicated or disposable equipment. -Use BLEACH based products to clean and disinfect resident rooms. -Use only dedicated or disposable equipment. On 7/7/26 at 1:25 P.M., the surveyor observed a Certified Nursing Assistant (CNA) #15 in Resident #152's room pick up linen from the floor and walk out of the room with linen/towels, unbagged. The CNA had no PPE on while in the room handling soiled linen and performed no hand hygiene upon exiting the room. On 7/7/26 at 1:25 P.M., the surveyor observed Nurse #12 enter Resident #152's room with no PPE on. Nurse #12 spoke with Resident #152, then exited the room, and did not perform hand hygiene. The Nurse walked to the medication cart at the end of the hall and poured medication for Resident #152 and returned at 1:30 P.M, then entered the room with no PPE and did not perform hand hygiene. During an interview on 7/8/26 at 3:47 P.M., Unit Manager #1 said the staff should be following contact precautions on sign outside of resident room and wearing PPE as directed. During an interview on 7/9/26 at 2:07 P.M., the Director of Nursing (DON) said she expects staff not to walk out of the room with unbagged linen and to follow the precautions patients have, they should wear PPE. 3. Resident #161 was admitted to the facility in June 2026 with diagnoses which included Chronic Kidney Disease, urinary retention, and bladder cancer. Review of the MDS Assessment, dated 7/6/26, indicated he/she was cognitively intact as evidenced by a BIMS score of 15 out of 15, had an indwelling Foley catheter (urinary drainage tube), had an unhealed pressure injury, and was not on isolation or quarantine. Review of the Comprehensive Care Plan indicated but was not limited to the following: -Placed on EBP. I am at increased risk of MDRO acquisition related to my wounds. (6/27/26) -I have been placed on droplet precautions secondary to suspected COVID-19 signs and symptoms (loose stool). (7/6/26) Review of the Physician's Orders indicated but were not limited to the following: -EBP related to Foley catheter. (6/22/26) -Isolation/Droplet Precautions related to COVID-19 signs/symptoms or confirmed to be positive. (start 7/7/26-end 7/8/26) -Maintain Contact Plus Precautions for loose stools. (7/8/26) Review of the Nursing Progress notes indicated but were not limited to the following: -6/29/26: Coccyx dressing dry and intact, EBP maintained. -7/1/26: Resident had frequent bowel movements (BM). BMs were solid but progressed to loose. Placed on Isolation Precautions. -7/3/26: Continues on Isolation. 4x loose BMs. -7/7/26: Compliant with Contact Isolation Precautions due to loose BMs. -7/8/26: Isolation Precautions maintained. -7/8/26: Contact Plus Precautions Maintained for loose stools. On 7/7/26 at 12:43 P.M., 1:30 P.M., and 4:57 P.M., the surveyor observed an EBP sign outside Resident #161's room. On 7/8/26 at 12:52 P.M., the surveyor observed a CONTACT PLUS PRECAUTIONS sign outside Resident #161's room. On 7/9/26 at 7:58 A.M, the surveyor observed a CONTACT PLUS PRECAUTIONS sign outside Resident #161's room. Review of the CONTACT PLUS PRECAUTIONS Sign posted at the door indicated the following: -Clean hands before entering a resident's room. -Put on gown. -Put on gloves. -Wash hands with soap and water before exiting a resident's room. -Hand Sanitizer alone, is not sufficient when EXITING a resident's room, -Hand Use dedicated or disposable equipment. -Use BLEACH based products to clean and disinfect resident rooms. -Use only dedicated or disposable equipment. Review of the website https://www.wsha.org indicated Contact Plus Precautions are an enhanced form of Contact Precautions designed to prevent the spread of highly drug-resistant or hard-to-kill pathogens, emphasizing stricter hand hygiene, PPE use, and environmental cleaning. On 7/9/26 at 7:58 A.M., the surveyor observed Nurse #1 prepare medications and enter Resident #161's room with gloves on; she failed to don a gown. Nurse #1 stood at the bedside, placed a medication cup on the table, made eye contact with the surveyor, then came back to the doorway of the room to look at the Precautions sign and place her stethoscope on top of medication cart, without cleaning it. During an interview on 7/9/26 at 8:01 A.M, Nurse #1 said Resident #161 is on CONTACT PLUS PRECAUTIONS, and she wasn't sure if she needed a gown, so she came back out of the room to check the sign. She said she should have had a gown on entering the room and to provide care. Nurse #1 donned a gown and returned to the bedside to finish administering medications. She said Resident #161 had been on EBP, then it was switched to ISOLATION, and now he/she is on CONTACT PLUS. She said the orders should match the sign and was unsure why the wrong sign (EBP Sign) was hanging for the last couple days because he/she should have been on ISOLATION PRECAUTIONS since last week. She said the sign is how the staff know what PPE to wear and everything should match. On 7/9/26 at 8:30 A.M., the surveyor observed CNA #1 enter Resident #161's room with gloves on carrying a breakfast tray. CNA #2 donned a gown and gloves and entered the room. The two CNAs boosted and repositioned Resident #161 in bed and served him/her their breakfast. CNA #1, did Hand Hygiene and exited the room. CNA #2 removed their PPE and washed hands with soap and water before exiting. During an interview on 7/9/26 at 8:33 A.M., CNA #1 said she only needed to wear a gown for close contact like washing/dressing and did not think she needed one to boost/reposition him/her in bed. During an interview on 7/9/26 at 8:35 A.M., CNA #2 said Resident #161 is on CONTACT PLUS Precautions and everyone needs a gown and gloves to enter the room to do anything. She said they know which type of Precautions a resident is on based on the sign outside the room and the signs tell you what PPE to wear. During an interview on 7/9/26 at 12:48 P.M., Unit Manager #2 said CONTACT PLUS Precautions are a little less than ISOLATION Precautions, because you don't need a N95 Mask (respirator/face mask), just PPE gown/gloves for any type of contact. She said she wasn't exactly sure if the gown and gloves were needed to enter the room or just for care, but by looking at the sign, it would be to do anything in the room. She said she would expect a gown and gloves if positive for C-Diff, but the sign doesn't indicate positive verses symptomatic, so everyone should probably always have the gown and gloves on because of the potential spores in the room. She said the Infection Preventionist (IP) usually handles all the sign changes, orders, and symptom review, but he had been off this week. Additionally, she said when someone goes on CONTACT, CONTACT PLUS, or ISOLATION Precautions and they were already on EBP, they do not discontinue the EBP order. She said they end up with both orders active because the Precautions are usually temporary and the EBP is not. She said it doesn't actually make sense, because the nurses are then signing off two conflicting orders, but that is what they do, and staff should follow the signs. During an interview on 7/9/26 at 1:17 P.M., the DON said the IP usually handles all of the Precaution signs, orders, and education and he had been out all week. She said her expectation is for staff to follow the signs posted at the door and don the PPE the sign indicates whether it is EBP, CONTACT, CONTACT PLUS, or ISOLATION PRECAUTIONS. She said the order in the medical record should match the sign and they should not have two different orders. She said one order should be discontinued and a new one written. The DON said she was not sure if they would need a gown and gloves for everything with CONTACT PLUS, but based on the sign, staff should do hand hygiene, put on a gown and gloves, and then use soap and water on the way out because the hand sanitizer is not sufficient.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential for foodborne illness to residents who are at high risk. Specifically, the facility failed to properly store thickened beverage products for one Resident (#206), out of a total sample of 35 residents. Findings include:Review of the facility's policy titled Storage of Leftover Foods, revised 4/2026, indicated but was not limited to the following:- [Corporate Name] facilities prepare, hold and store foods in accordance with Food Code Standards, observing state and federal regulations.- Only foods that have been held within Food Code Guidelines can be safely stored as leftovers. Hot foods must have been held at 135 degrees F (Fahrenheit) or above, cold foods at 40 degrees F or below.- Stored leftovers must be clearly labeled and dated, including resident name and room number, in food safe containers with secure cover/wrap. Resident #206 was admitted to the facility in May 2026 with diagnoses including dysphagia (difficulty swallowing food/liquids), type II diabetes, and dementia. Review of Resident #206's Minimum Data Set (MDS) assessment, dated 6/24/26, indicated he/she was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Furthermore, the MDS assessment indicated Resident #206 required a mechanically altered diet and needed staff assistance with eating. Review of Resident #206's Physician's Orders indicated but was not limited to the following:- 5/13/26: Diet - HCC, NAS (no added salt) - pureed with honey thick liquids On 7/7/26 at 8:50 A.M., the surveyor observed the following in Resident #206's room:- One bottle of honey consistency cranberry juice, opened and dated 6/25/26 stored on his/her dresser in front of the television.- One bottle of honey consistency lemon water, opened and dated 6/25/26, stored on top of the paper towel dispenser in the Resident's room.- Both bottles indicated the following manufacturer storing/handling recommendations: store in cool/dry place, refrigerate unused portion, discard if not used within 10 days of opening. On 7/7/26 at 1:22 P.M., the surveyor observed the following in Resident #206's room:- One bottle of honey consistency cranberry juice, opened and dated 6/25/26, stored on top of the paper towel dispenser in the Resident's room.- One bottle of honey consistency lemon water, opened and dated 6/25/26, stored on top of the paper towel dispenser in the Resident's room.- The bottles indicated the following manufacturer storing/handling recommendations: store in cool/dry place, refrigerate unused portion, discard if not used within 10 days of opening. On 7/8/26 at 8:01 A.M., the surveyor observed the following in Resident #206's room:- One bottle of honey consistency cranberry juice, opened and dated 6/25/26, store on top of the paper towel dispenser in the Resident's room.- The bottle indicated the following manufacturer storing/handling recommendations: store in cool/dry place, refrigerate unused portion, discard if not used within 10 days of opening. On 7/8/26 at 12:00 P.M., the surveyor observed the following in Resident #206's room:- One bottle of honey consistency cranberry juice, opened and dated 6/25/26, store on top of the paper towel dispenser in the Resident's room.- The bottle indicated the following manufacturer storing/handling recommendations: store in cool/dry place, refrigerate unused portion, discard if not used within 10 days of opening. On 7/9/26 at 8:28 A.M., the surveyor observed the following in Resident #206's room:- One bottle of honey consistency cranberry juice, opened and dated 6/25/26, store on top of the paper towel dispenser in the Resident's room.- The bottle indicated the following manufacturer storing/handling recommendations: store in cool/dry place, refrigerate unused portion, discard if not used within 10 days of opening. During an interview on 7/9/26 at 8:28 A.M., Certified Nursing Assistant (CNA) #5 said Resident #206 requires assistance with meals and needs thickened liquids. CNA #5 said the bottle of thickened liquids in Resident #206's room is used by staff when he/she needs or requests a drink. CNA #5 said staff use the honey thickened cranberry juice instead of honey thickened water in order to alternate between the two and give the Resident a different flavor of drink. CNA #5 said the bottle of honey consistency juice is kept in the Resident's room. During an interview on 7/9/26 at 9:00 A.M., Nurse #4 said Resident #206 requires honey consistency liquids. Nurse #4 said she was not sure where the honey consistency cranberry juice in his/her room came from and she does not use it during medication pass. Nurse #4 said the honey consistency bottles need to be labeled when opened and it can be stored in his/her room. During an interview on 7/9/26 at 1:25 P.M., the Food Service Director (FSD) said thickened drinks are kept in the unit refrigerators for residents who need them. The FSD said once thickened drink bottles are opened they need to be dated, kept in the refrigerator and discarded after 10 days. The FSD and the surveyor reviewed the observations in Resident #206's room. The FSD said she was not sure why the Resident would have a bottle in his/her room and would expect it to be stored in the refrigerator and discarded per the manufacturer's recommendations.

Based on observation, interview, and document review, the facility failed to ensure all medications used in the facility were stored and labeled in accordance with currently accepted professional standards. Specifically, the facility failed to ensure staff properly labeled and stored all medications in one of eight medication carts reviewed. Findings include:Review of the facility's policy titled Medication Storage, dated as revised 3/12, indicated but was not limited to the following:-Medications are stored safely, securely and properly-Medications are kept in the packaging in which they were dispensed by the pharmacy Review of the facility's policy titled Medication Storage in the Facility, dated March 2021, indicated but was not limited to the following:-Medications and biologicals are stored safely, securely, following manufacturer's recommendations.-All medications dispensed by the pharmacy are stored in the container with the pharmacy label. Review of the facility's policy titled Medication Administration - General Guidelines, dated March 2021, indicated but was not limited to the following:-When medications are administered by mobile cart, medications are administered at the time they are prepared. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time. During an observation with interview on 7/7/26 at 3:59 P.M., the surveyor completed a review of the medication cart on the Memory Care Unit #6, cart B, with Nurse #9, and made the following observations:-In the second drawer: two small, clear plastic medication cups, all uncovered and not labeled, which included the following:-One contained six loose pills; one contained a white powdery substance.-In the fourth drawer: one clear plastic medication cup, uncovered and not labeled, which included the following:-Four loose white pills.Nurse #9 said all three medication cups consisted of medications he had prepared for three different residents. He said he pre-poured the medications and was going to administer them after he went to get supplies for the medication cart.During an interview on 7/7/26 at 4:17 P.M., Unit Manager #4 said all medications should be prepared and administered to one resident at a time and not pre-poured and kept in the medication cart unlabeled and uncovered.During an interview on 7/9/26 at 2:45 P.M., the Director of Nursing (DON) said medications should not be stored in the medication cart once they are prepared for administration. She said medication administration should be completed for one resident at a time to reduce the risk of medication errors.

Based on interviews and record review, the facility failed to notify the facility's wound nurse of a change in wound condition for one Resident (#5), out of a total sample of 35 residents. Specifically, the facility failed to ensure the wound nurse was promptly notified of changes to Resident #5's right mid-back pressure injury, resulting in a 21-day delay for evaluation and potential implementation of new interventions. Findings include:Review of the facility's policy titled Wound & Skin Care Protocol Policy, dated 1/2026, indicated, but was not limited to, the following:-Notify the healthcare provider and responsible party for any changes in wound condition or development of new eschar (a dead layer of tissue that forms over a wound, often appearing dark brown or black). Resident #5 was admitted to the facility in August 2021 with diagnoses including dementia and diabetes. Review of Resident #5's Minimum Data Set (MDS) assessment, dated 5/15/26, indicated the Resident was severely cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Further review of the MDS assessment indicated the Resident was at risk of developing pressure ulcers/injuries and did not have any unhealed pressure ulcers/injuries. Review of Resident #5's Nursing Progress Notes indicated, but were not limited to, the following:-5/21/26 at 3:08 P.M.: Pt (Patient) reportedly had a blister-like area to his/her right mid-back. It now appears like a skin tear or sheer [sic] injury whereas it is open with serosanguinous (thin, watery, pink-tinged fluid that typically appears during the early stages of healing) drainage present. Measuring approximately 2.5 centimeters (cm) by 1.5cm.-6/3/26 at 3:13 P.M.: DSG (dressing) change at R (right) thoracic back wound, DSG had moderate purulent drainage (pus, drainage that comes from an infected wound). Cleansed, new DPD (dry protective dressing). Have evaluated by wound nurse. Review of Resident #5's medical record failed to indicate the physician was notified of the change in wound condition on 6/3/26 so a new treatment could be ordered, if indicated. Review of Resident #5's Physician Progress Notes, dated 6/5/26 and 6/17/26, failed to indicate the presence of the Resident's right mid-back pressure injury. Review of Resident #5's medical record failed to indicate the Resident was evaluated by the facility's Wound Nurse until 7/1/26. During an interview on 7/8/26 at 2:19 P.M., the Wound Nurse said she was just recently made aware of Resident #5's wound on his/her back and completed her initial assessment of the wound on 7/1/26. The Wound Nurse said she was not involved in the evaluation or management of the Resident's wound prior to 7/1/26 and did not know how the wound first presented. During an interview on 7/8/26 at 3:35 P.M., the Wound Nurse said if the nurses feel a resident should be evaluated by the Wound Nurse, they notify her via email, send a message via the facility's electronic health record system, or call and leave a voicemail. The Wound Nurse said she was notified of the need for evaluation of Resident #5's back wound on 7/1/26 from the nurse working the floor that day. During an interview on 7/9/26 at 10:58 A.M., Unit Manager #4 said she was not sure why the Resident was not evaluated by the Wound Nurse. Unit Manager #4 said the nurse assigned to the Resident should have emailed the Wound Nurse to request an evaluation in addition to writing a progress note. During an interview on 7/9/26 at 11:18 A.M., the Director of Nursing said when a nurse identifies a wound that should be seen by the Wound Nurse, the nurse should call and leave the Wound Nurse a voicemail or speak to her in person when she is in the facility on Mondays, Wednesdays, and Fridays. The Director of Nursing said the nurse identifying a concern with Resident #5's wound should have contacted the Wound Nurse for evaluation on 6/3/26.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was at risk for falls, had been exhibiting exit seeking behaviors, was at increased risk for elopement, poor safety awareness and required continual supervision by staff while ambulating, the Facility failed to ensure he/she was provided with the necessary level of staff supervision to prevent an incident resulting in injury, when on 09/19/25 sometime around 7:15 P.M., Resident #1 ambulated off of his/her unit undetected by staff, and walked to the Facility's main entrance where he/she opened the main entrance door and fell. Resident #1 was transferred to the Hospital's Emergency Department (ED) for evaluation and was diagnosed with a pelvic fracture. Findings include:Review of the Facility Policy titled Fall Prevention Program, dated as revised 10/2024, indicated that:-the Facility would prevent resident falls through systemic and regular identification of risk factors for each resident, and-interdisciplinary care plans would be established, revised and/or renewed each time a resident falls, and appropriate interventions to maintain resident's safety would be included. Review of the report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 09/20/25, indicated that on 09/19/25 at 7:15 P.M., Resident #1 wandered [off his/her unit] and was observed by staff (later identified as Receptionist #1) as he/she walked quickly towards the main entrance door, opened the door and fell. The Report indicated that Receptionist #1 was able to get the attention of a visitor who went to get help. The Report indicated that Resident #1 was sent to the Hospital's ED and diagnosed with a left pubic ramus (pelvic) fracture. Review of the Facility's Event Report, dated 09/19/25, indicated that Resident #1 was found outside on the front steps with complaints of left hip and leg pain. The Report indicated that the on-call provider was notified and Resident #1 was sent to the Hospital's ED. Review of the Hospital's ED Aftercare Summary, dated 09/23/25, indicated that Resident #1sustained a left inferior pubic ramus fracture (pelvic fracture). Resident #1 was admitted to the Facility in December 2022, diagnoses included dementia, epilepsy and anxiety. Review of Resident #1's Health Care Proxy Activation Form, dated 003/09/23, indicated his/her Health Care Proxy (HCP) had been activated. Review of Resident #1's Minimum Data Set (MDS) Quarterly Assessment, dated 08/07/25, indicated Resident #1 had severe cognitive impairment and required partial assistance for ambulation. Review of a Fall Risk Assessment, dated 08/08/25, indicated that Resident #1 was at risk for falls. Review of Resident #1's Care Plan, titled Falls, reviewed and renewed with his/her Quarterly MDS Assessment, dated 08/07/25, indicated the following:-he/she had poor sense of direction, destination, and poor safety awareness due to poor cognition,-he/she was at risk for eloping from his/her unit, and-he/she was not safe to leave his/her unit or building unassisted. Review of Resident #1's Care Plan, titled Ambulation/Locomotion, reviewed and renewed with his/her Quarterly MDS Assessment, dated 08/07/25, indicated that Resident #1 required continual supervision for ambulation with a rolling walker due to poor safety awareness. Review of Receptionist #1's Written Witness Statement, dated 09/19/25, indicated that on 09/19/25 sometime around 7:15 P.M. -7:30 P.M., he saw Resident #1 walk quickly toward the main entrance door, and that he tried to stop him/her (Resident #1), but it was too late. The Statement indicated that he rushed over to help him/her, but Resident #1 had already pushed the main entrance door open and fallen. The Statement indicated he (Receptionist #1) yelled out for help and a visitor came to help him, and he asked the visitor to go get staff to help. During a telephone interview on 10/24/25 at 10:39 A.M., Certified Nurse Aide (CNA) #4 said Resident #1 was on her assignment during the 3:00 P.M. to 11:00 P.M. (evening) shift on 09/19/25 and said Resident #1 needed continual supervision for safety because he/she was a fall risk. CNA #4 said Resident #1 had been standing up frequently and that she (CNA #4) had been in the dining room supervising him/her but had to care for another resident. CNA #4 said she then asked CNA #1 to supervise Resident #1 when she left the dining room to care for another resident. During a telephone interview on 10/14/25 at 12:38 P.M., CNA #1 said that she had not typically worked on Resident #1's unit but said she was familiar with Resident #1 and knew he/she required continual supervision due to his/her fall risk. CNA #1 said she had been supervising Resident #1 when she had to leave him/her to answer another resident's call light. CNA #1 said as she was walking into another resident's room, she saw Resident #1 walking toward another CNA, so she figured Resident #1 would be supervised. CNA #1 said that by the time she was done providing care for another resident, Resident #1 had already left his/her unit. During an interview on 10/14/25 at 3:16 P.M., Nurse #1 said Resident #1 requires continual supervision and should therefore always be in staff's line of site. Nurse #1 said Resident #1 had been agitated during the evening shift on 09/19/25 because he/she thought he/she had to go home to make dinner. Nurse #1 said she asked CNA #1 to keep a close eye on Resident #1 because she had to go give medications to another resident at the end of the hallway. Nurse #1 said Resident #1 should not have been able to leave the unit unsupervised and walk all the way down the hall to the front entrance where he/she opened the door and fell. Review of Nurse #5's Written Witness Statement, dated 09/19/25, indicated that on 09/19/25, she was working on a unit other than Resident #1's unit, when she heard a visitor call out that someone had fallen. Nurse #5 said she ran to the front entrance where she saw Resident #1 laying on the top step in front of the main entrance with his/her walker next to him/her and that Receptionist #1 was standing near Resident #1. Nurse #5 said she assessed Resident #1 for potential injuries and paged other nurses to emergently come to assist. During an interview on 10/15/25 at 2:35 P.M., the Director of Nurses (DON) said that Resident #1 required continual supervision for ambulation, and that staff should have known where he/she was and what he/she was doing at all times. The DON said that no one [staff working on Resident #1's unit] was aware that Resident #1 had left the unit. The DON said that had Resident #1 been supervised, he/she would not have been able to walk off his/her unit alone, make it to the front entrance door, and fall, which resulted in a pelvic fracture.

Based on records reviewed, and interviews for one of three sampled residents (Resident #1), who was at risk for falls, had severe cognitive impairment, and whose plan of care indicated he/she required continual supervision while ambulating, the Facility failed to ensure staff consistently implemented and followed his/her care plan interventions, when 09/19/25 sometime around 7:15 P.M. Resident #1 ambulated off of his/her unit undetected by staff, walked to the main entrance where he/she opened the main entrance door and fell. Resident #1 was transferred to the Hospital's Emergency Department (ED) for evaluation and was diagnosed with a pelvic fracture. Findings include: Review of the Facility's policy, titled Comprehensive Care Plan, dated as revised July 2025, indicated that the Facility would develop and implement a comprehensive person-centered care plan for each resident that will meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Review of the report submitted by the Facility via Health Care Facility Reporting System (HCFRS), dated 09/20/25, indicated that on 09/19/25 at 7:15 P.M., Resident #1 wandered [off his/her unit] and was observed by staff (later identified as Receptionist #1) as he/she walked quickly towards the main entrance door, opened the door and fell. The Report indicated that Receptionist #1 was able to get the attention of a visitor who went to get help. The Report indicated that Resident #1 was sent to the Hospital ED and diagnosed with a left pubic ramus (pelvic) fracture. Review of the Hospital Emergency Department Aftercare Summary, dated 09/23/25, indicated that Resident #1 sustained a left inferior pubic ramus fracture (pelvic fracture). Resident #1 was admitted to the Facility in December 2022, diagnoses included dementia, epilepsy and anxiety. Review of Resident #1's Minimum Data Set (MDS) Quarterly Assessment, dated 08/07/25, indicated Resident #1 had severe cognitive impairment and required partial assistance for ambulation. Review of Resident #1's Care Plan, titled Ambulation/Locomotion, reviewed and renewed with his/her Quarterly MDS Assessment, dated 08/07/25, indicated that Resident #1 required continual supervision for ambulation with a rolling walker due to poor safety awareness. Review of Resident #1's Care Plan, titled Falls, reviewed and renewed with his/her Quarterly MDS Assessment, dated 08/07/25, indicated that:-he/she had poor sense of direction, destination, and poor safety awareness due to poor cognition,-he/she was at risk for eloping from his/her unit, and-he/she was not safe to leave his/her unit or building unassisted. Review of Resident #1's Resident Profile (care card utilized by staff providing direct care, identifies individual residents' care needs) indicated that as of 12/21/22, he/she required continual supervision for ambulation with his/her rolling walker. Review of Receptionist #1's Written Witness Statement, dated 09/19/25, indicated that on 09/19/25, sometime around 7:15 P.M. -7:30 P.M., he saw Resident #1 walk quickly towards the main entrance door and that he tried to stop him/her (Resident #1), but it was too late. The Statement indicated that he (Receptionist #1) rushed over to help him/her, but Resident #1 had already pushed the main entrance door open and fallen. The Statement indicated he (Receptionist #1) yelled out for help, a visitor came to help, and he asked the visitor to go get staff to help. During a telephone interview on 10/24/25 at 10:39 A.M., Certified Nurse Aide (CNA) #4 said Resident #1 had been on her assignment during the 3:00 P.M. to 11:00 P.M. (evening) shift on 09/19/25 and said Resident #1 needed continual supervision for safety because he/she was a fall risk. CNA #4 said that Resident #1's information about level of assistance he/she required could be found on his/her care plan or on his/her resident profile card. CNA #4 said Resident #1 had been standing up frequently that evening and that she (CNA #4) had been in the dining room supervising him/her. CNA #4 said that when she had to care for another resident, she asked CNA #1 to supervise Resident #1 while she (CNA #4) stepped away. CNA #4 said that when she returned to supervise Resident #1, she heard Resident #1 had fallen. During a telephone interview on 10/14/25 at 12:38 P.M., (which included review of her Written Witness Statement, dated 09/19/25), CNA #1 said that she had not typically worked on Resident #1's unit but said she was familiar with Resident #1 and knew he/she required continual supervision due to his/her fall risk. CNA #1 said that on 09/19/25, Resident #1 kept trying to go to the exits at the ends of his/her unit hallway and she had stopped him/her (Resident #1) twice already before she had to go provide care for another resident. CNA #1 said as she was walking into another resident's room, she saw Resident #1 walking towards another CNA, so she figured Resident #1 would be supervised. CNA #1 said that by the time she was done providing care for another resident, Resident #1 had already left his/her unit. During an interview on 10/14/25 at 3:16 P.M., Nurse #1 said Resident #1 required continual supervision and should therefore always be in staff's line of site. Nurse #1 said Resident #1 had been agitated during the evening shift on 09/19/25 because he/she thought he/she had to go home to make dinner. Nurse #1 said she asked CNA #1 to keep a close eye on Resident #1 because she had to give medications to another resident at the end of the hallway. Nurse #1 said Resident #1 should not have been able make his/her way off his/her unit and all the way to the front entrance where he/she fell, but he/she had. During an interview on 10/15/25 at 2:35 P.M., the Director of Nurses (DON) said that according to his/her care plan and Resident Profile, Resident #1 required continual supervision for ambulation, which meant that staff should know where Resident #1 was and what he/she was doing at all times. The DON said that all CNAs know that they need to look at the Resident Profile for a resident's level of assist. The DON said that no one [staff working on Resident #1's unit] was aware that Resident #1 had left the unit. The DON said that, had Resident #1 been supervised as required, he/she would not have been able to walk off his/her unit alone to the front entrance door and fall, which resulted in a pelvic fracture. During an interview on 10/14/25 at 3:31 P.M., the Administrator said that if Resident #1's care plan indicated that he/she required continual supervision for ambulation, then he/she should have had continual supervision by staff.

Based on observations and interviews, the facility failed to follow infection control prevention practices. Specifically, the facility failed to: 1. Ensure effective hand hygiene practices and appropriate PPE (personal protective equipment) were utilized when entering in and out of resident rooms, including residents on transmission based precautions; 2. Ensure staff utilized appropriate PPE while providing direct care to Resident #36 on Enhanced Barrier Precautions; 3. Ensure staff and resident hand hygiene was implemented during meals on Unit 7 and Unit 2A; 4. Ensure that medication carts were maintained in a clean, sanitary condition to prevent contamination and transmission of disease from resident to resident; and 5. Ensure that sanitary practices were used by nursing while preparing and administering medications. Findings include: 1. Review of the facility policy titled Precautions to Prevent Infection indicated,dated as reviewed in July 2025 but was not limited to the following: -standard precautions are intended to be applied to the care of all patients in healthcare settings, regardless of suspected or confirmed presence of an infectious agent -transmission-based precautions are for patients who are known or suspected to be infected or colonized with infectious agents -the category of transmission-based precaution determines the type of PPE (personal protective equipment) to be used -proper hand washing remains a key preventative measure, regardless of the type of transmission-based precaution employed -when implementing transmission based precautions: post clear signage on the door or wall outside of the resident room indicating the type of precaution and required PPE Review of the transmission-based precautions signs indicated the following: -Isolation Precaution sign: staff and providers must clean hands when entering and exiting the room -Contact Plus precaution sign: staff and providers must clean hands before entering room, change gown and gloves between caring for each resident, wash hands with soap and water before exiting resident's room (hand sanitizer is not sufficient when exiting a resident's room), use bleach products to clean and disinfect resident rooms During an interview on 4/15/25 at 3:05 P.M., Unit Manager #5 said Resident #142 had been placed on Isolation precautions that morning related to an episode of vomiting and Resident #190 was on Contact Plus precautions related to loose stool. On 4/16/25 at 3:49 P.M., Certified Nursing Assistant (CNA) #9 was observed exiting the room of Resident #142 and placed a robe on the shoulders of Resident #142 who was sitting in the hallway. A sign on the room for Resident #142 indicated the Resident was on Isolation Precautions. CNA #9 was observed going back in the room of Resident #142 and coming out with an over the bed table with a stack of clean hospital gowns for residents. CNA #9 was not observed to perform hand hygiene when entering or exiting the room or following contact with the Resident and their clothing. CNA #9 then wheeled the over the bed table with the hospital gowns down the hall and entered the room of Resident #190 with the table, without performing hand hygiene prior to entering. CNA #9 was observed placing the resident gowns on the dresser of each resident in the room. CNA #9 exits the room of Resident #190 without performing hand hygiene, goes to the linen closet on the unit to obtain more briefs and returns to the room of Resident #190. CNA #9 then exits the room of Resident #190, without performing hand hygiene. CNA #9 was observed going to the linen closet and getting clothing protections and brining them to the unit dining room. CNA #9 was observed exiting the room without performing hand hygiene. During an interview on 4/16/25 at 4:06 P.M., CNA #9 said each of the signs outside of the resident's rooms indicated the type of precautions the residents were on. He said the signs indicated the directions for hand hygiene and PPE use and should be followed. During an interview at 8:55 A.M., the Infection Control Preventionist said when a staff enter the rooms of residents on precautions they should be performing hand hygiene when entering and exiting. For Contact Plus precautions the staff would need to don PPE if they are touching resident items, but not if they were only dropping off linen. 50740 2. Resident #36 was admitted to the facility in March 2025 with diagnoses including pressure ulcer of the sacral region and left calf hematoma requiring incision and drainage. Review of Resident #36's Care Plan indicated, but was not limited to, the following: Problem: EBP (Enhanced Barrier Precautions) - I am at increased risk of MDRO (multi-drug resistant organism) acquisition secondary to surgical wounds to my left lower extremity. Approach: -Do not wear the same gown and gloves for the care of more than one resident or reuse the gown and gloves for the same resident. -Post clear signage on the door or wall outside of the resident's room indicating the type of precautions and required personal protective equipment. *For enhanced barrier precautions, signage should indicate the high-contact resident care activities that require the use of gown and gloves. On 4/17/25 at 10:03 A.M., the surveyor observed the Centers for Disease Control and Prevention (CDC) Enhanced Barrier Precautions sign posted on the wall outside of Resident #36's room. The sign indicated that everyone must clean their hands and that providers and staff must wear gloves and a gown for high-contact resident care activities such as: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care, and wound care. Gowns were located in a hanging basket on the room door. On 4/17/25 at 10:03 A.M., Certified Nursing Assistant (CNA) #10 was observed in Resident #36's room providing incontinence care and assisting the Resident with turning and repositioning in bed. CNA #10 was wearing gloves but was not wearing a gown during care. On 4/17/25 at 10:15 A.M., the surveyor observed wound care provided to Resident #36. CNA #10 was present in the room and assisted in providing hygiene and positioning the Resident during wound care. CNA #10 was wearing gloves but was not wearing a gown. During wound care, the surveyor observed Nurse #4 remove her gloves and don new gloves without performing hand hygiene at 10:21 A.M., 10:23 A.M., and 10:25 A.M. During an interview on 4/17/25 at 10:35 A.M. Nurse #4 said Resident #36 required Enhanced Barrier Precautions and that CNA #10 should have had on a gown for high-contact care activities. Nurse #4 said that after removing gloves, hand hygiene should be performed before new gloves are put on. During an interview on 4/17/25 at 11:22 A.M., CNA #10 said Resident #36 required Enhanced Barrier Precautions and that she should have worn a gown when providing care, but was busy and forgot to. 49428 3. Review of the facility's policy titled Hand Hygiene, undated, indicated but was not limited to the following: Purpose - Hand hygiene continues to be the primary means of preventing the transmission of infection. Policy - All employees of the facility shall perform hand hygiene (such as hand washing or use of alcohol hand rubs) in accordance with the recommendations of the Center for Disease Control (CDC) Guideline for Hand Hygiene in Health Care Settings, World Health Organization (WHO), Centers for Medicare and Medicaid Services (CMS) Guidance. Hand washing with antimicrobial soap and water must be performed in the following situations: -When hands are visibly dirty or contaminated with proteinaceous materials or with blood or any body fluids; -Before and after eating or handling food. Alcohol based hand rubs can be used for routinely decontaminating hands if they are not visibly soiled and if the aforementioned situations do not exist. The following is a list of some situations that require hand hygiene: -Before and after eating or handling food (hand washing required); -Before and after assisting a resident with meals (hand washing required); -After handling soiled equipment or utensils; -After contact with objects and environmental surfaces in a resident's room or in vicinity of resident. On 4/14/25 at 12:10 P.M., the surveyor observed CNA #6 walking around the Unit 7 dining room feeding several residents. The surveyor observed CNA #6 feeding food and drinks to residents. The surveyor observed the CNA touch residents' utensils and serving ware, discard used placemats and finished meal items, and remove residents' used clothing protectors. The surveyor did not observe the CNA wash or sanitize her hands between these tasks or between assisting residents. On 4/16/25 at 7:17 A.M. to 7:50 A.M., the surveyor observed twelve residents sitting in the Unit 7 dining room awaiting the arrival of their meals. The surveyor observed staff preparing for breakfast by placing clothing protectors on residents and putting placemats on table. Residents were not offered hand hygiene at any time prior to being served breakfast. On 4/16/25 at 7:50 A.M., the surveyor observed staff serving breakfast to the Residents in the Unit 7 dining room. The surveyor observed staff did not offer Residents hand hygiene when serving the food. During an interview on 4/16/25 at 8:38 A.M., Nurse #1 said that hand hygiene should be offered to residents prior to them having their meal and she said she was not sure if it was offered. During an interview on 4/16/25 at 12:33 P.M., Resident Representative #1 said she sits with her husband almost daily in the dining room at lunch and she said she has not witnessed staff offer hand hygiene to residents prior to eating. On 4/16/25 at 12:05 P.M., the surveyor observed CNA #11 assisting three residents with lunch in the Unit 2A dining room. CNA #11 was observed moving from resident to resident without sanitizing her hands before assisting with their meals. CNA #11 was observed handling bread from one Resident's tray with her bare hands as she spread margarine on the bread with the Resident's utensils. CNA #11 then moved to feed another Resident without sanitizing or cleaning her hands. During an interview on 4/16/25 at 12:27 P.M., the Director of Nurses (DON) said her expectation is residents are being offered hand hygiene prior to every meal, and staff who are assisting/feeding residents should wash or sanitize their own hands when moving from one resident to the next. 15214 4. The Use of the Medication Cart policy, dated March 2021, and reviewed by the surveyor on 4/16/25, indicated but was not limited to: -J. The licensed personnel should maintain a clean top surface of the medication cart while passing medications and clean and replenish the medication cart after each use. During observation of the Med Cart, on the D-Wing, Unit 7, on 4/16/25 at 4:14 PM with Nurse #7, the following was observed: The 1st, 5th and 6th drawers of the medication cart were observed to be significantly dirty with black, soiled and sticky areas, with dark marks left on the bottoms of the drawers from sticky medication bottles. Nurse #7 said that the drawers in the med cart were dirty and in need of cleaning. Nurse #7 said that typically, the night shift cleans the medication carts. However, she also said that each nurse is responsible for ensuring the cleanliness of the medication carts during their shifts. During an interview on 4/17/25 at 11:21 A.M., the Director of Nursing (DON) said, after viewing the pictures of the dirty med cart provided by the surveyor, that is pretty gross. The DON said that the facility policy is for nurses to clean the med carts after each shift. 5. During observation on 4/15/25 at 9:10 A.M., Nurse #8, assigned to administer medications on the 2 AB Unit, was observed preparing medications for Resident #109. During the preparation process, the nurse indicated to the surveyor which pill in the cup was the Metformin (diabetic medication) that she had placed in the medication cup. Nurse #8 was observed inserting her finger in the medication cup and physically touched the pill with her finger. When the surveyor indicated that she had placed her finger in the cup and touched the pill, she said, That's a no no. She said that she understood that touching medication with bare hands is a violation of infection control procedures. During an interview on 4/17/25 at 11:33 A.M., the DON said that Nurse #8 should not have touched the Resident's medication with her bare finger. The DON said that it is an infection control issue.

Based on observation and interview, the facility failed to ensure for six residents of a total sample of 35 residents, that the Residents were provided respect and dignity in a manner and environment that promoted enhancement of the residents' quality of life and individuality. Specifically, the facility failed: To provide meal assistance in a respectful and dignified manner on units 1E, 2A, and 7. Findings include: Review of the facility's policy titled Tray Pass Guidelines, undated, indicated but was not limited to the following: -A tray may not be placed in front of a dependent feeder until someone is ready to sit down and immediately feed them. On 4/14/25 at 8:53 A.M., the surveyor observed on Unit 1E, two Certified Nursing Assistants (CNAs) standing and feeding two seated Residents, of which one CNA was standing directly in front of a Resident with the Resident's head reaching the height of the CNA's chest. On 4/14/25 at 12:20 P.M., the surveyor observed CNA #6 standing while feeding a Resident in the Unit 7 dining room. CNA #6 was observed walking around the dining room, feeding several seated residents while standing. On 4/14/25 at 12:24 P.M., the surveyor observed CNA #7 standing while feeding an entire meal to a Resident. During an interview with observation on 4/16/25 at 8:44 A.M., the surveyor observed CNA #7 standing while feeding a Resident in the dining room. The Resident was sitting in a Broda chair with a tray table in front of the chair with a pureed breakfast meal. CNA #7 said she is constantly moving in the dining room trying to get residents to eat and she will go from resident to resident providing a spoonful of food. She said she thinks the residents eat better when she feeds them a mouthful of food and then walks away and feeds another resident and then goes back to the first resident. She said she never sits down in the dining room. On 4/16/25 at 12:05 P.M., the surveyor observed CNA #11 standing while feeding lunch to two Residents who were seated in the Unit 2A dining room. During an interview on 4/16/25 at 12:06 P.M., the Director of Nursing (DON) said she expected staff to be seated while feeding residents.

Based on record review and interview, the facility failed to ensure a complete and accurate medical record was maintained for one Resident (#36), out of a total sample of 35 residents. Specifically, for Resident #36, the Resident's medical record failed to reflect accurate health care proxy activation status. Findings include: Review of the facility's policy titled Advance Directives Policy, dated ,d+[DATE], indicated, but was not limited to, the following: -If the resident is incapacitated at the time of admission, information may be given to the resident's family or surrogate. If the resident's condition reverses and he/she is no longer incapacitated, information shall be given to the resident at the appropriate time. -Implementation of resident self-determination begins on admission. -If the resident lacks decision-making capacity, the responsible party that is present during the admission process will be asked if the resident has designated a Health Care Proxy (HCP). The HCP shall be contacted to determine if the resident ever discussed or drafted advanced directives. The physician shall activate the HCP and the HCP will be responsible for executing advance directives on the resident's behalf. Resident #36 was admitted to the facility in [DATE] with diagnoses including left calf hematoma evacuation and wound debridement and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated the Resident was moderately cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of eight out of 15. Further review of the MDS indicated Resident #36's Health Care Proxy was invoked. Review of the outside hospital's Discharge Summary, dated [DATE], indicated Resident #36 had mild cognitive impairment and had signed advanced directives, including a Medical Orders for Life Sustaining Treatment (MOLST) document and Health Care Proxy document, during his/her hospitalization . Further review of the Discharge Summary failed to indicate the Resident's Health Care Proxy had been invoked. Review of Resident #36's Physician's Orders indicated the Resident's Health Care Proxy was activated on [DATE]. Review of Resident #36's Care Plan indicated, but was not limited to, the following: Problem: Advanced Directives - I am a DNR. I do not have any other advanced directives in place at this time. My healthcare proxy is activated. Goal: My HCP has chosen the following advanced directives to be carried out this quarter. Approach: -DNR - Do Not Resuscitate order will be honored while resident is in the facility. Upon finding the resident without pulse or respiration, NO CPR will be initiated per resident/HCP request and MD order. -My family is to be called with any changes in my condition and a decision will be made at that time to follow through on this POC or change it. -Please monitor and assess my condition for system management and provide adjustments/additions to my medication. Review of the physician (MD) and nurse practitioner (NP) progress notes for Resident #36 indicated, but was not limited to, the following: -[DATE] NP note: HCP is not activated. -[DATE] MD note: HCP is not activated. -[DATE] MD note: HCP is not activated. -[DATE] NP note: HCP is not activated. During an interview on [DATE] at 8:25 A.M., Unit Manager #1 said the order entered in Resident #36's record indicating the Resident's HCP was activated may have been entered in error.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure food items were properly dated and stored in three of three kitchenettes. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the FDA Food Code 2022 Chapter 3. Food Chapter 3 - 29 PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request. On 4/15/25 at 2:31 P.M., the surveyor observed on Unit 6 three opened and undated containers of thickened liquids. One container had a manufacturer's label indicating to use the contents within seven days of opening. Two containers had a manufacturer's label indicating to discard the contents if not used within 10 days of opening. On 4/16/25 at 1:01 P.M., the surveyor observed on Unit 6, one opened and undated container of thickened liquid with a manufacturer's label indicating to use the contents within seven days of opening. During an interview on 4/16/25 at 1:30 P.M., CNA #3 said there was no date on the thickened liquid container to indicate when it was opened. CNA #3 said any food or drink that was opened should be dated so staff know when to discard it. CNA #3 said they did not know when the thickened liquid container was opened. During an interview on 4/17/25 at 10:50 A.M., the Food Service Director (FSD) said once a food or drink item is opened, staff should date the item with the date opened. The FSD said thickened liquids should be dated with the date opened and discarded per manufacturer's instructions.

Based on observations, interviews, and record review, the facility failed to provide adaptive equipment for one Resident (#5), out of a total sample of 35 residents. Specifically, the facility failed to ensure Resident #5 was provided with built-up handles for utensils and a handled cup for beverages during meals. Findings include: During the entrance conference on 4/14/25 at 9:00 A.M., the Administrator said the facility had been making repairs in the kitchen and all residents were currently using disposable dishes and plastic utensils since February 2025. Resident #5 was admitted to the facility in September 2021 and had bilateral hand contractures. Review of the care plans indicated Resident #5 was received help with opening containers and cutting up food and was then independent with eating and drinking. The interventions included following any Occupational Therapy (OT) recommendations. Review of the OT Evaluation and Plan of Treatment, dated 2/25/25, indicated the following: -prior level of function: self-feed after set-up -presents with increased difficulty grasping and manipulating utensils and standard cups during mealtimes resulting in decreased efficiency during meals Review of the OT Discharge Summary, dated 3/4/25, indicated the following: -skilled interventions: built-up handles for plastic utensils provided and two handled cups were recommended to maximize independence in feeding -progress: functional performance has improved as a result of instruction to caregivers -discharge recommendations: provide set-up assistance with included built-up handles, nursing staff aware to issue for meals and to clean as needed. On 4/16/25 from 8:32 A.M. through 8:51 A.M., the surveyor observed Resident #5 in the unit dining room. The Resident was provided their breakfast meal in a disposable container and provided a plastic fork and a plastic spoon. The Resident was observed with bilateral hand contractures holding the plastic fork, without built-up handles on the utensil. The Resident was observed to have a standard disposable plastic cup of milk (without a handle) and a disposable container of orange juice. The Resident was observed to have difficulty holding the container of orange juice with both hands and trying to bring it to his/her mouth. On 4/16/25 at 11:48 A.M., the surveyor observed Resident #5 in the unit dining room. The Resident was provided their lunch meal in a disposable container and provided a plastic fork and a plastic spoon. The Resident was observed holding a plastic spoon, without a built-up handle, eating ice cream. The Resident then used the plastic fork, without a built-up handle, to eat the cut-up ham. The milk was in a plastic disposable cup, without a handle. During an interview on 4/16/25 at 11:57 A.M., Certified Nursing Assistant (CNA) #1 said Resident #5 previously had foam handles that would be put on the utensils to make for a better grip for the Resident, but the foam handles did not fit on the plastic utensils because the handles on the plastic utensils were too small. She said Resident #5 prefers to feed him/herself and will not let staff feed him/her. During an interview on 4/16/25 at 1:40 P.M., Unit Manager #4 said the process for when a resident discharged from a therapy service with adaptive equipment was for the OT to write up the recommendation, for the nurse to transcribe the order and for the Unit Manager to double check the order and then add any changes to the care plans. She said she would have to check on the process for when Resident #5 was discharged from OT on 3/4/25. During an interview on 4/16/25 at 2:39 P.M., Unit Manager #4 said she was unable to locate any documentation from when Resident #5 discharged from OT. She said based on the discharge summary the OT had educated the staff, but she was not sure who was educated. She said she found the red built-up foam handles for the utensils in the Resident's room and the staff had not been using them because the utensils moved when inside the handle, making it more difficult for the Resident to eat. She said the staff had not communicated this to her. During an interview on 4/17/25 at 8:10 A.M., the Occupational Therapist said Resident #5 had been referred for OT because of their decrease in self-feeding leading to a decrease in food intake. She said when she discharged the Resident from services the plan was for the red built-up handle covers to be added to the plastic utensils for a better grip and for all beverages to be provided in cups with handles (one or two handled cups). She said she had educated one of the CNAs but was not sure which one. She said she had not known at that time that the recommendations for staff to put the built-up handle on the plastic utensils needed to be in writing so the adaptive equipment could be added to the orders for effective implementation. She said the recommendation for cups with handles should have been communicated to the kitchen but it had not been done at that time.

Based on observation and interview, the facility failed to ensure that medications were labeled and stored in accordance with accepted professional principles for two Residents (#144 and #103), of a total sample of 35 residents. Specifically, the facility failed: 1. For Resident #103, to ensure medications were stored in the container with the pharmacy label; and 2. For Resident #144, to ensure that the Resident's topical medications were stored securely. Findings include: Review of the facility policy titled Storage of Medications, dated March 2021 and reviewed on 4/17/25, indicated but was not limited to, the following: C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. Review of the facility policy titled Medication Storage in the Facility, dated 1/9/17, indicated, but was not limited to, the following: -Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted [sic] to access medications. Medication rooms, carts, and medication supplies are locked when not in use or in direct view of persons with authorized access. 1. On 4/15/25 at 8:30 A.M., the surveyor observed Nurse #5 administering medications to Resident #103. While preparing the Resident's medications, Nurse #5 opened the third drawer of the medication cart and the surveyor observed an unidentified, unlabeled, white pill in a plastic medication cup. During an interview on 4/15/25 at 8:35 A.M., Nurse #5 said she didn't know what the medication was, the dose of the medication, who the medication was for, when it was placed there, or when it was to be administered. Nurse #5 said that the unlabeled medication in the drawer likely belonged to Resident #103, and could be the Resident's 6 A.M. dose of levothyroxine, however she was not sure. Nurse #5 said she could not say why the night nurse would have left the pill unlabeled in the medication cup and that doing so was prohibited. Nurse #5 said that medications should never be left unlabeled and stored in the medication cart. During an interview on 4/17/25 at 11:13 A.M., the Director of Nurses (DON) said that medications should never be left unlabeled and stored in the medication cart for any reason. 50740 2. During the course of survey, the surveyor made the following observations in Resident #144's room: -4/14/25 at 9:34 A.M.: two tubes of Mupirocin (a topical antibiotic ointment and Bacitracin (a topical antibiotic ointment) in a basin on top of the dresser. -4/15/25 at 9:30 A.M.: two tubes of Mupirocin and Bacitracin in a basin on top of the dresser. -4/16/25 at 7:35 A.M.: two tubes of Mupirocin and Bacitracin in a basin on top of the dresser. During an interview on 4/16/25 at 10:05 A.M., Unit Manager #1 said that Mupirocin and Bacitracin should not be stored, unsecured, in the Resident's room.

Based on observation, interview, and record review, the facility failed to implement the person-centered plan of care for one Resident (#173), out of 35 sampled residents. Specifically, the facility failed to implement the fall risk prevention intervention of having the call light within reach. Findings include: Resident #173 was admitted to the facility in May 2023 with diagnoses of dementia and a history of falling. Review of the care plans indicated Resident #173 had a history of falls with the following interventions: -call light in reach at all times; may not always know how to use due to cognitive loss (effective 5/10/23) -remind and educate to call for assistance (effective 7/3/23) -remind to use call light for assistance (effective 11/18/24) Review of the medical record indicated Resident #173 fell on [DATE], 12/24/24, 2/16/25, and 4/12/25. On 4/15/25 at 2:20 P.M., the surveyor observed Resident #173 in his/her room in a stationary reclining chair. The surveyor observed a red string attached to the wall call light box and on the Resident's bed. The call light cord was not within reach of the Resident. On 4/16/25 at 7:40 A.M., the surveyor observed Resident #173 lying in bed. The wall call light box was located towards the foot of the Resident's bed and the red string was hanging straight down at the Resident's foot of the bed and could not be easily reached by the Resident. On 4/16/25 at 9:02 A.M., the surveyor observed Resident #173 in his/her room in a stationary reclining chair with their breakfast on a table in front of them. The surveyor observed a red string attached to the wall call light box and on the Resident's bed. The call light cord was not within reach of the Resident. On 4/16/25 at 11:35 A.M., the surveyor observed Resident #173 in his/her room in a stationary reclining chair. The surveyor observed a red string attached to the wall call light box and on the Resident's bed. The call light cord was not within reach of the Resident. During an interview on 4/16/25 at 12:00 P.M., Certified Nursing Assistant (CNA) #2 said Resident #173 was able to ambulate with a rolling walker in his/her room and would attempt to get up on their own. She said the Resident preferred to sleep in their recliner on and off throughout the day. She said the Resident knew how to use the call light. During an interview on 4/16/25 at 1:46 P.M., Unit Manager #4 said Resident #173 needed supervision with walking and should be using the call light, although would forget at times. She said the call light should be within reach of the Resident and this was part of the care plan interventions.

Based on observations and interviews, the facility failed to ensure resident's privacy was maintained. Specifically the facility: 1. failed to perform a Brief Interview of Mental Status (BIMS) assessment in a private and confidential space. 2. failed to ensure resident protected health information (PHI) was secure and not visible to others on one nursing unit of seven nursing units. Findings include: Review of the facility's HIPAA Policy, undated, indicated but was not limited to, the following: -HIPAA is the Health Insurance Portability and Accountability Act of 1996. It requires that all health care providers and organizations develop and follow procedures that ensure the confidentiality and security of health information of an individual. -Confidentiality includes all personal information (name, social security, age, occupation, medical record number, address, diagnosis, treatments, why the resident is here, medical condition or medications). -Do's: Close resident's doors when discussing information, doing treatments or performing procedures. Close curtains and speak softly in semi-private rooms when discussing treatments or performing procedures. -Don'ts: Don't talk about residents in public areas, such as an elevator or break room. 1. Resident #143 was admitted to the facility in January 2024. Review of the medical record indicated Resident #143 had moderate cognitive impairment as evidenced by a BIMS assessment (cognitive assessment) score of 12 out of 15. On 4/15/25 at 11:10 A.M., the surveyor observed the Minimum Data Set (MDS) Nurse conducting Resident #143's BIMS assessment in the Unit 3 hall corridor. The surveyor observed four female residents and other staff passing by who could have easily heard the MDS Nurse assessing the Resident's cognitive status. The MDS nurse was overheard asking the Resident questions like, Repeat the following words: blue, bed, and sock. The Resident was overheard saying to the MDS nurse that he/she could not remember all three of the words that the MDS nurse had asked him/her to try to remember. During an interview on 4/15/25 at 11:12 A.M., the MDS Nurse said that she should not have performed the BIMS assessment in the corridor; she did not follow the HIPAA policy. She said she should have conducted the assessment in a private space such as the Resident's room where others could not overhear so as to protect the Resident's privacy and dignity. During an interview on 4/17/25 at 11:27 A.M., the Director of Nursing (DON) said that she had heard about the MDS Nurse conducting the BIMS assessment in the corridor on the B Unit. The DON said that the MDS nurse should have conducted the assessment in a private location to protect the Resident's privacy and dignity. 49424 2. On 4/14/25 at 11:41 A.M., the surveyor observed a sign posted to the Unit 6 dining room door titled Feeding List for 7-3 and 3-11 which included 19 residents first and last names along with their room number. The residents were having lunch in the dining room at this time with staff feeding residents their meals. On 4/14/25 at 5:00 P.M., the surveyor observed the same sign posted while residents were having dinner. The surveyor observed visitors in the dining room at this time. During an interview with observation on 4/15/25 at 7:39 A.M., Certified Nurse Aide (CNA) #5 said that she uses the list posted on the door as a reference as to which residents need to be fed their meals. She said the Unit Manager made this list for the staff and posted it on the dining room door for ease of access to information. During an interview on 4/15/25 at 7:50 A.M., CNA #4 said the sign on the door has been posted for reference for well over a month. She said the list is updated by the Unit Manager if someone needs to be fed. During an interview on 4/15/25 at 8:17 A.M., Unit Manager #5 said she created and posted the sign on the door as a cheat sheet for staff to know which residents need to be fed and which residents they can just set up their meals. She said she updates it with changes. She said she also keeps the seating chart posted on this door with Resident names for the dining room but she was not sure where that sign was moved to. During an observation with an interview on 4/15/25 at 11:50 A.M., the Administrator said this information should not be posted publicly. She said the sign violated HIPAA and should not be visible to other residents or visitors.

Based on interviews, record review, and policy review, the facility failed to prevent one Resident (#193), who had a history of agitation, aggression, and physical abuse of staff, from punching four Residents (#147, #83, #122, and #192), who had severe cognitive impairment, from a total sample of 38 residents. 1. On 2/13/24, Resident #193 punched Resident #147; 2. On 3/16/24 and 3/20/24, Resident #193 punched Resident #83; 3. On 3/16/24 and 3/20/24, Resident #193 punched Resident #192; and 4. On 3/18/24, Resident #193 punched Resident #122. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, by another person. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect Policy and Procedure, last revised 1/2024, indicated but was not limited to: Procedure: -Abuse is defined as, but not limited to, willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Resident to Resident altercation is defined as a physical or verbal act between two residents with or without resulting injury. -Employees are obligated, as a condition of employment, to report immediately to their supervisors or the administrator, any observed or suspected incidents of abuse when they have reasonable cause to do so. -The reporting is necessary in order that the nursing home can inform the alleged violations to the Department of Public Health prior to preliminary investigation as required and to protect the Resident from harm during the investigation of any such allegations. -The Administrator shall immediately take any and all protective actions necessary to prevent further harm to residents. Resident #193 was admitted to the facility in June 2023 with diagnoses including dementia. Review of the medical record indicated Resident #193 has a history of agitation, aggression, and physically assaulting staff since admission to the facility. Review of a Nursing progress note, dated 11/9/23, indicated Resident #193 exhibited increased agitation, combativeness and punched a Certified Nursing Assistant (CNA) in the face when attempting to provide care. On 11/14/23, Resident #193 was evaluated at the hospital and diagnosed with a urinary tract infection and metabolic encephalopathy. Review of the Minimum Data Set (MDS) assessment, dated 2/22/24, indicated a staff assessment of Resident's mental status identifying he/she had both long- and short-term memory problems, severely impaired skills for daily decision making, exhibited physical behaviors toward others such as hitting, kicking, pushing, scratching, and grabbing, and wandering. Review of Resident #193's Mood/Behavior Care Plan, dated 6/27/23, indicated, but was not limited to the following interventions: -Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). -If I become agitated, please try to assess for any unmet needs and redirect me with activities I enjoy; this will help calm me. Ensure that I am not in pain. Go slow with my care. Speak calmly to me while providing care. I enjoy conversations pertaining to my family. I light up when you talk to me about my granddaughter. -If I become physically and/or verbally abusive: assess whether the behavior endangers myself and/or others. Intervene as necessary. -Redirect me as needed and if that doesn't work, then just leave me alone if it is safe to do and return at a later time. -When I become physically and/or verbally abusive: keep distance between resident and others (e.g. staff, other residents, visitors). -When I become physically and/or verbally abusive: STOP and try task later. Do not force to do task. Review of the medical record indicated an interdisciplinary care plan meeting was held on 3/13/24. However, the current mood/behavior care plan was reviewed and renewed with no new interventions. Review of a psychiatric consultant Nurse Practitioner's note, dated 2/20/24, indicated Resident #193 was seen for aggressive behavior. The NP indicated a possibility that the Resident was annoyed by another resident's screaming. Recommendations included an increase in a medication used to treat akathisia (psychomotor restlessness), continue with supportive care, monitor for signs and symptoms of depression and notify the consultant provider with any changes. Further review of Resident #193's medical record indicated Resident #193 physically assaulted four residents on six occasions from 2/13/24 to 3/20/24 as follows: 1. Resident #147 was admitted to the facility with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated 3/1/24, indicated Resident #147 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, and required assistance from staff for all activities of daily living. Review of the medical record indicated on 2/13/24 at 6:30 P.M., while seated at a table in the unit dining room, Resident #147 was punched in the face by Resident #193. Review of the facility's Event Reports (for Residents #147 and #193), dated 2/13/24, indicated on 2/13/24 at 6:30 P.M., a Certified Nursing Assistant (CNA) observed Resident #193 approach Resident #147 while he/she was seated at a table in the unit dining room and punch him/her on the right side of the face, unprovoked. New interventions included 15-minute checks for 72 hours, and redirect the resident as needed. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. During an interview on 3/19/24 at 9:45 A.M., Resident #147 was unable to recall the incident that occurred on 2/13/24. 2. Resident #83 was admitted to the facility with diagnoses including dementia with agitation and anxiety. Review of the MDS assessment, dated 1/5/24, indicated Resident #83 had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, required supervision only for ambulation on the unit, wandered, and had verbal behavioral symptoms directed toward others. Review of Resident #83's Mood/Behavior Care Plan, dated 1/20/22, indicated, but was not limited to the following: -Problem: I am at risk for behaviors and/or mood issues secondary to Alzheimer's disease, dementia, anxiety, depression, paranoia. -Approach: I can be paranoid in my thinking and believe that people are trying to hold me hostage or do harm to me. -Goal: To have a sense of happiness, calmness, and my mood to be regulated so that I can enjoy the time I spend with my family when they visit and enjoy the interactions with staff and other residents (target date: 4/18/24). a. Review of the facility's Event Reports (for both Resident #83 and #193), dated 3/16/24, indicated on 3/16/24 at 10:15 A.M. a CNA observed Resident #193 punch Resident #83 in the back twice as the Resident walked by him/her in the unit hallway. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Resident #193 was placed on one-to-one (1:1) for the safety of others. b. Review of the facility's Event Reports (for both Resident #83 and #193), dated 3/20/24, indicated on 3/20/24 at 2:50 P.M., Resident #193 entered Resident #83's room and slapped him/her in the face. The report indicated a new intervention of redirection and Resident #193 was placed on 1:1. 3. Resident #192 was admitted to the facility with diagnoses including dementia and depression. Review of the MDS assessment, dated 1/19/24, indicated Resident #192 was unable to complete the BIMS assessment. Staff assessed that the Resident had both long- and short-term memory problems, severely impaired skills for daily decision making, physical and verbal behavior toward others and wandering behavior. Review of Resident #192's Mood/Behavior Care Plan, dated 4/29/23, indicated, but was not limited to the following: -Problem: I am at risk for behaviors and/or mood issues secondary to my Alzheimer's disease, dementia, and depression. -Approach: Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). -Goal: To have a sense of happiness, calmness, and my mood will be regulated so that I can enjoy the time I spend with my family when they visit and enjoy the interactions with staff and other residents (target date: 5/2/24). a. Review of the facility's Event Reports (for both Resident #192 and #193), dated 3/16/24, indicated on 3/16/24 at approximately 5:00 P.M., Resident #193, while being supervised by CNA #5 for 1:1, entered Resident #192's room and struck him/her in the chest with a closed fist while he/she was resting in bed. The CNA's witness statement indicated she followed Resident #193 into Resident #192's room and observed him/her hit the Resident with a closed fist in the upper chest area. The statement indicated she was able to stop the Resident by leading him/her out of the room. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. The Surveyor was unable to interview CNA #5 as she did not respond to the Department of Public Health's telephone message request for an interview. b. Review of the facility's Event Reports (for both Resident #192 and #193), dated 3/20/24, and review of the medical record indicated on 3/20/24 at 3:00 P.M., the facility Social Worker (SW) was doing rounds on the unit, and observed Resident #193 sitting on the edge of Resident #192's bed repeatedly striking him/her on the chest. The SW removed Resident #193 from Resident #192's bed and called for assistance of a CNA. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. The Resident was placed on 1:1, redirection as needed, and urinalysis and culture and sensitivity were ordered. During an interview on 3/21/24 at 9:00 A.M., Resident #192's family member said that her loved one was hit by a resident the other day and she was called by facility staff last night to inform her that her loved one was hit again by the same resident. She said Resident #192 makes loud vocalizations frequently and staff think that may be a trigger for the Resident. She said she doesn't want her loved one to get hit again. 4. Resident #122 was admitted to the facility with diagnoses including dementia, depression, and anxiety. The Resident was receiving Hospice services. Review of the MDS assessment, dated 1/4/24, indicated Resident #122 had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, and required assistance with all activities of daily living. Review of Resident #122's Mood/Behavior Care Plan, dated 9/4/23, indicated, but was not limited to the following: -Problem: I am at risk for behaviors and/or mood issues secondary to my dementia, depression and anxiety. -Approach: Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents); At times, I don't like being alone. I can become anxious and restless and yell out. -Goal: To have a sense of happiness, calmness, and my mood to be regulated so that I can enjoy the time I spend with my family when they visit and enjoy the interactions with staff and other residents this quarter (target date: 4/11/24). Review of the facility's Event Reports (for both Resident #122 and #193), dated 3/18/24, indicated on 3/18/24 at 3:15 P.M., Resident #122 was yelling out with distressing behavior and told a Nurse that he/she was thrown to the floor and punched two times in the back. Increased anxiety and shaking were noted. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Resident #193 was placed on 1:1, and redirect the Resident. During an interview on 3/21/24 at 2:10 P.M., Unit Manager #5 said Resident #193 has a history of aggression and assaulting facility staff. She said they have tried redirection, which really hasn't worked for a long time, every 15-minute checks (the staff go by the room and check on the resident), administration of as-needed (prn) antidepressant medication, and prn 1:1. The Unit Manager said prn 1:1 is only authorized by the Nursing Supervisor or Assistant Director of Nursing (ADON) and is when someone sits with a resident when they are behavioral, and once they are calm, the person leaves and the resident is unsupervised. She said 15-minute checks and prn 1:1 was not effective in preventing Resident #193 from punching Residents #147, #83, #192, #122 multiple times. Unit Manager #5 said Resident #193's behavior may be due to a urinary tract infection (UTI) and they are waiting for test results before implementing any interventions. During an interview on 3/21/24 at 2:40 P.M., the Assistant Director of Nursing (ADON) reviewed facility Event Reports for Residents #193, #147, #83, #192 and #122. She said Resident #193's behavior is unpredictable, and 15-minute checks and 1:1 was not effective in preventing Resident #193 from punching the Residents. She said the Resident is triggered by noise, and have considered moving his/her room, but he/she would be disruptive to others. The ADON said that when Resident #193 was at the hospital on 3/16/24, a urinalysis was negative for a UTI. She said the physician ordered another test and they are waiting for results. She said his/her behaviors may be due to a urinary tract infection (UTI), but they are waiting for the results before implementing any interventions. During interviews on 3/22/24 at 9:25 A.M. and 9:55 A.M., the Medical Director and the surveyor reviewed Resident #193's resident to resident altercations. He said after reviewing Resident #193's medical record, he consulted with the Resident's attending physician, and has decided to send the Resident out to the hospital for evaluation of his/her behaviors and psychiatric status. During an interview on 3/22/24 at 10:05 A.M., Social Worker #1 (SW# 1) said when Resident #193 was admitted to the facility, he/she would get nervous and combative with care only. She said the Resident had no aggression toward other residents until 2/13/24, when the Resident punched Resident #147. SW #1 said Resident #193's behavior has escalated over the past week and a half. She said they are waiting for test results to see if the Resident has a UTI, which may cause his/her behaviors. She said the Resident used to respond to redirection and would be calmed by talking about his/her family, but now he/she has just a blank stare. She said she had not contacted the facility's consultant psychiatric service provider for guidance related to managing Resident #193's behavior. SW #1 said there have been no updates or revisions to the Resident's care plan to prevent the resident from assaulting other residents. During an interview on 3/22/24 12:20 P.M., Nurse #7 said that she was working on 3/16/24 when a CNA told her that Resident #193 hit Resident #83 in the back. She said Resident #193 was redirected to his/her room; she notified the Supervisor and the Resident was placed on an as needed 1:1. Nurse #7 said she heard that Resident #193 hit another Resident in the afternoon and Resident #193 was sent out to the hospital. She said when she came back to work on the 17th, the Resident was not on a 1:1 and she didn't think of asking if he/she should be put back on a 1:1. She said she feels bad, because he/she hit someone else on 3/18/24. She said the Resident was started on continuous 1:1 last night. Nurse #7 said Resident #193's lab results came back positive for a UTI, but the physician is waiting for the culture and sensitivity results before prescribing treatment. During a telephone interview on 3/26/24 at 1:22 P.M., the consultant psychiatric Nurse Practitioner #1 (NP #1) said she has seen Resident #193 on several occasions for psychiatric medication management since his/her admission to the facility. She said the Resident's baseline behaviors include agitation, aggression and pacing behaviors. She said the Resident started a new medication, Rexulti (used to treat agitation associated with dementia) in December 2023 to address agitation and aggressive behaviors. NP #1 said she last saw Resident #193 on 2/20/24 upon staff request for aggressive behavior, medication review, breakthrough agitation, and an incident in which the Resident hit a peer and she recommended a dose increase to Benztropine (used to treat psychomotor restlessness). NP #1 said neither she nor her office was made aware of the Resident's multiple physical altercations with peers following the 2/13/24 altercation. She said the facility can contact her directly via her cell phone or email, or her office 24/7 and a clinician would contact them to set up a telehealth consult with the staff and Resident. She said if they had contacted her regarding the change in the Resident's violent behavior, she would have recommended they call 911 and have the Resident evaluated at the hospital.

Based on interviews and record reviews, the facility failed to implement protective interventions to prevent further instances of abuse, resulting in psychosocial distress for four cognitively impaired Residents (#147, #83, #122, and #192), in a total sample of 38 residents. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, by another person. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect Policy and Procedure, last revised ,d+[DATE], indicated but was not limited to: Procedure: -Abuse is defined as, but not limited to, willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Resident to Resident altercation is defined as a physical or verbal act between two residents with or without resulting injury. -The reporting is necessary in order that the nursing home can inform the alleged violations to the Department of Public Health prior to preliminary investigation as required and to protect the Resident from harm during the investigation of any such allegations. -The Administrator shall immediately take any and all protective actions necessary to prevent further harm to residents. Resident #193 was admitted to the facility in [DATE] with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated a staff assessment of the Resident's mental status identifying he/she had both long- and short-term memory problems, severely impaired skills for daily decision making, exhibited physical behaviors toward others such as hitting, kicking, pushing, scratching and grabbing, and wandering. Review of the medical record indicated Resident #193 has a history of agitation, aggression, and physically assaulting staff since admission to the facility. Review of Resident #193's Mood/Behavior Care Plan, dated [DATE], indicated but was not limited to the following interventions: -Avoid over-stimulation (e.g. noise, crowding, other physically aggressive residents) -If I become agitated, please try to assess for any unmet needs and redirect me with activities I enjoy; this will help calm me. Ensure that I am not in pain. Go slow with my care. Speak calmly to me while providing care. I enjoy conversations pertaining to my family. I light up when you talk to me about my granddaughter. -If I become physically and/or verbally abusive: assess whether the behavior endangers myself and/or others. Intervene as necessary. -Redirect me as needed and if that doesn't work, then just leave me alone if it is safe to do and return at a later time. -When I become physically and/or verbally abusive: keep distance between resident and others (e.g. staff, other residents, visitors). -When I become physically and/or verbally abusive: STOP and try task later. Do not force to do task. Review of a psychiatric consultant Nurse Practitioner's note, dated [DATE], indicated Resident #193 was seen for agitation and combativeness. Recommendations included but were not limited to monitoring and document changes in mood, behavior, mental status and cognition and contact the psychiatric service provider with any changes. Further review of Resident #193's medical record indicated Resident #193 physically assaulted four residents on six occasions from [DATE] to [DATE] as follows: 1. Resident #147 was admitted to the facility with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #147 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, and required assistance from staff for all activities of daily living. Review of the medical record indicated on [DATE] at 6:30 P.M., while seated at a table in the unit dining room, Resident #147 was punched in the face by Resident #193. Review of the facility's Event Reports (for Residents #147 and #193), dated [DATE], indicated on [DATE] at 6:30 P.M., a Certified Nursing Assistant (CNA) observed Resident #193 approach Resident #147 while he/she was seated at a table in the unit dining room and punch him/her on the right side of the face, unprovoked. New interventions included 15-minute checks for 72 hours, and redirect the resident as needed. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. During an interview on [DATE] at 2:10 P.M., Unit Manager #5 said as needed (prn) one to one (1:1) supervision is only authorized by the Nursing Supervisor or Assistant Director of Nursing (ADON) and is when someone sits with a resident when they are behavioral, and once they are calm, the person leaves and the resident is unsupervised No protective measures were put in place to protect any residents from Resident #193's aggressive behavior once 15-minute checks expired after 72 hours. 2. Resident #83 was admitted to the facility with diagnoses including dementia with agitation and anxiety. Review of the MDS assessment, dated [DATE], indicated Resident #83 had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, required supervision only for ambulation on the unit, wandered, and had verbal behavioral symptoms directed toward others. Review of the facility's Event Reports (for both Resident #83 and #193), dated [DATE], indicated on [DATE] at 10:15 A.M. a CNA observed Resident #193 punch Resident #83 in the back twice as the Resident walked by him/her in the unit hallway. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Resident #193 was placed on one-to-one (1:1) for the safety of others. The report failed to indicate any protective measures were in place at the time of the incident to prevent Resident #83 from being punched by Resident #193. During an interview on [DATE] at 2:10 P.M., Unit Manager #5 said Resident #193 did not have a prn 1:1 in place and was not on 15-minute checks at the time the incident occurred. 3. Resident #192 was admitted to the facility with diagnoses including dementia and depression. Review of the MDS assessment, dated [DATE], indicated Resident #192 was unable to complete the BIMS assessment. Staff assessed that the Resident had both long- and short-term memory problems, severely impaired skills for daily decision making, physical and verbal behavior toward others and wandering behavior. Review of the facility's Event Reports (for both Resident #192 and #193), dated [DATE], indicated on [DATE] at approximately 5:00 P.M., Resident #193, while being supervised by CNA #5 for 1:1, entered Resident #192's room and struck him/her in the chest with a closed fist while he/she was resting in bed. The CNA's witness statement indicated she followed Resident #193 into Resident #192's room and observed him/her hit the Resident with a closed fist in the upper chest area. The statement indicated she was able to stop the Resident by leading him/her out of the room. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. The Surveyor was unable to interview CNA #5 as she did not respond to the Department of Public Health's telephone message request for an interview. Review of hospital documentation, dated [DATE], indicated Resident #193 was evaluated for altered mental status and aggressive behavior due to dementia. A head CAT scan (computed tomography scan) and laboratory tests were performed which showed no abnormalities. The Resident was discharged and arrived at the facility at 11:50 P.M. on [DATE]. Review of Resident #193's medical record failed to indicate 1:1 supervision was resumed upon his/her return to the facility, and no other protective measures were put in place to protect any residents from Resident #193's aggressive behavior. During an interview on [DATE] at 12:20 P.M., Nurse #7 said when Resident #193 returned from the hospital on [DATE], the 1:1 was not resumed. 4. Resident #122 was admitted to the facility with diagnoses including dementia, depression and anxiety. The Resident was receiving Hospice services. Review of the MDS assessment, dated [DATE], indicated Resident #122 had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, and required assistance with all activities of daily living. Review of the facility's Event Reports (for both Resident #122 and #193), dated [DATE], indicated on [DATE] at 3:15 P.M., Resident #122 was yelling out with distressing behavior and told a Nurse that he/she was thrown to the floor and punched two times in the back. Increased anxiety and shaking were noted. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Resident #193 was placed on 1:1, and redirect the Resident. The report failed to indicate any protective measures were in place at the time of the incident to prevent Resident #122 from being punched by Resident #193. During an interview on [DATE] at 2:10 P.M., Unit Manager #5 said Resident #193 did not have a prn 1:1 in place and was not on 15-minute checks at the time of the incident. 5. Review of the facility's Event Reports (for both Resident #83 and #193), dated [DATE], indicated on [DATE] at 2:50 P.M., Resident #193 entered Resident #83's room and slapped him/her in the face. The report indicated a new intervention of redirection and Resident #193 was placed on 1:1. The report failed to indicate any protective measures were in place at the time of the incident to prevent Resident #83 from being slapped by Resident #193. During an interview on [DATE] at 2:10 P.M., Unit Manager #5 said Resident #193 did not have a prn 1:1 in place and was not on 15-minute checks at the time of the incident. 6. Review of the facility's Event Reports (for both Resident #192 and #193), dated [DATE], and review of the medical record indicated that on [DATE] at 3:00 P.M., the facility Social Worker (SW) was doing rounds on the unit, and observed Resident #193 sitting on the edge of Resident #192's bed repeatedly striking him/her on the chest. The SW removed Resident #193 from Resident #192's bed, and called for assistance of a CNA. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. The Resident was placed on 1:1, redirection as needed, and urinalysis and culture and sensitivity were ordered. The report failed to indicate any protective measures were in place at the time of the incident to prevent Resident #192 from being punched by Resident #193. During an interview on [DATE] at 2:10 P.M., Unit Manager #5 said Resident #193 has a history of aggression and assaulting facility staff. She said they have tried redirection, which really hasn't worked for a long time, every 15-minute checks (the staff go by the room and check on the resident), administration of prn antidepressant medication, and prn 1:1. She said 15-minute checks and prn 1:1 was not effective in preventing Resident #193 from punching Residents #147, #83, #192, #122 multiple times. Unit Manager #5 said Resident #193's behavior may be due to a urinary tract infection (UTI) and they are waiting for test results before implementing any interventions. During an interview on [DATE] at 2:40 P.M., the Assistant Director of Nursing (ADON) reviewed the facility's Event Reports for Residents #193, #147, #83, #192, and #122. She said Resident #193's behavior is unpredictable, and 15-minute checks and 1:1 was not effective in preventing Resident #193 from punching the Residents. She said the Resident is triggered by noise, and have considered moving his/her room, but he/she would be disruptive to others. The ADON said that when Resident #193 was at the hospital on [DATE], a urinalysis was negative for a UTI. She said the physician ordered another test and they are waiting for results. She said his/her behaviors may be due to a urinary tract infection (UTI), but they are waiting for the results before implementing any interventions. During an interview on [DATE] at 10:05 A.M., Social Worker #1 (SW# 1) said when Resident #193 was admitted to the facility, he/she would get nervous and combative with care only. She said the Resident had no aggression toward other residents until [DATE], when the Resident punched Resident #147. SW #1 said Resident #193's behavior has escalated over the past week and a half. She said the Resident used to respond to redirection and would be calmed by talking about his/her family, but now he/she has just a blank stare. She said they are waiting to update the Resident's care plan with new interventions until they receive test results to see if the Resident has a UTI, which may cause his/her behaviors. During an interview on [DATE] at 12:20 P.M., Nurse #7 said Resident #193 was started on continuous a 1:1 last night, more than five weeks after Resident #193 first struck a fell ow Resident.

Based on interviews, record reviews, and policy review, the facility failed to implement their abuse policy for prevention, protection and reporting to the Department of Public Health (DPH) for four Residents (#147, #83, #192, and #122), out of a total sample of 38 residents. Specifically, the facility failed to implement their policy: 1. For Resident #147, when he/she was struck by a peer on [DATE]. 2. For Resident #83, when he/she was struck by a peer on [DATE] and [DATE]. 3. For Resident #192, when he/she was struck by a peer on [DATE] and [DATE]. 4. For Resident #122, when he/she was struck by a peer on [DATE]. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, by another person. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect Policy and Procedure, last revised ,d+[DATE], indicated but was not limited to: Procedure: -Abuse is defined as, but not limited to, willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Resident to Resident altercation is defined as a physical or verbal act between two residents with or without resulting injury. -Employees are obligated, as a condition of employment, to report immediately to their supervisors or the administrator, any observed or suspected incidents of abuse when they have reasonable cause to do so. -The reporting is necessary in order that the nursing home can inform the alleged violations to the Department of Public Health prior to preliminary investigation as required and to protect the Resident from harm during the investigation of any such allegations. -Administrator must immediately report allegations of abuse to the Department of Public Health's Division of Health Care Quality within two hours and do so via online reporting system. -The Administrator shall immediately take any and all protective actions necessary to prevent further harm to residents. Resident #193 was admitted to the facility in [DATE] with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated a staff assessment of the Resident's mental status identified that he/she had both long- and short-term memory problems, severely impaired skills for daily decision making, exhibited physical behaviors toward others such as hitting, kicking, pushing, scratching and grabbing, and wandering. Review of the medical record indicated Resident #193 has a history of agitation, aggression and physically assaulting staff since admission to the facility. Review of Resident #193's medical record indicated Resident #193 physically assaulted four residents on six occasions from [DATE] to [DATE] as follows: 1. Resident #147 was admitted to the facility with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #147 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, and required assistance from staff for all activities of daily living. Review of the medical record indicated on [DATE] at 6:30 P.M., while seated at a table in the unit dining room, Resident #147 was punched in the face by Resident #193. Review of the facility's Event Reports (for Residents #147 and #193), dated [DATE], indicated on [DATE] at 6:30 P.M., a Certified Nursing Assistant (CNA) observed Resident #193 approach Resident #147 while he/she was seated at a table in the unit dining room and punch him/her on the right side of the face, unprovoked. New interventions included 15-minute checks for 72 hours, and redirect the resident as needed. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Review of the Health Care Facility Reporting System (HCFRS-system used in Massachusetts by facilities to report suspected abuse/misappropriation) on [DATE], indicated the facility submitted a report on [DATE] as a resident-to-resident altercation between Resident #193 and Resident #147, and not resident-to-resident abuse, and did not report within two hours as required. No protective measures were put in place to protect any residents from Resident #193's aggressive behavior once 15-minute checks expired after 72 hours. 2. Resident #83 was admitted to the facility with diagnoses including dementia with agitation and anxiety. Review of the MDS assessment, dated [DATE], indicated Resident #83 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, required supervision only for ambulation on the unit, wandered, and had verbal behavioral symptoms directed toward others. a. Review of the facility's Event Reports (for both Resident #83 and #193), dated [DATE], indicated on [DATE] at 10:15 A.M. a CNA observed Resident #193 punch Resident #83 in the back twice as the Resident walked by him/her in the unit hallway. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Resident #193 was placed on one-to-one (1:1) for the safety of others. b. Review of the facility's Event Reports (for both Resident #83 and #193), dated [DATE], indicated on [DATE] at 2:50 P.M., Resident #193 entered Resident #83's room and slapped him/her in the face. The report indicated a new intervention of redirection and Resident #193 was placed on 1:1. Review of the HCFRS on [DATE], failed to indicate the facility submitted a report for the resident-to-resident abuse between Resident #193 and Resident #83 that occurred on [DATE] and [DATE]. During an interview on [DATE] at 2:10 P.M., Unit Manager #5 said Resident #193 did not have a prn 1:1 in place and was not on 15-minute checks at the time the incident occurred. No ongoing protective measures were put in place to protect any residents from Resident #193's aggressive behavior. 3. Resident #192 was admitted to the facility with diagnoses including dementia and depression. Review of the MDS assessment, dated [DATE], indicated Resident #192 was unable to complete the BIMS assessment. Staff assessed that the Resident had both long- and short-term memory problems, severely impaired skills for daily decision making, physical and verbal behavior toward others and wandering behavior. a. Review of the facility's Event Reports (for both Resident #192 and #193), dated [DATE], indicated on [DATE] at approximately 5:00 P.M., Resident #193, while being supervised by CNA #5 for 1:1, entered Resident #192's room and struck him/her in the chest with a closed fist while he/she was resting in bed. The CNA's witness statement indicated she followed Resident #193 into Resident #192's room and observed him/her hit the Resident with a closed fist in the upper chest area. The statement indicated she was able to stop the Resident by leading him/her out of the room. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. b. Review of the facility's Event Reports (for both Resident #192 and #193), dated [DATE], and review of the medical record indicated on [DATE] at 3:00 P.M., the facility Social Worker (SW) was doing round on the unit, and observed Resident #193 sitting on the edge of Resident #192's bed repeatedly striking him/her on the chest. The SW removed Resident #193 from Resident #192's bed, and called for assistance of a CNA. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. The Resident was placed on 1:1, redirection as needed, and urinalysis and culture and sensitivity were ordered. Review of the HCFRS on [DATE], failed to indicate the facility submitted a report for the resident-to-resident abuse between Resident #193 and Resident #192 that occurred on [DATE] and [DATE]. No ongoing protective measures were put in place to protect any residents from Resident #193's aggressive behavior. 4. Resident #122 was admitted to the facility with diagnoses including dementia, depression and anxiety. The Resident was receiving Hospice services. Review of the MDS assessment, dated [DATE], indicated Resident #122 had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, and required assistance with all activities of daily living. Review of the facility's Event Reports (for both Resident #122 and #193), dated [DATE], indicated on [DATE] at 3:15 P.M., Resident #122 was yelling out with distressing behavior and told a Nurse that he/she was thrown to the floor and punched two times in the back. Increased anxiety and shaking were noted. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Resident #193 was placed on 1:1 and redirect the Resident. Review of the HCFRS on [DATE], failed to indicate the facility submitted a report for the resident-to-resident abuse between Resident #193 and Resident #122 that occurred on [DATE]. During an interview on [DATE] at 2:40 P.M., the Assistant Director of Nursing (ADON) reviewed the facility Event Reports for Residents #193, #147, #83, #192 and #122. She said Resident #193's behavior is unpredictable, and 15-minute checks and prn 1:1 was not effective in protecting any residents from being punched by Resident #193. During an interview on [DATE] at 8:10 A.M., the Administrator and ADON said they were confused on the definition of abuse as it relates to cognitively impaired residents, and after reviewing the incidents, the Administrator said all of the incidents are considered abuse and should have been reported within two hours.

Based on interviews, record reviews, and policy review, the facility failed to implement their abuse policy for four Residents (#147, #83, #192 and #122) out of a total sample of 38 residents. Specifically, the facility failed: 1. For Resident #147, to report abuse when he/she was struck by a peer on 2/13/24. 2. For Resident #83, to report abuse when he/she was struck by a peer on 3/16/24 and 3/20/24. 3. For Resident #192, to report abuse when he/she was struck by a peer on 3/16/24 and 3/20/24. 4. For Resident #122, to report abuse when he/she was struck by a peer on 3/18/24. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, by another person. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect Policy and Procedure, last revised 1/2024, indicated but was not limited to: Procedure: -Abuse is defined as, but not limited to, willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Resident to Resident altercation is defined as a physical or verbal act between two residents with or without resulting injury. -Employees are obligated, as a condition of employment, to report immediately to their supervisors or the administrator, any observed or suspected incidents of abuse when they have reasonable cause to do so. -The reporting is necessary in order that the nursing home can inform the alleged violations to the Department of Public Health prior to preliminary investigation as required and to protect the Resident from harm during the investigation of any such allegations. -Administrator must immediately report allegations of abuse to the Department of Public Health's Division of Health Care Quality within two hours and do so via online reporting system. Resident #193 was admitted to the facility in June 2023 with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated 2/22/24, indicated a staff assessment of Resident's mental status identifying he/she had both long- and short-term memory problems, severely impaired skills for daily decision making, exhibited physical behaviors toward others such as hitting, kicking, pushing, scratching and grabbing and wandering. Review of the medical record indicated Resident #193 has a history of agitation, aggression and physically assaulting staff since admission to the facility. Review of Resident #193's medical record indicated Resident #193 physically assaulted four residents on six occasions from 2/13/24 to 3/20/24 as follows: 1. Resident #147 was admitted to the facility with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated 3/1/24, indicated Resident #147 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, and required assistance from staff for all activities of daily living. Review of the medical record indicated on 2/13/24 at 6:30 P.M., while seated at a table in the unit dining room, Resident #147 was punched in the face by Resident #193. Review of the facility's Event Reports (for Residents #147 and #193), dated 2/13/24, indicated on 2/13/24 at 6:30 P.M., a Certified Nursing Assistant (CNA) observed Resident #193 approach Resident #147 while he/she was seated at a table in the unit dining room and punch him/her on the right side of the face, unprovoked. New interventions included 15-minute checks for 72 hours, and redirect the resident as needed. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Review of the Health Care Facility Reporting System (HCFRS-system used by facilities to report suspected abuse/misappropriation) on 3/21/24, indicated the facility submitted a report on 2/20/24 for the resident-to-resident abuse between Resident #193 and Resident #147, and not within two hours as required. 2. Resident #83 was admitted to the facility with diagnoses including dementia with agitation and anxiety. Review of the MDS assessment, dated 1/5/24, indicated Resident #83 had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, required supervision only for ambulation on the unit, wandered, and had verbal behavioral symptoms directed toward others. a. Review of the facility's Event Reports (for both Resident #83 and #193), dated 3/16/24, indicated on 3/16/24 at 10:15 A.M. a CNA observed Resident #193 punch Resident #83 in the back twice as the Resident walked by him/her in the unit hallway. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Resident #193 was placed on one-to-one (1:1) for the safety of others. b. Review of the facility's Event Reports (for both Resident #83 and #193), dated 3/20/24, indicated on 3/20/24 at 2:50 P.M., Resident #193 entered Resident #83's room and slapped him/her in the face. The report indicated a new intervention of redirection and Resident #193 was placed on 1:1. Review of the HCFRS on 3/21/24, failed to indicate the facility submitted a report for the resident-to-resident abuse between Resident #193 and Resident #83 that occurred on 3/16/24 and 3/20/24. 3. Resident #192 was admitted to the facility with diagnoses including dementia and depression. Review of the MDS assessment, dated 1/19/24, indicated Resident #192 was unable to complete the BIMS assessment. Staff assessed that the Resident had both long- and short-term memory problems, severely impaired skills for daily decision making, physical and verbal behavior toward others and wandering behavior. a. Review of the facility's Event Reports (for both Resident #192 and #193), dated 3/16/24, indicated on 3/16/24 at approximately 5:00 P.M., Resident #193, while being supervised by CNA #5 for 1:1, entered Resident #192's room and struck him/her in the chest with a closed fist while he/she was resting in bed. The CNA's witness statement indicated she followed Resident #193 into Resident #192's room and observed him/her hit the Resident with a closed fist in the upper chest area. The statement indicated she was able to stop the Resident by leading him/her out of the room. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. b. Review of the facility's Event Reports (for both Resident #192 and #193), dated 3/20/24, and review of the medical record indicated on 3/20/24 at 3:00 P.M., the facility Social Worker (SW) was doing round on the unit, and observed Resident #193 sitting on the edge of Resident #192's bed repeatedly striking him/her on the chest. The SW removed Resident #193 from Resident #192's bed, and called for assistance of a CNA. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. The Resident was placed on 1:1, redirection as needed, and urinalysis and culture and sensitivity were ordered. Review of the HCFRS on 3/21/24, failed to indicate the facility submitted a report for the resident-to-resident abuse between Resident #193 and Resident #192 that occurred on 3/16/24 and 3/20/24. 4. Resident #122 was admitted to the facility with diagnoses including dementia, depression and anxiety. The Resident was receiving Hospice services. Review of the MDS assessment, dated 1/4/24, indicated Resident #122 had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, and required assistance with all activities of daily living. Review of the facility's Event Reports (for both Resident #122 and #193), dated 3/18/24, indicated on 3/18/24 at 3:15 P.M., Resident #122 was yelling out with distressing behavior and told a Nurse that he/she was thrown to the floor and punched two times in the back. Increased anxiety and shaking were noted. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Resident #193 was placed on 1:1 and redirect the Resident. Review of the HCFRS on 3/21/24, failed to indicate the facility submitted a report for the resident-to-resident abuse between Resident #193 and Resident #122 that occurred on 3/18/24. During an interview on 3/22/24 at 8:10 A.M., the Administrator and Assistant Director of Nursing said they were confused on the definition of abuse as it relates to cognitively impaired residents, and after reviewing the incidents, the Administrator said all of the incidents are considered abuse and should have been reported within two hours.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who required use of a mechanical lift with the assistance of two staff members for transfers and was assessed at high risk for falls, the Facility failed to ensure he/she was provided with the necessary level of staff assistance, to maintain his/her safety to prevent incidents and/or accidents resulting in an injury. On 04/11/22, Certified Nurse Aide (CNA) #1 transferred Resident #1 with a mechanical lift, without another staff member present to provide assistance, Resident #1 fell out of the mechanical lift, sustained a laceration to the occipital scalp (back of head) and was transferred to the Hospital Emergency Department for evaluation of his/her injuries. Findings include: Review of the Facility's Policy, titled Fall Prevention Program, dated new review 10/2022 and was the current policy in use at the time of the incident per the Administrator, indicated that each resident will be assessed for risk factors and predisposition for falling and residents who score high on the Fall Risk Assessment will have a care plan with preventative measures/interventions listed per risk factor category identified on the assessment. Review of the Facility's Policy, titled Resident Transfer & Repositioning, dated new review 07/2022 and was the current policy in use at the time of the incident per the Administrator, indicated that all resident care will be provided in a safe, appropriate and timely manner in accordance with the individual resident's care plan. The Policy indicated that transfer of a resident utilizing a mechanical lifting device requires the assistance of two staff members. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) Report, dated 04/14/22, indicated that on 04/11/22, Resident #1, who was a fall risk, was found lying on the floor between the legs of the mechanical lift bleeding from a laceration to his/her occipital scalp. The Report indicated that CNA #1 transferred Resident #1 from the wheelchair to bed using a mechanical lift alone. The Report indicated that Resident #1 slid out of the mechanical lift sling sliding to the floor and hitting the back of his/her head. The Report further indicated that the Facility policy for mechanical lift indicated it must be done with two staff members. Resident #1 was admitted to the Facility in November 2021, medical diagnoses included Alzheimer's disease, type 2 diabetes, [CONDITION(S)] and anxiety. Review of Resident #1's Transfer Care Plan, dated 03/08/22, indicated that he/she was unable to transfer him/herself, bear weight and required a mechanical lift with a two person assist for transfers into and out of bed. Review of Resident #1's Mobility Care Plan, dated 01/12/22, indicated that he/she required the assistance of two staff members for transfers into and out of bed using a mechanical lift due to unsteady gait, heaviness, helplessness and poor safety awareness. Review of Resident #1's CNA Care Card, undated, indicated that he/she was dependent on two staff members for transfers utilizing a mechanical lift. Review of Resident #1's Fall Risk Assessment, dated 03/29/22, indicated that he/she was assessed by nursing as being at high risk for falls. Review of the Resident #1's Fall Incident Report, dated 04/11/22 at 3:45 P.M., indicated that he/she was being transferred with mechanical lift (by only one staff member) and slid out of the sling landing on the back of his/her head from approximately three feet up. The Report indicated that Resident #1 was bleeding from a one-and-a-half-inch laceration to the back of his/her head and was transferred to the Hospital Emergency Department for evaluation of his/her injuries. Review of a Nurse Progress Note, dated 04/11/22, indicated that Resident #1 was found on the floor with a large amount of blood on the floor. The Note indicated Resident #1's head was resting on the foot of the mechanical lift and a large hematoma and two-inch laceration was noted to the back of his/her head. The Note indicated Resident #1 was transferred to the Hospital Emergency Department. Review of CNA #1's Written Witness Statement, dated 04/11/22, indicated that she was transferring Resident #1 with a mechanical lift, the mechanical lift became stuck, the wheels did not move and locked up. The Statement indicated that CNA #1 was unable to pivot the mechanical lift because the wheels were stuck. The Statement further indicated that Resident #1 began to slide out of the mechanical lift sling, which was up in the air, and fell out of the sling onto the back of his/her head. During an interview on 04/28/22 at 2:10 P.M., CNA #1 said that she transferred Resident #1 with a mechanical lift, without the assistance of another staff member and said the mechanical lift became stuck and would not move. CNA #1 said that Resident #1 fell out of the mechanical lift sling when he/she was up in the air and landed on the back of her/his head. CNA #1 said Resident #1 was bleeding from the back of his/her head. CNA #1 said she was aware that Resident #1 required the assistance of two staff members with a mechanical lift transfer, but said that she usually transfers Resident #1 with a mechanical lift by herself and had not had any issues before this,with transferring Resident #1 without another staff member present. CNA #1 said that she should have transferred Resident #1 with the assistance of another staff member and said facility policy us that mechanical lift transfers require the assistance of two staff members. During an interview on 04/28/22 at 2:30 P.M., the Nursing Supervisor said Resident #1 was transferred using a mechanical lift and fell out of the sling during the transfer. The Nursing Supervisor said Resident #1 was bleeding from a laceration from the back of his/her head that was sustained during the fall. The Nursing Supervisor said that CNA #1 transferred Resident #1 with a mechanical lift by herself and said that mechanical lift transfers require the assistance of two staff members and said CNA #1 did not follow Facility policy. During an interview on 04/28/22 at 3:00 P.M., the Director of Nurses (DON) said that CNA #1 transferred Resident #1 with a mechanical lift by herself, that Resident #1's plan of care indicates that two staff members are required for mechanical lift transfers, and said that CNA #1 did not follow the Facility's mechanical lift policy On 04/28/22, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A) Resident #1 was immediately assessed by Nursing, emergent care was administered to his/her laceration to control the bleeding and he/she was transferred to the Hospital Emergency Department. B) 04/11/22, the mechanical lift was taken out of service immediately to ensure that there were no equipment failure issues. C) 04/11/22, CNA #1 was educated by the Nursing Supervisor on the requirement of two staff members for all mechanical lift transfers. D) 04/12/22, Facility wide audit was completed by the Unit Managers on all resident's who require mechanical lift transfer to ensure all have the appropriate size sling. E) 04/13/22, 04/14/22, Unit Managers and/or Nursing Supervisors conducted Educational In-services for nursing department staff on two person assist for all mechanical lift transfers and that all residents should have their own sling. F) 04/20/22, All residents who require mechanical lift for transfer were re-assessed by the Unit Managers to ensure they have the correct sling for their weight and size. G) 04/20/22, a Quality Assurance Performance Improvement (QAPI) committee meeting was held with all the department heads and Medical Director which included the discussion of the mechanical lift incident. H) 04/27/22, the Representative from the mechanical lift company provided an In-service for nursing staff on proper placement of the mechanical lift sling, how to correctly fit and measure the sling, and assessed the residents for proper sizing of the sling. I) Unit Managers and/or Supervisors to complete Weekly Observations/Audits of mechanical lift transfers during care to ensure there are two staff members during the transfer. J) The Director of Quality Assurance Performance Improvement (QAPI) will be responsible for ensuring on-going audits and will present the findings to the Monthly and Quarterly QAPI committee for 3 months for patterns, trends and continued recommendations for process monitoring and improvement. K) The Director of Nurses and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who required the assistance of two staff members with a mechanical lift for transfers, the Facility failed to ensure staff implemented and followed Resident #1's plan of care related to transfers, when on 04/11/22, Certified Nurse Aide (CNA) #1 transferred Resident #1 with a mechanical lift, without another staff member present to provide assistance, Resident #1 fell out of the mechanical lift, sustained a laceration to the occipital scalp (back of head) and was transferred to the Hospital Emergency Department for evaluation of his/her injuries. Findings include: Review of the Facility's Policy, titled Resident Transfer & Repositioning, dated new review 07/2022 and was the current policy in use at the time of the incident per the Administrator, indicated that all resident care will be provided in a safe, appropriate and timely manner in accordance with the individual resident's care plan. The Policy indicated that transfer of a resident utilizing a mechanical lifting device requires the assistance of two staff members. Review of the Facility's Policy, titled Comprehensive Care Plan, dated new review 07/2022 and was the current policy in use at the time of the incident per the Administrator, indicated that a comprehensive person-centered care plan will be developed and implemented for each resident. The Policy indicated that care plans include measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment and the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) Report, dated 04/14/22, indicated that on 04/11/22, Resident #1, who was a fall risk, was found lying on the floor between the legs of the mechanical lift bleeding from a laceration to his/her occipital scalp. The Report indicated that CNA #1 transferred Resident #1 from the wheelchair to bed using a mechanical lift alone. The Report indicated that Resident #1 slid out of the mechanical lift sling, sliding to the floor, hitting the back of his/her head. The Report further indicated that the Facility policy for mechanical lift transfers indicates it must be done with two staff members. Resident #1 was admitted to the Facility in November 2021, medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Transfer Care Plan, dated 03/08/22, indicated that he/she was unable to transfer him/herself and bear weight, and required a mechanical lift with a two person assist for transfers into and out of bed. Review of Resident #1's Mobility Care Plan, dated 01/12/22, indicated that he/she required the assistance of two staff members for transfers into and out of bed using a mechanical lift due to unsteady gait, heaviness, helplessness and poor safety awareness. Review of Resident #1's CNA Care Card, undated, indicated that he/she was dependent on two staff members for transfers utilizing a mechanical lift. Review of Resident #1's Fall Risk Assessment, dated 03/29/22, indicated that he/she was assessed by nursing as being at high risk for falls. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 04/11/22, indicated Resident #1 had severe cognitive impairment and was totally dependent on two staff members for transfers. Review of the Resident #1's Fall Incident Report, dated 04/11/22 at 3:45 P.M., indicated that he/she was being transferred with mechanical lift and slid out of the sling landing on the back of his/her head from approximately three feet up off the floor. The Report indicated that Resident #1 was bleeding from a one-and-a-half-inch laceration to the back of his/her head and was transferred to the Hospital Emergency Department for evaluation of his/her injuries. Review of a Nurse Progress Note, dated 04/11/22, indicated that Resident #1 was found on the floor with a large amount of blood on the floor. The Note indicated Resident #1's head was resting on the foot of the mechanical lift and a large hematoma and two-inch laceration was noted to the back of his/her head. The Note indicated Resident #1 was transferred to the Hospital Emergency Department. Review of CNA #1's Written Witness Statement, dated 04/11/22, indicated that she was transferring Resident #1 with a mechanical lift, that the mechanical lift became stuck, the wheels did not move and locked up. The Statement indicated that CNA #1 was unable to pivot the mechanical lift because the wheels were stuck. The Statement further indicated that Resident #1 began to slide out of the mechanical lift sling, which was up in the air, and fell out of the sling onto the back of his/her head. During an interview on 04/28/22 at 2:10 P.M., CNA #1 said that she transferred Resident #1 with a mechanical lift, without the assistance of another staff member and said the mechanical lift became stuck and would not move. CNA #1 said Resident #1 fell out of the mechanical lift sling when he/she was up in the air and landed on the back of her/his head. CNA #1 said Resident #1 was bleeding from the back of his/her head. CNA #1 said that Resident #1 required the assistance of two staff members with a mechanical lift transfer, but said she usually transfers Resident #1 with a mechanical lift by herself and had not had any issues transferring Resident #1 without another staff member before. CNA #1 said that she should have transferred Resident #1 with the assistance of another staff member. CNA #1 said the facility policy is that mechanical lift transfers require the assistance of two staff members. During an interview on 04/28/22 at 2:30 P.M., the Nursing Supervisor said Resident #1 was transferred using a mechanical lift and fell out of the sling during the transfer. The Nursing Supervisor said that CNA #1 transferred Resident #1 with a mechanical lift by herself and said CNA #1 did not follow Resident #1's plan of care. During an interview on 04/28/22 at 3:00 P.M., the Director of Nurses (DON) said that CNA #1 transferred Resident #1 with a mechanical lift by herself, said that Resident #1's plan of care indicates that two staff members are required for mechanical lift transfers, said that CNA #1 did not follow Resident #1's plan of care and said CNA #1 did not follow the Facility's mechanical lift policy On 04/28/22, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey, the Plan of Correction provided is as follows: A) Resident #1 was immediately assessed by Nursing, emergent care was administered to his/her laceration to control the bleeding and he/she was transferred to the Hospital Emergency Department. B) 04/11/22, the mechanical lift was taken out of service immediately to ensure that there were no equipment failure issues. C) 04/11/22, CNA #1 was educated by the Nursing Supervisor on the requirement of two staff members for all mechanical lift transfers. D) 04/12/22, Facility wide audit was completed by the Unit Managers on all resident's who require mechanical lift transfer to ensure all have the appropriate size sling. E) 04/13/22, 04/14/22, Unit Managers and/or Nursing Supervisors conducted Educational In-services for nursing department staff on two person assist for all mechanical lift transfers and that all residents should have their own sling. F) 04/20/22, All residents who require mechanical lift for transfer were reassessed by the Unit Managers to ensure they have the correct sling for their weight and size. G) 04/20/22, a Quality Assurance Performance Improvement (QAPI) committee meeting was held with all the department heads and Medical Director which included the discussion of the mechanical lift incident. H) 04/27/22, the Representative from the mechanical lift company provided an In-service for nursing staff on proper placement of the mechanical lift sling, how to correctly fit and measure the sling, and assessed the residents for proper sizing of the sling. I) Unit Managers and/or Supervisors to complete Weekly Observations/Audits of mechanical lift transfers during care to ensure there are two staff members during the transfer. J) The Director of Quality Assurance Performance Improvement (QAPI) will be responsible for ensuring on-going audits and will present the findings to the Monthly and Quarterly QAPI committee for 3 months for patterns, trends and continued recommendations for process monitoring and improvement. K) The Director of Nurses and/or Designee are responsible for overall compliance.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who required supervision with meals and required set up of one food item at a time during meals, the Facility failed to ensure staff provided adequate supervision during meals to prevent any injury or accident. Resident #1 spilled hot tea and sustained multiple second [MEDICAL CONDITION](partial thickness burns, involves the epidermis and part of the dermis layers of skin, burn site appears red, blistered, may be swollen and painful) to his/her right and left upper inner thighs. Findings include: Resident #1's [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was severely cognitively impaired and required extensive assist of one staff with eating. Resident #1's Nutrition Care Plan, dated (MONTH) 2019, indicated he/she required supervision and reminders with meals and set up with one food item at a time. Resident #1's Dysphagia (difficulty with swallowing) Care Plan, dated 5/14/19, indicated he/she required supervision with meals and to assist as needed with meals due to poor cognition and poor safety awareness. Resident #1's Certified Nurse Aide (CNA) Care Plan, undated, indicated he/she required supervision with meals and to set up one food item at a time during meals. A Resident Incident Report, dated 6/7/19 at 4:45 P.M., indicated Resident #1 sustained a second degree burn from spilling hot tea on his/her thighs and three blisters were noted on his/her left upper inner thigh. The Health Care Facility Reporting System (HCFRS) Report, dated 6/13/19, indicated that on 6/7/19 at 4:45 P.M., Resident #1 yelled out hot, hot, hot and staff observed that Resident #1's tea cup was spilled over and his/her pants were wet. The Report indicated Resident #1 was assessed by the nurse and both the left and right inner thighs were red and three blisters were noted on the left thigh and one blister noted on the right thigh. The Report indicated Resident #1 will feed him/herself if one food item at a time is placed in front of him/her. The Report indicated that the staff member who set up Resident #1's meal did not put one food item at a time in front of him/her. The Report indicated Resident #1 reached for the tea and accidentally spilled it on his/her thighs. The physician's orders [REDACTED]. CNA #2's written witness statement, dated 6/7/19, indicated she heard Resident #1 yell out hot, hot, hot and then she turned toward Resident #1 and noticed that his/her tea cup was tipped over and the hot tea had spilled on his/her lap. The Surveyor interviewed CNA #2 at 3:11 P.M. on 6/24/19. CNA #2 said was setting up another resident's tray and had her back towards Resident #1 when she heard Resident #1 yell out hot, hot, hot. CNA #2 said she turned around and saw that Resident #1's tea had spilled over onto his/her lap. CNA #2 said she did not witness Resident #1 spill his/her tea because her back was towards him/her. CNA #2 said that Resident #1 had the whole tray in front of him/her when he/she spilled the tea and said Resident #1 required that only one food item to be served to him/her at a time because he/she became too distracted when the whole tray was in front of him/her. CNA #2 said she did not set up Resident #1's tray for him/her. A Nurse Progress Note, dated 6/7/19, indicated Resident #1 spilled hot tea on his/her lap during dinner. The Note indicated Resident #1's left thigh had a bright red area measuring 11 centimeters (cm) by 15 cm. with three irregular shaped fluid filled blisters and his/her right thigh had a bright red area measuring 5 cm. by 7 cm. The Surveyor interviewed Nurse #1 at 1:28 P.M. on 6/24/19. Nurse #1 said that Resident #1 required tray set up of one food item at a time during meals to feed him/herself. Nurse #1 said Resident #1 became distracted and overwhelmed when served the tray in its entirety and spilled hot tea on his/her lap. The Surveyor interviewed CNA #1 at 11:46 A.M. on 6/24/19. CNA #1 said she set up Resident #1's tray in front of him/her in its entirety. CNA #1 said she did not put one item at a time in front of him/her and said she was unaware that Resident #1 required tray set up of one food item at a time. CNA #1 said she left the dining room once she set up Resident #1 in front of him/her. The Surveyor interviewed the Director of Nurses (DON) at 4:00 P.M. on 6/24/19. The DON said CNA #1 set up Resident #1's entire tray in front of him/her for dinner. The DON said Resident #1 required one food item at a time be served in order to feed him/herself. The DON said Resident #1 became distracted when the whole tray was put in front of him/her, said the accident was not witnessed by any staff member and said CNA #1 did not follow Resident #1's plan of care.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who required set up of one food item at a time during meals, the Facility failed to ensure staff followed Resident #1's plan of care when Certified Nurse Aide (CNA) #1 served Resident #1 his/her tray in its entirety. Resident #1 spilled his/her hot tea and sustained multiple second-[MEDICAL CONDITION](partial thickness burns, involves the epidermis and part of the dermis layers of skin, burn site appears red, blistered, may be swollen and painful) to his/her right and left inner thighs. Findings include: The Policy titled, Comprehensive Care Plan, dated as reviewed in (MONTH) (YEAR), indicated that the Facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment to meet the resident's physical, psychosocial and functional needs. The Policy indicated the comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Resident #1's [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) Assessment, dated 5/8/19, indicated Resident #1 was severely cognitively impaired and required extensive assist of one staff with eating. Resident #1's Nutrition Care Plan, dated (MONTH) 2019, indicated he/she required supervision and reminders with meals and set up with one food item at a time. Resident #1's Dysphagia (difficulty with swallowing) Care Plan, dated 5/14/19, indicated he/she required supervision with meals and to assist as needed with meals due to poor cognition and poor safety awareness. Resident #1's CNA Care Plan, undated, indicated he/she required supervision with meals and to set up one food item at a time during meals. A Resident Incident Report, dated 6/7/19 at 4:45 P.M., indicated Resident #1 sustained second [MEDICAL CONDITION] spilling hot tea on his/her thighs and three blisters were noted on his/her left upper inner thigh. The Health Care Facility Reporting System (HCFRS) Report, dated 6/13/19, indicated that on 6/7/19 at 4:45 P.M., Resident #1 yelled out hot, hot, hot and staff observed that Resident #1's tea cup was spilled over and his/her pants were wet. The Report indicated Resident #1 was assessed by the nurse and both the left and right inner thighs were red and three blisters were noted on the left thigh and one blister noted on the right thigh. The Report indicated Resident #1 will feed him/herself if one food item at a time is placed in front of him/her. The Report indicated that the staff member who set up Resident #1's meal did not put one food item at a time in front of him/her. The Report indicated Resident #1 reached for the tea and accidentally spilled it on his/her thighs. Review of CNA #2's written witness statement, dated 6/7/19, indicated she (CNA #2) heard Resident #1 yell out hot, hot, hot and then she turned toward Resident #1 and noticed that his/her tea cup was tipped over and the hot tea had spilled on his/her lap. The Surveyor interviewed CNA #2 at 3:11 P.M. on 6/24/19. CNA #2 said she was setting up another resident's tray and had her back towards Resident #1 when she heard Resident #1 yell out hot, hot, hot. CNA #2 said she turned around and saw that Resident #1's tea had spilled over onto his/her lap. CNA #2 said she did not witness Resident #1 spill his/her tea because her back was towards him/her. CNA #2 said that Resident #1 had the whole tray in front of him/her when he/she spilled the tea and said Resident #1 required that only one food item to be served to him/her at a time because he/she became too distracted when the whole tray was in front of him/her. CNA #2 said another CNA had set up Resident #1's tray. A Nurse Progress Note, dated 6/7/19, indicated Resident #1 spilled hot tea on his/her lap during dinner. The Note indicated Resident #1's left thigh had a bright red area measuring 11 centimeters (cm) by 15 cm., with three irregular shaped fluid filled blisters and his/her right thigh had a bright red area measuring 5 cm. by 7 cm. The Surveyor interviewed Nurse #1 at 1:28 P.M. on 6/24/19. Nurse #1 said that Resident #1 required tray set up of one food item at a time during meals to feed him/herself. Nurse #1 said Resident #1 became distracted and overwhelmed when served the tray in its entirety and spilled hot tea on his/her lap. The Surveyor interviewed CNA #1 at 11:46 A.M. on 6/24/19. CNA #1 said she set up Resident #1's tray in front of him/her in its entirety. CNA #1 said she did not put one item at a time in front of him/her and said she was unaware that Resident #1 required tray set up of one food item at a time. CNA #1 said she left the dining room once she set up Resident #1 with his/her tray. The Surveyor interviewed the Director of Nurses (DON) at 4:00 P.M. on 6/24/19. The DON said CNA #1 set up Resident #1's entire tray in front of him/her for dinner. The DON said Resident #1 required one food item at a time be served in order to feed him/herself. The DON said Resident #1 became distracted when the whole tray was put in front of him/her, and said CNA #1 did not follow Resident #1's plan of care.

Based on record review and interview, the Facility staff failed to prevent an accidental fall for 1 Resident (#168) in a total sample of 35 Residents. The Facility staff failed to implement the care plan intervention for fall prevention and provide adequate supervision to keep the Resident free from further falls resulting in injury. Findings include: For Resident #168, record review indicated an unwitnessed fall occurred on 2/1/18, which resulted in an injury diagnosed on [DATE], as a fractured ankle. After this fall, Resident #168's plan of care included to keep the Resident in supervised areas and not left alone. On 2/27/18, Resident #168 was found on the floor in the dining/day room, without adequate supervision, which resulted in an injury of fractured clavicle. Resident #168 was admitted to the Facility in 6/2013 for long term care. Record review of Resident #168 includes medical [DIAGNOSES REDACTED]. Review of the Fall risk Assessment documentation, dated 1/29/18, identified Resident #168 with a total score of 20, a score of 10 and above indicates a high fall risk. Resident #168 also had fall risk factors which included restlessness, impaired vision, with anxiety and agitation. Review of Resident #168's Nurse Aide Care Card for fall interventions included a sensor chair pad alarm, remind the Resident to call for help, and to keep the Resident in visual view if restless. A Nurse Progress Note, dated 2/1/18 (3:00 P.M. to 11:00 P.M. shift), indicated Resident #168 was found on the floor after the nurse heard an alarm sounding. Resident #168 was found lying with right side of body on the floor. The nurse's note indicated the Resident denied pain and had no apparent injury, vitals recorded, physician and health care agent were informed of fall. On 2/2/18, during morning care, Resident #168 exhibited pain and bruising to left foot / leg area. Further medical evaluation and x-ray report of 2/2/18 determined Resident #168 had a fractured left ankle as a result of the previous day fall and was admitted for acute care. Review of the Incident Report, dated 2/1/18, indicated Resident #168 was in the Unit 2 dining room at the time of the unwitnessed fall at 18:50 (6:50 P.M.). Per observations of Unit 2, this dining / activity room is located out of view from the Nurses' desk and only visible if in the room or at the corridor window/doorway just outside this dining/activity room. Further review of the Fall Incident indicated the Resident was trying to go home, with no details of Resident's mood or behavior. The report indicated there was no access to a call bell and that the Resident was last seen twenty minutes before the fall in the dining room at 6:30 P.M. Although details of the incident such as the floor was dry, footwear appropriate, no obstacles and area well lit were documented on the Incident report, there were no statements from staff working on the unit or evening shift included in the Facility's investigation report provided on 7/25/18 other than the nurse writing the fall report/supervisor review in order to identify the causative factor of the fall. A revision to the care plan added 2/2/18 for fall prevention, was to not leave the Resident unattended in the dining room after the supper meal. Review of the Significant Change Minimum Data Set (MDS), dated [DATE], indicated Resident #168 had severe cognitive impairment, with a BIMS (Brief Interview of Mental Status) score of 7 of 15; required extensive assist for transfers with 2 persons and assistance of one to ambulate in room, dependent for dressing and hygiene needs. The MDS indicted Resident #168 had a fall with a major injury. Rehabilitation Therapy Progress Notes, dated 2/7/18 through 2/27/18 indicated, Resident #168 was dependent for transfers, unable to maintain standing balance without support, used a controlled ankle boot (CAM) to left lower extremity, and walked with therapy assist using a wheeled walker. A Nurse Progress Note, dated 2/15/18, indicated Resident #168 had a fall in his/her room after an alarm sounded and was found sitting on buttocks. Review of the incident indicated Resident #168 was seen by speech therapy in the room and afterwards was left alone in the room. No injury was reported. Care plan revision, dated 2/16/18, included to remind and inform all staff not to leave Resident #168 unattended, and to position him/her at the Nurses' desk. A Nurse Progress Note, dated 2/27/18, indicated Resident #168 had another fall on 2/27/18 at 18:35 (6:35 P.M.). The progress note indicate an alarm sounded and Resident #168 was found on the floor of the dining room on his/her left side. The Incident Report, dated 2//27/18, indicated this fall was unwitnessed. The Incident Report indicated the Resident was seated in a wheelchair in the dining room after the supper meal when the fall occurred; the Resident reportedly said he/she wanted to get out of here. The Nurse Progress Note, dated 2/27/18, indicated after the fall, Resident #168 had complaints of left shoulder pain, with limited range of motion, and an abrasion to left knee area. The Physician and Health Care Agent were informed, and x-ray report results confirmed Resident #168 had a fracture to left clavicle. Although the recent interventions added 2/2/18 and 2/16/18 to the Resident's fall prevention care plan included not to leave the resident in the dining room after supper alone or unsupervised and to bring to nurses desk, the Facility staff failed to follow these interventions to avoid accidents / falls. A review of the Incident Investigation provided for the fall on 2/27/18, indicated Resident #168 was not adequately supervised and fell unwitnessed as staff heard an alarm coming from the dining/day room and was found on the floor; was unattended after supper in the dining/day room. The investigation report did not include any statements from staff working at that time for complete details of what occurred in order to identify all or potential causative factors. This was confirmed through interview with the Director of Nurses 7/26/18 at 3:05 P.M. After the 2/27/18 fall with injury, the fall prevention plan of care was revised and included a Velcro alarmed seat belt and anti-tippers on wheelchair.